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What a surprise, Tuesday morning the Dept. of Justice arrived to conduct a 6-8 hour survey. It is a first for us, and we were surprised that such a survey existed. It is a general survey and not an investigation. There were a few minor issues that will be easily addressed. They held their exit at 11:45 that morning, so their survey didn’t quite last a whole 6 hours. As the Dept of Justice surveyors were walking out of the door Licensing walked in to do their survey. We were floored!!! Licensing conducted two surveys this week, one was for Title II and the second was Fed. They conducted the Fed survey first, followed by title II.


Licensing held their exit at 11:40 today. The exit, again, consisted of two separate reports, the first Title II, the second Fed. They said that we would be receiving two separate 2567’s one for each survey.

There were no issues with activities. Praise God, there were no issues with Activities during all three surveys.


On their second day, following the Resident Council meeting, a surveyor met with me. She began by saying, “By the way the residents love you.” (That credit goes to my staff!!!)


We talked for a while about my younger residents and my concerns about them. I brought the subject up and addressed my concerns for each and talked about what I am working on with them and the outcomes that I hope for each. Since admission one resident is the local American Legions Auxiliary Chaplin and is a member of the hospital’s auxiliary and works in the gift shop. Members of those organizations come to take this resident to their meetings. Another is now on the County Transportation Department’s Advisory Committee, and is transported to those meetings via the city transportation van. Two residents call the city transportation van and go out to eat, shopping, etc on their own. A third is a photographer and we have this resident critiquing our dept photos, very educational for myself and my staff.


The surveyor asked for six months of my staff’s work schedules and for my certification. She also asked if there was any reason that mail would not be delivered on Saturdays. I told her that the only reason that residents would not receive mail would be if there was no mail to receive.


The next day I was asked to show a surveyor my supplies. We went to the supply closet and I showed her my sensory stimulation shelf that contains plastic shoe boxes, each with a theme name written on the outside, and inside the boxes are items to stimulate the senses according to the theme (Hawaii, school days, berry picking, gardening, western, southwestern, and a shopping bag with artificial groceries etc.) These theme boxes can also be use to cue reminiscence. I showed her my art therapy kit, physical games, Nintendo WII, Therapeutic Music and videos, cognitive supplies, table games, crafts, etc. I explained that I also kept supplies in our library for the staff to use when Activity staff is not available, and showed her our room to room cart.


While looking at the activity supplies she asked about a resident who is semi comatose and wanted to know what we are doing with that resident. She also asked if we have computers for the residents to use. I told her that we have two and that one resident has their own. I talked about how we are encouraging this resident to start using Netflix. She said that she thought that was a great idea. The surveyor commented that we were doing a good job.

She complemented us on having facility pets and talked about “community living” and how much emphasis is now on that. She told me about the buffet dining that is being done in several facilities to promote, “community living.”

The surveyor then said, “by the way I love your care plans. They are easy to read and follow. I can read right down the care plan and know exactly what you are doing.” I was blown away at that point. Last year, with the new regs, I changed my style of writing care plans and have been soooooo terrified that the new style would not fly with licensing.

Finally one of the surveyors asked me the standard FSD questions. What do you do during a fire? What is the code for a fire? How to you use a fire extinguisher? What do you do during an earthquake? And this one surprised me, “What do you do after the earthquake stops?” (answer: search for victims and begin assisting them)


We are waiting on another survey to become a critical access hospital. This survey should take place within the next few weeks. eeeeek


It has been a heck of a week but a good one.

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