NEW YORK STATE DEPARTMENT OF HEALTH NURSING HOME SURVEILLANCE UPDATE

Transcription

1 NEW YORK STATE DEPARTMENT OF HEALTH NURSING HOME SURVEILLANCE UPDATE S HELLY G LOCK, LNHA, MBA,CPHQ D EPUTY D I REC TOR D I V I S I ON OF N U RS I NG H O M ES AND I C F/ I I D S U RV E I LLANCE C E N T E R FO R H EALT H C A R E P ROVIDER S E RV I C ES AND O V ERS I GHT O F F I C E OF P R I MA RY C A R E AND H EALT H S YSTEMS M A N AGEMENT L EADING A GE, D I R EC TORS OF N U RS I NG S E RV I C ES/SOCI AL W O R K A N N UAL C O NFER ENCE, N OVEMBER 2 1,

2 DIVISION OF NURSING HOMES AND ICF/IID SURVEILLANCE DIRECTOR: JACKIE PAPPALARDI DEPUTY DIRECTOR: SHELLY GLOCK WESTERN REGIONAL OFFICE, AREA PROGRAM DIRECTOR: JOE EGNACZAK CENTRAL NEW YORK REGIONAL OFFICE, AREA PROGRAM DIRECTOR: NANCY FINNIGAN CAPITAL DISTRICT REGION, AREA PROGRAM DIRECTOR: KIM VALENTE METROPOLITAN AREA REGIONAL OFFICE, AREA PROGRAM DIRECTOR: LEAH RYER

3 DIVISION OF NURSING HOMES AND ICF/IID SURVEILLANCE MISSION STATEMENT THE DIVISION OF NURSING HOMES AND ICF/IID SURVEILLANCE WILL ENSURE RESIDENTS OF NYS NURSING HOMES AND ICF/IID FACILITIES ARE PROTECTED FROM HARM THROUGH: CLOSE SURVEILLANCE MONITORING TO ENSURE FACILITIES MEET APPLICABLE FEDERAL AND STATE HEALTH STANDARDS; AND FOSTERING OF CONTINUOUS IMPROVEMENTS THROUGH COLLABORATION WITH THE LONG-TERM CARE COMMUNITY

4 SURVEY PERFORMANCE

5 6,000 5,362 5,448 5,745 5,377 5,535 5,000 4,000 3,000 2,000 1,000 0 FFY- FFY- FFY- FFY- FFY Citations 5,362 5,448 5,745 5,377 5,535

6 ON AVERAGE, 8.2 (LSC AND HEALTH) CITATIONS ARE ISSUED PER RECERTIFICATION SURVEY IN NYS THE NATIONAL AVERAGE IS 9.4 CITATIONS National Average NYS Average

7

8 NYS ROCH BUFF NYC NR LI CNYRO CDRO Substantial Compliance D-F G+

9 TOP 5 CITATIONS INNYS FFY 2014 (THROUGH 9/22/14) (REPRESENTS 24% OF ALL CITATIONS ISSUED) Free of Accident Hazards/Supervision/Devices (F323) Infection Control, Prevent Spread, Linens (F441) Investigate/Report Allegations/Individuals (F225) Provide Care/Services for Highest Well Being (F309) Food Procurement, Store/Prepare/Serve -- Sanitary (F371)

10 F323 Free of Accident Hazards/Supervision/Devices (h) (1)The facility must ensure that the resident environment remains as free of accident hazards as is possible and (h)(2) each resident receives adequate supervision and assistance devices to prevent accidents. This includes: Identifying hazards and risks Evaluating and analyzing hazards and risks Implementing interventions to reduce hazards & risks Monitoring for effectiveness and modifying interventions when necessary

11 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES (F323) WET FLOORS NOT LABELED BATHING FACILITIES WITH NON-SLIP SURFACES WATER TEMPERATURE IN SINKS AND BATH TUBS

