Attachment C_Observation Record.pdf

Dates:

Site:

Observer:

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

Ample time alloted for residents

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

Resident / Family Individual

Interviews (Observations)

Observations of Care

Reviewer does not use leading questions, listens to responses

Privacy rules respected by reviewer before session begins

Reviewers introduced themselves and explained purpose in way can understand

Interacts with resident to inform them of why they are there

Asked permission from resident

Infection control practices observed

Privacy rules observed, with knocking, and dignity and respect by reviewer

Observations of Surveyor(s)

Score

Score

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

Reviewers have appropriately identified a quality of care concern based on the federal regulation requirement

Survey Determinations

(Observations, Conversations)

Non-intrusive during care

Score

Score

Exit Expectations Allows staff to present additional documentation

No final ratings or scope and severity ratings given

Team held a Final exit at appropriate time

Time of Exit Conference:

Reviewers establish a time to meet with their liaison the following day

Professional Attire

Professional Behavior

(personal observation)

Team Conferences

(survey team only)

SVH Daily Conferences

Resident Council

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

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

Reviewers have appropriately identified the correct scope and severity per each citation

TOTAL AVERAGE SCORE

Reviewers interpreted the Federal Regulations correctly within VHA guidelines and made accurate assessments during survey process

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

Reviewers followed contract when identifying a possible serious concern

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

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

Consultative in nature – answers questions, explains procedures/ process (if needed), transparent with areas of concern

COVID Protocol

Score

Score

Score

Score

Score

Serious Concern

FACILITY BASED SURVEY OBSERVATION RECORD

State Veterans Homes Survey Contract

Enter Notes for each Contract Surveyor on Team and then overall score

Names

Data Definition

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

Arrival Expectations

Introductions made to leadership

Clear explanation of survey process

Did Team lead or others inquire about access to EMR?

Score Key:

4. Conforms to contract requirements

3. Minor nonconformance

2. Does not conform but can be made to conform

1. Does not conform and cannot be made to conform

0. Did not observe

Criterion

Daily Debriefs and exit conferences scheduled with SVH

Leadership

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

Time of arrival: 9:00am day 1

Did surveyors complete all necessary COVID screenings?

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

Did surveyors wear necessary PPE?

Team is dressed in professional business clothing

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

Did team ask about COVID status in facility, Protocol used and community prevalence?

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

Reviewers answer questions and assist in request for references or regulations

Infection control practices observed

Dynamics of 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

Survey team stays in facility until abatement plan accepted

Score

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

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

Team conferences scheduled daily and attended by all reviewers

Each team member shares observations, findings and concerns with team

Daily meetings with SVH leadership scheduled in advance and consideration given

Survey team works together with SVH

Reviewer follows contract protocols of notifications

Feedback link provided

Planned the session with SVH in advance

Add another worksheet if you have more Team Members