By Courtney Lee, MS, RDN, CLT, CDN, CFCS
Going through a state or federal survey can be very intimidating, but it doesn’t have to be! Making sure your daily routines meet the Centers for Medicare & Medicaid Services (CMS) guidelines is key for your survey success.
However, anyone can get rattled when they know a surveyor is looking over their work. Whether you are a new registered dietitian, new to your facility, or a veteran consultant dietitian, this long-term care survey checklist can help you minimize your potential for mistakes and maximize your chances of a high survey score.
Commit the surveyor entrance “announcement” to memory.
Every facility has a way of notifying the building quickly that surveyors have arrived. This is especially important to know if you are new to the facility.
Go to the kitchen if you have food service responsibilities.
One surveyor is designated to walk through the kitchen within minutes of entering the building. If you have food service responsibilities, go to the kitchen immediately to correct any mistakes you see.
Remove any non-medical record logs from view.
You may use weight sheets or wound logs to gather information before it goes into the medical record. If you are responsible for managing a log like this, take it to your office before a surveyor asks to see it (which they can do).
Go to your office and prepare a matrix-ready list of residents.
Identify the residents that the surveyors will consider high nutritional risk. This includes residents with pressure ulcers, significant weight loss, routine dialysis treatments, and need for artificial nutrition/hydration.
Double-check every resident’s chart on your list.
Take a few minutes and go check your most recent note and care plan on each of these nutritionally high risk residents you know the surveyor’s will be looking at. Make sure the interventions you have listed on the care plan are actually happening.
Write nutrition progress notes on high-risk residents, if needed.
If you identify a new high-risk resident that you haven’t documented on yet, take the time to write a complete note and adjust your interventions and care plan as needed.
Check in with the Food Service Director.
Even if you don’t have routine food service responsibilities, check in with the Food Service Director once you know your documentation is sound. You may really be able to help the food service team.
Be available during meal service to help.
Sometimes an extra set of hands delivering meals is exactly what the team needs if a surveyor is holding someone else up. By sure you are comfortable with the meal service procedures before jumping in.
If asked a question by a surveyor, rely on the medical record only.
Be easy to find without loitering in the halls during a survey. If called upon to answer a question about a resident, don’t rely on your memory or any notes you may keep. You can say, “Let me just double check the chart to answer your question.”
Complete all your daily tasks as normal for that day
Try to have as normal of a day as possible — this will keep your mind focused and also demonstrate to yourself and the surveyors that you are survey-ready every day.
Want to learn more about survey success in long-term care? Check out our webinar available in the Dietitians On Demand CEU library delving into this topic.
Courtney Lee, MS, RDN, CDN, CLT, CFCS consults locally with Dietitians On Demand and also has a virtual private practice, Kitchen Nutrition, LLC. Courtney enjoys equipping dietitians and dietetic interns with the tools they need for professional success so they don’t have to learn the hard way. Courtney enjoys baking, running, and hosting friends and family in her home.
Find her on Instagram @yourkitchennutrition.
Dietitians On Demand is a nationwide staffing and recruiting company for registered dietitians, specializing in short-term, temporary and permanent-hire positions in acute care, long term care and food service positions. We’re dedicated to dietitians and helping them enhance their practice and excel in the workplace. Check out our job openings, request your coverage, or visit our store today!