QIS PROCESS, PREPARATION AND MANAGEMENT INTERVIEWS & QUALITY MEASURES-PART 2

Transcription

1 QIS PROCESS, PREPARATION AND MANAGEMENT INTERVIEWS & QUALITY MEASURES-PART 2 for clients of: Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL

2 QIS Survey-Part 2 Limited Copyright: August 2014, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH52a - Developed by Polaris Group Page 1 of 91

3 QIS Survey-Part 2 POST-TEST 1. MDS coding will influence care areas chosen for review. a. True b. False 2. Most Critical Elements include staff and resident interviews as well as chart audits and observations: a. True b. False 3. Which of the following statements are incorrect: a. Surveyors are never allowed to interview RN or LPN b. Surveyors expect to see care plan updates post fall c. Surveyors monitor to see if care plan is implemented d. All of the above 4. Which of the following statements are correct: a. Surveyors will use critical elements for their chart reviews b. Surveyors expect to find an accurate MDS c. Surveyors expect to see revisions in care plans d. All of the above FH52a - Developed by Polaris Group Page 2 of 91

4 QIS Survey-Part 2 POST-TEST ANSWERS 1. MDS coding will influence care areas chosen for review. a. True TRUE b. False 2. Most Critical Elements include staff and resident interviews as well as chart audits and observations. a. True TRUE b. False 3. Which of the following statements are incorrect: a. Surveyors will not interview RN or LPN b. Surveyors expect to see care plan updates post fall. c. Surveyors monitor to see if care plan is implemented d. All of the above A 4. Which of the following statements are correct: a. Surveyors will use critical elements for their chart reviews. b. Surveyors expect to find accurate MDS c. Surveyors expect to see revisions to care plans d. All of the above D FH52a - Developed by Polaris Group Page 3 of 91

5 QIS PROCESS, PREPARATION, & MANAGEMENT Focus on Interviews & Quality Measures Part 2 1 Identify Stage 2 Reviews QIS Survey Prep Use Stage 1 Tools and QMs to select high risk residents for survey 2 FH52a - Developed by Polaris Group Page 4 of 91

6 Stage I Reviews (results drive Stage II) Admission Record Review LOS Discharge location Admitted from Died within 30 days Readmit within 30 days of NH admission i Pressure Ulcer first 30 days Weights and heights 3 Stage I Reviews (results drive Stage II) Census Sample Cn Census Smpl Sample Record rdreviews Resident Interviews & Observations Family Interviews Staff Interviews 4 FH52a - Developed by Polaris Group Page 5 of 91

7 Stage I Reviews (results drive Stage II) Census Sample Record Reviews Diagnosis i ADL status Stability of Conditions Pressure Ulcers Psychotropic drug use supported Weights and Heights get weights in order. They must get 4 weights as part of audit. 5 Stage I Reviews (results drive Stage II) Resident Interview Areas reviewed Atiiti Activities Participation in Care plan Building and Environment Contractures Abuse Interaction with others Personal property 6 FH52a - Developed by Polaris Group Page 6 of 91

8 Resident Interview Areas reviewed Pin Pain Stage I Reviews (results drive Stage II) Food quality Hydration Choices? Dignity? i Cleanliness/Grooming/Oral Incontinence 7 Stage I Reviews (results drive Stage II) Resident Interview Areas reviewed Dressing Sufficient Staff Oral Health Privacy Exercise of frights Personal funds 8 FH52a - Developed by Polaris Group Page 7 of 91

9 Stage I Reviews (results drive Stage II) Family Interviews - must interview 3 families of residents that are non-interviewable Select from different units; may ask staff for help. Ask about extent of relationship Choices Activities Privacy Dignity Interaction with others Sufficient Staff 9 Stage I Reviews (results drive Stage II) Family Interviews ADL Assistance Oral Health Abuse Personal Property Building and Environment Exercise of Rights Costs and Personal Funds Admission Process Notification of Change Participation in Care Plan 10 FH52a - Developed by Polaris Group Page 8 of 91

10 Stage I Reviews (results drive Stage II) Staff Interviews May be with RN or LPN Like an open book test Knowledge of resident and care plan Catheter in use? Reason? Nutrition - Nourishments Skin Care/Pressure Ulcer Side Rails Contractures Falls and Fractures 11 Resident Interview & Observation Surveyor makes final decision after talking with each individual resident The BIMS is used to determine interview ability Score 8, resident is interviewable Score 7 or 99, resident is non-interviewable and set to family interview status 12 FH52a - Developed by Polaris Group Page 9 of 91

11 Identify high risk residents for survey High Risk Residents for Survey QMs at the 75 th percentile or greater Pressure ulcer & weight loss & dehydration UTI & catheter and/or Low Risk Incontinence Falls and restraints decline Psychoactive medications ADL decline and restraints Pain& ADL Depressed FH52a - Developed by Polaris Group Page 10 of 91

12 15 Focus QA on High Risk Residents Use QM to select residents for QA checks. Use Census and Admission tools to identify high risk short term residents. Perform Interviews using Interview Tools and observations as part of ongoing QA. Integrate into quarterly care conference process. 16 FH52a - Developed by Polaris Group Page 11 of 91

13 Stage 1 Findings lead to Stage 2 Critical Element Review 17 Critical Element Pathway Each CE Pathway is set up with the same basic format: Assessment F272 Care planning F279 Professional Standards of Care F281 Provision of care and services F281 Care plan revision F280 Concerns with structure, process and/or outcomes related to process of care Guides surveyors through pathway similar to the CAAs. Each pathway suggests specific F-tags that should be considered. 18 FH52a - Developed by Polaris Group Page 12 of 91

