10 Day Facility Observation Experience for New Surveyors

Introduction

The Human Resource Code §22.039, as a result of Senate Bill 1839, requires surveyors complete a basic training program before the surveyor inspects, surveys or investigates an assisted living facility, nursing facility, or intermediate care facility. The training must include observation of facility operations unrelated to the survey, inspection or investigation process for a minimum of 10 working days within a 14 day period.

When

• This training component will be arranged before the new employee inspecting, surveying or investigating a long-term care facility as a qualified regulatory services (RS) surveyor.
• This observation will be scheduled and coordinated by the surveyor's regional program manager (PM). The Life Safety Code (LSC) program manager will coordinate Life Safety Code observations.

Why

• This is intended to be an educational experience, unrelated to the survey process.
• The purpose is to acclimate newly hired surveyors to the long-term care arena and facilities' operational systems.

Where

• Regional directors or designees will identify and select facilities to participate in this program.
• The selection criteria may include previous survey results, facility willingness and geographic location.

What

• This program is "observation" only. The new surveyor will wear a name tag designating his/her role as an observer.
• Due to liability issues for the facilities and surveyors, no resident care will be performed.
• Volunteer facilities will be advised of the overall curriculum for the program and will agree to allow the trainee to observe recommended aspects of the facility operations.
• Another part of this training will include verbal interactions with facility staff to gain insight into facility systems and operations.
• At the discretion of the regional office, and with the concurrence of the facility, there may be some fluctuation of the surveyor's daily work schedule to allow for specific observation opportunities. Flexibility will be allowed to accommodate activities at the facility. To provide guidance for recommended areas of observation the attached checklist and comment sheets are completed by the trainee and given to the trainee's program manager at the end of the observation period.
• These records will be kept in the region.
• A certificate of completion (attached) will be faxed to Educational Services at 512-438-2113, attention: attention CAPPS  Transcript Coordinator or Training Registrar. Educational Services will enter completion date into PeopleSoft for tracking purposes.
• If an immediate jeopardy situation or other event, such as resident abuse is witnessed or identified during the observation period, the surveyor will notify the facility administrator or designee and the regional PM. Appropriate protocols will be followed by those entities, as needed.

How

• Regional RS administrative staff may accompany observers to the host facility on the first day of observation and introduce them to the facility liaison.
• The checklist will be shared with the providers.
• No more than 3 surveyors, depending on the size of the facility, will be assigned to one place.
• The PM or designees will be available to the trainee and/or facility via telephone and on-site visits, as necessary, and at their discretion.
• With the varied sizes of the long-term care facilities more than one facility per trainee may be used during the 10-day period. This will be at the discretion of the PM and with approval of the participating facilities.
• The overall program will be evaluated and changes made based on feedback from providers, trainees and program managers.

Methodology

Overall structure and purpose

• The purpose of the experience is to observe "the operations of a long-term care facility unrelated to the survey, inspection, or investigation process."
• The length of the experience will be 10 days within a 14-day period. This training component will be arranged before the new employee begins inspecting, surveying or investigating a long-term care facility as a qualified Regulatory Services (RS) surveyor.
• From one to 3 surveyors may be assigned to one facility, depending on the size of the facility.
• The experience is observational only; no resident care delivery will be permitted. The trainee will be identified as an observer.
• Surveyor trainees will
  • observe facility operations,
  • interact with staff, residents, families and volunteers, and
  • peruse facility policies, procedures, programs and systems.
• The checklist format with recommended observations will be shared with the host facility.
• Surveyor trainees may spend time in the following departments:
  • Health surveyors:
    • Administration
    • Dietary
    • Human Resources
    • Housekeeping
    • Laundry
    • Maintenance
    • Facility Construction
    • General Safety
    • Nursing
    • Pharmacy Services
    • Rehabilitation Services
    • Social Services
    • Any Specialized Units
    • Volunteer Programs
  • Life Safety Code surveyors:
    • Systems review, including policies & procedures (i.e. fire drills)
    • Facility construction
    • General safety
    • Fire alarm systems
    • Sprinkler systems
    • Emergency electrical
    • Kitchen and laundry
    • Housekeeping and maintenance

• Trainees may have the opportunity to observe operating systems on all three shifts.
• Trainees complete the attached observation checklist and comment sheets and return these to their program manager at the completion of the observation period.
• During observation, trainees will ask questions and be positive and unobtrusive.
• Trainees won't provide consultation services.
• Trainees will use this time to increase knowledge and awareness of the host facility's operations.

Coordination and Monitoring

• Each participating facility will designate a person to serve as liaison with the RS regional office.
• The 10-day observation experience will be coordinated and monitored by the facility liaison and the regional health, ICF or LSC program manager.
• On the first day a regional administrative staff member may accompany the trainee to the host facility and make introductions to the liaison.
• The participating facility will provide a general orientation of the facility on the first day of observation.
• The regional PM will be available for telephone consultation and on-site visits as needed.

Facility selection process

• Regional directors will select participating facilities.
• Selection criteria may include prior survey results, facility willingness and geographic location.

Objectives

At the completion of the ten-day long-term care experience, the new Regulatory Services (RS) surveyor will be able to:

For the Health RS Surveyor

1. Identify structures and systems commonly used to provide care to individuals in long-term care settings.
2. Identify challenges for care providers in the long-term care setting.
3. Identify several basic principles in the care of individuals in long-term care settings.
4. Identify processes and systems that are being utilized by a facility when negotiating facility operations versus a resident's individual choice.

For the Life Safety Code RS surveyor

1. Identify structures and systems commonly used to provide shelter to residents in long-term care settings.
2. Identify challenges for care providers relative to the physical plant and construction for long-term care facilities.
3. Identify basic principles in the housing of residents in long-term care facilities.
4. Differentiate between the building features choice for the different programs, i.e., nursing facility, assisted living facility, and intermediate care facility for individuals with an intellectual disability or related conditions.

Forms

• Form 5404, Facility Observation Program
• Form 5405, Life Safety Code Facility Observation Program
• Form 5406, Ten Day Facility Observation