DCSIMG

An Overview of Residential Surveys

An Introduction to Residential Surveys

Residential Surveys:

A residential survey is an evaluation of a residential facility to determine the facility’s compliance with state rules. The survey evaluates the faciilty on such areas as nursing services, medical staff, dietary services, infection control, medical records, governing board, quality assessment and improvement, medical services, and physical environment.

Pursuant to Indiana Code 16-21, residential facilities must be licensed. The Indiana State Department of Health is the licensing authority and has adopted rules for the operation of residential facilities. The state rules may be found at 410 Indiana Administrative Code 15. Residential facilities surveys evaluate the facility for compliance with these rules.


Surveyors:

Surveys of Indiana residential facilities are conducted by public health nurse surveyors and medical surveyors from the Indiana State Department of Health (ISDH) Division of Long Term Care. A majority of the surveyors are registered nurses. Surveyors are experienced medical professionals and receive extensive training in residential facilities rules. Every surveyor is required to complete a CMS training program. Surveyors receive additional training throughout the year on the latest medical advances and updates to rules.


The Survey Process:

The survey process varies depending on the type of survey. Surveys may take only a few hours or last a week. Most all surveys are unannounced. Surveys generally include surveyor visits to the licensed residential facility operated under the license. During a survey, ISDH surveyors will tour the facility, interview staff, and review patient records and other documents to determine compliance with state rules.

At the conclusion of the survey, surveyors prepare a report of their findings. The survey report lists and describes all violations of state rules.

If deficiencies are cited on a survey, the facility may be requested to complete a plan of correction on how and when they will achieve compliance with each deficiency and who will be responsible to ensure the corrections are made and will not reoccur in the future. The facility submits the plan of correction to the ISDH within fifteen (15) days of the issuance of the survey report. The ISDH reviews and approves the plan of correction.


Types of Surveys:

There are numerous types of residential facility surveys. These include:
• state licensure surveys
• state and federal complaint surveys
• post-survey revisit surveys
• preoccupancy surveys
• initial surveys
• life safety code survey

The following is a brief description of a few of the common residential facility surveys.


State Licensure Surveys

Indiana Code 16-21 requires that every Indiana residential facility be licensed. The Indiana State Department of Health (ISDH) is designated as the licensing authority. The ISDH conducts a state licensure survey at each licensed residential facility approximately once per year.

The licensure survey is a comprehensive review of the residential facility and the facility’s compliance with state rules (410 Indiana Administrative Code 15). State licensure surveys are conducted by a team of ISDH surveyors. The survey is unannounced. A state licensure survey is usually completed in one to four days. The survey includes surveyor visits to the licensed residential facility.  During a licensure survey, ISDH surveyors will tour the residential facility, interview staff, and review patient records and other documents to determine compliance with state rules.


Federal and State Complaint Surveys

Any person may file a complaint with the ISDH about a residential facility. The ISDH investigates all complaints. Complaints may be filed in person at the ISDH, in writing, by telephone, or by email. The toll-free complaint number is 1-800-246-8909. Instructions for submitting a complaint by email are found in the ISDH Regulatory Services Web site under “contact us.” Complaints are prioritized and scheduled for investigation based on their potential to place the health and safety of patients at risk. Complainants are informed (except anonymous complainants) upon receipt of the complaint by the surveyor and at closure of the complaint of the findings of the investigation.

A complaint survey is a focused survey reviewing the specific allegations of the complaint. The purpose of a complaint survey is to determine if the residential facility is compliant with the state licensure rules (410 Indiana Administrative Code 15). A complaint survey is unannounced and the name of the complainant is not disclosed to the residential facility. During the course of a complaint survey, surveyors may expand the scope of the survey if additional problems are observed. Complaint surveys are generally completed by only one or two surveyors and last a few hours to a day. Similar to the licensure survey, surveyors will visit the residential facility, interview staff, and review records to determine compliance with state rules.

If in the course of investigating the complaint allegations a violation of state rules or regulations is found by surveyors, the complaint is said to be “substantiated with findings.” These findings would be reported on the survey report issued at the conclusion of the survey.


Back to LTC Consumer Reports main page