What to Expect on Your Next Survey

Transcription

1 What to Expect on Your Next Survey Linda M. Elizaitis RN, BS, RAC-CT President CMS Compliance Group, Inc. E. T.

2 Understand the key elements of the new Long-Term Care Survey Process (LTCSP) Review the most frequently cited deficiencies in New York for 2017 Review important systems for quality improvement under the updated RoPs and LTCSP What do we want to accomplish today? cmscompliancegroup.com 2

3 Long-Term Care Survey Process Overview Offsite Prep Entrance Initial Pool / Sample Selection Remainder of Survey Investigations Facility Tasks Closed Record Review What to Expect and Not Expect cmscompliancegroup.com 3

4 Offsite Prep Review of pre-selected residents Review of prior survey / complaints / POCs submitted / CASPER 3 / Quality Measures Sample size 70% offsite selected / 30% survey selected (on-site) Based on facility census Entrance Brief Entrance Conference with Administrator Surveyors go to assigned units Provide immediately: Complete matrix for new admissions within last 30 days who still reside in facility List of residents who smoke, smoking times / locations Census Alphabetical list of residents Overview of the Long-Term Care Survey Process (LTCSP) cmscompliancegroup.com 4

5 Within 1 hour of entrance Within 4 hours of entrance By end of 1 st day of survey Dining/Food schedules, locations, menus Med admin times, number and location of med rooms/carts Staff schedules, list of key personnel, paid feeding assistant info Completed facility matrix for residents not part of 30 day admission matrix Admissions packet Dialysis info (if applicable) Hospice agreements and P&Ps Infection Control program standards, antibiotic stewardship program, immunization P&Ps QAA/QAPI QAA committee info, names/meeting frequency and QAPI Plan Abuse Prohibition P&Ps Description of any experimental research being conducted Facility Assessment Nurse staffing waivers List of any rooms meeting a condition that requires a variance Electronic Health Record Information Form should be completed Legionella information Within 24 hours of entrance Completed CMS-671 Medicare/Medicaid Application Completed CMS-672 Census and Condition Information Completed Beneficiary Notice Form - Residents discharged within last 6 mos. Timeline for What Needs to be Provided cmscompliancegroup.com 5

6 Initial Pool & Sample Selection All residents in assigned area are screened All interviewable residents are interviewed Limited Record Review completed for initial pool: Offsite selected residents (mandatory) New admissions Vulnerable residents Complaints/ Facility Reported Incidents (max. of 5 total) Any other identified concern Finalizing the Sample Surveyors meet to discuss and select sample Additional identified concerns can be added Remainder of Survey Investigations Observations, Interviews and Record Reviews Mandatory Facility Tasks: Beneficiary Protection Notification Review Dining Observation Kitchen Observation Infection Control Sufficient / Competent Staffing Medication Storage Medication Administration QAA / QAPI Resident Council Meeting Triggered Tasks: Environment Personal Funds Resident Assessments Closed Record Review (3) Death Hospitalization Community Discharge Overview of the Long-Term Care Survey Process (LTCSP) cmscompliancegroup.com 6

7 Observations Interviews Staff responsiveness to residents distress, requests for assistance, etc. If care planned interventions are being used Staff attempting non-pharmacological interventions Infection control Resident/ Rep asked about involvement in CP process, ability to make choices, staffing levels Staff asked specific questions about residents, their care, interventions, preferences, etc. they need to know the individual residents Record Review Common Themes in the LTCSP Surveyors expected to review records out on units, so record review will be focused on validating observations Application of person-centered care principles in care plans cmscompliancegroup.com 7

8 Critical Element Pathways Investigation Tools Critical Element (CE) Pathways Abuse Unnecessary Medications, Psychotropic Medications,& Medication Regimen Review Behavioral and Emotional Status Dementia Care Preadmission Screening and Resident Review Activities Communication and Sensory Problems Dental Status and Services Dialysis Pain Recognition and Management Physical Restraints Pressure Ulcer/Injury Specialized Rehabilitative or Restorative Services Respiratory Care Nutrition Hydration Tube Feeding Status Activities of Daily Living (ADL) Positioning, Mobility & Range of Motion (ROM) Urinary Catheter or Urinary Tract Infection Bladder or Bowel Incontinence Accidents Discharge Hospitalization Hospice and End of Life Care and Services Death General Extended Survey (for SQC) cmscompliancegroup.com 8