12 INFECTION CONTROL, PREVENT SPREAD, LINENS (F441)

13 INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS (F225) SUPERVISION!!

14 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING (F309) DELIVERY OF CARE

15 FOOD PROCUREMENT, STORE/PREPARE/SERVE SANITARY (F371)

16

17 # of Surveys FFY 2010 FFY 2011 FFY 2012 FFY 2013 Recert Complaint FFY 2014

18 TOP IMMEDIATE JEOPARDY (IJ) CITATIONS

19 F323 Accidents Elopement Falls Fires Hot water temperatures Siderails Smoking-assessment and supervision

20 F333 Medications Facility failed to ensure newly admitted/readmitted residents received significant meds timely Facility failed to notify physician when medications were not given as ordered Facility failed to ensure that finger stick blood sugar results were assessed, monitored and reported to physician as indicated

21 F223 Abuse prevention Department of Health staff will continue to review the handling of allegations during survey/complaint investigation by application of the CMS Abuse Prohibition Protocol. 1. SCREENING OF POTENTIAL HIRES 2. TRAINING NEW & ONGOING 3. IDENTIFICATION OF INCIDENTS & ALLEGATIONS WHICH NEED INVESTIGATION 4. RESIDENT PROTECTION DURING INVESTIGATIONS 5. INVESTIGATION OF INCIDENTS & ALLEGATIONS 6. FACILITY REPORT & RESPONSE TO INCIDENTS & INVESTIGATIONS 7. PREVENTION CORRECTIVE ACTION TO PREVENT RECURRENCE, IDENTIFY TRENDS,

22 Common Problems Abuse has not been ruled out Investigation is not initiated immediately The accused continues to have access to resident care Resident or other residents are left unprotected Facility investigation is inconclusive Identification of a need to change the care plan as a result of the incident is not implemented Lack of appropriate training or supervision of staff, or investigative (root cause analysis) skill development 22

23 Advance Directives Advance Directives IJ s have consistently been in the top IJ findings Immediate Jeopardy regulatory tags cited in either: F155- failure to identify or know resident wishes F309- failure to act correctly IJ cited in both standard and complaint surveys The Department expects that nursing facilities will have in place systems, policies and procedures that ensure that resident advance directives regarding basic life support will be identified, known, and honored.

24 What Surveyors look for A written policy and procedure regarding advance directives Each resident has an identified decision maker, when they can no longer make their own decisions Residents and their representatives are provided with Advance Directive education (both verbal and written) and are being provided with the right to formulate an advance directive choice. This should be done as soon as possible following admission. A physicians order is obtained and is the same as the resident s chosen advance directive. The advance directive is documented and communicated to staff Facility staff knows how to access the resident advance directive information in routine and/or urgent situations Facility is trained, react appropriately and deliver care as directed by the advance directive.

25 Advance Directives Findings: The system to identify Advance Directives is not current and/or consistent with residents wishes Staff are unaware of the system to identify residents wishes Staff are not aware of the guidance regarding CPR Systems are convoluted and confusing Complications: Resident has a change in status or condition Resident or legal representative change decision about directives Best Practice: Obtain Advance Directive status on admission and follow through on documentation to support residents wishes Have documentation of residents Advance Directive wishes easily obtainable If in doubt, start CPR and contact

26 OVERVIEW OF COMPLAINT PROGRAM THE CENTRALIZED COMPLAINT INTAKE UNIT ENTERS OVER 10,000 COMPLAINTS/INCIDENTS PER YEAR ABOUT 38% OF ALL INTAKES REQUIRE ON-SITE INVESTIGATION AT THE FACILITY BY REGIONAL OFFICE STAFF, RESULTING IN 3,200 COMPLAINT/INCIDENT SURVEYS PER YEAR THE FOCUS IS ON REGULATORY COMPLIANCE AND FACILITY CULPABILITY TO SUBSTANTIATE COMPLAINTS 10% OF ALL INTAKES INVESTIGATED ON-SITE RESULT IN A STATEMENT OF DEFICIENCY (SOD)

