The NY State Health Department team arrived on October 19th. Of course un-announced as always, but the unusual thing this year was it was on a Monday. In the past, the team would get all their paperwork together on Mondays and then visit a facility on Tuesday. They came with all the paperwork needed on a Monday! I think the process is becoming better organized.
Four Health Department people were on the team, an RN Team Leader, a Sanitarian, a Social Worker and another Nurse. They come prepared with a list of resident records they want to review for their sample. These were chosen from information in their office files. For example, we submit detailed patient care reports called MDS's on all residents at multiple times during their stay. These reports are used to profile the care residents are receiving. These reports plus any complaint reports plus any items from their previous surveys they want to follow up on make up the initial sample residents and files to look at. While doing this they also make observations on their unit tours and during observations of medication passes and meal times. In addition, they review the environment, life safety, kitchen, and quality assurance assurance efforts of the facility. To top this off and as a very important part of the survey process, they interview resident's families and meet with the Resident Council.
Wow !! What a lot of work to accomplish! They stayed through Wednesday October 21st and left after an "Exit Conference" Overall I feel the survey was very resident focused and the issues brought to our attention were valid and relatively minor. We will not know exactly what our deficiencies will be until their final report which should arrive sometime this month.
When this "SOD" (Statement of Deficiencies) arrives we will respond with our "Plan of Correction". This plan addresses exactly what we are going to do about any findings they may have had. The next step is their review of our response. This could include a follow-up survey or a desk review of our response. We should know by December how the response was accepted.
A final Statement as to our being in "compliance" is then issued.
Please note that by NY State law, the State Survey results are always posted publicly for anyone to review at any time. The on-line postings always lag somewhat because of the lengthy process as above.