14 Stage II Investigation Critical Elements Reviews Activities Activities of Daily Living and/or Range of Motion (includes Cleanliness, Grooming, and Positioning Behavioral and Emotional Status Bowel or Bladder Function / Use of an Indwelling Catheter Communication and Sensory Problems (includes Hearing and Vision) Dental Status and Services Dialysis 19 Stage II Investigation Critical Elements Review Hospice and Palliative Care Hospitalization or Death Hydration Tube Feeding Status Pain Management Physical Restraints PASRR Pressure Ulcers Unnecessary Drugs Rehabilitation and Community Discharge Ventilator Dependent Residents 20 FH52a - Developed by Polaris Group Page 13 of 91

15 Task 7: Stage II Investigation Critical Elements General Critical Elements Accidents Fecal Impaction Other Skin Conditions (such as abrasions, bruises, skin tears, or burns) Non-urinary tract-related infections (such as respiratory or wound infections) Also used for other concerns not related to an existing CE Pathway, such as diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, and non-pressure-related wound care (venous/arterial or neuropathic ulcers) 21 SOM Guidance Only Abuse Accidents/Falls Resident Rights Choices Accommodation of needs Dignity Privacy Social Services Food quality Nutrition Foot care Notification of change Personal property Participation in care plan Rehabilitation 22 FH52a - Developed by Polaris Group Page 14 of 91

16 Pain Short and Long Stay residents with at least one episode of moderate/severe pain or horrible/ excruciating pain of any frequency. 23 F309 Pain Critical Elements Use for any resident with pain Observations For resident pain Care plan implementation Resident/family Interviews Involvement in care planning Nurse Aid Interviews Identifying and reporting pain Record Review Assessment, care plan, revision to care plan Interview of Health Care Practitioners 24 FH52a - Developed by Polaris Group Page 15 of 91

17 F309 Pain Critical Elements Use for any resident with pain Observations For resident pain Care plan implementation Resident/family Interviews Involvement in care planning Nurse Aid Interviews Identifying and reporting pain Record Review Assessment, care plan, revision to care plan Interview of Health Care Practitioners 25 F309 Pain Critical Elements Pain Related F-tags F155 Right to Refuse F279 Comprehensive Care Plans Treatment F280 Care plan revisions F157 Notification of F281 Service meet Professional Changes Standards F242 Self-Determination F282 Care by Qualified Staff and Participation F329 Unnecessary Drugs F246 Accommodation of F385 Physician Supervision Needs F272 Comprehensive Assessments F278 Accuracy of Assessments F425 Pharmacy Services F501 Medical Director F514 Medical Records 26 FH52a - Developed by Polaris Group Page 16 of 91

18 Minimize Risk - Pain Bottom line: Why does the resident have pain? What ongoing ginterventions are in place? Revisions to care plan? Pain Screening and Pain Assessments/CAA for verbal and non-verbal residents resident s pain goal? Monitoring of pain routinely. Pharmacy involvement. Non-drug interventions. Monitoring for effectiveness of meds via medication sheets. 27 Pressure Ulcers Percent of short stay residents with new or worsening Stage 2 4 Pressure Ulcers. The percentage of long stay, highrisk residents with Stage 2-4 Pressure Ulcers 28 FH52a - Developed by Polaris Group Page 17 of 91

19 F314 Pressure Ulcer Critical Elements Observations Care plan implemented? Observe dressing change and wound Resident expresses or appears in pain Resident/family interviews Staff interviews across shift Knowledge of prevention and treatment Interviews with Health Care Practitioners DON or Medical Director 29 F314 Pressure Ulcer Critical Elements Record Review - Assessment Check MDS, CAAs and Assessments. If developed within 1 to 2 days, was risk documented upon admission? Was ulcer assessed for risk, and then documented per recommended criteria? If no signs of healing, was physician called within 2 4 weeks? Take entire resident status into account. 30 FH52a - Developed by Polaris Group Page 18 of 91

20 F314 Pressure Ulcer Critical Elements Record Review - Care Plan Individualized care plan addresses prevention, care and treatment of pressure ulcers. Specific interventions for each risk factor. If refuses or resists, were other measure tried? Record Review Revision to Care Plan Determine e how staff monitors response se to interventions. t Revisions are made if needed. Revisions to interventions if new pressure ulcer or not healing. 31 F314 Pressure Ulcer Critical Elements Compliance with 314 Necessary Services to prevent avoidable PU Treatment effective/revise Other F-Tags that could be cited F157 Notification of changes F272 Comprehensive Assessment F279 Comprehensive Care Plan F280 Comprehensive Care Plan Revision F281 Services provided meet professional standards 32 FH52a - Developed by Polaris Group Page 19 of 91

21 F314 Pressure Ulcer Critical Elements Determination of Compliance F271 Admission orders F278 - Accuracy of Assessments F309 Quality of Care F353 Sufficient Staff F385 Physician Supervision F498 - Proficiency of Aides F501 Medical Director F514 - Medical Records 33 Minimize Risk Pressure Ulcer Risk tools and Assessment/CAA notes Interventions for risk factors QA all new pressure ulcers Consider Incident Report for in-house PU Ensure family, physician called. Care plan revision/change interventions. Write a summary IDT/Assessment note outlining risk factors. Ensure weekly assessments. Ensure physician notified if not progressing. 34 FH52a - Developed by Polaris Group Page 20 of 91

