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Passing the JCAHO (Medicare, CARF, etc) Survey

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have been through 4 CARF surveys which we passed. The first survey I missed due to a death in the family. The second survey the suveyors asked the OT what recreational therapy did on the unit. The third survey I stressed recreational therapy involvement in the survey process and I was initally scheduled to drive the van to pick up the surveyors from the hotel. "WOW" I convienced them I couldn't talk and drive at the same time so another driver was found. The surveyors ask me questions about the van and community reintegration outings, during the ride. The most recent survey we had a recreational therapist as a surveyor who told me about previous work experiences as a RT and I gave the other surveyor a tour of the van per their request. Well there is always hope for the next survey.
Monday, May 17, 2004 at 21:00:36 (CDT)
I am currently a CTRS working on a subacute unit in a LTC facility. We recently had JCAHO and state surveyors come through our facility. JCAHO asked for our Activity Policy and Procedures manual. They were interested in types of interventions for low functioning clients, as well as religious/spiritual opportunities. The state surveyors looked at past and present activity calendars, as well as what type of 1:1 interactions we were doing with our low functioning clients. I spoke with the state surveyors and they happened to say that when they meet with subacute client, they typically ask "are you bored." On the LTC units, they held a Residents Council meeting and asked to look at the past three months minutes. If you do what you are supposed to on a regular basis and MEET THE NEEDS OF THE PEOPLE YOU SERVICE - then its a piece of cake!
Wednesday, June 12, 2002 at 18:28:08 (CDT)
state inspection of NJ
burlington woods
Wednesday, May 15, 2002 at 19:37:19 (CDT)
I work at a Rehab/Sub-Acute/LTC facility. We had three surveyors. There was alot of documentation review and alot of ?? about education and how it was documented. They met with each Team and wanted to see how you interacted and co-treated with each other. They met with our Volunteer Coordinator and asked to see a volunteer file including their Competencies. They asked for a Resident Council meeting on the LTC unit and asked the typical questions that a State surveyor would ask. They asked to speak with the therapist on the LTC unit and asked for her calendars. They asked her how the calendar reflected the individual care plans. Rec. Therapy was very involved in this survey.
Monday, June 18, 2001 at 14:50:05 (CDT)
Passing Joint Commision should be able to be done at any time, not just when they are inspected
Monday, May 28, 2001 at 18:47:00 (CDT)
Policies, Procedures & Competencies. That is all you need to know. That is all you need to do.
Saturday, January 20, 2001 at 00:48:25 (CST)
I personally have not gone through a survey,but I am scheduled to go through one next year.I would like tips on what to expect.
Sunday, October 08, 2000 at 18:25:40 (CDT)
We had JCAHO come through our hospital a few months ago, and they were very interested in the treatment protocols, what groups we offered for the pt, and the benefits thereof, as well as new TR programs that had been started. I was lucky enough to have been a new employee of 3 months, and invited to have a sit down meeting with the surveyor along with all the other disciplines on the rehab unit. The surveyor seemed very impressed with the enthusiasm everyone showed with what they do. We scored 96%!!
Tuesday, September 12, 2000 at 18:25:01 (CDT)
I learned that others are always watching.
Sunday, August 13, 2000 at 18:10:49 (CDT)
I need some no nonsense information on exactly JCAHO wants from the T.R./Activitiers Therapy programs. Exactly what qualifications are needed by staff to chart, assess and do groups. Looking through the manual one gets a headache and confused. I get conflicting information for those that are supposed to be in the know I am tired of searching . HELP!!!!
Wednesday, August 02, 2000 at 19:24:05 (CDT)
I happen to be a surveor and a Master's Prepared CTRS - please don't think all of the survey teams are not interested - because they do ask me a lot of questions. We also have a OTR who is a surveyor out of my office!
Monday, July 31, 2000 at 14:31:32 (CDT)
I have been in the Activity profession for numerous years in one form or another. Just recently JACHO and State surveyor are looking into Low functioning residents and their participation and lack thereof. They do like to see more low functioning programs on the Activity Calendar for SNF's. They are more interested in making sure the documentation coinsides with the resident.
Monday, July 03, 2000 at 18:25:46 (CDT)
I work in 120 SNF/LTC, we scored 100% on or JCAHO surevey. The surveyor asked many questions on Voting registration, Religious resources and acitivities and Resident Council meetings for LTC. There were hardly any questions about documentation, program protocol or treatment plans for the skilled rehab unit.
A. Benfield, CTRS in Central Florida
Wednesday, April 05, 2000 at 19:31:29 (CDT)
I work in 120 SNF/LTC, we scored 100% on or JACHO surevey. The surveyor asked many questions on Voting registration, Religious resources and acitivities and Resident Council meetings for LTC. There were hardly any questions about documentation, program protocol or treatment plans for the skilled rehab unit.
A. Benfield, CTRS in Central Florida
Wednesday, April 05, 2000 at 19:29:49 (CDT)
I found the JACAHO survey very helpful and very interested in patients quailty of life. New York state was very clinical and was looking for you to "mess Up".
Sunday, March 05, 2000 at 18:01:43 (CST)
survey, strong interdisciplinary focus, teamwork
Friday, October 15, 1999 at 14:20:08 (CDT)
I am the Activity Director on a sm. sub acute care unit in Maryland. Topics of noted importance by the survey team re: activities focused on: a). The overall Activity I determine/plan the monthly activities. Including input from our patients/residents; b). Ways inwhich activites are modified for specific populations; c). The interdisciplinary approach which occurs on the unit; and d). Care plan interventions.
Wednesday, September 15, 1999 at 08:31:13 (CDT)
I worked for Lorien Nursing Home in Maryland and while JCAHO was there the Recreation department was the least of their concern, that's why the recreation department at Lorien is one of the worst I have ever seen!
Thursday, July 01, 1999 at 22:45:23 (CDT)
Just finished survey last week. So long as you provided one to one attention to those who required it, thats all the surveyors looked at. LONG TERM CARE
Thursday, April 29, 1999 at 00:33:40 (CDT)
have not had one yet
Friday, April 09, 1999 at 10:50:39 (CDT)
While I was working at a LTC facility, the state came in and hardly looked at our program. They did not even look at one activity in progress, nor did they ask us any questions! All they looked at was if the patients nail polish was chipped! Can you believe they did not even look at how in -depth our progress notes were or the quality of our activities!
Wednesday, March 03, 1999 at 14:26:12 (CST)
During my last survey in Indiana our facility did very well,we had almost a perfect survey. I do believe that the length of our management team (7-8years)was impressive and the facility was only a 55 bed. Small family run business with a positive resident oriented staff. Now I am with a huge corp. and am not looking forward to survey.I learned over the past 18 years in long term care...not to fear...its all in a days work and if hit hard, repair and go on...or go into another field! Most surveyors are not activity professinal and don't know much about activities to begin with! This is a major concern to me and always has been! I remember in the early 80's surveyors told me what they thought I should plan now I ask if "suggestions" are regulations! All in all I have been lucky and remained employed!But that could change...
Wednesday, January 27, 1999 at 23:56:21 (CST)
The state surveyors hit all PA long term and continuing care homes very hard this year. We got through it well, but many other facilities in our area did not. Many local facilities in my area are currently not allowed to admit new residents.
Saturday, January 09, 1999 at 09:20:02 (CST)

Although we did exceptionally well and JCAHO was impressed, this was NO piece of cake!!! Although only 1 surveyor, the surveyor was everywhere (could've sworn he had clones). And don't let the pleasant, participitative manner fool you. Nothing gets past them. Surveyor was extremely knowledgeable, and refreshingly, had a very comprehensive understanding of TR and a respect for our clinical discipline. That in itself is a nice change of pace from State Survey. We do have a Spiritual Assessment, so this was not an issue, but I particularly want to thank the person who commented on that in their submission in October. It was comforting to know going in to survey that we had it covered (one less thing to stress about). Basically, in preparation we spent the early part of the year reviewing the standards and checking our current practice to standards (I recommend buying your own copy, rather than relying on getting xeroxed sections distributed to you from admin. You can get info from the JCAHO website - ) -- reviewed and updated the entire manual, audited 100% of charts with staff, and implemented the spiritual assessment, because in our review we felt this was an area that could use some firming up. Best to start prepping in earnest at least 9 months before so you don't get frazzled. Then once it's over keep prepping for the next one!
- Tuesday, December 02, 1997 at 19:18:40 (PST)

LTC JCAHO Accrediation: more positive experience than state surveys. Need spiritual assessment- can be 1 question asking about a person's faith. Safety and security plan important. Survey is more of dialogue in nature- ask questions. Have chance to point out the good things that you and your facility do. BRAG.
- Tuesday, October 21, 1997 at 16:11:25 (PDT)

The survay is a piece of cake. There is only one surveyer per facility and they spend most of there time looking through piles of paperwork that you already have prepared for them. They ask you a few simple questions about volunteers and activites and thats about all. Everything you need to know is in the crosswalk and there is no suprises. Much easier then OBRA survey!!!!!!
robyn segal
- Friday, October 17, 1997 at 18:26:06 (PDT)

Survey teams are basically nice. They like staff to know the procedures for an emergency and the codes used. From past experiences they like to get the sense that employees enjoy their jobs and work together as a team. Groups with various disciplines are a plus. Community committees and advisory groups are a plus. Of course they enjoy seeing community outings. This is from a physical rehab objective.
- Thursday, October 09, 1997 at 20:02:02 (PDT)

Having a spiritual assessment was a big area of discussion during my survey. We were deficited on this. It needs to be more involved then what a patient's religion is. It also needs to be a team goal and not the sole responsibility of the TR department.
- Sunday, October 05, 1997 at 19:08:16 (PDT)



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