ANNUAL CONFERENCE RECAP | 2018
Survey Success Using the Critical
Element
Pathways
Dawn Carter RN Consultant/Analyst for Leading Age New York ProCare
Preparing for the Department of Health (DOH) survey is always a challenge
especially now that New York State DOH survey teams are using the new Long
Term Care Survey Process (LTCSP) a combination of both Quality Indicator
Survey (QIS) and traditional survey. By using the Critical Element Pathways
(CEP), planing for the survey process can make your facility not only prepared
but can also assist you in determining any areas that might need to be added to
your Quality Assurance/Quality Improvement process to identify concerns and
develop and implement a plan of action to correct potential deficiencies before
the DOH survey begins. They are a way for you to dot your I’s and cross your
T’s in assuring quality in all care areas in your facility. They put all the survey
pieces into a complete jigsaw puzzle without the stress of trying to figure out
where each piece belongs by yourself. These CEPs provide a comprehensive
approach to looking at the facility as a whole and allows the
interdisciplinary team to become an active role in survey preparedness.
Surveyors are required to use these standardized forms in compliance
Providing the solutions you need...for the results you want.
with federal regulations. They must follow and adhere to each pathway
as written, as they were designed to guide them to a more objective process.
There is a long list of individual pathways with detailed information for the
LeadingAge New York ProCare
surveyor to follow for each care area during survey. Each pathway provides
consultants have experience
detailed instructions on: what to review in advance to guide their observations
working with CEPs and can
and interviews; what to observe for that specific area; questions for interview
provide a proactive approach
of the resident, resident representative or family; which of the pertinent staff
to interview with specific questions to ask; record review specifics which then
and outside perspective with
correlate any concerns to be evaluated for the F-Tag deficiency associated in
a Mock Survey for survey
each area.
Each pathway can guide you to look at the care areas from the surveyor’s
detailed pathway. Be your own surveyor before your actual survey begins and
they can systematically assist you in investigating and analyzing concerns,
adverse events, identify deviations from standards and plan corrective
actions, giving you opportunity to monitor for effectiveness and review your
documentation to ensure that no care areas are missed and the plan of care is
evaluated and correlated. A key component along with following the pathways
is to ensure your staff is educated in these areas and evaluated for competence
inside of their practice.
The Critical Element Pathways are available for viewing and printing at:
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/
GuidanceforLawsAndRegulations/Nursing-Homes.html
preparedness.
They make recommendations
for improvement in any areas of
concern that may be noted and
help ensure staff is educated and
prepared. ProCare works and
collaborates with each facility to
assist in achieving a successful
survey. Contact them at:
www.leadingageny.org/procare
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