9 What to Expect and not Expect LTCSP and Enforcement LTCSP became effective Nov. 28, 2017 New survey protocol can be found in the Long-Term Care Survey Process (LTCSP) Procedure Guide Appendix P is no longer in use All States/Regions fully trained on LTCSP and expected to implement CMS S&C: Ref: S&C: NH (11/24/17) Current Enforcement (Post-Nov. 28, 2017) If only Phase 1 Ftags are identified: Normal enforcement policies apply If both Phase 1 Ftags and Phase 2 Ftags are identified: Normal enforcement policies in place for Phase 1 Ftags Directed Plan of Correction (DPOC) or Directed Inservice Training (DIST) only for Phase 2 Ftags If only Phase 2 Ftags are identified: 18-month moratorium enforcement policies apply for DPOC/ DIST for certain Ftags cmscompliancegroup.com 9

10 What to Expect and not Expect Phase 2 is effective with changes Temporary Enforcement Delays for Certain Ftags 18-month moratorium on CMPs, DPNAs and discretionary termination for certain Phase 2 Ftags Ftags that are part of the moratorium will still be cited as appropriate and sent to RO CMS S&C memo: Ref: S&C NH (11/24/17) Phase 2 Ftags under Enforcement Moratorium F655 Baseline Care Plan F740 Behavioral Health Services F741 Sufficient/ Competent Staff Behavioral Health Needs F758 Free from Unnecessary Psychotropic Meds/ PRN Use related to PRN usage F838 Facility Assessment F881 Antibiotic Stewardship Program F865 QAPI Program/ Plan, Disclosure/ Good Faith Attempt related to development of the QAPI Plan F926 Smoking Policies cmscompliancegroup.com 10

11 Five-Star Quality Rating Changes & Nursing Home Compare Updates What to Expect and not Expect Five Star Rating and Nursing Home Compare Updates for 2018 Health Inspection star ratings will be temporarily frozen starting in 2018 for approximately 1 year Surveys/ complaints conducted before 11/28/17 will continued to be calculated (includes revisits/ IDR /IIDR changes) Health Inspection will be based on a 2 year survey cycle Current 3-year survey cycle will be changed in 2018 Health Inspection survey cycle weighting will be changed Most recent survey cycle will carry 60% weight Prior survey cycle will carry 40% weight Nursing Home Compare website to be updated with summaries of recent survey findings Total # of deficiencies / highest scope/severity / deficiency-free / Full SOD for each survey Future improvements inclusion of PBJ data cmscompliancegroup.com 11

12 Deficiencies & Systems Most frequently cited deficiencies New York National What to know about top deficiencies under the new RoPs, LTCSP and systems to review cmscompliancegroup.com 12

13 2016 Top 10 New York 2017 Top 10 New York 1. F371 Food Procurement, Store/Prepare/Serve Sanitary 1. F329 Drug Regimen is Free From Unnecessary Drugs ( ) 2. F329 Drug Regimen is Free From Unnecessary Drugs 2. F371 Food Procurement, Store/Prepare/Serve Sanitary ( ) 3. F441 Infection Control, Prevent Spread, Linens 3. F441 Infection Control, Prevent Spread, Linens ( ) 4. F309 Provide Care/Services for Highest Well Being 4. F279 Develop Comprehensive Care Plans ( ) 5. F279 Develop Comprehensive Care Plans 5. F309 Provide Care/ Services for Highest Well Being ( ) 6. F253 Housekeeping and Maintenance 7. F323 Free of Accident Hazards/Supervision/ Devices 8. F280 Right to Participate in Care Planning Revise CP 9. F431 Drug Records, Label/Store Drugs & Biologicals 10. F514 Resident Records Complete/ Accurate/ Accessible 6. F253 Housekeeping and Maintenance ( ) 7. F323 Free of Accident Hazards/ Supervision/ Devices ( ) 8. F282 Services by Qualified Persons/ Per Care Plan (new) 9. F280 Right to Participate in Care Planning Revise CP ( ) 10. F514 Resident Records Complete/ Accurate/ Accessible ( ) 2016 vs Top Deficiencies New York State cmscompliancegroup.com 13

14 2017 Top 10 National 2017 Top 10 New York 1. F441 Infection Control 2.F371 Food Procurement 3.F323 Free of Accident Hazards/ Supervision/ Devices 1. F329 Drug Regimen is Free From Unnecessary Drugs 2. F371 Food Procurement 3. F441 Infection Control 4.F309 Provide Care/ Services for Highest Well Being 4. F279 Develop Comprehensive Care Plans 5.F431 Drug Records Label/ Store Drugs and Biologicals 5. F309 Provide Care/ Services for Highest Well Being 6.F279 Develop Comprehensive Care Plans 6. F253 Housekeeping and Maintenance 7.F329 Drug Regimen is Free From Unnecessary Drugs 7. F323 Free of Accident Hazards/ Supervision/ Devices 8.F514 Resident Records Complete/ Accurate/ Accessible 8. F282 Services by Qualified Persons/ Per Care Plan 9.F241 Dignity and Respect of Individuality 9. F280 Right to Participate in Care Planning Revise CP 10.F278 Assessment Accuracy/ Coordination/ Certified 10. F514 Resident Records Complete/ Accurate/ Accessible 2017 Top Deficiencies - National vs New York State cmscompliancegroup.com 14

