QIS: Where Regulation Meets Quality Kenneth Daily Elder Care Systems Group kenn@qissurvey.com 2014 OHCA Annual Convention Quality Care or Compliance? CMS Approach to Change Value 5 Star Rating Survey Staffing QMs QAPI Data Leadership Process Culture Change Satisfaction Environment MDS 3.0 Interviews Relevant data Fiscal Policy VBP Bundling Hospitalizations 1
Customer Value Expectations Costs Product Need $$$$ Cost Service Expectation Time Cost Personnel Expectation Psychological Cost Improving Value 1. Know your consumer and manage touch points with the aim of maximizing customer outcomes 2. Understand the customer needs, preferences, goals and satisfaction. 3. Integrate our message 4. Recognize outstanding employees 5. Make it easy for customers to reach appropriate personnel and express their needs, perceptions, and concerns. 6. Build competitive advantage beyond our own operations, into value chains of its suppliers, distributors and customers to create a superior value delivery network (supply chain) 7. Don t exaggerate the product / service s capabilities or set expectations too low Template for Nursing Care? Conduct assessments; provide medications and treatments May have team nursing, led by LPN or RN to whom staff report RNs/LPNs Provides all direct care with exception of medications CNAs RESIDENT Feeding Assistant/ Aides Permitted by federal law; receive specific training. Medication and skilled treatments Aides. Staff. (RN, LPN, CNAs) are permanently assigned to the same unit in many NHs; in a growing number of NHs Administers the CNAs have Medication permanent resident assignment. 2
What is Culture Change? Culture change in longterm care is an ongoing transformation in the physical, organizational and psycho-socialspiritual environments that is based on person-centered values such as respect. Culture Norms Expected Behavior Standards Chain of command Wardrobe Languages Jargon terminology slang Heroes & Heroines Personify values create role models intuitive & visionary success attainable standard of performance motivate employees Folkways Customs Unconscious acts Shaking hands Arriving early Culture Myths Frequently told stories Based on true or imaginary events shared & told to newcomers Mores Subclass of folkways Survival techniques right v wrong behavior cheating Ceremonies & Rites How we conduct planned events or celebrations reinforce specific values create bond of common understanding anoint cultural heroes & heroines Symbols Events & things with special & deeply held meanings large office with window seating close to CEO Sitting at head of table Culture Change??? Eden Alternative, Green Houses, Small Houses and Pioneer initiatives Or the superficial displays of culture change: Having mailboxes and front doors yet no one knocks or takes seriously the privacy it is meant to offer Fin, fur and feathers Food line buffet Memory boxes Brag board All these efforts are important but these do not deliver culture change 3
Team Discussion 1. Describe the artifacts of culture change developed by CMS 2. What are the underlying values and culture that these artifacts represent? 3. What are the strengths and weaknesses of this culture? 4. Is there a gap between where the organization is and where it would like to be? 5. If you were to attempt culture change, how would you go about it? Quality Is Product or service meets its specifications This can be problematic for long term health care systems Natural tension between business needs, everyone's expectations, and government quality requirements (safety, efficiency, reliability, etc.) Some quality requirements are difficult to specify in an unambiguous way quality of life Often the specifications for care are incomplete and inconsistent because of human nature. 1987 Nursing Home Reform Amendments (OBRA 87) State licensure State Medicaid standards Medicare 5 Star rating Professional standards Risk group or preferred provider group Facility policy and procedures Your personal standards or code of ethics 4
Quality Improvement Variations on those themes Quality assurance Quality improvement Risk management Quality assurance/ performance improvement Compliance and quality improvement Total quality management Evaluation and measurement of success Assessment of causative factors Implementation consistently with eye on evolving issues NURSING HOME QUALITY Care Planning/ interventions undertaken Determination of where you want to be Quality Assurance and Performance Improvement (QAPI) Significantly expands the level and scope of required Quality activities Ensure that facilities continuously identify and correct quality deficiencies as well as sustain performance improvement QA: QUALITY ASSESSMENT How are we doing compared to our industry? PI: PROCESS IMPROVEMENT Making it better 5