27 Common Complaints by Third Party Care issues-family reports symptoms to staff, no action taken Development of pressure sores Medications not available (especially pain meds) Staffing concerns Medication use of particular drug or overuse of psychoactive medications Not assisting with toileting, incontinence care and eating. No call bell response. Abuse allegations

28 Common facility Reported Incidents Abuse, neglect, mistreatment, and misappropriation of resident property Resident to Resident abuse Dignity issues-staff treating residents poorly Elopements Medication errors

29 QIS UPDATE FOR NEW YORK STATE NYS DOH HAS CONDUCTED 431 QIS SURVEYS IN FFY 2014 (THROUGH 9/22/14) THE AVERAGE CITATION RATE IS 4.5 (1,919 CITATIONS ON 431 SURVEYS) FOR FFY 2014 (THROUGH 9/22/14) ON QIS RECERTIFICATION, HEALTH SURVEYS QIS WILL BE USED IN ALL REGIONS QIS SURVEYS TYPICALLY REQUIRE 4-5 DAYS ON-SITE AT A NURSING HOME THERE ARE 76 REGISTERED QIS SURVEYORS IN NYS

30 QIS Statistics Annual average number QIS citations/total number of QIS surveys by region: FFY 2012 FFY 2013 FFY 2014 CDRO 10.4/25 5.0/4 4.0/6 MARO 5.6/ / /305 WRO 6.1/ / /136 Statewide 6.1/ / /447 30

31 Top Three QIS Citations FFY 2012 FFY 2013 FFY 2014 F 282 3% F 282 3% F 282 3% Services by qual. persons in accord with care plan Services by qual. persons in accord with care plan Services by qual. persons in accord with care plan F 279 3% F 279 3% F 279 3% Dev. comprehensive care plans Dev. comprehensive care plans Dev. comprehensive care plans F 280 3% F 280 3% F 371-3% Dev/prepare/review comprehensive care plan Dev/prepare/review comprehensive care plan Store/prepare/distribute food under sanitary cond. 31

32 QUALITY IMPROVEMENT

33 MEDICATION WORK GROUP INITIATIVE A WORK GROUP WAS CONVENED TO ADDRESS RESIDENTS NOT RECEIVING SIGNIFICANT MEDICATIONS IN A TIMELY MANNER UPON ADMISSION/READMISSION GOAL IS TO IDENTIFY ROOT CAUSE AND DEVELOP OPPORTUNITIES FOR IMPROVEMENT THROUGH COLLABORATION/PARTNERSHIP WITH PROVIDERS MULTIPLE MEETINGS HAVE BEEN HELD TO DATE GUIDANCE RESULTING FROM THE WORK GROUP S EFFORTS WILL BE FORTHCOMING

34 MEDICATION WORK GROUP INITIATIVE SOME COMMONALITIES TO CONSIDER: 1) ARE STAFF AWARE OF PHARMACY DELIVERY SCHEDULES? 2) IS THERE A SYSTEM IN PLACE FOR OBTAINING MEDICATIONS FOR LATE AFTERNOON/EVENING ADMISSIONS? 3) IS THERE COMMUNICATION WITH PHYSICIANS WHEN MEDICATIONS WILL NOT BE AVAILABLE FOR NEXT SCHEDULED DOSE? 4) IS THERE A LACK OF STAFF KNOWLEDGE ABOUT POLICIES/PROCEDURES TO OBTAIN ORDERED MEDICATIONS (COMPLACENCY REGARDING MISSED MEDICATIONS)? 5) ELECTRONIC MEDICAL RECORD (EMR) CONCERNS

