Survey Readiness and the Mock Survey Process in Assisted Living

This information will enable assisted living facility management to prepare for survey and implement a program to remain prepared.  We will also review various methods to conduct a mock survey to ensure effectiveness. The elements for an effective mock survey will be reviewed for dietary, nursing, pharmacy, personnel, and environmental services.  The assisted living facility management will be able to implement a program to screen and remain in compliance in its various departments.

The mock survey process can be performed by various individuals and in different ways. The list below suggests some different methods for performing your mock survey.

  • Perform at least every quarter
  • Performed by sister facility
  • Performed by various managers in different departments
  • Performed by manager of department
  • Performed at one time as actual survey or one department at a time
  • Unannounced or scheduled
  • Use results for performance improvement program

The following areas should be reviewed in a mock survey:

  • Medical Records
  • Medication compliance
  • Infection control
  • Environmental
  • Life safety code
  • Personnel
  • Dietary
  • Administration

A quarterly schedule is suggested, but a facility may conduct its mock survey as often as monthly to as seldom as annually. A sample schedule is listed below.

January, April, July, October

  • Incident, complaint, and infection trends
  • Chart audits
  • Personnel audits

February, May, August, November

  • Infection control review
  • Environment and life safety code review

March, June, September, December

  • Dietary review
  • Medication compliance review

Medication compliance and proper pharmacy procedures are essential to operating a safe assisted living facility. The following list provides items to review when auditing these areas:

  • Observe at least two medication passes
  • Handwashing between residents
  • Verification of medication: correct resident, dose, time
  • Documentation of administration
  • Narcotic documentation and count
  • PRN documentation of reason given and effectiveness
  • Blood pressure and other parameters measured, documented, and followed
  • Eye drop administration: gloves, handwashing, time between drops
  • Crushed medications have order for crushing
  • Medication aide able to identify medication and reason for use when questioned
  • Audit medication cart and room for three to four residents
  • Verify orders, MAR, and medication are in agreement
  • Ensure there are no medications in cart or med room without orders
  • Ensure there are no orders without medication
  • Ensure orders match the medication record
  • Verify glucometer control log is kept up to date
  • Review the pharmacy order and receipt log
  • Review process for drug destruction and documentation
  • Audit four to five narcotic medications to ensure count and documentation is correct
  • Ensure that topicals, eye drops, and external use drugs are kept separate from PO medications
  • Verify that the medication refrigerator has a temperature log that is being kept
  • Verify medication room, key, and cart security
  • Ensure that poison control number is posted in the medication room and drug reference material is available in electronic or paper form
  • Ensure that refrigerated narcotics are locked by two locks
  • Verify that residents on coumadin and digoxin have lab testing completed
  • Ensure that residents self-administering drugs have a monthly assessment

Medical record requirements are very specific in the assisted living regulations. Auditing resident charts is necessary to ensure compliance. The following items must be present within the required time frames:

  • Face sheet has the required elements
  • Assessment and service plan completed within 14 days of admission, annually, and on a significant change in condition
  • History and physical completed no more than 30 days prior or 14 days after admission
  • Admission packet has the required documents and signatures obtained
  • Allergies, evacuation, and code status noted on the medical record and easily available to staff
  • Physician statement that appropriate for assisted living
  • Physician orders for all medications
  • Home health and hospice notes and care plan accessible in building
  • Documentation forms used by the facility should be complete and not have blanks

Life safety code is a very serious area and each facility should perform its own audits to ensure proper operation of equipment. Many vendors conduct testing, but sometimes are not reliable in their testing methods. A suggested simulation survey list is described below.

  • Pull fire alarm
    – Check for signal receipt at monitoring company
    – Check for release of doors with manual reset
    – Check for closure of smoke doors and dampers
  • If have generator, transfer power
    – Check for it to go off in 11 seconds of less
    – Release of doors with manual reset
    – Ensure emergency lighting and plugs working
  • Check battery operated emergency lights for proper operation (not required if generator present)
  • Ensure proper operation of exit signs
  • Review life safety book for completion of required drills and inspections
  • Ensure no penetrations in smoke barrier walls following contractor work
  • Ensure emergency/disaster plan up to date with phone numbers and emergency agreements
  • Interview at least three staff members regarding what to do in case of fire and severe weather
  • Review environment for proper storage requirements, cleanliness and good repair of paint, gutters, sidewalks, parking lots, signage, etc.
  • Verify water temperatures between 100 and 120 degrees

An assisted living facility must keep organized records for all required drills and testing. It is recommended that a life safety code book be created with dividers to organize information. The items listed below must be completed on schedule and available during a survey.

  • Fire Drills (1 per shift per quarter)
  • Fire and Sprinkler Inspections (every six months)
  • Range Hood Inspections (every six months)
  • Fire Extinguisher Inspections (annually by outside, monthly inside)
  • Fire Marshal Inspection (annually)
  • Smoke Sensitivity Inspections (every two years)
  • Flame Spread Testing on Flooring, Window Coverings, and Textiles
  • Emergency Lighting and/or Generator Checks (monthly)
  • Gas Pressure Testing (when interruption or work on gas service)

An assisted living facility is required to have infection control policies and procedures to prevent the spread of infection. The items to review to ensure compliance with regulations and keep residents and staff safe are listed below:

  • Ensure there is an infection control and exposure plan policy
  • Ensure there is a vaccine policy for residents and employees
  • Review the procedure for isolation and universal precautions by questioning at least three staff members
  • Review the supplies available for staff: gloves, soap, gel sanitizer
  • Review the procedure followed for biohazard disposal
  • Inspect rooms and residents for cleanliness
  • Observe staff with linen and trash transport
  • Observe staff providing care
  • Review resident and staff TB testing compliance
  • Review Hep B offer/declination within 10 days of employment
  • Verify the infection control documentation and trending process

Besides medications the second most important thing an assisted living facility provides is nutritional services. The facility not only gets surveyed by the state, it also receives an inspection from the local health department. Many of the items that are reviewed are listed below:

  • Ensure staff wearing apron, hair nets
  • Ensure staff keeping temperature logs of food prior to serving
  • Observe staff serving food, handwashing, sanitizing surfaces
  • Check diets and meal time compliance
  • Verify the posted menu is followed
  • Verify residents are provided adaptive equipment and assistance if needed
  • Verify refrigerator and freezer temperature are recorded
  • Ensure items out of original container are dated and labeled and kept only for three days
  • Ensure nourishment refrigerators are in compliance with temperatures, food disposal, labeling, and sanitation
  • Verify storage of items 6 inches from floor and 18 inches from ceiling
  • Ensure damaged cans and chipped/cracked dishware are disposed of
  • Review the current cleaning schedule to ensure compliance
  • Verify that ppm chemical and/or temperatures of dish machine are measured three times a day at first dish run
  • Verify that ppm of chemicals used for pot/pan sink and surface sanitation are recorded and measured for sanitizing requirements
  • Ensure chemicals are stored separately from food and MSDS

A clean and safe environment is provided for in each facility. Frequent environmental rounds, at a minimum weekly, should be conducted to keep a facility in good condition. However, an occasional extensive audit of practices must be conducted of the items below:

  • Verify up to date MSDS book
  • Question staff members regarding how to locate MSDS information
  • Ensure housekeeping closet, cart and chemicals are locked
  • Ensure that all containers have proper labels
  • Question staff regarding cleaning procedures to ensure meets infection control standards
  • Inspect rooms: shower, refrigerator, sheets, etc.
  • Inspect grounds: dumpster area, facility furniture and common areas, smoking areas
  • Observe staff handling laundry for handwashing between soiled and clean
  • Verify dryer lint cleaned every shift

Personnel charts should be reviewed after a new associate is hired to ensure completeness of the associates file. Audits must also be conducted on a regular basis to ensure continued compliance with education needs. Periodically the new hire process and paperwork needs to be reviewed for compliance based on changes in laws. The key elements of an audit are listed below:

  • Review new hire packet
  • Review 10% or five employee files for compliance
  • Verify background checks completed: Criminal history and EMR on hire and annually
  • Verify TB within 14 days, Hep B with 10 days, SB9, and compliance with vaccine policy completed
  • Verify staffing levels are posted in the facility
  • Verify required labor law postings are present
  • Verify required training completed and content:
    – Manager: 24 hour initial, 12 hour annual, 6 hour for memory care
    – Care staff: 4 hour for AL and 8 hour for MC initial with 16 hour OTJ and inservice training of 6 hours for AL and 12 hours for MC annually
    – Activity staff: 17 or more residents part time required with proper training and 6 hours CEU annually
    – Food service: Safe Serve training
    – Van driver: Van Safety training
    – RN delegation training: medication administration and other delegated services

Administrative requirements are listed below and should be reviewed for compliance. Many regulations and procedures change. Changes in management and staff also cause processes to break down and things to slip through the cracks.

  • Required postings are present and up to date
  • Admission packet has all the required items
  • Advertising has facility ID listed on marketing materials
  • Policies have cover sheet and are approved annually
  • Manager and alternate manager designated
  • Staffing posted
  • Activity Calendar complete for the month and if Alzheimer’s Certified has the required elements
  • Menu posted for the week