QAPI Design and Scope Ongoing and comprehensive Includes all departments and functions Governance and Leadership Administration leads with input from facility staff, as well as from residents and their families Feedback, Data Systems and Monitoring Systems to monitor care and services Performance Improvement Projects (PIPs) Performance Improvement Projects Systematic Analysis and Systemic Action Data driven Systematic approach to determine problem, its causes, and implications of a change. Uses of Data 1. Uncover problems that might otherwise remain invisible. 2. Convince the need for change. 3. Can confirm or discredit assumptions 4. Prioritize vulnerabilities 5. Can help evaluate program effectiveness 6. Can prevent one-size-fits-all and quick solutions. 7. Give the ability to respond to accountability questions. 8. Can build a culture of inquiry and continuous improvement. Facility Quality Measure Report Falls w/injury 6
Resident Level QM Report Root Cause Analysis Finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms Asks why, why, why at each level Interdisciplinary- involves those closest to the situation Identifies changes that need to be made Identifies risks and how they contributed Leads the team to potential process improvements Move beyond a culture of blame Tools for RCA 7
Brainstorming Rules Non-judgmental communications Encourage wild and exaggerated ideas. Quantity counts at this stage, not quality. Build on the ideas put forward by others. Every person and every idea has equal worth. WHY??? Resident fell last night Resident pushed called light and no one came to help Resident always just gets up even though not steady It was dark and tripped going to bathroom Needs to go to bathroom every night Therapist told resident to be more independent 1. Dark bathroom 2. Strength training 3. Toileting and staff response Now What??? Have active and effective QAPI program Auditing, rounding and accountability William Deming Plan, Do, Study and Act Planning is the identifying of hazards and risk Do is the implementing of interventions to reduce risks and hazards Study is the monitoring of effectiveness Act is the effectiveness and modifying as necessary 8
The PDSA Cycle Act What changes are to be made? Adapt? Adopt? or Abandon? Next cycle? Study Complete the analysis of the data Compare data to predictions Summarize what was learned Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Do Carry out the plan Document problems and unexpected observations Begin analysis of the data 25 What Will We Do Today? What is a fall? Who is at risk? What could the causes be? Ideas for investigation What interventions/care planning could help? Possible ways to approach falls as a facility Ideas for assuring that interventions are in place When will you re-evaluate the resident? How will you know that your program is working? Falls With Injuries The issue is falls and residents experiencing serious injuries Who should the team be? What is the problem? What is the source of the problem? What is the goal? What do you really want to improve? Develop plan, change policies, procedures, conduct training, alter paperwork DID IT WORK??? 9
What is the PDSA Cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Your PLAN and should answer WHO; WHAT; WHEN; WHERE; HOW PLAN 1. What are we testing? 2. On whom are we testing the change? 3. When are we testing? 4. Where are we testing? Data - What data do we need to collect? 1. NF s falls mgt. policy and procedure 2. Nursing home residents 3. At all times 4. Throughout the facility to see if facility procedures reduce falls. Falls numbers, days of the week, time of day, location, possible reasons, contributing factors, etc. What is the PDSA Cycle? Do Carry out the plan Document problems and unexpected observations Begin analysis of the data DO (WRITTEN IN PAST TENSE): The reader should be able to read exactly what your team DID. 10
DO 1. What was actually tested? 2. What happened? 3. Success or failures? 1. Procedure tested for an entire month. The facility census was stable though we did admit/discharged 9 residents 2. There were 19 falls involving 14 residents. One resident experienced a serious injury A. Total number of falls increased B. One resident sustained a serious injury hip fracture C. Three residents fell more than twice in the month but that is half as many as month before D. Nurses completed investigations more timely and correctly E. Interventions such reducing meds seems to help some What is the PDSA Cycle? Study Complete the analysis of the data Compare data to predictions Summarize what was learned STUDY: should be a reflection of what the team learned by what they DID as they had PLANNED to meet the OBJECTIVE. It is the conclusion you draw based on the data and should tell you whether or not you met your objective. Study Analysis of data to determine what changed, improved or didn t Our initial feeling was that the facility had a good policy and procedure but it turned out that we don t. There is now a sense of urgency to revise our processes to improve. 11
