Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help

Self-Assessment/Mock Survey
Today, more than ever, nursing facilities must be prepared to demonstrate compliance with federal regulations
not only at survey time, but all year long. Survey teams can arrive at facilities as soon as nine months after the
last annual survey. They can appear at any time to conduct complaint investigation surveys. And, these days,
they are likely to begin surveys at nontraditional times and on weekends. These changes in the frequencies,
times and types of surveys make it imperative that facilities be prepared at all times.
Nevertheless, with rapidly increasing turnover rates for nursing staff and managers, facility staff might not be
familiar with surveyors' procedures, care observations, interviews, and record reviews and could be unprepared
to meet these challenges.
To adequately prepare staff to succeed at survey time, and to ensure that the facility complies with regulations
at all times, periodic self-assessments or mock surveys can be an important feature of a facility's quality
assurance process. A mock survey can be performed by facility staff, by corporate advisors or by outside
consultants. In whatever manner your facility chooses to provide these services, there are a few guidelines to
bear in mind.
1. Enlist "fresh eyes" to see existing problems clearly. Be sure to include new employees, an "outsider" or other
mock surveyors who are not overly familiar with the facility's staff and residents. If using facility staff, ask
them to review areas outside their direct span of control.
2. Replicate "real" survey procedures as faithfully as possible. Use precise observation methods, select a sample
of residents according to survey guidelines and interview the same staff that real surveyors are likely to
interview.
The following pages include a variety of tools for you to use for your own self-assessment—use all or some of
them. Remember, if you find any deficient practices be sure you bring it to your Quality Assurance Meetings,
document your findings, and come up with a workable plan to correct the problem.
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