110 Pre-Survey Information

Policy

The Long-Term Care Ombudsman Program provides appropriate information to Healthcare Facility Regulation (HFR) in order to assist in the planning of standard surveys for nursing facilities.

Procedures

  1. SLTCO role

    1. The SLTCO shall exercise every prudent means of protecting the confidentiality of the survey schedule and shall not disclose the scheduled date of any survey to anyone outside of the LTCOP nor to any volunteer in the LTCOP unless the volunteer is certified.

    2. The SLTCO shall immediately notify HFR of any known allegations that any individual associated with the LTCOP has in any way given prior notification to a facility of a survey date.

  2. LTCOP role

    1. The LTCOP shall provide pre-survey information in a timely manner to the SLTCO for use by HFR for every nursing home survey for which the LTCOP is informed.

    2. All ORs and volunteers shall exercise every prudent means of protecting the confidentiality of the survey schedule and shall not disclose the scheduled date of any survey to anyone outside of the LTCOP.

    3. All ORs and volunteers shall exercise caution, especially during telephone calls, facility visits, and conversations which might lead to sharing schedule-related information.

  3. Protocol for Providing Pre-Survey Information to HFR

    1. The SLTCO shall receive survey schedules from the HFR and, by the end of the next working day, notify the ORCs that the survey schedules have been received for the following month.

    2. The LTCOP Coordinator shall obtain the schedule from the SLTCO promptly after notification that survey schedules are available, and in no case later than the 25th day of the month prior to the survey schedule.

    3. The SLTCO shall provide information about scheduled surveys only to the ORCs and those certified ORs who need the information in order to compile information for HFR.

    4. Information about survey schedules shall:

      1. Not be taken into facilities.

      2. Be filed and stored out of sight, not exposed on desktops.

      3. Be removed from view when unauthorized persons visit.

      4. Be delivered to authorized persons in person or in a protected manner.

      5. Not be stored in labeled folders on desktops, work tables, bookcases, or unsecured files.

    5. The ORC shall coordinate the completion of pre-survey reports within the LTCOP and share information about scheduled surveys only with those certified Ombudsmen Representatives who need the information to compile information about the facility for HFR.

    6. The LTCOP shall provide the SLTCO with information, in a format approved by HFR and the SLTCO, by uploading a pre-survey report into OmbudsManager under Activity Type “Pre-Survey Report Submitted to OSLTCO for HFR” and notifying the SLTCO of the activity entered by referencing only the Activity Code ID Number. No indication of the date of the survey shall be on any correspondence.

    7. In order to be timely, pre-survey information must be submitted to the SLTCO on or before the Tuesday of the week prior to the scheduled survey unless otherwise instructed by the SLTCO.

    8. Each Wednesday, the SLTCO shall deliver pre-survey information to HFR, unless otherwise instructed by HFR.

    9. ORs may share additional, appropriate information with HFR surveyors as requested.

    10. ORs may participate in exit conferences at the end of HFR surveys.

    11. ORs may request the opportunity to observe the survey process at a particular facility by making the request of the appropriate HFR Regional Director. Granting such opportunity shall be at the discretion of HFR.

ORs are encouraged to observe a survey at a facility not regularly visited by the OR. This will enable the OR to observe the survey without confusing residents or facility staff about the purpose of the OR’s presence in the facility.