Ask the Nursing Expert about ... the new survey process

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Amy Franklin, RN,  DNS-MT, QCP-MT
Amy Franklin, RN, DNS-MT, QCP-MT

I'm feeling a bit overwhelmed. Do you have any tips to assist with the new survey process?

I suggest you use the Critical Element Pathways (CEPs) that the Centers for Medicare & Medicaid Services adapted from the original Quality Indicator Survey. The CEPs are questionnaires and observational checklists that surveyors will use to guide the interactions between the survey team and your care staff during the new process. 

Read and review all the CEPs. The nonclinical CEPs in particular can help you to identify areas of potentially deficient practice that may be suspected during the survey. 

Crosswalk the clinical CEPs to applicable policies. When preparing for staff education, attach the CEPs to the applicable policies and/or procedures. This will help your staff connect the dots between your facility process and the federal requirements. 

Educate your nurse leaders on how to use CEPs. This includes unit managers, MDS nurses, shift leaders, and the in-service director. Empower them to take ownership of the training for areas they are in charge of, critiquing and improving their training methods to include relevant CEP guidance. 

Regroup with your nurse leaders to assess potential knowledge gaps. Ask the following questions: 

• Were any gaps in policies or procedures identified during training? 

• How often will the staff need to be retrained per the CEP guidance — annually, or more frequently? 

• Do we need to refer to QAPI for a possible audit tool or workflow adjustment?

By effectively incorporating the guidance provided by the CEPs into your staff education, you will expose your nursing department to the surveyors' perspective of the new survey process, which will greatly help to prepare your team for your next survey.