• ‘gut instinct’

• ‘chance’

Valid conclusions about activities or performance will not be able to be drawn unless the

surveyor has a clear understanding of what it means for the entity to perform the condition or

task correctly.

= Circumstance commonly triggering more detailed examination; i.e., evidence from record

reviews, interviews and observations could have begun to reveal:

• emerging pattern of deficient performance of some extent and/or frequency

• episode(s) of a resident/patient/client experiencing serious harm

• complaints on file may trigger more in-depth inquiry

• several residents/patients/clients complaints about a particular staff, situation or

environmental issue

= Look first to the regulations and survey protocols to see if there is definition of the facts that

must be shown to prove a deficiency or incident.

=‘ If Official guidance. is unclear, than consult further with superiors to determine theforms of

investigative information that are needed to support a deficient practice.

=‘ Critically review the ‘lead’, the known facts, ultimately, should be able to answer all the who,

what, when, where, how and why.

Locate and review each applicable requirement(s) and other official policy directives, if any.

Use observation, interview and documentary sources to obtain the additional relevant facts

that describe the practice, condition or portion of the environment under scrutiny.

= List the precise minimum criteria necessary for the entity to demonstrate its compliance with

the requirement.

=‘ bevelop a corresponding line of inquiry, that when answered to completion, provides clear.

and convincing evidence relative to compliance with the requirements.

_ Analyze and correlate the available information.

Avoid arriving at conclusions based on observations and record reviews without asking

related follow-up questionsto staff or residents, if possibie.

Develop one or more likely working hypotheses that explain in a comprehensive fashion how

the entity’s practices or conditions could be consistent with the available survey findings..

NEC — Principles fInvestigation
Do not allow personal feelings about the issue to substitute for a decisFon that has otherwise been properly made.

Do not permit your observations and interpretations to be biased in favor of the hypothesis.

Seek information from others (surveyors/investigators). V

NEC — Principles of Investigation

3/2000
Day One

Each group will receive a case study and an Investigative Planning Form. Within your

group, assign a recorder and

a reporter. One person can serve as both. Using the

preliminary information from the case study, your group will complete the Investigative

Planning Form.

As

a group, you will determine:

• What you will need to look at,

• Who you will want to interview,

• What observations you will need to make,

• What resources you will need to consult.

After completing the form, the designated reporter will present the group’s plan to the

rest ofthe class.

Day Two

On day two, you will receive additional information regarding your case study. Using

this information, along with the information from the Investigative Planning Form you

completed on day one, you will decide as

a group the two primary persons you wish to

interview. The group will identify questions to ask of each ofthe persons chosen to be

interviewed. It is recommended that the recorder write these questions on the, “Inter-view

Notes” handout. Copies will then be made for everyone in their case study group to use

when taking notes during the interviews.

Next, each group will determine two people who will be conducting the interviews.

Arrangements have been made for persons from the case studies to be available for the

interviews. Each interviewer will be allowed 10 minutes per interview. After the

interview has been conducted, time will be allowed for a group critique.Interview notes will need to be taken during the iizterviewpertainiizg to your case

study. Each group will decide bow notes will be taken. Options include:

Having a note taker present during the interview

Each member, including the interviewer takes notes

*Each member of the group, except the interviewer, takes notes.
tivity. 

p

g

If you have any questions regarding this, please ask an instructor!

Day Three

FromSummary.

the interview

After

notes taken on day 2, each person will write an Investigative

member, exchangeyour report has been completed you will pair yourselfwith another class

you pair yourself withreports and provide constructive feedback to each other. The person

not from your case study

should preferably be a person who shares your same discipline, but

nursing home group. (Example: nursing home surveyor critiques another

children’s program surveyor’s report, children’s program licensing specialist critiques another

a class member, volunteers licensingwill specialist’s report.) After all reports have been reviewed by

class. be asked to share their report and have it critiqued by the

Formats ofreports may vary, but all reports will be critiqued on: • Details

• Sequence

• Clarity

• Relevancy

• Accuracy

• Objectivity

• Use of quotes

• Closure

4/09

Documents and records to be gathered (including photos, diagrams, charts). Why? What information will or should they contain?

What to observe? Why? What do.you expect to see or learn?

7)OG