Survey & Licensing

Going through survey and licensing is one of the most stressful parts of this field. Having strangers inspect your facility, observe everything the staff does, asking questions, and reviewing charts can be enough to make a grown professional cry out in frustration.

After all, both you and your team’s hard work over the past year is up for criticism. But, the more refined your facility the easier it is to find problems or concerns. When your charts, documentation, and data sheets are straightforward and easy to follow licensing is more likely to pin point areas of imperfection. However, this is not to say that your charts should be unorganized, or your data sheets hard to read, or the monthlies difficult to decipher. Appearing unorganized is how you will wind up with citations instead of just a few minor deficiencies. The same is true for housekeeping, staff interactions, and general active treatment.

Meeting the basic conditions of participation and avoiding citations is simple as long as you are familiar with the regulations. Unfortunately, many facility owners have never even glanced at them. Owners who are not actively involved in the programming aspect of the facility may find it difficult to understand that a condition regarding a physical plant can close them down as fast as a condition regarding client protections, active treatment or nursing. Getting a facility through licensing takes cooperation from everyone, including the owners, licensee, RN, QIDP, consultants, doctors, schools, day programs and most importantly the direct care staff. If you have all this, that’s great! If not, be prepared to add more to see that all the conditions will be met.

There are only so many conditions that licensing can throw out at one time, but there are a multitude of areas they can use to combine to produce a condition as out of compliance. There are many, many details involved in providing appropriate housing, care, and programming for the clients.

I have experienced first hand, and heard the horror stories from others about the many challenges faced with licensing. This whole process is much more manageable if some basic principles are followed. First, is staff training--if the direct care staff do well with general care, interactions and active treatment, the surveyor will not look so hard for other problems. Second, if the facility is well maintained they won’t care if it isn’t pretty. Third, if the charts can at least be read and followed easily (meaning they can find the information needed for their reports) they will leave sooner and ask fewer questions. I feel it’s better to receive a book of minor deviancies which are easy to fix, as long as there are no conditions or citations. It is highly recommended that these main areas be addressed before licensing knocks at your door. Most importantly remember “Repeated issues can result in a condition out” and “Just because they didn’t catch a problem on your past surveys doesn’t mean an issue will not come up on the next one”.