22 Minimize Risk - Pressure Ulcer Ongoing: Repeat Stage 2 care plan revised Admission Accurate assessment and documentation of pressure ulcers. Review care plan for any residents with worsening pressure ulcers to ensure all risk factors are documented and care planned. Revise care plan and notify physician if PU is not improving. Ensure care plan is implemented. 35 Falls Percent of long stay residents who have experienced one or more falls with major injury reported. The Percentage of residents who have had a Fall. FH52a - Developed by Polaris Group Page 21 of 91

23 General Critical Elements Use accidents or risk, falls, other issues Observations Care plan implementation Resident/family Interviews Involvement in care planning Nurse Aid Interviews Identifying and reporting pain Record Review Assessment, care plan, revision to care plan Interview of Health Care Practitioners 37 Reviews: General Critical Elements F323 Accidents F-tags: Accommodation of needs, Assessment, care planning, professional practices, staffing, devices, records, medical director, pain. 38 FH52a - Developed by Polaris Group Page 22 of 91

24 Minimize Risk Falls F323 Ongoing QA: Fall Risk at admission and quarterly Fall CAA complete Care plan addresses risk factors Interventions followed Creative solutions less restrictive Review assessment to underlying cause and care planning prior to fall to determine if fall or injury might have been avoidable. 39 Minimize Risk - Falls Ongoing QA: Ensure incident ident report completed. If major injury, ensure reported as required by State. Ensure care plan reviewed and revised post event. Date interventions. Ensure realistic goals. Refer to therapy or restorative as indicated. 40 FH52a - Developed by Polaris Group Page 23 of 91

25 Restraints The percent of long stay nursing facility residents who are physically restrained on a daily basis. 41 Physical Restraint Critical Elements Use restraint or device Observations Care plan implementation Resident/family Interviews Involvement in care planning Nurse Aid Interviews Identifying and reporting pain Record Review Assessment, care plan, revision to care plan Interview of Health Care Practitioners 42 FH52a - Developed by Polaris Group Page 24 of 91

26 Physical Restraint Critical Elements F221 Physical Restraints F-tags: Assessment, care planning, professional practices, staffing, devices, records, medical director, quality of life, resident rights, pain. 43 Minimize Risk - Restraints Ongoing QA: Restraint CAA complete. Ensure assessment in place. Physician orders and consent in place. Care plan is current. Physician orders are followed. Continue to reduce and ensure least restrictive Note: QM does not include restrictive side rails or other. 44 FH52a - Developed by Polaris Group Page 25 of 91

27 Minimize Risk - Restraints Ongoing QA: Obtain orders for all types of devices even if used for positioning. Get orders for side rails which could be restrictive Document why a device is not restrictive for that resident. Lap buddy Floor cushion chair Wall Lap table Wedge pillow Merry walker Side rail 45 Reclined chair UTI Percentage of long stay residents who have a urinary tract infection 46 FH52a - Developed by Polaris Group Page 26 of 91

28 Lose Control Bladder/Bowel The percent of long stay residents who frequently lose control o of their bowel or bladder. 47 Catheter Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder. 48 FH52a - Developed by Polaris Group Page 27 of 91

29 Catheter Justification: Urinary retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible and is characterized by: Documented post void residual (PVR) volumes in a range over 200 milliliters (ml); Inability to manage retention/incontinence with intermittent catheterization; and Persistent overflow incontinence, symptomatic infections, and/or renal dysfunction. 49 Catheter Justification: Contamination of Stage 3 or 4 pressure ulcer with urine which has impeded healing, despite appropriate personal care for the incontinence; and Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain. 50 FH52a - Developed by Polaris Group Page 28 of 91

30 F315 Bowel/Bladder/Catheter Critical Elements Observations Staff implements care plan consistently over multiple shifts. Will observe peri-care. Indwelling catheter Infection control regarding hand washing, catheter care, tbi tubing and collection bag. 51 F315 Bowel/Bladder/Catheter Critical Elements Resident/family interviews Involvement in care plan, goals and preferences honored. Awareness of existing continence program. Nursing Assistant Interviews Awareness of current interventions. Interviews with Health Care Practitioners Interview if care practices do not seem to reflect current standards or best practices - physician, Medical Director, charge nurse, or DON. 52 FH52a - Developed by Polaris Group Page 29 of 91

31 F315 Bowel/Bladder/Catheter Critical Elements Record Review - Assessment Check MDS and CAAs and Assessments. Rationale for toileting plan and voiding pattern. Rationale for use of indwelling catheter. Type of incontinence. Record Review - Care Plan Specific interventions i to minimize i i incontinence. i Scheduled toileting or retraining plan. Approaches for check and change. Indwelling catheter protocol care. 53 F315 Bowel/Bladder/Catheter Critical Elements Record Review Revision to Care Plan Determine that staff monitors response to interventions. Revisions are made if decline or improvement. Alternative approaches tried if failed or noncompliant. Compliance with F-tag 315 Provide care and treatment to prevent incontinence. Provide justification for use of indwelling catheter. 54 FH52a - Developed by Polaris Group Page 30 of 91

