Survey is over! Now what?

What to expect during a survey by NMDOH

Let’s face it- inspection time is extremely stressful! No matter how much you have prepared or how long you have been in the “industry” when an inspector shows up to your community it can be a nerve-wracking experience. In New Mexico, the Department of Health can show up anytime they see fit to conduct an inspection of every nook and cranny of the facility. Be prepared, be cordial and be open with inspectors and you will certainly have a much better experience. Check out the following regulation for what to expect during the inspection process:

7.8.2.11                 SURVEY OR MONITORING VISITS:

  1. The licensing authority shall perform on-site survey or monitoring visits at all assisted living facilities to determine compliance with this rule.
  2. The facility shall provide the licensing authority full access to all facility operations, buildings and information related to the operation of the facility.
  3. The most recent survey inspection reports and related correspondence shall be posted in a conspicuous public place in the facility.
  4. Failure by the facility to provide the licensing authority access to the premises or information, including resident records, may result in the imposition of sanctions including but not limited to civil monetary penalties, license revocation or an order to cease and desist, as deemed appropriate by the licensing authority.

[7.8.2.11 NMAC – Rp, 7.8.2.11 NMAC, 1/15/2010]

 

7.8.2.12                 CORRECTIVE ACTION:  If violations of this rule are cited, the facility will be provided with an official statement of deficiencies within ten (10) business days following the survey.

  1. Informal dispute review (IDR).  The facility may request an informal review of survey deficiencies by providing a written request to the licensing authority within ten (10) calendar days of receipt of the written survey findings.  With the request, the facility shall include information or evidence that justifies the disagreement with a cited deficiency.

(1)           The licensing authority will review the submitted information and make a determination.

(2)           If the deficiency is removed, a new statement of deficiencies will be issued to the facility.

(3)           The facility shall provide a new plan of correction for all remaining deficiencies upon receipt of the new statement of deficiencies.

(4)           A copy of the “IDR operating rules” is available upon request.

  1. Plan of correction (POC).  The facility shall submit a plan of correction within ten (10) calendar days of receipt of the statement of deficiencies and after receipt of a revised statement of deficiencies, when the findings are changed pursuant to an IDR.

(1)           If the first plan of correction (POC) is rejected by the licensing authority, the facility will be sent a second (2nd) copy of the statement of deficiencies.  The facility shall complete and return the second copy of the statement of deficiencies with an acceptable plan of correction within three business days.  The process will repeat until an acceptable plan of correction is received by the department.

(2)           Failure to provide an acceptable plan of correction (POC) within a reasonable period of time, may lead to civil monetary penalties or other sanctions.

(3)           The plan of correction shall:

(a)           address how all violations identified in the official statement of deficiencies will be corrected;

(b)           address how the facility will monitor the corrective action and ensure ongoing compliance; and

(c)           specify the date that the corrective action will be completed.

(4)           All cited violations shall be corrected within thirty (30) calendar days from the date of the survey; unless the licensing authority approves an extended date.

(5)           Failure to submit an acceptable plan of correction may result in sanctions, including but not limited to civil monetary penalties, suspension or non-renewal of the facility license.

(6)           The licensing authority may accept, reject, or direct the plan of correction.

Top Takeaway:

  • Plan of correction (POC).The facility shall submit a plan of correction within ten (10) calendar days of receipt of the statement of deficiencies and after receipt of a revised statement of deficiencies, when the findings are changed pursuant to an IDR.

When you are tagged with any violations you are required to submit a plan to correct the issues at hand. You will need to include the measures you used to immediately correct the deficiencies as well as the stop measures you plan to put in place to avoid future transgressions.

 

Pro Tip:

  • Work with the surveyor and their teams needs
  • Be professional and try to develop a rapport with the surveyor
  • Be honest
  • Use their feedback to make needed changes to your facility

 

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