Survey Window

It’s survey time. State surveyors are on the premises asking questions and expecting valid explanations. What may feel like a terminal inquisition to the Infection Control Designee may go something like this:


  • Where is your Infection Control Manual?
  • Do you follow your own Policies and Procedures? Where are they located?
  • Where is your Policy for Scabies?
  • How long does the patient need to be on contact isolation after treatment with Elimite for Scabies?
  • Who needs to be offered treatment for Scabies?
  • Do you have a policy for Outbreak Management? May we see it?
  • Do you have an effective hand hygiene program?
  • We observed the wound care nurse removing her gloves and not washing her hands or using alcohol sanitizer.
  • We observed the Nursing Assistant in the hallway with gloves on.
  • We observed a Dietary Aid taking a tray into the room of a patient on Contact Isolation without using PPE.
  • This patient was re-admitted from the hospital with MRSA of the Nares; why isn’t she on Isolation?

There is a good answer for every one of these queries; some depend on individual facility Policies and Procedures; most answers can be found in the CDPH Infection Control Guidelines for Long-term Care

If you are familiar with your Policies and Procedures, the answers are really not that  difficult; if not, one could become rattled and lose the ability to effectively communicate with the surveyors; what then?

Will you be able to call your consultant in time to find answers to the questions?

Will the consultant be available at the moment you need them?

Would you choose a mad, fearful last minute scramble, or would you rather plan ahead, remain calm and retain those good feelings of being in control?  The reality is the DSD, or whoever is the infection control designee, should know the answers to the questions. Now is the time to really educate ourselves.   

The truth is no one can educate us; they may offer resources and in some cases opportunity for educational experiences, but for the most part, we have to make the effort to find out as much as we can about the specialty we are in charge of, and there is much to learn. It doesn’t have to be overwhelming, to start with, don’t allow yourself to become dependent on someone else; instead, take control of your future and educate yourself.

Start by locating and reading your Infection Control Manual with every opportunity. Find out what your policies are; learn them, understand why you use them, share them and educate others to them. Lastly, insist on compliance.

Most of all don’t wait. Could you answer the questions I mentioned? Don’t depend on a consultant, another nurse, or anyone other than yourself, to find the answers. If you do, it will be too late; you need to be confident enough to answer questions related to the Infection Control Program in your facility. Educate yourself; knowledge brings confidence. Commit to understanding what you do, why you do it, and where the supporting documents for your facility Policies and Procedures are located.

Once you commit to your own education,  your experience will become your expertise and you will be in the position of educating those who are asking all the questions.