32 F315 Bowel/Bladder/Catheter Critical Elements Determination of Compliance F312 Quality of Care hygiene F385 Physician Services F441 Infection Control hand washing F498 Proficiency of Nurse Aides F353 Sufficient Staff F501 Medical Director Did Medical Director Assist with development of policies and program standards 55 F315 Bowel/Bladder/Catheter Critical Elements Determination of Compliance Other F-Tags that could be cited F157 Notification of changes F241 - Dignity F272 Comprehensive Assessment F279 Comprehensive Care Plan F280 Comprehensive Care Plan Revision F281 Services provided meet professional standards F309 Quality of Care pain 56 FH52a - Developed by Polaris Group Page 31 of 91

33 Minimize Risk - UTI/Catheter/Lose Control Bladder/Bowel Ongoing QA: Why is resident wetting themselves and can it be avoided? Admission and Quarterly assessments. Voiding pattern at admission, decline/failure to meet goal, or SCSA. Care plan addresses elimination and toileting plan. Staff toilet residents per plan. 57 Minimize Risk - UTI/Catheter/Lose Control Bladder/Bowel Ongoing QA: Measure success by coding on MDS in terms of episodes of incontinence. If resident has an increase in incontinence, perform voiding pattern and adjust toileting plan. Re-do voiding pattern if increase in number of episodes of incontinence Observe staff providing peri-care 58 FH52a - Developed by Polaris Group Page 32 of 91

34 Ongoing QA: Minimize Risk - Catheter Physician iindocumentation mnttinsupports pprt medical mdi necessity. Ensure infection control practices are followed. Ensure dignity is maintained. 59 ADL Decline The percent of long stay residents whose need for help with late-loss Activities of Daily Living (ADLs) has increased when compared to the prior assessment 60 FH52a - Developed by Polaris Group Page 33 of 91

35 ADL and ROM Critical Elements Observations Care plan implemented? Observe care/may review restorative doc. Resident expresses or appears in pain Resident/family interviews Staff interviews across shift Knowledge of prevention and treatment Interviews with Health Care Practitioners DON or Medical Director 61 ADL and ROM Critical Elements ADL / ROM Critical Elements Includes cleanliness, grooming and positioning Reviews: F310, 311, 312 Maintaining ADLs F317 and 318 Maintaining ROM F-tags: Accommodation of needs, Assessment, care planning, professional practices, staffing, devices, records, medical director, pain. 62 FH52a - Developed by Polaris Group Page 34 of 91

36 Ongoing QA: Minimize Risk Decline in ADL/ROM Therapy to review QA report rt monthly for possible referral. Ensure if coding decline in ADLs, to reassess and update care plan. List all risk factors. Refer to restorative/or therapy if declined. Include ROM and positioning devices on care plan. 63 Weight Loss The percentage of long stay residents who had a weight loss of 5% or more in the last month or 10% or more in the last two quarters and were not on a physician prescribed weightloss regimen. 64 FH52a - Developed by Polaris Group Page 35 of 91

37 Weight Loss Use General Critical Elements No Nutrition Critical Element at this time Use Hydration or Tube Feeding Critical Elements 65 Ongoing QA: Minimize Risk - Nutrition Ensure accurate risk identification for weight loss or hydration. Clear criteria for referral to Nutrition Risk team Monitor high risk residents with at least a monthly summary and weekly weights. Revise care plan if weight loss can be minimized. 66 FH52a - Developed by Polaris Group Page 36 of 91

38 Minimize Risk Nutrition Ensure interventions are in place to meet hydration needs if fluid needs are not met. RD oversight for all tube feedings. Observe tube feedings and medication administration. Ensure orders are followed Notify dietary of who is under survey. Perform QA checks for temps and matching tray to diet order/preferences. 67 Depressed State The percentage of long stay residents who have had symptoms of depression during the 2-week period preceding the MDS 3.0 target assessment date. 68 FH52a - Developed by Polaris Group Page 37 of 91

39 Behavior Symptoms Percentage of residents who have bh behavior symptoms that affect others. Physical Behavior directed towards others Verbal behaviors directed toward others Oh Other behaviors directed dtoward others Rejection of Care Wandering 69 Behavioral & Emotional Status Critical Elements Observations Care plan implemented? Observe care/may review restorative doc. Resident expresses or appears in pain Resident/family interviews Staff interviews across shift Knowledge of prevention and treatment Interviews with Health Care Practitioners DON or Medical Director 70 FH52a - Developed by Polaris Group Page 38 of 91

40 Behavioral & Emotional Status Critical Elements F319 Services for mental and psychosocial adjustment F320 Minimize decline in mental and psychosocial well-being. Other F-tags: Accommodation of needs, Social Services, Assessment, care planning, professional practices, staffing, devices, records, medical director, pain. 71 Minimize Risk Depressed State/Behaviors Ongoing QA: Care plan addresses mood and behavior issues. Ensure referral to mental health specialist as indicated. Appropriate medication management: If not on anti-depressants, why not? Non-drug interventions are included on care plan. 72 FH52a - Developed by Polaris Group Page 39 of 91

41 Minimize Risk Behavior Symptoms Ongoing QA: Ensure behaviors are assessed for root cause. Care plan designed to decrease episodes or intensity. Behavior monitor in place to identify non-drug interventions. Care plan may include medication management. Obtain diagnosis. 73 Psychoactive Medications The Percentage of residents who are receiving antipsychotic medications. Percentage of residents now receiving antipsychotic medications. (short stay) Percentage of residents who are receiving antianxiety or hypnotic medications, but do not have evidence of a psychotic or related condition. 74 FH52a - Developed by Polaris Group Page 40 of 91