What is the PDSA Cycle? Act What changes are to be made? Next cycle? ACT (WRITTEN IN FUTURE TENSE): should describe what your next steps will be to meet the objective based on what you learned from what you did according to the plan to meet the objective. ACT 1. What adjustments to the change or method of testing should we make before the next cycle? Team will redraft policy and procedures, risk assessment, investigation tools, QA review tool 1. Are we ready to implement the change we tested? Total facility reeducation 2. What will the next test cycle be? Next months data related to falls will begin test our ability to successively revise policy and procedure. The QIS Process The Quality Indicator Survey process is a revised survey process that changes how surveyors determine a facility's compliance Phase I Collected comprehensive set of resident sampling data consisting of standardized questionnaires, specific observations and record reviews which is used to determine a facilities Quality Indicators Phase II Once the quality indicators are determined surveyors investigate items which exceed CMS thresholds Goes beyond previous traditional survey process by measuring quantified quality of life aspects of care 12
Tools For Quality Improvement Family and staff interviews Resident interviews, observations and record reviews 150+ Quality Indictors Care pathway investigations Facility level investigations Mandatory and triggered Nat l QIS OH QIS Average Number of Citations/ Survey 7.2 4.1 Deficiency free 6.9% 14.9% Leading Deficiencies Quality of Care F309 Accident/ Hazards F323 Unnecessary Meds F329 Infection Control F441 Food Handling F371 Care Planning F279 Resident Abuse F225&26 Dignity F241 Notify of change F 157 Assessment F272 Prof Standards F282 Pressure Sores F314 Bowel/Bladder F315 Environment F253 Staffing F353 13
Trigger Responses and Stage II Investigations QIS rates for: Family Interview 19.6% Resident Interview 19.4% Staff Interview 18.6% Admission Clinical Record 17.8% Resident Observation 16.6% Census Clinical Record 15.2% Triggered vs. Deficiency Care Area Trigger % Citation % Accidents 99% 27% Pressure Ulcers 77% 21% Community Discharge 77% 11% ADLs 60% 11% Nutrition 58% 16% Rehabilitation 58% 2% Urinary Incontinence 56% 0% Dental 55% 23% ROM 46% 15% Abuse 43% 22% Admis/ Transfer 41% 11% Environment Observations 41% 63% Triggered vs. Deficiency Care Area Trigger% Citation % Dignity 40% 15% Choices 40% 17% Activities 40% 27% Personal Funds 38% 17% Staffing 36% 6% Personal Property 35% 8% Hydration 26% 8% Catheter Use 21% 12% Participation in Care Planning 17% 16% Hospitalization 15% 0% Restraints 15% 35% Skin Conditions 15% 32% 14
Triggered vs. Deficiency Care Area Trigger % Citation % Food Quality 12% 6% Pain Management 11% 18% Privacy 9% 9% Notification of Change 8% 22% Positioning 1% 38% Social Services 1% 100% Behavior Emotion Status - 2% Infections - 25% Vision - 27% UTIs - 0% Stage II Investigations Task Triggered Task Triggered Extended Surveys 62% Personal Funds 18% Environment 58% Dining 17% Unnecessary Med 40% Med. Admin 11% Infection Control 33% Liability Notices 5% Kitchen 26% Staffing 5% Abuse Prohibition 24% QA & A 4% Med Storage 23% Resident Council 4% Average number of tasks triggered = 12.1 Survey is Survey Facility appearance & what surveyors see, hear, feel and smell is important Residents with obvious unmet needs Resident interactions Activities Dining experience Personal items stored & labeled Data Weights Skin Behavior Falls Splints and restorative care Wheelchairs and lifts Therapy gym Remember: survey is about the basics 15
Off-site to Entrance Review facility history is reviewed including the CASPER, past survey history and patterns of repeat deficiencies Contact ombudsman Conduct entrance conference with Administrator/designee 1 surveyor meets with administrator 2 surveyors begin tour plus the kitchen 1 surveyor completes reconciliation Provide resident census Medicare beneficiaries of last six months sampled from MDS data for review of Liability Notice and Beneficiary Appeal Rights review Entrance Activities QIS brochure is provided Given the CMS 671 and CMS 672 Resident lists: PASRR II Services Ventilator This is where 5 Star staffing comes from Dialysis Unit, Peritoneal, Home Certified Medicare Hospice Comfort/ End of Life care One Resident will be chosen from each care area during stage II Initial Tour Characteristics of the facility, special care areas, staff resident interactions, response to resident requests, behaviors Ask nursing assistants questions, such as How many residents are under your care today? Who determines the assignment? Is there enough time to complete your assignment? What happens if you do not get your assignment completed? What steps do you take when the fire alarm sounds? What is RACE? 16
Entrance Notebook Alphabetical Resident Census New Admission Information (last 30 days) Facility floor plan Staffing schedules for survey period List of key employees Resident Council President Meal times and locations Medication times Whether facility utilizes paid feeding assistants Influenza/ Pneumococcal Immunization policy and procedure Entrance Notebook List of rooms that would require a variance Less than required square footage More than 4 residents Below ground level No window to the outside No access to an exit corridor Quality Assessment and Assurance (contact, members, frequency) Experimental research Contact person for Abuse policies and procedures Whether or not DON is full time Emergency water policy/ contact Additional Information CLIA certificate Surety Bond Fire drills past year Activity calendar Resident council minutes (3-6 months) Abuse policy and self reported incidents STNA Registry update Criminal background logs Medical Director reports Grievance committee minutes/ policy Resident Council minutes Smoking policy Infection control policy Nurse aides less than 4 months Employee files (Mantoux, H/P, in-servicing) Department heads less than 1 year Resident account balances Medical director information 17
