1. Adult Day Care Chapter 605 Survey Process OSDH

2. Introduction  Adult Day Care Facilities/Centers are required to be in compliance with laws established by Title 63 of the Oklahoma Statutes Section 1-870 et seq.

3. Survey Process  Objectives of the survey protocol and process include the following :  To provide guidance that define procedures and direct surveyor performance.  To provide consistent approaches for completing survey tasks and standardizing the survey process; and  To provide consistent approaches for analyzing and determining noncompliance with the Rules and Act (deficiency criteria).

4.  The survey protocol and process in composed of nine tasks. It is a resident centered outcome oriented survey which relies on a stratified case-mix sample of participants to gather information about the facility’s compliance with state licensure requirements.

5. TASK 1 OFFSITE SURVEY PREPARATION  The purpose of this task is to gather specific information to determine facility/center characteristics and compliance history;  Surveyors complete an Offsite worksheet that contains the following information:  Previous compliance history  Incident and accident reports  Complaint investigation reports  Participant capacity.

6. Task 2 Entrance Conference  The purpose of this task is to let you know who the surveyor is and that they will be conducting a survey at your center.  They will also explain the survey process and answer any questions you may have.  They will ask you to inform the participants and staff that they will be conducting interviews with them privately.

7. Task 3 Initial Tour  The purpose of this task is to make preliminary observations of the physical plant and the participants currently in the center.  They will observe participants receiving care and attending activities if there are activities being provided at that time.  They will use the information to select a sample of participants for Task 4.

8. Task 4 Sample Selection  The purpose of this task is to select a sample that reflects the overall population of the facility/center. In selecting this sample we consider:  New admissions  Physical Disabilities  Special Diets  Self-Administration of Medications  Census

9.  Participants receiving nursing interventions/special treatments  Closed records  Physical restraints,  If concerns are identified based on the center’s noncompliance history reports, pre- survey file reviews, complaints or initial tour observations, participants may be added to the sample as needed at any time during the survey.

10. Task 5 Medication Administration  The purpose of this task is to determine if your center has adopted written policies and procedures to ensure safe- administration of medications to participants, accountability of medications, proper handling, storage and safe disposal of all medications.  The surveyor will observe random observations of participants receiving medications if applicable to determine: 1. If the staff are confirming the participants identity prior to administration. 2. Whether the staff are documenting the administration or refusal of medication after attempting to administer.

11. Task 6 Information Gathering  This is the task where the surveyors determine compliance with regulatory requirements based on observation, record reviews and interviews.  During this task, the surveyor(s) will make observations, complete resident review records and conduct interviews with team members, staff, residents and family members to determine compliance with regulatory requirements.  The surveyors will maintain an open dialogue throughout the survey process.

12. Task 7 Team Analysis and Decision Making  The purpose of this task is to review and analyze all information collected and to determine whether or not the center has failed to meet one or more of the regulatory requirements.  Deficiency determination is a team decision with each member of the team having input. The team may consist of one or more than one surveyors.

13. Task 8 Exit Conference  The purpose of this task is to inform the center of the survey team’s observations and preliminary findings.  The surveyor/team will provide the center with a list of the participants that were sampled and explain that the participants will be referenced by number rather than name to protect the resident’s privacy.

14.  The surveyor/team will describe the deficient practice that has been identified.  The center will, during this task, provide the center with the opportunity to discuss and supply additional information they believe is pertinent to the identified findings.  There should be no instances where the home is not aware of surveyor concerns due to the open dialogue that will be maintained.

15.  At the end of the exit conference, the surveyor will explain that you will receive a written statement of deficiencies and will need to prepare a plan of correction describing how the deficient practice will be corrected.

16. Task 9 Documentation of Deficiencies  The purpose of this task is to write the statement of deficiencies in terms specific enough to allow a person to understand the requirement(s) that the center failed to meet.

17. Top Deficiencies  The top deficiencies cited in the past year include:  0610-Staffing Requirements (related to tuberculin skin testing for staff).  0718-Required Services (related to Chapter 257 Food Code Regulations).

18.  0501-Admission (related to participants current medical information).  0503-Admission (related to participants plan of care).  0608-Required Services (related to requirement to have qualified staff to administer medications with nursing oversite).

19.  0723-Required Services (related to posting current menus in a prominent area for viewing).  0502-Admission (related to participants medical report to include activity and restrictions, therapies and medications).  0749-Additional Services (related to all medications administered must have a physician’s order).

20.  0735-Required Services (related to requirement to have at least one direct care staff person on duty at all times who is trained in CPR).

21. QUESTIONS  Thank you and if you have additional questions please contact:  Debbie Zamarripa  405-271-6868 ext 57935  Or Lisa McAlister  405-271-6868 ext 57922