Survey Process for Community-Based Care Facilities

Overview

ODHS conducts unannounced surveys at least once every 24 months in assisted living and residential care facilities. The survey process seeks to ensure a safe and secure environment to:

Enhance the residents' dignity, independence, individuality and decision-making ability; and
Allow residents to function at the highest levels possible.

What to expect

Entrance conference

The purpose of the entrance conference is to announce the survey, introduce the survey team and team coordinator, meet the facility staff, establish a daily communication plan and explain the survey process including:

Inquire about any recent changes in the facility.
Inform/remind the administrator of who is interviewed during the survey.
Provide the administrator with a copy of the entrance conference checklist, review each item and indicate what is needed and when.
If a licensure survey is being conducted, the facility will be asked to post survey announcement signage.
Ask for names of any residents in acute bereavement, who are on hospice, acutely ill or who might be agitated if approached by a surveyor.
Arrange for a group interview with resident council members or ask for a list of cognitively intact residents with good hearing abilities.

Tour of the environment, resident areas and kitchen/food service areas

Determines how the physical features of the facility, such as resident rooms, dining, activity and shower/bathing rooms, affect the residents' quality of life, health and safety.

Staff interviews regarding systems

Interviews with direct caregivers for all residents on the sample are used to learn about care and services, the capabilities of residents, what services are provided to the residents and their effectiveness and about recent changes or events in the residents' lives, cares, abilities or needs.

Medication and treatment administration review

Medications and treatments ordered are reviewed to ensure medications are prescribed by an authorized person and were provided by the facility and documented on the medication and/or treatment administration records.

Resident services review

This review is completed to verify evaluations and/or assessments and service plans reflect the resident's needs and preferences while supporting dignity, privacy, choice, individuality and independence.

Team decision-making

Survey Team members review findings and make preliminary decisions regarding citations.

Exit conference

The purpose of the exit conference is to discuss findings, explain what the findings mean and explain the report time frames.