Census and Admission Sample Census and Admission sample drawn from MDS sample plus census reconciliation Thresholds are broken into categories small and not small. Small would be when there are 35 or fewer residents Census sample random sample current residents Resident interviews and observations Staff and family interviews Record reviews Admission sample random sample of up to 30 discharged residents Record review Census Sample Update The Census Sample (affecting 50% of facilities) was altered to speed up process If facility census is: > 100 residents = sample size of 40 61-100 residents = sample size of 35 33-60 residents = sample size of 30 1-32 residents = the sample will automatically be set to 90% of the total Sentinel QIs QIS indicators set at 0-1% threshold 1. Abuse 2. Dangerous device use 3. Fall/Fracture 4. Activities 5. ADL Assist 6. Admission process 7. Exercise Rights 8. Death 9. Dehydration 10. Hydration 11. Notification of family 12. Personal Funds 13. Privacy 14. Medicaid costs 15. Range of Motion 16. Oral health status 17. Comfortable Temperatures 18. Pest control 19. Electric cords & outlets 20. Ambulation, therapy equip. 21. Bathing safety 22. Call light 23. Chemical-Hazard 24. Unsafe hot water 25. Sufficient staff 26. Participate in care plan 27. PU @ stage 3 or 4 28. Presence - incontinence 18
Admission Sample Record Review Up to 30 residents Only closed records reviewed Targets residents with vulnerabilities Pressure Sores developed within first 30 days, admitted with and worsening? Weights and height Census Sample Record Review Stability of condition Pressure sores Unnecessary medications Weights and height 19
Unnecessary Medications Sampling Algorithm for QIS Census Sample residents are chosen for the Unnecessary Medications Residents receive a score based on the medications that they receive Algorithm scores range from 0 to 18. 5 residents with the highest scores are included in the sample Unnecessary Medication Scoring Residents with diagnosis of dementia or Alzheimer's AND receiving Antipsychotic 3 points Residents who have a fall or fracture AND receiving: Antipsychotic Antianxiety Antidepressant Hypnotic Mood Stabilizer Diuretic 2 points Resident score point(s) for receiving each of the following: Antipsychotic (excluding Alzheimer s/dementia diagnosis) Antianxiety Antidepressant Hypnotic Mood Stabilizer Anticoagulant Insulin Up to 7 points Residents receive an additional points when they receive med above and a marked as sedated, weight loss, 2 or more of these meds, Alzheimer's/ dementia and/or falls 1 point for each Unnecessary Medication Algorithm QIS software will select 5 resident based on surveyor responses to selected questions in the Census Sample resident observation, record review, and staff interview components of the QIS. Scores range from 0 to 18. The five residents with the highest scores are included in the sample 20
Resident Interview & Observation Key surveyor interview and observation tool Surveyor makes final decision after talking with each individual resident The BIMS is used to determine Interviewablity Score > or = to 8, resident is interviewable Score < or = to 7 or 99, resident is non interviewable and set to family interview status The second part of each of the questions intended to probe for additional information when a resident responds negatively to the initial portion of the question. Probing questions may be asked to obtain appropriate information to start an investigation in Stage 2 Participation in Care Plan: Physician orders a change in your medications and RESIDENT is made aware of the change? If the physician is contacted about you, are you made aware of the results? Does staff tell you the results of tests like lab work or x-rays? If you need to have an appointment scheduled (for instance with an outside physician), are you informed of the appointment? Have you brought questions or concerns about your care to the attention of facility s staff? If so, what happened as a result? 21
ABUSE questions have been reworded Physical Restraints are triggered from an observation of the potential presence of a restraint If the resident has concerns related to food: Is there a particular food item or meal that is not appetizing or doesn t taste good Is the food served too hot or too cold? Is there a certain meal such as breakfast, lunch or supper or snack that is consistently served poorly or not at the proper temperature? Where are your meals served? Do you eat your meals in the dining room, in your room, or in another location? 4/28/2014 65 Environment Vulnerabilities 22
The surveyor may need to ask probing questions to help determine if the resident understands the difference between a commercial bank account and the facility s Sleeping Resident? 4/28/2014 67 Staff Interview Staff interviews are conducted with licensed staff, either the RN or LPN Catheter Use Nutrition Skin care/ Pressure Ulcers Side Rails Contractures Falls or fractures Family Interview Three family members or resident representatives who know the resident well and visit the facility Choices Activities Privacy Dignity Interactions with others Sufficient staff Activities of daily living (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 23
