4/13/2018. Sanderson & Scott. Survey Compliance Consultants IDAHO HEALTH CARE ASSOCIATION. April 27, 2018 Pocatello, Idaho

Size: px

Start display at page:

Download "4/13/2018. Sanderson & Scott. Survey Compliance Consultants IDAHO HEALTH CARE ASSOCIATION. April 27, 2018 Pocatello, Idaho"

Audrey Wiggins
5 years ago
Views:

1 Sanderson & Scott Survey Compliance Consultants 1 IDAHO HEALTH CARE ASSOCIATION April 27, 2018 Pocatello, Idaho 2 1

2 New SNF Survey Process - First 8-10 hours Survey Preparation Strategies What does the data so far show 3 But first The Golden Rule! Everything you do as a member of your facility s healthcare team should begin with, follow, and reflect the Nursing Process Document EVERYTHING 4 2

3 Nursing Process? A Refresher Assess What is the issue Diagnose What is causing the issue Plan What is the best solution Implement - Act Monitor Are interventions implemented per the Plan? Revise Is the solution working? If at first you don t succeed 5 The Critical First 8-10 Hours of Survey What you can expect from the State Survey Team What YOU can do to prepare for these first critical 8-10 hours of the new CMS survey process 6 3

4 Know What Your Residents Will Say Have concerns brought forward at Resident Council been addressed to the Council s satisfaction? Have Grievances been addressed to residents and/or family s satisfaction? Is there an on-going system to address/monitor resolution to these concerns? Document your efforts, follow-up, and resident/family/staff feedback 7 Resident Interviews In the first 8-10 hours, the State Survey Team will interview each resident in your facility to assess the facility s provision of cares, their quality of life at the facility, and any concerns related to staff, meals, activities, etc. 8 4

5 Resident Interviews, cont. The State Survey Team will interview the Interested Party for those residents who cannot speak for themselves. Surveyors will not necessarily interview you at this time. Surveyors will interview each resident and/or Interested Party at your facility. Have you? 9 Surveyors will focus especially on Residents who require assistive devices Residents dependent upon staff for ADL assistance Residents with a history of behaviors and/or elopement Residents receiving dialysis and/or hospice services Residents with indwelling urinary catheters Residents with Alzheimer s Disease Residents who have been recently hospitalized Residents who have been admitted within the previous 30 days 10 5

6 Surveyors will focus especially on, cont. Residents with recent changes in condition Residents who smoke Residents currently being treated for infection(s) Resident hygiene, including personal grooming, oral care, clothing Staff infection control practices Staff response to call lights Staff interaction with residents General environmental concerns, including noise Residents/Staff during meal service Residents involved in Facility Reported Incidents 11 Pre-survey Assessment 3 Questions Begin your assessment by personally interviewing each resident or Interested Party. A helpful beginning may be Do you have any concerns with your care or life here? What are those concerns? If you could change anything about your life here, what would be the top 3 changes you would make? What do you most enjoy about your life here? Is there anything we could do to make your life here better? 12 6

7 Know What Your Staff Will Do Assess/Monitor staff provision of cares Assess/Monitor staff interaction with residents Do you have a sufficient number of adequately trained staff per the new regulatory requirements 13 Know what your staff will do, cont. Are nurses and nurse aides providing full care with each resident encounter Are staff encounters with residents helpful, resident-focused, timely, respectful, and friendly Are staff adequately trained to provide care for residents with special needs, per regulatory requirement, including those residents with PTSD, cultural considerations, dementia, dialysis, etc. 14 7

8 New Survey Process Required Tasks Kitchen Inspection/Meal Service Medication Administration/Storage Quality Assurance & Performance Improvement Resident Council Sufficient & Competent Staffing Infection Control Demand Bill 15 Kitchen Inspection & Meal Observation An initial kitchen inspection will take place upon the Survey Team s entrance to the facility A more thorough kitchen/meal service inspection will occur later in the survey week The first full meal service following the Survey Team s entrance to your facility will be observed for deficient practice by your staff The Survey Team will conduct a second meal service observation if there are any concerns discovered with the first meal service, or when any related concerns have been brought to the Survey Team s attention before/during resident/family interviews 16 8

9 Policy Review Are these policies consistent with the new regulatory requirements Abuse Prevention, Identification, Protection, Reporting, Investigation, including new regulatory requirements - F600 to F610 Infection Control F880 Immunizations F883 Indwelling Urinary Catheters F690 Incontinence Management F690 Feeding Tube Management F658 (Professional Standards) & F693 Diabetes Management F658 Grievances F Policy Review, cont. Hospice & Dialysis Coordination of Care F849 & F698 Smoking F926 Narcotic Reconciliation F658 Room Changes F559 Universal Precautions All Staff F880 Anticoagulant Therapy F756 Oxygen Therapy/Equipment Management F695 Pain Control F697 Psychotropic Therapy, including PRN medications F

10 What survey data shows us so far IJ/Harm Nine surveys are available for analysis since new CMS regulations took effect in November 2017 These nine surveys resulted in a total of 75 federal citations Specific F-Tag citations numbered 54 in these nine surveys These nine surveys resulted in 1 K (Immediate Jeopardy) citation; 1 Substandard Quality of Care (SQC) citation; and 7 different citations issued at the harm level Scope & Severity of G or greater 19 What survey data shows us so far IJ/Harm One K level citation at F805 (Food & Nutrition Services) related to dietary textures One SQC citation at F883 (Infection Control) related to Influenza and Pneumococcal Immunizations F550 (Resident Rights) related to dignity Harm Level Citation F600 (Freedom from Abuse, Neglect, and Exploitation) related to verbal & mental abuse Harm Level Citation F684 (Quality of Care) related to pressure ulcers Harm Level Citation F689 (Quality of Care) related to accidents/supervision Harm Level Citation 20 10

11 What survey data shows us so far IJ/Harm F690 (Quality of Care) related to incontinence/toileting plans, indwelling urinary catheters, UTI Harm Level Citation F692 (Quality of Care) related to weight loss and dehydration Harm Level Citation F744 (Behavioral Health Services) related to dementia care and services Harm Level Citation 21 What survey data shows us so far Most Commonly Cited Regulatory Deficiencies F658 Professional Standards: Comprehensive Resident Centered Care Plan F689 Quality of Care: Accidents & Supervision F812 Food & Nutrition Services: Kitchen Sanitation F880 Infection Control: Infection Prevention & Control 22 11

12 Most Commonly Cited Regulatory Groupings Resident Rights (F550 F586) Resident Assessments (F635 F646) Comprehensive Resident-Centered Care Plans (F655 F661) Quality of Care (F684 F700) Pharmacy Services (F755 F761) Food & Nutrition Services (F800 F814) Infection Control (F880 F883) 23 A Final Word! Don t Forget The Golden Rule Everything you do as a member of your facility s healthcare team should begin with, follow, and reflect the Nursing Process Document EVERYTHING 24 12

NEW LONG TERM CARE SURVEY PROCESS PHASE 2 REQUIREMENTS OF PARTICIPATION AUGUST 23, 2017

NEW LONG TERM CARE SURVEY PROCESS PHASE 2 REQUIREMENTS OF PARTICIPATION AUGUST 23, 2017 Disclaimer: The information contained in this presentation is representative of the current information provided