Using an eHR for daily management of resident care helps you stay ready for state assessments and avoid the tedious work of “getting ready” for your assisted living community’s survey. But you’ll still want to give some thought to policies and protocol when you use an eHR to manage care in your assisted living communities.
Here are some tips for using an eHR effectively to support the state survey process:
Define Your Data Policy
It’s important to explicitly define what constitutes the “residents’ chart” for your company well before a survey starts. For example, ALIS allows caregivers and clinicians to record different types of Observations, not all of which are within a surveyor’s purview because of their nature as internal work product. In these cases, make it a practice to explicitly state what types of data are part of the chart and what are not. Another example is related to incidents. Your community may track some “incidents” purely for informational and training purposes while others may need to be reported to a State agency. A strong policy will help staff properly navigate their duties for both types of data.
Document Your Process
Once you have a defined data policy, it’s critical to define your survey process. Your process should define your organization’s standard response when a state survey is conducted and include answers to questions like:
- Who should be notified when a surveyor arrives?
- Who will support the surveyor and provide any information needed to support the assessment?
- If you choose to allow them access to the eHR system, how should they be added and with what role?
- Where should the surveyor work and with what computer (if applicable)?
- If you are printing forms for a state surveyor’s review, which reports should be used?
- What information is available to surveyors and what is not?
- What support is available from your software vendor during the survey process?
Gather Your Data
Whether you’re printing or helping a surveyor navigate to the information in your electronic records, make sure all the relevant team members across your communities know how to access the necessary data quickly.
Be prepared to provide:
- Nurses Notes or Observations
- Physician Orders
- DNR status
- Face sheets
- Vital signs
- Service Plans
- Care Plans
- Incident Records
NOTE: ALIS provides easy access to print resident records in bulk and our customers enjoy unlimited support.
After your successful state survey, track compliance activities on an ongoing basis.
As they say, if you stay ready, you don’t have to spend so much time to get ready.