42 Unnecessary Meds & Med Regimen Review Critical Elements Applies to all medications, not just psychoactive meds. Designed to determine whether the resident receives: Only medications clinically indicated in the dose and duration to meet the resident s needs. GDR attempts for antipsychotics unless clinically contraindicated and tapering for other medications. Applied to all resident reviews: Triggered because of type of meds. 75 Unnecessary Meds & Med Regimen Review Critical Elements Aspects of the unnecessary medication requirement leading to noncompliance: Inadequate indications for use including antipsychotics Inadequate Monitoring Excessive Dose Excessive Duration Adverse Consequences Antipsychotic Medications without GDR and Behavioral Interventions unless clinically contraindicated 76 FH52a - Developed by Polaris Group Page 41 of 91

43 Unnecessary Meds & Med Regimen Review Critical Elements Observations For adverse effects for care plan interventions meds and non-drug. Resident/family interviews Record review Clinical indications for use Monitoring in place Dose/duration Reduction attempts 77 Unnecessary Meds & Med Regimen Review Critical Elements Medication Regimen Review Determine: Whether the pharmacist reported any irregularities with the medication regimen. Whether the attending physician or DON acted on identified irregularities. Whether the pharmacist identified d a suspected adverse consequence to which the attending physician did not respond, but the staff followed up. 78 FH52a - Developed by Polaris Group Page 42 of 91

44 Unnecessary Meds & Med Regimen Review Critical Elements Record review Assessment, care planning, professional practices Staff interviews/medical Director/Pharmacist F-tag: F329 Unnecessary drugs F428 Medication Regiment Review 79 Unnecessary Meds & Med Regimen Review Critical Elements Additional F-tags F157 Notification of change F Notice of Rights and Services/Free choice F272 Comprehensive Assessments F Comprehensive Care Plan F310 Decline in ADLs F315 Urinary Incontinence F Mental and Psychosocial Functioning F325 Nutritional parameters 80 FH52a - Developed by Polaris Group Page 43 of 91

45 Unnecessary Meds & Med Regimen Review Critical Elements Additional F-tags F327 Hydration F329 Unnecessary Medications F385 Physician Supervision F386 Physician Visits F425 Pharmacy Services F428 Medication Regimen Review F501 Medical Director 81 Minimize Risk - Antipsychotic/Antianxiety/Hypnotics Ongoing QA: Ensure accurate coding of diagnoses of symptoms and meds. Ensure medical record contains a diagnosis for use even if not one of the exclusions. Evidence of drug reduction or documentation by physician supporting decision to not reduce meds. Pharmacy drug reviews in compliance. 82 FH52a - Developed by Polaris Group Page 44 of 91

46 Minimize Risk - Antipsychotic/Antianxiety/Hypnotics Ongoing QA: Pharmacist aggressive in documentation ti n to support use; ensure correct dosage/duration. Monthly reviews consider adverse reactions to meds. Behavior monitor in place to help measure effectiveness. Side effect monitoring in place i.e. med sheet. Review and summary at least quarterly. 83 Leading Deficiencies Assessment F272 Care Planning F279 Professional Standards of Care F281 Accident/Hazards F323 Quality of Care F309 Unnecessary Medications F329 Bowel/Bladder Function F315 Dignity F241 Food Handling F371 Pressure Sores F 314 Infection Control F441 Environment F253 Notify of Change F157 Resident Abuse F Staffing F FH52a - Developed by Polaris Group Page 45 of 91

47 F272/F279 Assessments and Care Plans Behaviors/Psychoactive Medication Use Refusals of care or treatment Restraint use Nutrition Skin Conditions (pressure and non-pressure n r related conditions) Discharge planning Failure to follow-through Failure to be measureable Dehydration Catheter use Activities Advance Directives 85 F282 Qualified Persons Labs and medications not initiated, as ordered Diet not served as ordered; mechanically altered Blood glucose monitoring/ insulin coverage not administered as ordered Fall interventions not in place as ordered Failure to monitor and document consumption of supplements Failure to clarify medication orders to ensure complete medication orders are in place 86 FH52a - Developed by Polaris Group Page 46 of 91

48 F282 Qualified Persons Appointments not scheduled Treatment not provided as ordered Positioning devices Adherence to fluid restrictions Thickened liquids Splint/orthotic i application i as ordered d Dressing not in place as ordered 87 F323 Accidents/Supervision Side rails/assessment/entrapment risk Utilize lift according to manufacturer s instructions Proper transfers as per plan of care Residents toileted; left unattended Meds unattended/cart unlocked 88 FH52a - Developed by Polaris Group Page 47 of 91

49 F323 Accidents/Supervision Fall risk identified/interventions implemented/root cause identified/avoidable Bed and chair alarms not in place as indicated in POC Improper storage of chemicals Elopement risk/supervision Unsafe water temperatures 89 F309 Quality of Care Pain End-of-Life (Hospice) DNR Fractures Diabetes Renal disease Non-pressure related skin issues Resident positioning Abnormal lab results (reporting and treatment) Coordination of dialysis services (monitoring weight, access site) Timely specimen collection Evaluation and treatment of resident pain Assessment of bruising, skin tears (non-pressure e related skin conditions) Failure to notify physician of change in condition (deterioration) 90 FH52a - Developed by Polaris Group Page 48 of 91

50 F329 Unnecessary Drugs Antipsychotics without medical justification and/or lacking monitoring for side effects Hypnotics without adequate justification Anticoagulent medication and laboratory monitoring Adequate indications for PRN anti-anxiety medication administration Lack of attempted non-pharmacological interventions Lack of review for Gradual Dose Reduction 91 F315 Bowel and Bladder Function Lack of proper incontinence care Decline in bladder function- lacking assessment, training, etc. Lack of order for use and care of an indwelling catheter UTIs and catheter utilization Drainage bag/tubing bin maintenance n n (below bladder level) Obtaining timely UAs, as ordered Lack of medical justification for catheter use 92 FH52a - Developed by Polaris Group Page 49 of 91

51 F314 Pressure Sores Lack of skin assessment Dressing not changed, as ordered Failure to comprehend care plan and address specific conditions Failure to obtain treatment (wound worsened) Lack of position changes Cushions/devices not in use Treatment not done in accordance with physician s orders 93 Summary Use QMs to identify if high h risk residents for survey. Integrate Interviews into ongoing QA and quarterly care reviews. Focus efforts on ensuring high risk charts are in compliance. 94 FH52a - Developed by Polaris Group Page 50 of 91

52 Resident Interview Ask screening questions similar to the following: 1. Are you from around here, the area, etc? 2. Tell me a little about yourself. 3. How long have you been here? 4. What is the food like here? Proceed with the interview questions below if you are comfortable that the resident is interviewable. A Cognitive Status 1) Is the resident able to be interviewed? Not Interviewable Interviewable Resident refused interview Resident is unavailable for an interview If the resident is interviewable, proceed to the Resident Interview section on the following page. If the resident is not interviewable, refuses, or is unavailable (after repeated attempts to interview) proceed to the Resident Observation section on the following page (the resident is excluded from the resident interview). Notes: FH52a - Developed by Polaris Group Page 51 of 91

53 An asterisk * indicates that this care area has a low triggering rate from the DAR-RO. B Choices QP234 Resident Interview 1) Do you choose when to get up in the morning? If No: What time do you get up? What time would you like to get up in the morning? 2) Do you choose when to go to bed at night? If No: What time do you go to bed? What time would you like to go to bed? 3) Do you choose how many times a week you take a bath or shower? If No: How many times a week do you get a bath or shower? How many times a week would you like to bathe? 4) Do you choose whether you take a shower, tub, or bed bath? If No: What type of bathing are you receiving? What would you like to receive? 5) Can you have visitors anytime during the day or night? If No: What are the visiting restrictions? Comments: C Dignity QP212* 1) Do staff treat you with respect and dignity? If No, Tell me some examples about when staff did not treat you with respect and dignity. The focus of this question is how well staff interacts with the resident. N/A, the resident is independent with ADLs N/A, the resident is independent with ADLs N/A, the resident is independent with ADLs N/A, the resident is independent with ADLs Resident Observation A Cleanliness/Grooming/Oral QP075* QP216 1) Based on general observations, did you see any of the following? (Mark all that apply) A: Unpleasant body odor (other than signs of incontinence) B: Skin unclean (i.e., food on face and hands) C: Eyes are matted D: Mouth contains debris, or teeth/dentures not brushed, or mouth odor, or dentures not in place E: Teeth broken/loose, or inflamed/bleeding gums, or problems with dentures F: Hair is uncombed and not clean G: Facial hair not removed or unshaven H: Fingernails are unclean and untrimmed I: Clothing and/or linens are soiled (other than signs of incontinence) J: Glasses are dirty or broken K: None of the above B Incontinence QP260* 1) Are there signs of incontinence, such as odor and/or wetness? C Dressing QP074 1) Based on general observations, did you see any of the following? (Mark all that apply) A: Clothing in poor repair, improper fit, or worn inappropriately B: Inappropriate foot coverings (i.e., shoes without non-skid soles) C: None of the above Comments: FH52a - Developed by Polaris Group Page 52 of 91

54 An asterisk * indicates that this care area has a low triggering rate from the DAR-RO. D Activities QP208* Resident Interview 1) Do you participate in any of the activity programs here? 2) Do the organized activities meet your interests? 3) Do you receive assistance for things you like to do, such as supplies, batteries, books? (Facility should have items available for residents to use.) 4) Are there activities offered on the weekends, including religious events? 5) Are there activities available in the evenings? Comments: Do not wish to participate Resident Observation D Activities QP096* (Complete for residents who are not interviewable due to cognitive screening. Do not complete for residents who are interviewable, have refused to be interviewed, or are unavailable.) 1) Did you observe the resident in activities during the two days of Stage 1? (This is not limited to group activities or scheduled activities.) 2) Is the resident actively participating in the activities or does staff encourage the resident to participate? Comments (skip to E) E Building and Environment QP201* 1) Is this a comfortable building in which to live? (Comfortable includes appropriate temperature, lighting, and noise levels.) 2) Is the facility clean? Comments: E Contractures QP077 QP076 1) Does the resident have a contracture? (Defined as a condition of fixed high resistance to passive stretch of a muscle.) If unable to determine ask staff member. 2) Does the resident have splint devices in place? (Answer "No" if device not present or is incorrectly applied.) Comments: (skip to F) F Participation in Care Plan QP210 1) Have you been involved in decisions about your daily care? FH52a - Developed by Polaris Group Page 53 of 91

55 An asterisk * indicates that this care area has a low triggering rate from the DAR-RO. Resident Interview G Abuse QP253 1) Have you ever been treated roughly by staff? 2) Has staff yelled or been rude to you? 3) Do you ever feel afraid because of the way you or some other resident is treated? If the resident answers Yes, ask who, what, when, where, how often? H Interaction with Others QP246* 1) Have there been any concerns or problems with a roommate or any other resident? 2) Has the staff addressed the concern(s) to your satisfaction? I Personal Property QP194 1) Were you encouraged by staff to bring in any personal items? If No: Do you wish to have items brought in? 2) Have you had any missing personal items? If Yes: What is still missing and how long has it been missing? 3) Did you tell staff about the missing item(s)? If Yes: Who did you tell about the missing item? If the answer is "Yes," then ask question 4. 4) Has staff told you they are looking for your missing item(s)? If No, do you know who or which department is supposed to be looking for your missing item? Comments: (skip to I) N/A, the resident is a short-stay resident Resident Observation F Abuse QP205 1) Are staff treating the resident in a manner that may indicate abuse (yelling at resident, striking resident, treating resident in a rough manner, etc.)? G Skin Problems/Conditions (other than pressure ulcers) QP261* 1) Were any of the following observed? (Mark all that apply) A: Abrasions and/or lacerations B: Bruises C: Skin Tears D: Burns E: None of the above H Potential Restraints QP089* QP092 1) Does the resident have a potential restraint in place (physical device or equipment that may potentially restrict a resident s movement and/or access to her/his body)? (skip to I) 2) Which potential restraints are being used? (Mark all that apply) A: Potential limb restraint B: Potential trunk restraint C: Chair potentially prevents rising D: Bed side rails E: Other (e.g., mittens), please describe 3) Is the device correctly applied? (Such as potential trunk and limb restraints. See Section L below for bed side rails.) Comments: FH52a - Developed by Polaris Group Page 54 of 91

56 An asterisk * indicates that this care area has a low triggering rate from the DAR-RO. J Pain QP255* Resident Interview 1) Do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief? Comments: I Pain QP129* Resident Observation 1) Were any of the following observed? (Mark all that apply) A: Vocalization of pain: constant muttering, moaning, groaning B: Breathing: strenuous, labored, negative noise on inhalation or expiration C: Pained facial expressions: clenched jaw, troubled or distorted face, crying D: Body language: clenched fists, wringing hands, strained and inflexible position, rocking E: Movement: restless, guarding, altered gait, forceful touching or rubbing body parts F: None of the above K Food Quality QP249* 1) Does the food taste good and look appetizing? 2) Is the food served at the proper temperature? L Hydration QP258* 1) Do you receive the fluids you want between meals? Comments: N/A, does not take fluids orally Comments: J Hydration QP182* 1) Does the resident demonstrate physical signs of dehydration (i.e., dry, cracked lips and/or dry mouth; exhibits signs of thirst, etc.)? Comments: FH52a - Developed by Polaris Group Page 55 of 91

57 An asterisk * indicates that this care area has a low triggering rate from the DAR-RO. M Sufficient Staff QP232* Resident Interview 1) Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? N Oral Health QP254 QP256 1) Do you have mouth/facial pain with no relief? 2) Do you have any chewing or eating problems (could be due to: no teeth, missing teeth, oral lesions, broken or loose teeth)? 3) Do you have tooth problems, gum problems, mouth sores, or denture problems? 4) Does staff help you as necessary to clean your teeth? 5) How often are your teeth/dentures/mouth cleaned (routine oral hygiene)? O Privacy QP204* 1) Does staff provide you privacy when they work with you, changing your clothes, providing treatment? 2) Do you have privacy when on the telephone? 3) If you would have a visitor, do you have a private place to meet? Comments: N/A, do not need assistance (Skip to O) Daily Weekly Monthly Never N/A, do not use telephone K Positioning QP233* Resident Observation 1) Were any of the following observed? (Mark all that apply) A: Sagging mattress while lying in bed B: Bed sheets tucked tightly over toes holding the feet in plantar flexion C: Legs and/or feet hanging off the end of a too-short mattress D: No padding between bony prominences (residents not able to position themselves) E: Wheelchair too big or too small (i.e., seat too long/short, seat too high/low) F: Uncomfortable geri-chair positioning, hyperflexion of the neck, sliding down in the chair, no support for the legs G: Dangling legs and feet (that do not comfortably reach floor and/or without needed foot pedals in place) H: Leaning to the side without support to maintain an upright position I: Lack of needed head or torso support J: Lack of arm/shoulder support K: Resident observed in the same position for long periods of time when in the wheelchair or in bed (Resident is not repositioned in chair at least every hour and in bed at least every two hours) L: None of the above Comments: L Potential Accident Hazards/Bed Side Rails QP218 1) If the bed side rails are in the up position, do the bed side rails fit the bed properly to prevent the resident from being caught between the side rails and mattress? Comments: N/A, side rails are not observed in the up position FH52a - Developed by Polaris Group Page 56 of 91

58 An asterisk * indicates that this care area has a low triggering rate from the DAR-RO. P Exercise of Rights QP250 Resident Interview 1) Have you been moved to a different room or had a roommate change in the last nine months? 2) Were you given notice before a room change or a change in roommate? Q Personal Funds QP199 1) Do you have a personal funds account with the facility? 2) Does the facility let you know how much money you have in your account? 3) Can you get your money when you need it, including on weekends? (Skip to Q) (Skip #2 & 3) Do Not Know (Skip #2 & 3) Do Not Know Do Not Know M Resident s Room* Resident Observation 1) Were any of the following observed? (Mark all that apply) A: Odor in resident s room QP221 B: Walls, floors, ceilings, drapes, or furniture are not clean or are in disrepair QP222 C: Environment does not accommodate individual needs and preferences QP147 D: Lighting levels are inadequate or uncomfortable QP223 E: Room temperatures are uncomfortable or unsafe QP224 F: Sound levels are uncomfortable QP225 G: Bedrooms are not equipped to assure full privacy (i.e., curtains, moveable screens, private rooms, etc.) QP151 H: Clean bed/bath linens are not available or are in poor condition QP152 I: Evidence of insects or rodents in bedrooms or bathrooms QP226 J: None of the above Comments: 2) Were any of the following observed? (Mark all that apply) A: Electric cords, extension cords, or outlets are in disrepair or used in an unsafe manner QP228 B: Bed and linens are visibly soiled with stool or urine QP260 C: Resident care equipment is unclean, in disrepair or stored in an improper or unsanitary manner QP140 D: Ambulation, transfer or therapy equipment are unclean or in unsatisfactory condition QP229 E: Safety equipment in bedroom or bathroom is inadequate (i.e. grab bars, slip surface) QP230 F: Call system in room or bathroom is not functioning. Call light not within reach for residents capable of using it QP231 G: None of the above Comments: FH52a - Developed by Polaris Group Page 57 of 91

59 An asterisk * indicates that this care area has a low triggering rate from the DAR-RO. Resident Observation N Dignity QP266* 1) Based on general observation, did you see any of the following? (Mark all that apply) A: Staff dressed resident in institutional fashion such as a hospital type gown during the day B: Clothes labeled with the resident s name visible C: Staff failed to knock and/or request permission to enter the room or wait to receive permission to enter D: Staff failed to explain the service or care they are going to provide E: Staff failed to include the resident in conversations while providing care or services F: Staff used a label for the resident (e.g., feeder or honey ) G: Staff posted confidential clinical or personal care instructions in areas that can be seen by others H: Staff failed to treat the resident respectfully when providing care to the resident s roommate; I: Staff failed to treat the resident with respect and dignity during care and services, such as: Making disapproving comments such as What do you want now? Mimicking or making fun of the resident Displaying disapproving behavior (rolling their eyes, or sighing) J: Staff failed to provide visual privacy of the resident s body while transporting him/her through common areas, or uncovered in their rooms but visible to others K: Staff failed to cover a urinary catheter bag or any other type of body fluid collection device L: Staff failed to respond to the resident s call for assistance in a timely manner M: Any other identified dignity concerns (document concerns) N: None of the above O Sedation 1) Is the resident excessively sedated? FH52a - Developed by Polaris Group Page 58 of 91

60 The survey team will interview three (3) family members in each facility during Stage 1 of the survey process. This interview will be conducted with a person (family, friend or guardian) who knows the resident well and visits the facility often enough to provide information about service provided. Adjust the questions and probes as necessary to make them applicable to this resident and the individual being interviewed. If an interviewee is not appropriate for an interview or two attempts to reach the family member/friend have been unsuccessful, select another sample resident from the sample of non-interviewable Census Sample residents. Do not move outside the Census Sample. Exhaust all possible sample residents form the sample of non-interviewable Census Sample residents either by onsite contact or telephone. Select family members of residents from various units in the facility when possible. Instructions: Introduce yourself, explain the survey process, and the purpose of the interview using the following concepts. It is not necessary to use the exact wording. At all times, be cognizant of resident confidentiality. [Name of facility] is inspected by a team from the [Name of State Survey Agency] periodically to assure that residents receive quality care. While we are here, we make observations, review the nursing home s records, and talk to residents and family members or friends who can help us understand what it s like to live in this nursing home. We appreciate your taking the time to talk with us. We ask these questions because we want to know about [resident s name] prior lifestyle and discuss with you whether her/his past preferences are still applicable and if the facility accommodates them. We want to know about your opportunity for involvement in decisions about [resident s name] care and schedule. We also want to know your views on services she/he receives here, and in general, what you think of the facility. The following questions are asked to determine the family member s awareness and satisfaction with certain aspects of facility life and care for the resident. The surveyor should probe more deeply, using the suggested probes, whenever there is a negative response to determine the exact nature of the concern. FH52a - Developed by Polaris Group Page 59 of 91

61 Screening Questions The questioning below screens the interviewee to see if she/he knows the resident well enough to complete the rest of the interview. Based on answers to question 1, decide whether you can complete the interview, can complete it partially if the family member knows about some areas of the resident s care, or should conclude the interview. If you find that the family member has little or no knowledge of the resident s past history, you may want to discontinue the interview. However, if he/she visits the facility frequently, his/her answers may give information about the current care of the resident. Ask about the nature and extent of the relationship between the interviewee and resident both prior to and during nursing home residence: a. With whom did your relative/friend live before coming to the nursing home? If the resident did not live with you, how often did you see her/him? b. Are you familiar with her/his preferences and daily routines when she/he was more independent and more able to make choices and express preferences? (If the resident has had a lifelong disability, ask about choices and preferences prior to moving to this facility. Adapt additional questions as necessary.) If No, conclude interview. c. How often do you visit the resident now? When do you visit (time of day, day of the week)? If you decide you must conclude this interview because the interviewee has little or no knowledge of the resident or only visits occasionally, ask a general question that lets the family member say what he/she wishes about the facility such as: Is there anything you would like to tell me about this facility and how your relative is treated? Record any pertinent information in the comments section. Comments: FH52a - Developed by Polaris Group Page 60 of 91