Facility Level Investigations Resident Council President/ Representative interview Dining observation Kitchen/ food service Infection control No second probe Liability Notice and Beneficiary Appeal Rights Quality assessment and assurance review Infection Control Medication Pass CMS policy change to reduce from 50 to 25 opportunities Resident Council President To ensure that the facility listens to and responds in a timely manner to concerns voiced by the residents Council F 243 Grievances F244 Rules F242/F244 Rights F151, F153, F156, F167, F179, F172, F242 Dining Observation of overall dining experience (in various dining rooms and resident rooms) and the availability of staffing to assist the residents Staff prepare, serve, and assist at meal times F353/F362 Meals served within 14hours / or 16 hours w/substantial snack F368 Assistance with meal F311/F312 Staff infection control F371/ F441 Dignity and Independence F241 Non-disposable cutlery and plates/napkins Resident desires considered when using clothing protectors Meal service including substitutes F366 Positioning F310 Dining room atmosphere F464/F258/F253 Furnishings and space F464 Food quality F364 Liquids at meal time F327 24
Kitchen/ Food Service To observe general sanitation practices, cleanliness of the kitchen and any practice that might indicate potential food-borne illness Food storage F371 Storage temperatures F371/F456 Food preparation and service F364/F371 Dinnerware sanitization and storage F371 Refuse/ pest control F372/F369 Equipment Safe/Clean F456 Infection Control System to prevent the development and transmission of diseases F441 Flu and Pneumococcal immunization policy F334 Surveyors will observe specific areas of the facility at various times during the survey F441 Hand washing techniques Glove issues Staff free from communicable diseases Linen handling, sharps disposal, dressings, disposals Isolation procedures Liability Notice & Beneficiary Appeal Rights To ensure the facility properly handles Medicare non-coverage Advanced Beneficiary Notice (ABN SNF) Notices include Appropriate notice information F156 Date of non-coverage F156 Provided prior to date of noncoverage F156 Acceptable reason F156 Option to request demand bill and was handled appropriately F 492 25
Quality Assessment and Assurance Part I (all facilities) F520 Determine if the facility has functioning QAA committee Medical director involvement Identify participants Identify committee leader Determine frequency of meetings Part 2 (completed when potential quality deficiencies are identified) F520 Determine if the QAA committee effectively identifies and addressing quality deficiencies Medication Administration To observe facility s medication administration system in operation and to verify the accuracy, technique and compliance with professional standards Selection of 10 residents 25 medication administrations per team prefer to view different routes, shifts and staff Observe medicine storage Review the MAR Transition from Stage I to Stage II Software calculates the indicators and compares results to national rates Determine what stage II facility level tasks have been triggered and require an in-depth investigation is required Stage II sample selected by software Fewest residents with most issues Normally three residents - each triggered area Triggered Tasks Environmental review Resident Funds Admission, Transfer, and Discharge Sufficient Staff Abuse prohibition review 26
Environmental Review Pest Control Room Odors Functioning Call System Call Light in Reach Chemical/Hazards in Room Homelike Environment Room Accommodations Clean Building Lighting Levels Comfortable sound levels Comfortable Room Temperatures Resident Care Equipment Ambulation, Transfer and Therapy Equipment Bedroom Privacy Clean Linens Available Unsafe Hot Water Lack of Hot Water Room Furnishings Electric Cords and Outlets Bathing Safety Equipment Resident Funds Ensure that the facility appropriately handles a residents personal funds Informed services and costs F156 Week end access to $$ F159 Accounting practices, interest, surety bond F159 Quarterly statements F159 Notice w/in $200 Medicaid limit F159 Conveyance upon death F160 Admission, Transfer, and Discharge Review To ensure that the facility properly handles resident admission, transfers and discharges Application for Medicare and Medicaid benefits F208 Inform of rights F156 Room changes F247 Third party guarantee F208 Bed hold F205 Facility initiated discharge/transfer F204, F250, F309 27