35 REDUCING THE USE OF ANTIPSYCHOTIC MEDICATIONS IN NURSING HOME RESIDENTS CMS ANTIPSYCHOTIC INITIATIVE CMS FORMED THE PARTNERSHIP TO IMPROVE DEMENTIA CARE, AN INITIATIVE TO ENSURE APPROPRIATE CARE AND USE OF ANTIPSYCHOTIC MEDICATIONS FOR NURSING HOME RESIDENTS GOAL- ENHANCE THE USE OF NON-PHARMACOLOGICAL APPROACHES AND PERSON CENTERED CARE PRACTICES. INITIAL FOCUS-REDUCE THE NATIONAL RATE OF ANTIPSYCHOTIC MEDICATION USE IN PERSONS LIVING IN NURSING HOME BY 15% BY THE END OF 2012, NEW GOAL OF 25% REDUCTION END OF 2015 (15.97% NYS), 30% GOAL BY END OF 2016 (14.91% NYS) DISTRIBUTED TO ALL NURSING HOMES THE HAND IN HAND TRAINING SERIES THAT EMPHASIZES PERSON-CENTERED CARE, PREVENTION OF ABUSE AND HIGH QUALITY OF CARE FOR RESIDENTS

36 REDUCING THE USE OF ANTIPSYCHOTIC MEDICATIONS IN NURSING HOME RESIDENTS NYS DOH ANTIPSYCHOTIC INITIATIVE NYS DOH IS FOCUSING ON INCREASING KNOWLEDGE AND SUPPORTING SURVEYORS TO DETERMINE COMPLIANCE AND EVIDENCE OF ALTERNATIVES INCREASING AWARENESS OF INITIATIVE AMONG SURVEYORS IDENTIFICATION/SHARING OF BEST PRACTICES AMONG SURVEYORS IDENTIFICATION/SHARING OF EDUCATION AND TRAINING OPPORTUNITIES AMONG SURVEYORS NYS CURRENTLY RANKED 22 NATIONALLY FOR Q (LOWER=BETTER) DATA DEMONSTRATES 17.2% RELATIVE IMPROVEMENT Q Q WITH RATE OF 17.6% FOR Q2 2014

37 REDUCING THE USE OF ANTIPSYCHOTIC MEDICATIONS IN NURSING HOME RESIDENTS Percentage of Long-Stay Residents who Received an Antipsychotic Medication 2011 (Second Quarter) 22.0% 2012 ( Second Quarter) 20.8% 2013 (Second Quarter) 18.9% 2014 (Second Quarter) 17.6%

38 CMS FOCUSED DEMENTIA CARE SURVEY PILOT NYS WAS SELECTED TO BE ONE OF 5 STATES TO PARTICIPATE IN THE PILOT 5 NURSING HOMES SURVEYED ALL SURVEYS HAVE BEEN COMPLETED AND CMS IS NOW ANALYZING THE DATA PILOT SHOULD RESULT IN STREAMLINED SURVEY PROCESS AND GIVE SURVEYORS A BETTER WAY TO ACCURATELY IDENTIFY AND CITE DEFICIENT PRACTICES RELATED TO DEMENTIA CARE NYS CONDUCTED TRAINING FOR ALL NYS SURVEYORS IN OCTOBER

39 Updated F309 and F329 S&C NH: Advanced Copy: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309 Quality of Care and F329 Unnecessary Drugs A new section of interpretive guidance at F309 related to the review of care and services for a resident with dementia; Revisions to the antipsychotic medication section of Table 1 at F329; New severity example at the end of the interpretive guidance at F329 (Unnecessary drugs)

40 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) THE BIG PICTURE QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) DOES NOT REFER TO A PROGRAM QAPI IS AN APPROACH TO DOING OUR WORK COMBINES QUALITY ASSURANCE (QA) AND PERFORMANCE IMPROVEMENT (PI) QAPI USES DATA TO IDENTIFY QUALITY PROBLEMS, CONDUCT ROOT CAUSE ANALYSIS, IDENTIFY OPPORTUNITIES FOR IMPROVEMENT, MONITOR PROGRESS, SET PRIORITIES FEDERAL REGULATIONS UNDER DEVELOPMENT, BUT NOT YET FINALIZED. NO CMS TIMELINE PUBLISHED. TRACK PROGRESS AT:

41 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) QAPI AS A FOUNDATION FOR PERSON-CENTERED CARE: RELIES ON THE INPUT OF RESIDENTS AND FAMILIES MEASUREMENT OF NOT ONLY PROCESS, BUT ALSO OUTCOMES FOR DEFINING QUALITY AS HOW WORK IS DONE BROAD SCOPE ENTIRE ORGANIZATION (ALL STAFF, ALL DEPARTMENTS) LEADERSHIP EXPECTED TO BE A MODEL FOR SYSTEMS THINKING PROACTIVE ANALYSIS VS. BAND-AID APPROACH DATA AND MEASUREMENT DRIVEN SUPPORTED BY TOOLS DEFINING QUALITY AS FEEDBACK DATA SYSTEMS AND MONITORING

42 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) WERE DO I BEGIN? QAPI TOOLS AND RESOURCES QAPI AT A GLANCE FACILITY SELF-ASSESSMENT DEVELOPMENT OF A QAPI PLAN CMS QAPI WEBSITE: CERTIFICATION/QAPI/NHQAPI ALIGNMENT WITH STATE AND NATIONAL INITIATIVES ADVANCING EXCELLENCE IN AMERICA S NURSING HOME CAMPAIGN:

43 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) QUALITY IMPROVEMENT OPPORTUNITY!! QUALITY IMPROVEMENT ORGANIZATION (QIO) QUALITY INNOVATION NETWORK (QIN) NURSING HOME PARTICIPATION WILL PROMOTE: IMPROVED RESIDENT CARE IMPROVED SURVEY PERFORMANCE IMPROVED FIVE-STAR QUALITY RATING REDUCTION/ELIMINATION OF ENFORCEMENT ACTIONS POTENTIAL NURSING HOME QUALITY POOL ELIGIBILITY NYS DOH/QIN PROVIDER RECRUITMENT (FALL 2014) nursinghomes.ipro.org

44 44

45 DISCHARGE PLANNING DO ISSUE WRITTEN NOTICES OF TRANSFER OR DISCHARGE AND/OR CITE REGULATORY BASIS PRIOR TO ANY TRANSFER OR DISCHARGE (LONG TERM CARE AND SUBACUTE) ACCEPTABLE BASES FOR TRANSFER OR DISCHARGE INCLUDE: RESIDENT WELFARE AND RESIDENT NEED CANNOT BE MET AFTER REASONABLE ATTEMPTS AT ACCOMMODATION RESIDENT HEALTH HAS IMPROVED SUFFICIENTLY SO RESIDENT NO LONGER NEEDS SERVICES HEALTH OR SAFETY OF INDIVIDUALS IN THE FACILITY ARE ENDANGERED AND ALL REASONABLE ALTERNATIVES HAVE BEEN EXPLORED FAILURE TO PAY DO READMIT NURSING HOME RESIDENTS WHO ARE TEMPORARILY HOSPITALIZED (NEXT AVAILABLE SEMI-PRIVATE BED) WITHOUT REGARD TO PAYMENT SOURCE WITH OR WITHOUT BED HOLD DO FOLLOW TRANSFER AND DISCHARGE REQUIREMENTS FOR THE SUBACUTE POPULATION

