Overview

DHS conducts unannounced surveys at least every 24 months in assisted living and residential care facilities. The survey process seeks to ensure a safe and secure environment to:

  • Enhance a resident's dignity, independence, individuality and decision-making ability; and
  • Allow residents to function at the highest level possible.

What to expect

Entrance Conference
The purpose of the entrance conference is to announce the survey, introduce the survey team and team coordinator, meet facility staff, establish a daily communication plan and explain the survey process including:

  • Inquire about any recent changes in the facility.

  • Inform/remind the administrator of who is interviewed during the survey.

  • Provide the administrator with a copy of the entrance conference checklist, review each item and indicate what is needed and when.

  • If a licensure survey is being conducted, the facility will be asked to post survey announcement signage.

  • Ask for names of any residents in acute bereavement, who are on hospice, acutely ill or who might be agitated if approached by a surveyor.

  • Arrange for a group interview with resident council members or ask for a list of cognitively intact residents with good hearing abilities.

Tour - Environment, Resident Areas and Kitchen/Food Service Areas
The purpose of this task is to determine how the physical features of the facility (such as resident rooms, dining, activity, and shower/bathing rooms) affect the resident's quality of life, health and safety.

Staff Interviews Rgarding Systems
Interviews with direct caregivers for all residents on the sample are used to learn about resident care and services, to learn about the capabilities of the residents, what services are provided to the residents and their effectiveness, and finally recent changes or events, if any, in the residents' lives, cares, abilities or needs.

Medication and Treatment Administration
Medications and treatments ordered are reviewed to ensure medications are prescribed by an authorized person and were provided by the facility and documented on the medication and/or treatment administration records.

Resident Services Review
This review is completed to verify evaluations and/or assessments and service plans reflect the resident's needs and preferences, and support dignity, privacy, choice, individuality and independence.

Team Decision-Making
To review findings with survey team members and to make preliminary team decisions regarding citations.

Exit Conference
The purpose for the exit conference is to discuss findings, explain what the findings mean, and to explain the report time frames.

Related Documents

  
2020ScheduleQMCommunications
Assisted-Living-Residential-Care-Facilities
CBC Entrance Checklist 1013
CBC Environment Tour
CBC Family Interview Guideline with fields 052010
CBC Group Interview Guideline and HCBS with fields 052010
CBC Inspection Survey Sign
CBC Kitchen Food ServiceAD1 with fields
CBC Resident Interview Guide with fields 052010
CBC Sample Resident Matrix
CBC Survey Process Guide 2016
Change-Condition-IG-November-2019
Elements of Delegation with fields
Palliative-Care-Toolkit
Understanding Accurate MARs

Protocols

  
Pressure Ulcer
Staffing
Unplanned Weight Change