2/28/2018. Marilyn Mines RN, BC, RAC CT

Transcription

1 Illinois Council on Long Term Care HealthCare Council of Illinois The New Long Term Care Survey Process March 1, 2018 marcumllp.com Marilyn Mines RN, BC, RAC CT Marcum LLP Nine Parkway North Deerfield, Illinois P: (847) F: (847) Objectives At the end of this session, attendees will know what to expect during the new LTC survey process as it relates to: Surveyor preparations Completion of the required Entrance information and timelines Surveyor observations, interviews, and chart reviews Critical Element Pathways Surveyor tools How citations are determined 3 1

2 Resources Enrollment and Certification/GuidanceforLawsAndRegulations/Nursing Homes.html 5 6 2

3 Overview Best parts of the traditional and QIS survey Because it is computer based, there is less interpretation and more evidence based determinations Compliance will be determined by use of the interpretive guidance, investigative protocols and procedures, CE Pathways, and other observation tools/tasks 7 Comparison Between the Traditional and New Survey Process Computers Traditional Used to develop the 2567 form: data written on paper New Process Used throughout the survey, with information being entered and synthesized/ organized by new software 8 Comparison Between the Traditional and New Survey Process Traditional New Process Sample Based oncensus Maximum of 30 Pre selected based on QM/QI reports Adjusted based on issues identified while on tour Includes complaints Based oncensus Maximum of 35 70% pre selected, 30% survey selected based based on observations, interviews and limited chart review Includes complaints 9 3

4 Comparison Between the Traditional and New Survey Process CASPER 3and 4 reports Traditional Reviewed with the QI/QMs to further identify preliminary resident sample New Process Each team member reviews the CASPER 3 report on their own Review off site selected residents and indicators 10 Comparison Between the Traditional and New Survey Process Roster Matrix CMS 802 Required info Traditional Completed for facility census New Process Two are completed (new form) 1) entire census and 2) those admitted within last 30 days Alpha resident list List of residents who smoke and designated smoke time 11 Comparison Between the Traditional and New Survey Process Traditional New Process Entrance to facility Initial tour Observe for additional concerns Determine if pre selected residents are still appropriate 1 3 hours No tour Each team member goes to their assigned unit and begins observations, interview, and limited chart reviews 8 10 hours 12 4

5 Comparison Between the Traditional and New Survey Process Traditional New Process Misc. Phases Focus and Comprehensive reviews based on identified issues and QM/QI reports Focused record review Interview, observations, limited chart review for residents in the initial pool process Team meet and discuss/add new concerns 13 Comparison Between the Traditional and New Survey Process Traditional New Process Misc. Environmental and other tasks during the survey Meet with Resident Council Review minutes Investigations with critical element pathways Facility tasks and closed record reviews are done Meet with Resident Council Review minutes 14 The Process There are numerous steps that are involved in the preparation and execution of the new process 1. Offsite preparations 2. Facility entrance 3. Initial pool process 4. Sample selection 5. Investigation 6. Ongoing and other survey activities 7. Potential citations 15 5

6 1. Offsite Preparations The team coordinator (TC) is required to download numerous facility specific files as close to the survey date as possible no more than 5 business days prior to the survey Most current MDS information Most recent standard survey Complaint surveys since most recent standard survey Casper 3 report (repeated deficiencies) Facility reported incidents (FRI) Variances and waivers 16 Offsite Preparations The downloaded information allows the survey team to view the facility s history of Allegations of abuse Active enforcement cases 17 Offsite Preparations The Team Coordinator (TC) assigns a variety of tasks to the team members Beneficiary Protection Notification Review Dining observation Infection Control Kitchen Medication Administration Medication Storage QAA/QAPI Resident Council meeting Sufficient/competent nurse staffing The State Ombudsman is informed 18 6

7 Offsite Preparations There are several other documents that must be downloading to each surveyor s computer a. b. c. 19 Offsite Preparations There are several other documents that must be downloading to each surveyor s computer continued d. Appendix Q Guidelines for Determining Immediate Jeopardy (IJ) and Guidance/Guidance/Manuals/downloads/som107ap_q_immedjeop ardy.pdf e. Chapter 7 of the State Operations Manual and Guidance/Guidance/Manuals/Downloads/som107c07.pdf 20 Offsite Preparations There are several other documents that must be downloading to each surveyor s computer continued f. Psychosocial Outcome Severity Grid and Guidance/Guidance/Transmittals/Downloads/R156SOMA.pdf g. Principles of Documentation and Guidance/Guidance/Manuals/downloads/som107 _exhibit_007a.pdf 21 7

8 Offsite Preparations 70% of the sample is chosen off site By reviewing facility information, a determination of concerns/potential concerns is made Closed record review (discharge records) must include one resident in each of the following categories Unexpected death Hospitalization Community Team members independently review offsite information 22 Recently posted for surveyors to use during offsite preparations Facility Entrance There is no entrance tour Team surveyors immediately go to their assigned areas Each team member will request the resident roster for their area Residents admitted within the last 30 days must be identified matrix for new admission 24 8