46 DISCHARGE PLANNING HOSPITALS ARE NOT ACCEPTABLE FINAL DISHCARGE LOCATIONS!!

47 MDS TRAINING KNOWLEDGE AND SKILLS TO ACCURATELY AND EFFICIENTLY IDENTIFY, UNDERSTAND AND SCHEDULE MDS 3.0 ASSESSMENTS BEGINNER AND ADVANCED 2 FORMATS (1-DAY IN-PERSON WORKSHOP OR 6-MODULE WEBINAR SERIES) STARTING IN JANUARY, 2015 THROUGH MARCH INFORMATION WILL BE ON THE SCHOOL OF PUBLIC HEALTH WEBSITE AT CONED@ALBANY.EDU WEBINAR -NEW YORK S COMMON MDS CODING ERRORS : STRATEGIES TO IMPROVE MDS ACCURACY. (SPH & DOH PARTNERSHIP) THE WEB BASED TRAINING S WILL BE HELD ON THE FOLLOWING DATES: 1. DECEMBER 3, :30 AM - 11:30 AM 2. JANUARY 7, :00 PM 3:00 PM TO REGISTER FOR THE TRAINING : QUESTIONS?: OR CONED@ALBANY.EDU

48 MDS SURVEY PILOT CMS issued AdminInfo Memo in February 2014 inviting volunteer states to participate in a short-term focused review to assess Minimum Data Set, Version 3.0 (MDS 3.0) coding practices in nursing homes. The purpose of this pilot was to inform future activities to enhance MDS 3.0 accuracy and care planning, including potentially more wide-spread, review activities focused on MDS 3.0 coding accuracy. CMS is now planning to expand this initiative in FFY2015 to approximately MDS Focused Surveys nationwide, 2 2.5% of our nursing homes in NYS. CMS expects the scope of these Focused Surveys will expand to include a verification of the staffing levels of the nursing facility to verify the data self-reported by the nursing home and that was collected during the most recent recertification survey.

49 2014 Nursing Home Quality Initiative*(NHQI) Comprised of three areas: 1. Quality measures- 70 points * Calculated from MDS 3.0 ( all 4 quarters 2013) data, NYS employee flu vaccination data, NH cost report data (annual level of contract/agency staff used), and CMS 5 star quality rating for staffing Includes 14 quality measures each worth max of 5 points 2014 methodology includes paying for high performance as well as improvement from previous year performance for 9 QM s based on quintile distribution( not for threshold value measures) * 49

50 2014 Nursing Home Quality Initiative (NHQI) 2. Compliance-20 points CMS 5 star quality rating for health inspections as of 4/1/14- (adjusted for regional variation by the NYS DOH) - 10 points Timely submission on NH certified cost reports-5 points Timely submission of employee flu immunization data- 5 points. (2.5 points for 11/15/13 & 5/1/14). Single report in 2015 closing 5/1/15* 50

51 2014 Nursing Home Quality Initiative (NHQI) 3. Potentially avoidable hospitalizations-10 points* Based on NHVBP demonstration Currently being reviewed internally by NYSDOH MDS 3.0 assessments 1/1/13-12/31/13 time period. Only long stay NH episodes (101 days or more) used Rate of potentially avoidable hospitalizations per 10,000 long stay episode days Based on primary hospital discharge diagnosis Rates are risk adjusted 51

52 2014 Nursing Home Quality Initiative (NHQI) Ineligibility Immediate Jeopardy deficiencies (J, K, L) between 7/1/13 (measurement yr) & 6/30/14 (reporting yr) Assessed on Oct 1 of reporting year to allow for IDR process Any new JKL deficiencies between July 1 and Sept 30 of reporting yr (2014) are not included in current NHQI but will be included in the next cycle. Exclusions include non-medicaid facilities, CCRC, TCU, specialty facilities and units (vent, TBI, peds, AIDS, BI) Questions: Office of Quality & Patient Safety NHQP@health.ny.gov 52

53 Electronic Prescribing Permissive now Electronic prescribing mandated for ALL prescriptions March 27, 2015 Practitioners and pharmacists are required to use a certified application Certified application must be registered with BNE If the prescription starts electronically, it remains electronic (Fax does not equate to electronic) Current practitioner applications probably do not meet the requirements for electronic prescribing Bureau of Narcotic Enforcement Phone: (866) narcotic@health.state.ny.us

54