Sufficient Staff Sufficient staff available to meet the residents needs F353 and F354 Facility has licensed registered nurses and available to provide and monitor the delivery of care Advised of care plan changes Adequate to meet care needs of resident Appropriately deployed RN coverage Nursing aides Adequate assistance with meals Abuse Prohibitions To determine if the facility has developed and operationalized policies and procedures including 1. Screening of potential employees; 2. Training of employees (both for new employees, and ongoing training for all employees); 3. Prevention policies and procedures; 4. Identification of possible incidents or allegations which need investigation; 5. Investigation of incidents and allegations; 6. Protection of residents during investigations; and 7. Reporting of incidents, investigations, and facility response to the results of their investigations. Unnecessary Drug Appropriate dose consider duplicative therapy? In the presence of adverse consequences which would indicate the dose should be reduced or discontinued Adequate indication for use? Adequate monitoring? Appropriate duration? Gradual dose reductions unless clinically contraindicated Medication dose reduced or discontinued in presence of adverse drug reactions or side effects Appropriate monitoring, duration, dose and indication for use. 28
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 investigation Each pathway suggest specific F-tags that should be considered plus additional areas to consider/ investigate SOM Guidance Only Abuse Accidents/ Falls Resident Rights Choices Accommodations of needs Dignity Privacy Social services Rehabilitation Food quality Nutrition Hydration Foot care Notification of change Personal property Participation -care plan Critical Element Pathways Activities ADLs/ ROM Behavioral and emotional status Incontinence, Catheters, UTIs Communication and sensory problems Dental status and services Dialysis General Hospice-Paliative Care Hospitalization or death Pain management Physical restraints Pressure ulcers Psychoactive medications Rehabilitation and community discharges Unnecessary Meds PASARR Hydration Ventilator dependent residents Tube feeding status Dementia (2014) 29
Dementia Investigation F309 Assess behavior (onset, duration, intensity, possible precipitating events or environmental triggers, etc.) and related factors (appearance, alertness, etc.) I Staff assess the underlying cause of behaviors When there is a suspected change in condition or worsening from baseline, did staff contact the attending physician/practitioner immediately for a medical evaluation If medical causes are ruled out, did staff attempt to establish other root causes of the behavior using individualized knowledge about the person and when possible, information from the resident, family, previous caregivers and/or direct care staff? As part of the comprehensive assessment did facility staff evaluate: The resident s usual and current cognitive patterns, mood and behavior, and whether these present a risk to the resident or others? How the resident typically communicates a need such as pain, discomfort, hunger, thirst or frustration? Prior life patterns and preferences customary responses to triggers such as stress, anxiety or fatigue, as provided by family, caregivers, and others who are familiar with the resident before or after admission? Dementia Care Planning Was the resident and/or family/representative involved in discussions about the potential use of any interventions, and was this documented in the medical record? Does the care plan reflect an individualized team approach with measureable goals, timetables and specific interventions for the management of behavioral and psychological symptoms? Does the care plan include: Involvement of the resident/representative to the extent possible? A description of and how to prevent targeted behaviors? Why behaviors should be prevented or otherwise addressed (e.g., severely distressing to resident)? Monitoring of the effectiveness of any/all interventions? If the resident or family/representative refused a recommended treatment or approach, was counseling on consequences and alternative approaches to address behavioral symptoms provided? Care Plan Implementation Identify, document and communicate specific targeted behaviors and expressions of distress as well as desired outcomes? Implement individualized, person-centered interventions by qualified persons and document the results? Communicate and consistently implement the care plan, over time and across various shifts? If there is a sudden change in the resident s condition and medical causes of behavior or other symptoms are suspected, is the physician contacted immediately and treatment initiated? Is there a sufficient number of staff to consistently implement the care plan? (Surveyors should focus on observations of staff interactions with residents who have dementia to determine whether staff consistently applies basic dementia care principles in the care of those individuals). 30