9 Facility Entrance The team member assigned to do the kitchen tour visits that area immediately: before proceeding to their assigned area 25 Facility Entrance Prior to going to her/his assigned area, the TC will conduct an entrance conference with the administrator If the entrance is during off hours, a short entrance conference will be held with whomever is in charge Once the administrator arrives, a full entrance conference will be conducted 26 Facility Entrance The entrance begins with a give and take relationship The administrator immediately gives the TC Census number minus bed holds Complete matrix for new admissions (within the last 30 days) who are still residing in the facility An alphabetical list of all residents (note any resident out of the facility) A list of residents who smoke, designated smoking time, and locations 27 9

10 Facility Entrance The entrance begins with a give and take relationship The administrator immediately gives the TC continued Information regarding full time DON coverage Information regarding emergency water source Name of Resident Council President Updated floor plan, if necessary Facility Assessment 28 Facility Entrance The entrance begins with a give and take relationship continued The TC gives A copy of the Casper 3 report Signs indicating that surveyors are in the facility, which must be prominently posted Worksheet 29 Facility Staff Must Give ONE HOUR Meal times Location of dining rooms Medication pass times Number and location of med storage rooms and carts Working schedules for licensed and registered nursing for the survey time period List of key personnel, location, phone numbers If paid feeding assistants are used, their training, names, and residents who receive the service 30 10

11 Facility Staff Must Give An admission packet Dialysis information Contracts, agreements, policies and procedures including agreements for transportation List of staff providing dialysis Identification of certified unit Hospice agreements with each provider Infection prevention and control program standards, policies and procedures Antibiotic stewardship program FOUR HOURS 31 Facility Staff Must Give FOUR HOURS Flu and Pneumococcal immunization policy and procedures QAA committee information QAPI plan Abuse prohibition policy and procedures Description of any experimental research in facility Nurse staffing waivers List of rooms requiring a variance Facility Assessment Completed matrix for entire facility 32 END Facility Staff Must Give OF FIRST DAY Completed Electronic Health Record Information portion of the Entrance Conference Worksheet Tells the surveyor were items for review are located If in the EHR system, how to find specific documents If on paper and not scanned into the system, where those items are located 33 11

12 34 Entrance Conference Worksheet EHR Access Care Area Location of info Care Area Location of info 1. Pressure ulcers 9. Elopement 2. Dialysis 10. Change of condition 3. Infections 11. Medication s 4. Nutrition 12. Diagnoses 5. Falls 13. PASARR 6. ADL Status 14. Advance directives 7. Bowel & Bladder 15. Hospice 8. Hospitalization 35 Facility Staff Must Give Completed CMS Forms 671 and 672 Completed the Beneficiary Notice portion of Entrance Conference Worksheet 24 HOURS 36 12

13 3. Initial Pool Process Screening includes all residents in the assigned area, including those on the new admission matrix All residents must be screened before identifying the 8 per surveyor that will be included in the initial pool Initial Pool Process If the survey team arrives during off hours, the initial pool process will be slightly different Accommodations should be made based on resident activities Observations and screening will be done for those residents who are available If other tasks are appropriate, they will be started This process requires the surveyors to be on the unit with residents 39 13

14 Initial Pool Process Observation by all surveyors of the first full scheduled meal since entrance Must start at the beginning of the meal All dining rooms All room trays Include those in the initial pool with weight loss, nutritional and/or hydration concerns If an issue is identified, must observe more residents 40 Initial Pool Process The initial pool includes residents from the surveyor s assigned area who are Offsite selected residents Complaint/facility reported incident (FRI) residents (a limit of 5 in total) Vulnerable residents New admissions within the last 30 days Others with concerns Residents will be interviewed and observed differently depending on their subcategory 41 Initial Pool Process There are several options on how to conduct the screening, interviews and observations The surveyor may choose whatever way they are more comfortable Directions are clear: go room to room without staff 42 14

15 Initial Pool Process Review resident s information prior to entering the room Introduce self and have a short conversation Do a head to toe observation while talking to the person Determine whether the resident is interviewable or not 43 Initial Pool Process: Conduct a Full interview on Interviewable Residents The MDS indicators and active complaint/facility reported incidents residents appear the computer screen Prompted to question these care areas Choices Activities Dignity Abuse Resident to resident interaction Privacy Accommodation of Needs Person Funds Personal Property Sufficient Staffing Participation in care planning 44 Initial Pool Process: Conduct a Full interview on Interviewable Residents Prompted to question these care areas continued Community Discharge Environment Food Dental Nutrition Hydration Tube Feeding Vision and Hearing ADLs ADL Decline Catheter Insulin or Blood Thinner Respiratory infection Urinary Tract Infection 45 15

16 Initial Pool Process: Conduct a Full interview on Interviewable Residents Prompted to question these care areas continued Infections other than respiratory or urinary Hospitalizations Falls Pain Pressure Ulcers Skin condition Limited ROM Rehab Dialysis B&B incontinence Constipation/Diarrhea Smoking Hospice Other concerns 46 Initial Pool Process: Conduct a Full interview on Interviewable Residents If concerns are voiced in any of the care areas, the surveyor must determine if further investigation is needed and/or whether the MDS should be reviewed 47 Initial Pool Process: Conduct a Full interview on Interviewable Residents Even if the care area doesn t apply, each item must be reviewed and have a response Although the questions may be asked in any manner comfortable for the surveyor, the intent must be maintained If the MDS must be viewed to identify a discrepancy, it can be done at any time during the process, but it must be confirmed or denied prior to the exit 48 16

17 Initial Pool Process: Conduct a Full interview for Non Interviewable Residents The interview for resident s representative has the same questions as the one for residents with one additional question: notification of change These interviews should be conducted on the first day 49 Initial Pool Process: Conduct a Full Resident Observation Based on information input to the computer, areas are identified for further observation with probes being listed Rounds must continue with observations to answer all of the care area items 50 Initial Pool Process: Conduct a Full Resident Observation Each of the following care areas must be observed Activities Mood/Behavior Dignity Restraints Abuse Accident hazards Privacy Unsafe wandering/elopement Accommodating of Call light in reach, call system needs functioning Language/ communication 51 17

18 Initial Pool Process: Conduct a Full Resident Observation Each of the following care areas must be observed continued Environment Dental Nutrition Edema Hydration Tube Feeding Vision and Hearing ADLs Catheter Psych med side effects Psych/opioids med side effects Anticoagulant med side effects 52 Initial Pool Process: Conduct a Full Resident Observation Each of the following care areas must be observed continued Respiratory Infection Urinary Tract Infection Infections other than respiratory or UTI Oxygen Positioning Falls Pain Pressure Ulcers Skin conditions Limited ROM Hospice Vent/Trach B&B continence Smoking Other Concerns 53 Initial Pool Process: Conduct a Full Resident Observation As with the interview process, it is necessary to document if there is no issue, the need for further investigation, and MDS discrepancies 54 18

19 Initial Pool Process: Limited Record Review Care area probes look at many of the same areas identified on the interviews and observations Different areas are reviewed based on resident specific circumstances For all residents observed, the record review must be done to confirm the use of high risk medications and PASSAR if they are indicated Insulin Anticoagulant PASARR Antipsychotic with Alzheimer's or dementia 55 Initial Pool Process: Limited Record Review Different areas are reviewed based on resident specific circumstances continued For any resident marked non Interviewable, out of the facility, or unavailable, a record review must be conducted whether the following indicators were identified or not Pressure ulcers Falls Dialysis ADL decline Respiratory infection Low risk B&B Urinary tract infection Hospitalization Other infections Elopement Nutrition Change in condition 56 Initial Pool Process: Limited Record Review Different areas are reviewed based on resident specific circumstances continued For all residents observed during the initial pool process a record review is conducted to verify Advanced Directives Other Concerns For new admissions added (no MDS) High risk medication Diagnosis Hospice 57 19

20 Initial Pool Process: Limited Record Review Document findings Limited time should be spent on the record review 58 Initial Pool Process: End of Day 1 Team Meeting The computer program includes a Team Meeting screen that lists items that must be discussed Should only be minutes Basically the survey team is guided through questions: their responses are entered into the computer to keep the information updated If substandard quality of care is suspected, the sample must be expanded to either rule it out or determine the scope 59 Initial Pool Process: Daily Data Sharing All surveyors share their data at the end of each day via the computer TC accesses information and shares with the team 60 20

21 4. Sample Selection The team meets and discusses all potential sample residents about 1 hour to select the sample Those in the actual sample will have a full blown investigation for any area of concern that was noted and marked for investigation If there are residents with concerns that are not in the actual sample, those concerns will still be investigated through others in the sample If there is no other resident with the concern, include that resident in the sample 61 Sample Selection Total number in the sample does not include discharged or closed records, only active resident Those identified through the initial pool process Those identified during rounds and review Must include any resident with An abuse concern Potential harm Transmission based precautions All other care areas of concern Up to 5 complaints or FRI residents 62 Sample Selection Software program will ensure that all areas are represented It will select 5 residents for a full medication review of unnecessary medications: may or may not be in the sample Will indicate which facility tasks are triggered and require investigation Environment Personal funds Resident assessments 63 21

22 Sample Selection Software program will ensure that all are areas are represented continued Ensures that the correct number of resident are in the sample, based on census information Indicates what areas of care are to be investigated Team discusses concerns for each resident chosen and is mandated to refer to the Sufficient and Competent Nurse Staffing task to determine if any of the concerns indicate staffing issues 64 Sample Selection Sufficient and Competent Nurse Staffing Was updated in November 2017 Although every surveyor observes for compliance, at the end of the day, when the team meets and discusses the days observations and concerns, the one assigned to this task determines whether any further investigation is warranted 65 Sufficient and Competent Nurse Staffing Survey team is asked whether observations, interviews, or resident record reviews conducted during the initial pool process and via general oversight suggested staffing issues might lead to negative outcomes Observations Offensive odors Residents in bed and not dressed after 9am Slow response time to call lights No staff interaction with residents Unsupervised wanderers 66 22

23 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Observations continued Lack of assistance during meals Licensed staff helping unlicensed staff Sedated residents Use of position alarms Staff rushing to get there work done Delay in receiving medication Repositioning not done on a timely basis Display of pain, combative behavior, crying out, or yelling 67 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Observations continued Avoidable accidents, elopement, resident to resident altercations Lack of competency while administering resident care Interviews Do you feel there is enough staff? Has anything happened while you were waiting for staff to help you? 68 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Interviews continue Do you eat in your room but want to eat elsewhere? Are you able to make choices regarding dressing, eating, and activities? Get your medications on time? Do they make you sleepy? Do you think the staff is competent? How did staff respond to a concern or problem you expressed? How many residents are you responsible for? 69 23

24 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Interviews continue How many residents are you assigned? Have enough time to complete your assignment? How often are you asked to work overtime? Any devices available to prevent falls, wandering, etc.? Able to complete restorative interventions? Do you have input into staffing schedules and numbers? How are care plans updated and changes in resident s needs communicated? 70 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Interviews continue How do you identify resident s change in condition How are they communicated? How often, and why, are resident s sent to the hospital? Have you been trained to do your job? Are there in services on abuse, dementia care, resident rights, etc.? Are agency staff used? How often? 71 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Interviews continue Does the Facility Assessment include levels and competency of staff needed? Did (do) you have input in the Facility Assessment? How often is the Facility Assessment updated? How does resident acuity, needs, and diagnosis influence staffing requirements and assignments? Does census influence staffing levels? 72 24

25 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Interviews continue Have there been concerns regarding staffing levels brought to your attention? How was this handled? How does staff identify resident s change in condition? Most common reason for hospitalization? How do you assure that competent staff is assigned to meet residents needs? How do you assure that care plan interventions are implemented? 73 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Interviews continue Use of temporary or contract staff? How do you know their skill set? How are staff competencies assessed? Record reviews If position alarms are used, is there sufficient documentation to indicate the justification for its use and its impact on the resident? If sedating medications are used, does the clinical record support its use? 74 Sufficient and Competent Nurse Staffing Survey team is asked.lead to negative outcomes Record reviews continue If there were changes in condition, does documentation indicate they were reported and timely? Does document suggest that a transfer to the hospital could have been avoided? Nursing schedules include 24 hour licensed nurse coverage 8 hours RN coverage daily Full time DON 75 25

26 Sample Selection Should there be a need to add residents (to meet the required sample size) the following guidelines are used Residents with the most concerns or those with concerns related to QOL and resident rights Residents who computer selected for the unnecessary med review but who are not in the sample Prior survey and complaint results Unrepresented area(s) of the building 76 Sample Selection Investigation Each surveyor is mandated to conduct an investigation on the residents identified in their sample The investigations may be conducted By resident By care area 78 26

27 Investigation Software guides the surveyor through the investigation to determine compliance decisions and FTag citations Critical Element Pathways will be triggered for any care area of concern All questions on the Critical Element Pathways must be answered If there is no Critical Element Pathway for an identified concern, the surveyor is instructed to use Appendix PP 79 Investigation The Facility Assessment must be reviewed if there are concerns related to Hospice Dialysis Ventilators Activities Nutrition Behavioral/emotional Dementia Lack of resources 80 Investigation Observation Staff, residents, representative Consistent implementation of the care plan all shifts, at all times Any deviations from the care plan AM care, wound care, restorative, incontinent care and transfers as indicated by the areas of concern There is a body map in the computer which is used to draw observations of wounds Nutrition or weight concerns require use of a weight calculator 81 27

28 6. On going and Other Survey Activities Assigned tasks using pathway tools may be completed at any time during the survey process Closed record reviews It is recommended that is review takes place early in the survey process to allow time for investigation of identified concerns Sample selection is done by the software Review unexpected deaths, hospitalizations, and discharges to the community for last 90 days using the appropriate pathways 82 On going and Other Survey Activities Additional dining observation A second one is done if any concerns were identified during the initial full meal observation After reviewing other surveyor s notes, the decision to cite or not will be made Infection Control All surveyors are responsible for observing throughout their observations One is assigned to coordinate and review other s notes when completing this task 83 On going and Other Survey Activities SNF Beneficiary notification review Using the info on the Beneficiary Notification worksheet, 3 residents are randomly selected The worksheet, one for each resident in the sample, will be given to the facility for completion Findings will be reviewed with the provider if issues are noted 84 28

29 On going and Other Survey Activities Kitchen Observations are made throughout the survey process One item on the Kitchen task requires unit refrigerators to be observed for temperature and labeling of food items This may be done by one person or by each surveyor information will be shared with the person assigned to complete this form 85 On going and Other Survey Activities Medication administration 25 medication opportunities Should be conducted by a nurse or pharmacist Although the preference is to observe residents in sample, any resident may be observed if the opportunity arises Different shifts, different units, different routes should be observed 86 On going and Other Survey Activities Medication storage May be done by any surveyor Observation of half the medication carts and storage rooms (defined by software) If concerns are noted, the review will be expanded 87 29

30 On going and Other Survey Activities Resident council meeting Group interview with active members should be conducted by day 2 allows time to pursue problems identified Any resident can attend but should be limited to 12 Include ombudsmen if requested If no council exists, identify attempts to get one started 88 On going and Other Survey Activities Resident council meeting continued With permission of president, 3 months of council minutes should be reviewed Identify whether issues brought up have been resolved Sufficient and Competent Nurse Staffing Throughout the entire survey process, all surveyors will be observing for problems or complaints that might be related to staffing One surveyor responds to the questions of the pathway 89 Triggered Tasks: Only To Be Done if a Concern Is Identified If any of these are triggered for review, only the applicable section is to be completed Personal funds if residents indicate they do not have access to their funds Environment concerns only if they are identified with the sampled resident Not to be redundant of the LSC, will not investigate disaster and emergency preparedness, oxygen storage, or generator 90 30

31 Triggered Tasks: Only To Be Done if a Concern Is Identified If any of these are triggered for review, only the applicable section is to be completed continued Resident Assessment will only be investigated by each surveyor if there are concerns with Timing Discrepancies for care areas Potential Citations Team meets to determine compliance Severity Scope Isolated Pattern Wide Spread 4 Immediate Jeopardy J K L 3 Actual Harm not IJ G H I 2 No actual harm/potential for more than minimal harm D E F 1 No actual harm potential for minimum A B C 92 Potential Citations Team will determine scope and severity for all the potential deficiencies The meeting for these decisions should take about an hour Every tag that was identified by the individual surveyors must have a compliance decision made 93 31

32 Exit Conference With administration and leadership team Ombudsman, president or officer of resident council, and one or two residents should be invited May conduct two separate exits with an abbreviated one for residents who may be in attendance Ombudsman may go to either or both Indicate the observations and preliminary findings while keeping the resident s identity hidden 94 Exit Conference Provider will be informed that deficiencies may be amended following new findings in the event that the survey is expanded Facility will be allowed opportunity to discuss and give more information if appropriate Resident roster information can be given at this time 95 Surveyor Investigation/Observation Tools and Tasks 32

33 Mandatory Tasks Beneficiary Notices Dining Infection Prevention Control Kitchen Med Administration Medication Storage Resident Council Sufficient and Competent Nursing Staff 97 Triggered Tasks Environment Personal Funds Resident Assessment Extended Survey If there is any suspicion of SQC the survey must be extended to determine whether there is SQC or not 98 A few refer to the appropriate Critical Element Pathway Misappropriation of Resident F602 Property and Exploitation F603 Involuntary Seclusion Reporting Of Reasonable Suspicion F608 Of A Crime F620 Admissions F678 Regarding Basic Life Support, CPR F700 Bed Side Rails 99 33

34 A few refer to the appropriate Critical Element Pathway F740 Behavioral Health Services F741 Sufficient Staff F743 Decreased socialization F757 & F758 Chemical Restraints Use F949 Use of paid feeding assistants 100 A few that refer to the appropriate Critical Element Pathway F622 Transfer and discharge F684 Quality of Care (End of Life) 686 Pressure Ulcer F690 Bowel and Bladder F692 Nutrition and hydration 101 Investigative Procedures F660 F694 F760 F842 Effective discharge planning process IV oversite and observations Medication Administration med errors Medical Records

35 Facility Responsibilities and Preparation Familiarize staff with investigative protocols and procedures, FTags, and the survey process Knowledge isn t power until it is applied Dale Carnegie PROACTIVE REACTIVE 104 Prepare Educate staff on new survey process, new FTags, investigative protocols and procedures, and survey tools Identify staff s responsibility prior to and during the survey process Assist staff in the proper ways to respond to surveyor interviews Have all the required information available

36 Interdisciplinary Team Review the new survey process elements Know your function in interviews, observations, and record reviews Study the Investigative Protocols related to the interdisciplinary team and your specific discipline Learn all the requirements of the Critical Element Pathways related to your discipline Understand how the CE Pathways Facility Tasks will be used Prepare as if you were the surveyor 106 FTags

37 109 Tag # SQC (As of Tag? Nov. 28, 2017) X = Yes F Tag Crosswalk Tags / Subparts Old Tag (Taken from Tag Title CFR Regulatory Groupings Implemented App PP in Phase ) Regulation Text that was Moved to New Tag F540 Definitions F F550 X Resident Rights/Exercise of (a)(1)(2)(b)(1)( Resident Rights 2) Rights F (b)(1)(2) F551 Rights Exercised by Representative (b)(3) (7)(i) (iii) Resident Rights F (b)(3) (7) F573 Right to Access/Purchase Copies of Records (g)(2)(i)(ii)(3) Resident Rights F (g)(2)(3) F552 Right to be Informed/Make Treatment Decisions (c)(1)(4)(5) Resident Rights F (c)(1)(4)(5) Right to Participate in Resident F (c)(2)(3) F (c)(2)(iii) Planning Care Rights Request/Refuse/Discontinu (c)(6)(8)(g)(12) Resident F578 e Treatment;Formulate Adv F (c)(6)(8)(g)(12) (i) (v) Rights Directives Cardio Pulmonary F678 X Resuscitation (a)(3) Quality of Life F (a)(3) (CPR) Resident F572 Notice of Rights and Rules (g)(1)(16) F (g)(1)(16) Rights F574 Required Notices and Contact Information (g)(4)(i) (vi) Resident Rights F (g)(4) 110 FTags Hundreds of tags, associated with the various paragraphs of the Requirements of Participation (Appendix PP) Must know what they are and how to achieve and maintain compliance Assign various staff and team members to review and outline the contents to educate others in their department Staff must know which tags impact their discipline

38 Interdisciplinary Team (IDT) 112 IDT 113 IDT

39 IDT 115 IDT 116 Discipline Specific/Shared Crosses over several disciplines but primarily is the responsibility of physical engineer and housekeeping

40 Discipline Specific/Shared Admissions Billing Nursing Social Services Physician Nursing Medical Director Physicians/non and physician practitioners 118 Discipline Specific/Shared Administration Nursing Medical Director Human Resources/ Personnel Nursing Administration Social Services Physicians/ Medical Director 119 Discipline Specific/Shared Nursing Physicians Medical Director Administration Nursing Dietary Dentist/physician

41 Discipline Specific/Shared Administration Nursing Dietary Physician Dentist Activities Administration Board of Directors 121 Discipline Specific/Shared Therapies Nursing Physician Restorative Administration 122 CE Pathways and Facility Tasks 41

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43 * * * * * * * * * * * * 127 Initial Pool Process Interviews, Observations, and Record Review The interdisciplinary team and specific disciplines must be familiar with the facility tasks 128 Surveyor Facility Tasks Interdisciplinary Team Environment QAA/QAPI Dining Infection Prevention and Control Extended Survey Social Services Beneficiary Notices Personal Funds Resident Council

44 Surveyor Facility Tasks Nursing Medication Administration Medication Storage and Labeling Sufficient and Competent Nursing Staff Dietary Kitchen 130 Critical Element Pathways Pain Management 131 Critical Element Pathways Social Services Death Discharge Hospitalization PASARR (Admissions) Activities Activities Dietary/Nursing Dental Hydration Nutrition Tube feeding

45 Critical Element Pathways Nursing Dialysis Pressure Ulcer (Laundry & Dietary) Respiratory Care Unnecessary Medications Urinary Catheter UTI 133 Critical Element Pathways Nursing/Therapy/Restorative Activities of Daily Living Bowel and Bladder Incontinence Physical Restraints Positioning, Mobility and ROM Rehabilitation and Restorative

46 Mapping for All Areas 26 pages of information that tells the surveyor what to look at and how to do their observations and investigations 1. Initial Pool Area 4. Investigative tools 2. Probing words Pathway 3. Initial information source RI=resident interview Investigative Protocol RO=resident observation RRI=resident 5. Critical Element and Tag number representative interview RR=resident record 6. Description of tag Initial Pool Area Accident Hazards Initial Pool Intent Key Probing Words Example Bed rails or mattress entrapment Restraint applied correctly Unsafe cords, outlets, handrails Inadequate safety equipment or lighting (grab bars, ambulation, transfer, or therapy Chemicals/other hazards Exposure to unsafe heating surfaces Locks disables, propped fire doors, irregular walking surfaces Residents adequately supervised Initial Pool Source RO Investigative Tool CE # Tag# Tag Description Accidents Pathway for all CEs Additionally, Investigative Protocol for CE 2 (F700) 1 F689 2 F700 Bedrails Free of accident hazards/supervision/devices 3 F909 Resident bed 4 F655 Baseline care plan 5 F636 6 F637 Comprehensive Assessment and timing Comprehensive Assessment after significant change 7 F641 Accuracy of assessment 8 F656 Development/implementation of comprehensive care plan F657 Care plan Timing and Revision 46

47 Example Accident Hazards Pathway for all CEs Interviews Resident, resident representative or family interview asks questions related to all items on the pathway Nurse Aides are asked their knowledge of the resident's care and circumstances around the accident Therapy/Restorative nursing personnel are asked about the interventions, their implementation, and response to the accident 139 Example Accident Hazards Pathway for all CEs Interviews continued Nurses are asked about resident care, risk factors, specifics about the incident Social Service personnel are questioned about behaviors and care planning to manage the concerns Record review of all notes to determine Whether risks were identified Whether the risks were properly managed Investigation of the incident 140 Example Critical Element Decisions 1) Based on observation, interviews, and record review, did the facility ensure the resident s environment is free from accident hazards and each resident receives adequate supervision to prevent accidents? If No, cite F

48 Example Critical Element Decisions continued 2) Based on observations, interviews, and record review, did the facility assess each resident for risk of entrapment and only use bed rails after trying other alternatives and explaining the risks and benefits to the resident or the resident s representative? If No, cite F700 NA, bed rails were not investigated. 142 Example Critical Element Decisions continued 3) Based on observations, interviews, and record review, did the facility appropriately install and inspect the bed rails, use compatible bed mattresses, bed rails and frames, and identify any risks of entrapment? If No, cite F909 NA, bed rails were not investigated 143 Example Critical Element Decisions continued 4) For newly admitted residents and if applicable based on the concern under investigation, did the facility develop and implement a baseline care plan the care within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident? Did the resident or resident representative receive and understand the baseline care plan? If No, cite F

49 Example Critical Element Decisions continued 5) If the condition or risks were present at the time of the required comprehensive assessment, did the facility comprehensively assess the resident s physical, mental, and psychosocial needs to identify the risks and/or to determine underlying causes, to the extent possible, and the impact upon the resident s function, mood, and cognition? If No, cite F Example Critical Element Decisions continued 6) If there was a significant change in the resident s status, did the facility complete a significant change assessment within 14 days of determining the status change was significant? If No, cite F Example Critical Element Decisions continued 7) Did staff who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's status, needs, strengths and areas of decline, accurately complete the resident assessment (i.e., comprehensive, quarterly, significant change in status)? If No, cite F

50 Example Critical Element Decisions continued 8) Did the facility develop and implement a comprehensive person centered care plan that includes measureable objectives and timeframes to meet a resident s medical, nursing, mental, and psychosocial needs and includes the resident s goals, desired outcomes, and preferences? If No, cite F656 NA, the comprehensive assessment was not completed. 148 Example Critical Element Decisions continued 9) Did the facility reassess the effectiveness of the interventions and review and revise the resident s care plan (with input from the resident or resident representative, to the extent possible), if necessary to meet the resident s needs? If No, cite F657 NA, the comprehensive assessment was not completed OR the care plan was not developed OR the care plan did not have to be revised. 149 Example This Accident Hazards CE Pathway also suggest further investigation 1. Tags 2. Care areas 3. Facility tasks 4. Investigative protocol IF THEN

51 Example 1. Tags F580 F552 F635 F658 F710 F906, F907, F909 thru F918, F920, F922, F925 Notification of Change Right to be Informed Admission Orders Professional Standards Physician Supervision Physical Environment 151 Example 2. Care Areas Restraints Abuse Choices General Pathway ADLs Behavioral Emotional Status Unnecessary Medications Dementia Care 152 Example 3. Tasks Environment Sufficient and competent staffing QAA/QAPI Rehabilitation and Restorative 4. Investigative Protocol if F700 is cited A sampled resident who has MDS data that indicates a bed/side rail is used; Surveyor observation of the use of a bed/side rail for a resident; and/or An allegation of inappropriate use of a bed/side rail received by the State Survey Agency

52 Investigative Protocol Bed/Side Rails Protocol has many elements quite similar to the critical element pathway Once the assessment, care plan, and orders are reviewed, with interventions identified, observations will be made, with interviews and record reviews conducted to corroborate what was observed 154 Investigative Protocol Bed/Side Rails Protocol has many elements quite similar to the critical element pathway continued A resident may have a device in place that the facility has stated can be removed by the resident. For safety reasons, do not request that the resident remove the bed rails, but rather request that staff ask the resident to demonstrate how he/she releases the bed rails Must answer what medical need is met by using the bed rail

53 Matrix 157 Matrix Categories 1 Date of admission if admitted within past 30 days 2 Alzheimer s /dementia diagnosis *3 MD, ID or BC, & no PASARR Level II Medications: Insulin, Anticoagulant, Antibiotic, Diuretic, *4 Anti anxiety, Antipsychotic, Antidepressant, Respiratory 5 Facility acquired pressure ulcer 6 Worsened pressure ulcer 7 Excessive weight loss without prescribed program 8 Tube feeding 9 Dehydration 10 Physical restraint 158 Matrix Categories *11 Fall with injury or major injury 12 Indwelling catheter *13 Dialysis 14 Hospice 15 End of life/comfort care/palliative care 16 Tracheostomy 17 Ventilator 18 Transmission based precautions 19 IV therapy *20 Infections

