Proactive is better than reactive.
Nothing brings out anxiety in long-term care settings more than state survey inspections. In my state of Massachusetts, a team of inspectors evaluates nursing homes twice a year. Although these surveys are unannounced, administrators at most homes are aware when their facility is “in the window” for a visit.
These inspections can last from three days to a week. Inspectors review a number of areas to evaluate quality of care delivered and, in their final reports, may cite areas found to be deficient. When deficiencies occur, nursing home personnel are required to submit a corrective plan of action. If gross neglect is found, fines may be assessed and payments withheld, although this is extremely rare. Surveys can be quite helpful, as they acknowledge good work being done and provide an opportunity to correct areas that need improvement.
If you work in a long-term care setting, how does your facility respond during these surveys? I have seen nursing administrators respond calmly when reviewers point out areas of concern, and I have also witnessed the opposite reaction. Those who overreact do so because they view every concern as a sure citation. Surveyors, however, bring up numerous issues, many of which never surface in the final report. When nursing home personnel discuss concerns that surveyors raise in an honest and direct way, these items often turn out to be non-issues.
A consultant psychiatrist is asked to see a patient who seems depressed, although insurance authorization for the consult has not yet been obtained. He will not be back for a week, so staff members want to make sure he sees the patient, who has agreed to talk to him. The psychiatrist determines that, yes, the patient is depressed and writes a note suggesting an antidepressant. He doesn’t bill for this service because insurance authorization hasn’t been obtained yet. He views this as a courtesy visit.
Two days later, a surveyor who has begun an audit notices that there was no release authorizing the psychiatrist to see this patient, and the psychiatrist is surprised when the nursing home administrator, who is relatively new to that facility, calls him and accuses him of seeing a patient without authorization and committing “fraud.” In response, the psychiatrist points out the facts: He was given the patient as a referral by staff members, the patient verbally consented to speak to him, and he didn’t bill for the consult. He regards his action as being helpful—seeing a depressed patient who, because insurance authorization had not yet been secured, would otherwise have had to wait another week for the consult. To help resolve the administrator’s concern, he offers to speak to the reviewer.
But the administrator, supported by her corporate adviser, isn’t listening. In panic mode, they decline the psychiatrist’s offer to speak with the reviewer. “It’ll just make things worse!” they say. Instead, they tell medical records personnel to go back and check every consult the psychiatrist has seen who needed prior authorization and also to check the records for every patient he has seen, to make sure there was a registration form authorizing each visit.
When he accepted his position as consulting psychiatrist, the agreement was that nursing would get all of the doctor’s orders and would get registration forms signed. Because of high staff turnover, they often failed to do this, however, so the psychiatrist, trying to be helpful, would get the registration forms signed. The survey revealed that a few forms are missing. Moreover, the social worker, who normally stores copies of the notes and registration forms, resigned a few weeks earlier, so the documents cannot be located. The administrator and corporate adviser are now convinced they will be tagged.
The doctor again offers to talk to the reviewers and even suggests a corrective action plan if it turns out the facility is in noncompliance, knowing from previous surveys that providing a plan of correction to surveyors during the survey process will often resolve an issue and avoid “tagging.” His suggestion is rather simple: Include the psychiatric registration form in the admission packet so that it is signed upon admission and have the nurse confirm that, before the referral is written in the book, there is a doctor’s order and signed form.
Members of the nursing home’s administrative staff disagree and decide on a different plan of correction. They will change psych services. Even though the psychiatrist has been there five years and has a good relationship with clinical staff, patients, and their families, he is regarded as the source of the “deficiency,” so he is notified that his services are no longer needed.
What if …
A few weeks later, the official report comes back and, indeed, the facility is tagged. Changing psych services, the report states, does not address the issue. What is the acceptable action? The one the psychiatrist proposed, which included getting authorization prior to referral.
We cannot know if the doctor’s offer of talking to the reviewer would have avoided the tagging, but a lot of extra work and anxiety by medical records personnel, nursing staff, and others could have been avoided had the issue been addressed early, at the time of the survey. After all, the corrective action is still the same, but with the loss of a caring and involved psychiatrist!
Michael C. LaFerney,PhD, RN, PMHCNS-BC, is a psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA.