Maplewood - New York State Survey Results
On Wednesday, March 3, 2010 the New York State survey team walked into Maplewood. This is the final year that the surveyors will be using the current survey system. Next year there will be a whole new way in which they incorporate new technology to review a building. The way the current process works is that the team will first do some investigative work back at the office before coming out to Maplewood. They look at MDS information (Clinical Profiles) of all our patients over the last 12 months and look for areas of differences from other patients who live in nursing homes in New York State. For example, if a lot of patients are losing weight at Maplewood compared to other places, they look at the food, feeding practices, feeding equipment etc… This is one way that surveyors decide, before they even get here, what might be wrong and how they will evaluate the facility. Once they arrive at the facility they spread out right away and begin observing and experiencing what is going on that particular day. Tours, paperwork, interviews and lots of talking amongst themselves are all ways in which they decide how to rate a facility. At the end of the 3 day process an exit conference is held and potential deficiencies are discussed. The team goes back to the office and tells their bosses what they have found. If the Department of Health Administrators agree with the findings then the facility is given a written statement of deficiencies and has 10 days to submit a plan of correction to fix the problems.
The exit conference at Maplewood was held Friday, March 5th. 3 potential deficiencies were verbally described at the exit conference. The first potential deficiency related to the facility not complying with all the elements required to investigate whether a patient had suffered abuse in connection with an accident report where an injury to the patient had occurred. Although the surveyors all agreed that they had no suspicion or evidence to suggest any foul play in connection with the injury, N.Y.S. regulation requires that the facility follow certain paperwork guidelines in each and every case where an injury of unknown circumstance occurs. The second potential deficiency stemmed from the facility not justifying often enough the continued use of a particular medication. Certain meds require documentation that dose reduction and discontinuance attempts are made on a regular basis. The final potential deficiency occurred when the survey team found us to be using a process in connection with urine testing that did not comply with the manufacturer’s instructions. Maplewood was aware of the fact that the procedure we were using was different that the manufacturer’s instructions. As a precaution, we asked the department of health prior to using the method and at that time they certified that we complied with acceptable standards.
As you can see, the potential violations we encountered were all fairly minor. No harm to any patients has been alleged and we believe that several of these potential deficiencies should not even rise to a citation level. The Survey team was very deliberate in pointing out all the good things that families and visitors had to say about Maplewood. They specifically mentioned the smiles, cooperation and pleasant atmosphere they experienced while at our facility. I am proud of the fine job each department and each staff members does in maintaining our reputation each and every day. This survey to me is just another reason why our employees are truly top of the class when it comes to running a nursing and rehab facility. Great job everyone!