SOM Shortcomings: Why the Heart of the Survey is Missing Some Beats

Part Three of a Series on the Survey Process

By Steven Levenson, MD, CMD & Charles Crecelius, MD, CMD

If the survey process proceeded as intended, surveyors would draw relevant conclusions about actual facility problems that would result in correction and progressive improvement. But the process often misses the mark because the survey instructions (presented in the State Operations Manual, including Guidance to Surveyors and Investigative Protocols) have many of the same shortcomings for guiding surveyors as the OBRA regulations have for guiding care (see "Why OBRA Regulations & Surveys Can't Fix LTC," in the October 2001 issue of Caring, p. 26).

Critical Goals

One must understand the objectives of information gathering in order to collect and properly interpret relevant information. Surveyors collect and interpret information that is used to assess compliance with federal requirements for the provision of institutional long-term and skilled nursing care. For such assessments to have meaning, the criteria for compliance should be compatible with proper practices and care process.

To conduct effective surveys, surveyors must be skilled detectives--gathering and analyzing information, obtaining additional information to verify or refute tentative conclusions, and identifying problems (as opposed to deviations) in such a way that facility staff can get to the root of the difficulty, take actions, and adjust those actions based on subsequent monitoring.

Information Gathering

The survey process consists of a number of tasks (see box at right). Tasks 1 through 4 involve preparation for the heart of the process: tasks 5 (information gathering) and task 6 (analysis). Task 5 has seven subtasks and should reflect an organized, systematic way of finding and interpreting information needed to assess facility compliance.

The Center for Medicare and Medicaid Services expects facilities to meet certain OBRA requirements--for example, administration and physical environment--that are not related to resident care. But most requirements are centered on resident care. Surveyors are charged with evaluating the staff's care and practices vis-a-vis individual residents and the facility's systems and processes that affect such services. To do this, they must collect information about specific areas--such as how staff members provide skin and wound care or manage disruptive behavior--by reviewing assessments and care plans, observing and talking with residents, watching staff prepare meals and deliver care, and so on.

Surveyors must evaluate interventions and outcomes in the broader context of each resident's current status and prognosis. They are also instructed to collect information that verifies provisional conclusions about a facility's practices or performance.

Since no one surveyor can gather all relevant information, surveyors must share pertinent observations and perspectives. In order to conduct a fair, impartial review, they are supposed to maintain an open dialogue with the facility's management, staff, and residents, and allow those involved in giving care to provide pertinent information. Sometimes, facility staff fail to provide enough information to permit adequate evaluation. But at other times, surveyors may finalize determinations based on isolated observations or questionable interpretations.

The SOM tells surveyors to "use the Guidance to Surveyors for specific requirements to focus your questions and determine the significance of the answers." But the Guidance to Surveyors covers only some elements of good care, and not all surveyors know how to determine the significance of the information they find. For example, an Investigative Protocol may state that diabetes can affect the onset or healing of pressure ulcers, but how do surveyors decide whether to consider the effects of delirium, gastrointestinal bleeding, or recent pneumonia on the healing of an ulcer in someone who also has diabetes?

What determines compliance if some elements are present while others are not? How should surveyors incorporate information that the regulations don't address?

Information Analysis for Deficiency Determination

According to the SOM, the objectives of Task 6 are to review and analyze all information collected and determine 1) whether a facility has failed to meet one or more of the regulatory requirements, 2) the appropriate level of severity and scope for cited deficiencies, and 3) whether to conduct an extended survey. Surveyors are instructed to review their worksheets "to identify concerns and specific evidence relating to requirements that the facility has potentially failed to meet."

But it does not tell them how to organize the information effectively, distinguish important from incidental facts, or know if vital information is missing. The SOM has additional shortcomings:

The SOM doesn't explain sufficiently how to interpret information. Regulations give only minimal guidance to care providers in how to use the information they gather to provide more effective care. Similarly, the SOM offers surveyors only sparse instructions about general methods of interpreting information; it focuses too much on care practices (i.e., interventions) and doesn't provide sufficient references to sound care processes other than assessment and care planning.

For instance, the SOM states: "As appropriate, use the interpretations, definitions, probes, and procedures provided in the Guidance to Surveyors to guide your investigation and to help determine whether, based on your investigation and findings, the facility has met the requirements." Then, surveyors are told to "relate to the requirements and provide clear evidence, as appropriate, of the facility's failure to meet a requirement."

But many of the SOM's interpretations, definitions, probes (series of questions to guide surveyor observations), and procedures are incomplete or disorganized. The regulations place the burden on facilities to prove that negative outcomes are unavoidable. But how does the surveyor decide if the facility's evidence is satisfactory, or whether an assessment is "comprehensive" or "accurate" enough?

The probes are listed randomly, instead of being clearly related to specific surveyor inquiries about such aspects of the care process as problem recognition, cause identification, and so forth. Thus, a surveyor may ask the questions but not know what to make of the answers.

