What to expect during an inspection
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 Jersey, 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:
- 8:36-2.4 Surveys
(a) When the written application for licensure is approved and the building is ready for occupancy, a survey of the facility by representatives of the Assisted Living Assessment and Survey Program of the Department shall be conducted to determine if the facility adheres to the provisions of this chapter.
- The facility shall be notified in writing of the findings of the survey, including any deficiencies found.
- The facility shall notify the Assisted Living Assessment and Survey Program of the Department when the deficiencies, if any, have been corrected, and the Assisted Living Assessment and Survey Program shall schedule one or more resurveys of the facility prior to occupancy.
(b) A license shall be issued to a facility when the following conditions are met:
- A preliminary conference to review the conditions for licensure (see N.J.A.C. 8:36-2.2(d)1 through 8) and operation has taken place between the Long-Term Care Licensing Program and representatives of the facility, who will be advised that the purpose of the conference is to allow the Department to determine the facility’s compliance with N.J.S.A. 26:2H-1 et seq., and amendments thereto, and the rules pursuant thereto;
- The initial survey required by N.J.A.C. 8:36-2.4(a) results in a finding of substantial compliance with the requirements of this chapter;
- The completed licensure application is on file with the Department;
- The fee for filing of the application has been received by the Department;
- A copy of the admission agreement is on file with the Department;
- The applicant has submitted approvals from the local zoning, fire, health, and building authorities, and a copy of the certificate of occupancy or a certificate of continued occupancy that has been issued by the appropriate local authority, to the Long-Term Care Licensing Program of the Department;
- Written approvals of the water supply and sewage disposal system from local officials are on file with the Department for any water supply or sewage disposal system not connected to an approved municipal system; and
- Personnel are employed in accordance with the staffing requirements in this chapter.
(c) No facility shall admit residents to the facility until the facility has the written approval and/or license issued by the Long-Term Care Licensing Program of the Department. Violators of this requirement shall be subject to penalties for operating a facility without a license, pursuant to N.J.S.A. 26:2H-14 and N.J.A.C. 8:43E-1.
(d) Survey visits may be made to a facility at any time by authorized staff of the Department. Such visits may include, but not be limited to, the review of all facility documents and resident records and conferences with residents.
- (d) Survey visits may be made to a facility at any time by authorized staff of the Department. Such visits may include, but not be limited to, the review of all facility documents and resident records and conferences with residents.
The language in this regulation essentially provides the director with the ability to inspector any ALF at their discretion in addition to the required biennial survey. You need to do all things in your power to avoid being on the frequent visit list.
- 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