54 Status in Illinois IDPH on the New Survey Process Since this is a new process, there is a learning curve for both the provider and surveyors Surveyors will explain the process to providers as they conduct the survey The use of laptops and tablets makes this a slower process than before Although regulations regarding complaints are new, the survey is conducted as in the past 161 IDPH on the New Survey Process Surveyor have been instructed to Not hold facilities responsible for issues prior to with the new regulations and survey process Communicate with staff concerns related to resident care, not staff management (staff is to notify management of the issues raised) Focus on quality of care and quality of life for the resident

55 IDPH on the New Survey Process Medication Pass Various surveyors will conduct random observations rather than just one person doing them all There is a higher medication error rate noted with the new process The in depth med review, whose residents are chosen by the computer from MDS data, still concentrates on psychotropic and anti psychotic medications Emergency preparedness is evaluated during the annual survey 163 IDPH on the New Survey Process Exit conference will only relate the areas of concerns, not the tag numbers Tag numbers will be on the 2567 If the facility requests the potential tag numbers, the surveyors will tell them Roster key and other key Resident key will be included with the 2567; names those residents cited in deficiencies Other key includes names of others (staff, physician, family, etc.) that are included in deficiency information 164 IDPH on the New Survey Process Facility staff must focus on the Matrix completion and information since the medical conditions identified on the matrix drive the surveyors review Doing a good job with the residents identified on the Matrix assumes the facility is doing a good job in other areas Emergency Preparedness These ETags citations are on a separate 2567 Will be conducted as part of the healthcare annual survey

56 IDPH on the New Survey Process Emergency Preparedness Relate to Emergency plan Policies and procedures in the plan Communication plan Staff training Conducted the 2 mandated exercises Differs from the Life Safety survey where the focus is on E15 Policies & Procedures E22 Implementation of policies and procedures E41 Emergency power systems 166 IDPH on the New Survey Process The number of deficiencies cited is similar to the traditional survey results, with the citations being the same top ten as the traditional survey Compare Illinois to the other states Quality, Certification & Oversight Reports Search criteria CY 2017 December and January 2018 Illinois and National Standard Health survey Any F Tag cites 167 National Results Total of 559 Surveys Completed F880 Infection Prevention & Control F656 Develop/Implement Comprehensive Care Plan Food Procurement, Store/Prepare/Service F812 Sanitary F689 Free of Accident Hazards/Supervision/Devices F657 Care Plan Timing and Revision F761 Label/Store Drugs and Biologicals F550 Resident Rights/Exercise of Rights F684 Quality of Care F758 Free from Unnec Psychotropic Meds/PRN Use F641 Accuracy of Assessments Illinois Results Total 26 Surveys Completed Food Procurement, Store/Prepare/Service F812 Sanitary F880 Infection Prevention & Control F689 Free of Accident Hazards/Supervision/Devices F656 Develop/Implement Comprehensive Care Plan F693 Tube Feeding Management/ Restore Eating Skills F686 Treatment/Svcs to Prevent/Heal Pressure Ulcers F657 Care Plan Timing and Revision F677 ADL Care Provided for Dependent Residents F690 Bowel/Bladder Incontinence, Catheter, UTI F692 Nutrition/Hydration Status Maintenance 168 Request/Refuse//Discontinue Treatment; Adv. F578 Directives 56

57 In Summary Be Prepared Have a notebook with all required information available on a daily basis Continually update matrix information, in particular for those admitted within the last 30 days Education ALL staff on the Care Areas FTags as appropriate Documentation Specific responsibilities Interview techniques Investigative protocols and procedures Infection control Service in dining rooms Etc. 170 Moratorium You will still be cited though may not get civil monetary penalties for noncompliance with certain Phase 2 requirements 18 months to allow for education and implementation Involves forbidding the imposition of civil monetary penalties and denial of payment for new admissions Citations in all Phase 1 and Phase 2 requirements not exempt will be subject to mandatory denial of payments for new admission and termination if compliance is not achieved

58 Moratorium F Tags F655 F740 F741 F758 F838 F881 F865 F926 Baseline care plan Behavioral Services Sufficient/competent staff/access staff behavioral health Psychotropic medications related to PRN limitation Facility assessment Antibiotic Stewardship Program QAPI program and plan related to the development of the QAPI plan Smoking policies 172 Moratorium Directed Plan of Correction or Directed In Service Training may be required for Phase 2 elements that are included in the moratorium If citations are written for both a Phase 1 and a Phase 2 requirement in the same area, enforcement may only be on the Phase 1 requirement Be aware that statutorily mandated remedies are not included by federal law Correction within 3 month Termination after 23 for immediate jeopardy Star Implications The star for health inspection surveys will be frozen for 1 year to allow time for compliance and understanding of the new survey process Only those occurring after November 28, 2017 Applies to annual and complaint surveys Health inspection methodology also changing Will only include the two most recent survey data The most recent is weighted at 60% The prior cycle data is weighted at 40% The number of deficiencies cited and the highest scope and severity will be posted on NHCompare

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