2005 Quality Improvement Plan Outline for Nursing Facility Survey Process

Update: July 2005


  • Expanded survey staff to include other disciplines: occupational therapist, physical therapist, additional occupational therapist or physical therapist and pharmacist to be added later.
  • Initiated ongoing monthly review by division management of survey data monthly reports, information communicated to program managers, supervisors and staff.


  • Facilitated meeting of supervisors addressed reducing variation in the survey process. Products include a general framework for conducting the survey process, including guidance for resolving survey issues consistently when internal structures do not adequately address or resolve survey questions, and a draft work plan.


  • Began joint training on pressure ulcers for providers, surveyors, and stakeholders

April – May

  • Conducted 10 additional workshops on pressure ulcers across the state


  • Provided Life Safety Code training for provider facilities staff


  • Quality Improvement Nurse Specialist joins staff
  • Produce a single work plan that incorporates recommendations from the Management Analysis Division report, the Office of the Legislative Auditor report, the LTC Ad Hoc Committee, the supervisor’s retreat and which includes a
  • Section on Quality Improvement in annual work plan


  • Conduct additional Life Safety Code training sessions for provider facilities staff
  • MDH Division management and all L & C supervisors participated in 360 review

September – October

  • Joint training for surveyors, providers, stakeholders, StratisHealth on urinary incontinence


  • Continue use of “mix/max” teams for surveying
  • Monthly review by supervisors of results of mix/max teams
  • Monthly review by supervisors (and subsequent sharing with staff) of average and mean numbers of deficiencies by team
  • Participation in LTC Ad Hoc Committee, professional and provider associations


  • Use results of 360 degree reviews for Individual Development Plan development for supervisors
  • Additional training initiatives; possible topics include Pain Assessment & Management, Nursing Assistant Awareness Program for Dental and Vision Care
  • Produce video on the role of all parties involved in the survey process, including the provider, surveyor, consumer, advocates, etc. in the survey process


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