15 F282 F441 F371 F371 F329 F279 F371 F441 F329 F371 F371 F323 F323 F441 F441 F441 F282 F225 F309 F279 F323 F279 F279 F279 F309 F280 F309 F282 F253 F253 F225 F253 F280 F323 F323 F281 F280 F241 F280 F282 F309 F281 F309 F431 F280 F253 F225 F329 F514 F514 Ftags that appear every year: F279 CCPs F280 Revise CPs F309 Quality of Care F323 Accidents F371 Kitchen Sanitation F329 Unnecessary Drugs has been on the list since 2015 (#10) -> #1 in 2017 New York State Top Deficiencies cmscompliancegroup.com 15

16 What to Know: Medications NYS Top Deficiency: F329 Unnecessary Drugs F757 Drug Regimen is Free from Unnecessary Drugs F758 Free from Unnecessary Psychotropic Meds/ PRN Use Moratorium on PRN use enforcement CE Pathway: Unnecessary Medications, Psychotropic Medications and Medication Regimen Review Dementia Care CE Pathway used for residents with dementia receiving psychotropics Mandatory Tasks: Medication Administration Observation Medication Storage and Labeling Medications Rooms & Carts cmscompliancegroup.com 16

17 Systems to Review: Medications Rationale for use Gradual Dose Reduction (GDR) attempts PRN limits psychotropic and antipsychotic meds Antibiotic use protocols Non-pharmacological interventions Monitoring High-risk meds Adverse psychosocial/ behavioral/ mental/ physical consequences Med monitoring order implementation by staff Reporting Written MRR irregularity reports and responses Change in condition cmscompliancegroup.com 17

18 Systems to Review: Medications Med rooms and carts Controlled substances Multi-dose vials Expired meds Cleanliness Medication Administration Competencies Oral/NG Tube Injections Insulin/FSBS Infection control cmscompliancegroup.com 18

19 What to Know: Kitchen NYS Top Deficiency: F371 Kitchen Sanitation F812 Food Procurement, Store/ Prepare/ Serve Sanitary F813 Personal Food Policy Mandatory Task: Kitchen Observation 1 surveyor goes to kitchen immediately upon entrance for initial brief tour cmscompliancegroup.com 19

20 Systems to Review: Kitchen Food storage Storage temperatures Food preparation and distribution Holding temperatures Cooling temperatures Sanitization Equipment cleaning Dishwashing Logs Remote kitchens Infection control Personal food policy cmscompliancegroup.com 20

21 What to Know: Infection Control NYS Top Deficiency: F441 Infection Control F880 Infection Prevention & Control F881 Antibiotic Stewardship Program Enforcement moratorium on F881 F883 Influenza and Pneumococcal Immunizations Mandatory Task: Infection Prevention, Control & Immunizations 1 surveyor reviews: Overall Infection Prevention and Control Program (IPCP) Annual review of IPCP policies and practices Review of surveillance and antibiotic stewardship programs Tracking influenza/ pneumococcal immunization of residents Surveyors will also review: Laundry services 1 resident on transmission-based precautions (if any) 5 sampled residents for immunizations Any other care-specific concerns identified cmscompliancegroup.com 21

22 Systems to Review: Infection Control Infection Control Hand hygiene Personal protective equipment (PPE) Transmission-based precautions Surveillance plan based on Facility Assessment for identification, tracking, monitoring and/or reporting of infections Laundry Services Storage/ handling/ transport Antibiotic Stewardship Antibiotic use protocols and reporting Immunizations Documentation Education Staff immunizations cmscompliancegroup.com 22

23 What to Know: Care Planning NYS Top Deficiencies: F279 Comprehensive Care Plans and F280 Participate in Care Planning/ Revise CP F553 Right to Participate in Planning Care F639 Maintain 15 Months of Resident Assessments F656 Develop/ Implement Comprehensive Care Plans F657 Care Plan Timing and Revision CE Pathway: Surveyors use CE Pathway associated with issue under investigation If there is no specific CE Pathway, the General CE Pathway is used along with the IG cmscompliancegroup.com 23

24 Systems to Review: Care Planning Resident/ Representative involvement in CP process Scheduling Documentation of participation/ decline Copy of Baseline Care Plan and CCP Measurable objectives, interventions and timeframes Specialized services/ interventions for PASARR recommendations Discharge planning/ goals Significant change revisions Interdisciplinary team cmscompliancegroup.com 24

