The Mad Scramble




“State is coming!”

No three words strike more fear and anxiety into the hearts of long-term care staff and management than “State is coming!” Except, of course, “State is here!”

Among many direct care workers “State” has become a catch-all term for any kind of inspection or survey. It is an intimidating word, complete with Orwellian overtones. This all-powerful Leviathan appears suddenly in the form of nicely dressed professionals with scowls on their faces, disrupting our routine and bringing judgement down upon all of us.  You half expect to see black helicopters hovering outside the windows, having a look-see at what we’re up to.

When “State” walks through the door, the atmosphere of the place undergoes a radical transformation. A mad scramble takes place as things that are normally out are put away, people you ordinarily don’t see on the units suddenly appear and everyone starts acting as if they’ve gone completely insane. For the next several days, this menace will have the facility by its figurative (I hope that’s all) balls and we all become hostages to its apparent whims – and our own insecurities.

Amidst the rampant paranoia, there are always those smug staff members who simply shake their heads and say something to the effect: “If they would just do things right all of the time, this wouldn’t be such a big problem.” They being management or at least someone other than themselves. Others insist that they have nothing-nothing-nothing, absolutely nothing to hide and they have no reason to fear “State.” And still others see “State” as a powerful moral ally and take a little more vindictive approach: “I hope they get caught this time!” Again, meaning management or someone other than themselves.

Of course, this all goes to hell the moment they are personally observed. Because we all behave differently when we know we’re being watched. It’s just human nature. And those who insist that it really doesn’t matter and strain so mightily to act naturally seem to lack even the slightest awareness of how nervous they appear, how eager to please they’ve suddenly become. And how relieved they look when they pass inspection while simultaneously and with false bravado insist “It was no big deal” on their way to the staff bathroom to throw up.

You don’t have to be “guilty” of anything to be apprehensive. Because it’s not really about what you’re doing and how you’re doing it, it’s about how you think it’s being perceived. We are indeed at the mercy of the attitudes and prejudices of those who are watching.

So too for the facility as a whole. The public stance of administrators and managers has to be “we welcome it,” “we want it,” “bring it on!” Meanwhile, they drive the mad scramble, hoping that they’ve done enough to prepare and praying that some random staff member doesn’t do or say something completely stupid. It’s a crapshoot for them and by the end of inspection week, they’re exhausted. An hour after the exit meeting you won’t see a single one of them around the place. Half of them have gone off to get drunk and the other half home to the medicine cabinet.

While I know next to nothing about the inspection business, what it looks like from their end, I’m sure there are specific things they’re looking for and guidelines they have to follow. F-tags, deficiencies, violations, citations – the dread-filled terms that I only half understand. Most of it is probably necessary and useful in some way. However, they do seem oblivious to or unable to address some things that many people would consider quite important. And there has always been something capricious at the heart of the whole process. It’s easy to have high expectations and standards if you’re not required to practice them. The people who actually run and work in these facilities are the real heavy lifters, the practitioners that deal with the daily challenges and realities of long-term care. My personal prejudice is that most of the folks in the inspection business couldn’t begin to handle it.

It could be that when the facility goes nuts at inspection time, the problem isn’t with the facility but with the process itself. In any case, it’s good that we should question it and ask if there might not be a better way to ensure accountability.

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