New survey process offers opportunities, experts advise

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LEESBURG, Va. — As directors of nursing prepare for a new survey process from the Centers for Medicare & Medicaid Services, there are opportunities to set standards and promote high-quality care, experts said Friday.

When the survey changes, starting Nov. 28, “Surveyors will be just as new as us,” reminded Diane Vaughn, RN, CDONA/LTC, LNHA, the vice president of Clinical Services at Volunteers of America. “We should lead like we are supposed to and be prepared.”

During a series of sessions Friday at the AADNS conference in Leesburg, VA, numerous experts offered tips on best practices for clinicians.

These included documenting skin conditions, with daily checks by direct caregivers and weekly checks by licensed staff, said Jeri Lundgren,  RN, BSN, PHN, CWS, CWCN, CPT, president at Senior Providers Resource. There also should be a check before a planned discharge, as well as daily checks in acute care and a check by a nurse for each home visit.

Lundgren told about wound care documentation that proved the facility wasn't responsible for a fistula or ulcer that arose suddenly.

“Skin checklists can seem so benign, but it can be very costly,” she told McKnight's. She also reminded attendees about handwashing protocols and infection control standards, such as applying sterile dressings.

“One wound nurse can't do the program by herself,” Lundgren said. “Floor nurses and assistants need to be actively involved. In a lot of buildings, the nursing assistants run the program, with the wound nurse monitoring and providing education.”

Dining should be part of any facility assessment in preparation for the new survey process. For example, ask if your facility offers substitutes of similar nutritional value to residents who refuse food. And inquire as to whether there are comfortable sound levels or if the facility provides adequate and comfortable lighting, Vaughn advised.

It's also wise to discuss with staff how to speak with a surveyor. She recalled a surveyor who said, “I have the same disorder as this resident. This medication never worked for me. Don't you agree she needs something stronger?” In that instant, Vaughn said she knew she couldn't agree, so she took a moment and eventually said that she'd be happy to get the physician on the phone to discuss the order with the surveyor.

“The more they understand the survey process, the better,” she said.

With regards to addressing antibiotic stewardship, urinary tract infections may be one area to focus on, said presenter Sarah Kabbani, M.D., MSC, medical officer at the Centers for Disease Control and Prevention: “UTIs are a good first target for antibiotic stewardship,” she explained. 

She stressed that the CDC is not advocating withholding antibiotics but that “Our mission is to improve care across the spectrum. It's about the right drug at the right time.”

In addition to concerns over UTIs being overtreated with antibiotics, one metric a nursing home could start looking at is how many urine cultures are being taken. For example, physicians may order a culture that reveals asymptomatic bacteria, and that, along without symptoms, such as a lack of burning during urination, should not be treated, she advised.

One issue related by providers to Kabbani was the number of community physicians who are ordering urine cultures routinely. Kabbani stressed facility leadership should convey the antibiotic stewardship plan and make clear to those physicians who are overordering why it's an issue.

“Many times, they just don't know,” she noted.

Some nurses were wary of how much clout they might have to push back against prolific orderers of urine cultures, but the overriding sense was that they would try.