STATE VETERANS HOME
Survey Process Updates
Nancy Quest
Office of Geriatrics and Extended Care
Patient Care Services
Department of Veterans Affairs
STATE VETERANS HOME
VHA Handbook 1145.01 ~ May 17, 2010
 Survey Procedures for State Veterans Homes
(SVH) Providing Nursing Home & Adult Day
Health Care
– Provides guidance to the field for
overseeing and processing annual,
recognition, and “for-cause” surveys of
SVH providing nursing home and adult
day health care
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STATE VETERANS HOME
Geriatrics & Extended Care (GEC) – VACO
 Provide oversight for clinical & survey program
 Manage SVH recognition survey process
 Manage the annual survey process
 Authorizes and manage “for cause” surveys
 Manage the national contract supported surveys
(i.e., Ascellon Corp contract)
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STATE VETERANS HOME
Veterans Integrated Service Network
(VISN) Director
 Administers the SVH program within the
VISN
 Appoints a SVH VISN Liaison
 Submits Issue Briefs
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STATE VETERANS HOME
SVH VISN Liaison
 Manages the SVH program with the VISN
 Notifies GEC VACO of sentinel / reportable
events at SVH
 Serves as the point of contact VACO, VAMC,
SVH
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STATE VETERANS HOME
VA Medical Center of Jurisdiction Director
 Field level official responsible for oversight of
the SVH program
 Appoints SVH VA Medical Center
Representative & Fiscal Surveyor
 Approves/disapproves survey reports and
corrective action plans
 Certifies compliance with VA standards
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STATE VETERANS HOME
SVH VA Medical Center Representative
 Manages the SVH program at field level
 Coordinates communication between SVH, VA
Medical Center Director, SVH VISN Liaison and
GEC VACO
 Serves as team co-lead during surveys
 Oversees the survey process
 Monitors and communicates reportable events
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STATE VETERANS HOME
VA Medical Center Fiscal Representative
 Communicates, collaborates and participates
with the VA Medical Center Representative in
all surveys
 Reviews fiscal standards during surveys
 Submits findings to VA Medical Center
Representative
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STATE VETERANS HOME
VA Survey Process
 Surveys are conducted to determine compliance
with VA standards
 Annual and For Cause surveys are unannounced
 Recognition survey is pre-arranged
 VA standards and VA ratings remain unchanged
 Survey teams are comprised of VA and contracted
surveyors
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STATE VETERANS HOME
Vision of the Survey Process
 Consistency of survey approaches
 Clear protocol - pre, during and post survey
 Smaller numbers of experienced surveyors
 Clear and objective statements of findings
 Consistency in dealing with findings
 Timely reporting to State Veterans Homes
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STATE VETERANS HOME
New Survey Process
 New contract-supported survey process
since November 2009
 Approximately 70+ annual surveys
 Approximately 5 recognition surveys
 Fewer than 10 ‘for cause’ surveys
 One formal appeal
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STATE VETERANS HOME
Year to Date Most Commonly Cited Deficiencies
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STATE VETERANS HOME
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Most Commonly Cited Deficiencies
Clinical records were incomplete or inaccurate
Physician orders were not followed
Lack of fall prevention measures
Thickened liquids were not provided as prescribed
or prepared incorrectly
Weekly fire pump tests not conducted
Facility in disrepair ~ holes, nicks & torn wall board,
chipped paint, scuffed doors, missing & detached
baseboards, rust in the shower room
Lack of direct supervision for cognitively impaired
residents who smoked
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STATE VETERANS HOME
Acceptable Corrective Action Plan
 Address how corrective action will be
accomplished for those residents found to
have been affected by the deficient practice;
 Address how the facility will identify other
residents having the potential to be affected
by the same deficient practice;
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STATE VETERANS HOME
 Address what measures will be put into
place or systemic changes made to ensure
that the deficient practice will not recur;
 Indicate how the facility plans to monitor its
performance to make sure that solutions are
sustained.
 Include dates when corrective action will be
completed.
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STATE VETERANS HOME
THANK YOU!!
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