The SOM also tells surveyors that "in any care area in which you determine that there has been a lack of improvement, a decline, or failure to reach highest practicable well-being, assess if the change for the resident was avoidable or unavoidable. Note both the faulty facility practice and its effect on resident(s)," as well as the number of residents affected and the number of residents at risk.

But such guidelines don't explain how to know when the facility's actions or evidence are inadequate. Nor do they clarify such issues as how much is enough, how soon is soon enough, or how long is long enough. For example, what if staff stop an intervention thinking that a problem is resolved--but then the resident experiences a complication? How does a surveyor decide whether missing or discontinuing parts of the care plan--or interventions that were not done exactly right--made a difference in the outcome? The SOM says little about how to connect the lack of care plan goals with a resident's decline other than to "...use your professional judgment and team approach to determine if a deficient practice has occurred."

Surveyors and state agency supervisors are left to fill in the gaps. But many of them don't know how to distinguish meaningful from irrelevant information. What the SOM calls "your professional judgment" often is little more than personal opinions based on limited knowledge and experience. The result: disputes--based on different criteria and without objective evidence--between surveyors and facility staff about whether someone did or might have achieved the highest practicable outcome, or whether an outcome was "medically unavoidable."

SOM instructions are inconsistent. The SOM promotes conflicting methods for identifying and interpreting evidence. On the one hand, it instructs surveyors to conduct a full investigation before trying to draw conclusions about facility compliance. For instance: "If in conducting the information-gathering tasks of the survey you identify a possible noncompliant situation related to any requirement, investigate the situation to determine whether the facility is in compliance with the requirements."

On the other hand, it tells surveyors that they may draw conclusions based on isolated findings, even before they have obtained all relevant evidence or tried to put the isolated findings in context: "Some requirements need to be met for each resident. Any violation of these requirements, even for one resident, is a deficiency."

And elsewhere, the SOM advises surveyors that if a resident tells them something that they cannot verify from another source of information, "...citation of a deficiency may be based on resident information alone."

Trouble is, some surveyors don't bother to seek other sources or to verify information. Others find deficiencies based on isolated observations that are inadequate to prove that deficient practice occurred or that such practice caused a particular outcome. An example is the interpretation of quality-of-life requirements, which are often so nebulous that surveyors can apply almost any criteria they choose, disguised as "judgment." So, one surveyor may cite a single act or an omission from the care plan as "proof" that a resident did not reach the highest practicable outcome while another may approve of a care plan despite incorrect management of the causes of a problem. There is no rational basis for these markedly inconsistent evidentiary requirements.

Some surveyor interpretations of the SOM's "Immediate Jeopardy" section illustrate this problem. This section provides a list of situations that could be construed as Immediate Jeopardy, but offers few explicit methods for deciding whether the situation is Immediate Jeopardy.

Incredibly, because of such vagueness, some surveyors have been known to cite excess furniture sitting in the hallway as Immediate Jeopardy, while others overlook or do not cite poor practices that almost certainly contribute to functional decline.

No wonder we can't fix the real problems of long-term care!

Flawed Priorities

Currently, the regulations and enforcement provisions assume that the "whole" (a facility's overall performance) is reflected in its parts--i.e., compliance is determined by assessing hundreds of individual items. For each item, surveyors must answer such key questions as:

1. Were the facility's practices adequate or were some of them "faulty or "deficient"?
2. Did residents suffer negative outcomes?
3. How widespread were any faulty practices, and did any cause or contribute to the negative outcomes (i.e., were some outcomes "avoidable") or cause "harm" to the resident?
4. Did any of the facility's faulty practices have the potential to cause negative outcomes, even if a negative outcome has not yet occurred?

This approach has serious flaws that may explain why many facilities continue their inadequate performance through the years.

First, although the key terms (e.g., "faulty" practices, "avoidable" outcomes) are defined, they are not clarified enough to allow consistent interpretation.

Second, with respect to facility performance, the whole definitely is more than the sum of its parts. Many outcomes have multiple causes, so it is often inappropriate to match a specific outcome to a given finding or problem. Significant problems with specific aspects of care are symptomatic of bigger process problems, such as failures of management accountability and practitioner performance. Collecting information and writing deficiencies by Tag numbers focuses too much attention on individual conditions and misses common underlying causes.

Now is the time to reconsider how surveyors collect and use information to draw conclusions about facility practices and performance. Subsequent columns in this series will examine in more detail how surveyors determine deficiencies and assess penalties, and propose alternatives to the current overly complex, inconsistent survey process.

Dr. Levenson is a Multi-Facility Medical Director in Baltimore and Chair of Caring's Editorial Board. Dr. Crecelius is President of the Missouri Association of Long-Term Care Physicians and Medical Director of Demar Gardens West in St. Louis.

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