25 Systems to Review: Quality of Life/ Care NYS Top Deficiencies: F309 Provide Care/ Services for Highest Well Being F675 Quality of Life F684 Quality of Care F697 Pain Management F698 Dialysis CE Pathways: Quality of Life - Noncompliance at F675 used for IJs when there is an environment of pervasive disregard for QoL Quality of Care - General Critical Element Pathway or Hospice and End of Life Care and Services CE Pathway along with F684 IG Pain Management Pain Recognition and Management CE Pathway Dialysis Dialysis CE Pathway cmscompliancegroup.com 25

26 Systems to Review: Quality of Life/ Care Quality of Life Person-centered care and services that honor and support residents preferences, choices, values and beliefs Quality of Care Consistent implementation of interventions Communication Change in condition reporting Care plan revisions Shift-shift communication Hospice care / End of Life Coordinated care planning between facility and hospice cmscompliancegroup.com 26

27 Systems to Review: Quality of Life/ Care Pain Management Pain assessment PRN pain meds Pain regimen reviews Non-pharmacological interventions Dialysis Pre/post treatment monitoring Intake/ fluid restriction monitoring Facility/provider communication Assessment/care of access site Infection control Hand hygiene PPE Staff competencies Accommodation of residents needs: Transportation Medication administration Meals cmscompliancegroup.com 27

28 What to Know / Systems: Housekeeping & Maintenance NYS Top Deficiencies: F253 Housekeeping and Maintenance F584 Safe/ Clean/ Comfortable/ Homelike Environment Triggered Task: Environmental Observations Systems to Review: Ticketing/ Requests system/log Precautions Handrails Equipment maintenance checks cmscompliancegroup.com 28

29 What to Know: Accidents NYS Top Deficiencies: F323 Accidents F689 Free of Accident Hazards/ Supervision/ Devices F700 Bedrails CE Pathway: Accidents Critical Element Pathway Smoking Wandering/ Elopement Resident-Resident Aggression Falls Entrapment/ Safety Environmental Hazards cmscompliancegroup.com 29

30 Systems to Review: Accidents Smoking Assessments Location / Need for equipment Wandering and Elopement Monitoring - visual Personal security devices Resident-Resident Altercations Supervision Interventions / triggers Falls Staff response times Alarms Restraints cmscompliancegroup.com 30

31 Systems to Review: Accidents Entrapment/ Safety Transfers Bed rails Physical restraints Environmental Hazards Handrails Assistive devices Equipment condition Chemical and toxin storage Water temperatures Electrical equipment Power strips Personal use items Lighting cmscompliancegroup.com 31

32 What to Know & Systems to Review: Qualified Persons NYS Top Deficiencies: F282 Qualified Persons/ Per Care Plan F659 Qualified Persons Systems to Review: Staff competencies based on Facility Assessment CPR certifications cmscompliancegroup.com 32

33 Sufficient Competent Sufficient is determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility s resident population in accordance with the Facility Assessment Competent - Facility Assessment must include/address an evaluation of staff competencies necessary to provide the level and types of care needed for the facility s unique resident population Change in Condition - Nursing staff must be aware of each resident s current health status and regular activity, and promptly identify change in condition and take appropriate action What s important in the new RoPs Documentation of attending training, listening to a lecture or watching a video is not sufficient Staff must be able to use and integrate the knowledge/skills learned during the training Sufficient and Competent Staff LTCSP: Each day, a surveyor collects and consolidates staffing info from all surveyors that includes examples with either potential/actual negative outcomes or harm cmscompliancegroup.com 33

34 What to Know & Systems to Review: Resident Records NYS Top Deficiencies: F514 Resident Records F842 Resident Records Identifiable Information EHR use during survey: If EHR is used in facility, survey team must receive: Timely access (by end of 1 st day of survey) Instructions on use No restrictions Systems to Review: Privacy lock screens, etc. cmscompliancegroup.com 34

35 Other Areas to Focus on: Meaningful Activities Activities CE Pathway and referenced in many others Behavioral Health Services Behavior and Emotional Status CE Pathway PASARR CE Pathway Staff competencies Moratorium Treatment/ Service for Dementia Dementia Care CE Pathway QAPI Moratorium on the QAPI Plan Good Faith attempts Smoking Policies Moratorium Training Abuse, Neglect, Misappropriation and Exploitation Abuse CE Pathway Neglect CE Pathway cmscompliancegroup.com 35

36 Thank you to ChemRx for having CMS Compliance Group present today on What to Expect on Your Next Survey. For LTPAC compliance & quality improvement information and news, visit the CMSCG Blog: Thank you! cmscompliancegroup.com 36