Dates:

Site:

Observer:

Team Leader Team Member Team Member Team Member Team Member Team Member

Professional Behavior (personal observation)

Professional Interaction w/ SVH leaders, not aggressive, condescending, or leading Professional Interaction w/ SVH staff, not aggressive, condescending, or leading

Score

Score

Professional Attire Team is dressed in professional business clothing

Each team member is wearing a visible, official ID Badge at all times

Score

Infectious Disease Protocol

Did surveyors complete all necessary screenings if required by the SVH?

Did surveyors wear necessary PPE if required by the

SVH?

Did team ask about infectious disease status in facility, protocol used and community prevalence?

Was social distancing observed in conference rooms and out on units if appropriate?

Score

Exit Expectations

Team held a Final exit at appropriate time

Time of Exit Conference:

Allows staff to present additional documentation

No final ratings or scope and severity ratings given

Feedback link provided

Arrival Expectations

Entrance to SVH was done as a team, requested contact with Administrator, courtesy to SVH, held at proper time in the AM.

Time of arrival: 9:00am day 1

Introductions made to leadership

Clear explanation of survey process

Did Team lead or others inquire about access to EMR?

Pre work completed; survey report, Care Compare, QM, sentinel events

Daily Debriefs and exit conferences scheduled with SVH Leadership

FACILITY BASED SURVEY OBSERVATION RECORD

State Veterans Homes Survey Contract

Score Key:

0. Did not observe

Names

Criterion Data Definition Enter Notes for each Contract Surveyor on Team

Add another worksheet if you have more Team Members

Score

Reviewers have appropriately identified a quality of care/clinical concern based on the federal regulation requirements

Reviewers have appropriately identified a life safety concern based on the federal regulation requirements

Survey team reviewers were consultative in nature with SVH staff – answers questions, explains procedures/ process (if needed), transparent with areas of concern

Observations of Surveyor(s)

Privacy rules observed, with knocking, and dignity and respect by survey team reviewer Survey team reviewers introduced themselves and explained purpose in way can understand

Observations of Care Communicates with resident to inform them of why they are there

Was direct care observed by reviewers? (i.e. wound care, tube feedings, Cath care, etc.)

Survey team reviewer was non-intrusive during care observation

Requested and received permission from resident to observe care

Score

Resident / Family Individual Interviews (Observations)

Survey team reviewer does not use leading questions, listens to responses

Infection control practices observed if required

Privacy rules respected by survey team reviewer before session begins

Resident Council

Dynamics of survey team interviewer were positive, considerate to all attendees, listened, did not interrupt, asked clarifying questions, did not attempt to give immediate resolutions, controlled the session.

Questions are simple & clear, open ended, not complicated or too many questions to residents or family

Planned the session with SVH in advance Infection control practices observed if required

Ample time allotted for residents

Score

Serious Concern

Reviewer follows contractual protocols and requirements for notifications.

Survey team stays in facility until abatement plan accepted

Score

Team Conferences (survey team only)

Team conferences scheduled daily and attended by all reviewers

Each team member shares observations, findings and concerns with team

Survey vendor corporate office follows contractual

SVH Daily Debrief Conferences

Daily meetings with SVH leadership scheduled in advance and consideration given Reviewers answer questions and assist in request for references or regulations Reviewers establish a time to meet with their liaison the following day Survey team works together with SVH

Professional Interaction w/residents. Considers privacy and seeks permission in advance

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

TOTAL AVERAGE SCORE

Survey Determinations (Observations, Conversations)

Reviewers have appropriately identified an administrative concern based on the federal regulation requirements

Reviewers have appropriately identified a fiscal concern based on the federal regulation requirements

Reviewers have appropriately identified the correct regulation for the concern and rating

Reviewers have appropriately identified the correct scope and severity per each citation Reviewers interpreted the Federal Regulations correctly with VHA guidelines and made accurate assessments

Reviewers kept within the scope of their assigned role, regulations and comments

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