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Does the Survey Process Enhance or Detract From Quality of Care?

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January 04, 2021

ilene warner-maron, phdIn an editorial published in the Journal of the American Medical Directors Association, authors highlighted the issues from the first COVID-19 cases in Kirkland, WA, in which Life Care Centers were cited with an “Immediate Jeopardy” and fined in excess of $600,000. These citations involved the failure to have an alternative emergency plan in place, as well as an effective infection control plan.  As we look back ten months, we now understand that 1% of Americans reside in long-term care facilities, however, 38% of the deaths have occurred in nursing home residents.  Clearly, this virus has challenged all of us to reconsider the manner in which we complete emergency disaster planning, as well as provide effective infection control practices with sufficient PPE. 

This editorial raises additional issues regarding whether the standard nursing home survey process is able to identify quality of care or if the survey itself contributes to decreased performance outcomes.  Twelve recommendations were offered by the AMDA task force to address survey-associated issues including the need for specific research to determine the relationship between compliance with regulation and the facility’s quality of care. Further research is also needed to determine how the survey process itself may negatively impact facility practices as well as staff turnover.  Identifying and addressing surveyor bias as well as the variability among field offices and state survey practices; the funneling of Civil Monetary Penalties (CMPs) back into the operation specifically to improve functions or oversight rather than draining necessary funds away from cash-strapped facilities; engaging experts in geriatrics and quality processes to reshape the manner in which facilities are surveyed and finding methods to improve compliance using positive motivators may be more valuable than the current inspection processes and penalties.

Facilities are expected to answer their 2567’s by the use of audits and in-services.  For example, deficient practices in medication errors usually includes the auditing of a certain percentage of charts and the in-service education of nurses in an area of medication administration.  The issue at the heart of the citation, however, is usually a process issue that requires a root cause analysis to be performed to uncover the cause of the issue.  As a result of a focus on audits and in-services, the root cause of the deficient practice is not identified, and cycle repeats itself again and again.

The editors argue that the COVID-19 crisis is the right time for us to rethink, rework and revise the way that surveys are performed.  Their article serves as a wake-up call to the industry.

Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, is an assistant professor in the Department of Geriatrics and Palliative Medicine at the Philadelphia College of Osteopathic Medicine. Dr Warner-Maron is also the executive director of the Eastern Pennsylvania Geriatric Society. 


Nazir A, Steinberg K, Wasserman M, Horowitz AC, Lett JE 2nd. Time for an Upgrade in the Nursing Home Survey Process: A Position Statement From the Society for Post-Acute and Long-Term Care Medicine. J Am Med Dir Assoc. 2020;21(12):1818-1820. doi:10.1016/j.jamda.2020.09.022

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