Resident Care If during the survey a concern is identified that an antipsychotic medication is given by staff for purposes of discipline or convenience and not required to treat the resident s medical symptoms, review F222 483.13(a). If the physician does not respond to the notification, does staff contact the medical director for further review? If the medical director was contacted, does he/she respond and intervene as needed? Did the facility provide the necessary care and services for a resident with dementia to support his or her highest practicable level of physical, mental and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care? If No, cite F309 Care Plan Revision/Monitoring and Follow up Does staff, in collaboration with the practitioner, adjust the interventions based on the impact on behavior or other symptoms as well as any adverse consequences related to treatment? When concerns related to the effectiveness or adverse consequences of a resident s treatment regimen are identified: Does staff modify the care plan and, if appropriate, notify the physician and does the physician respond and initiate a change to the resident s care as necessary? Quality Assessment and Assurance Do resident care policies and procedures clearly outline a systematic process for the care of residents with dementia? Does the QAA Committee monitor for consistent implementation of the policies and procedures for the care of residents with dementia? Has the QAA committee corrected any identified quality deficiencies related to the care of residents with dementia? Has the QAA committee provided monitoring and oversight for the care and services for a resident with dementia? 31
General The critical element pathway is utilized when the area of investigation is not addressed by other CEs such as: Non-pressure related wound care (venous/arterial or neuropathic ulcers) Bowel management problems including fecal impaction Diabetes mellitus and congestive heart failure Accidents and supervision including falls Fractures Elopement Other hazards related to the use of assistive devices Activities Assessment Identify individual activity preferences and interests Adaptations Care Planning Input from the resident and/or representative that provides to the extent that provides for the resident's participation in activities of choice? Associated tags F 164 privacy F 172 Access and Visitation F 242 Self Determination F 246 Accommodation of Needs F250 Social Services F 353 Sufficient Staff F464 Dining and Activities Rooms ADLs Determine: Adequately assess to determine the level of ADL, functional ROM and contractures Causal and contributing factors Potential to improve? Consistent implementation Staff knowledge Changes in condition Effectiveness Risks and approaches Various F-tags including F310 Current ADL performance F311 potential for improvement but none F312 Resident unable F309 Unable to position F317 No limitations, but now has some 318 Limitations but potential for 32
Behavioral and Emotional Status Observations Staff and resident interactions, appropriate care for behavioral, mental and/or emotional status and ensuring safety Assessment and care Planning Individualize interventions that are known to the staff and are consistent including protocols for treatment including deviations Associated tags F319 appropriate treatment for mental/ psychosocial difficulties F320 no development of unavoidable mental issues F309 Provide necessary care for highest practical well being F223 abuse F241 dignity F250 social services 97 F329 unnecessary medications Bowel and Bladder Function Assessment Resident's overall condition including continence status and patterns Fluid intake Medications Clinical reasons for catheter and alternatives Care planning Identifies objectives and potential psychosocial complications Education component Environmental approaches F tag issues F315 urinary incontinence F241 dignity F309 quality of care F312 ADLs F353 sufficient staff F385 physician services F444 infection control Communications Observations Activities and interactions consider any limitations in communications including vision and hearing Assessment Considers all contributing factors, potential for decline and lack of improvement Care Planning Specific protocols that are known to all staff and implemented consistently Need for assistive devices and use Examinations Environmental factors Risks for accidents F tags F310/ F311 ADLs F313 Vision and hearing 33
Dental Observations Difficulties with chewing Denture issues Mouth care Medications Hygiene issues Knowledge of staff and interventions delivered Dentist services available Assessment Contributing factors Impact of oral health on functions such as eating, social, overall health Care planning Consistent with specific needs of resident Treatment protocols Consistent with goals and strengths F tags F411 and F412 Dental services Residents Who Receive Dialysis Assessment F tags Medical status including vital signs F309 quality of care Psychosocial needs Risk factors and complications F282 qualified staff Care Planning F425 Pharmacy Developed for specifics of the services resident and related to dialysis F455 emergency services, including Nutritional and hydration issues power Medications Care of access site Infection control and skin measures Vital signs and weights Hospice Assessment Contributing factors Continence Nutrition Medication interactions or side effects Spiritual needs Values, wishes, choices and goals Care planning Meets specific needs of resident conditions, risks, needs, behaviors, preferences and current standards of practice F tag considerations F309 Quality of care F164 Privacy and confidentiality F172 Access and visitation F242 Self determination F246 Accommodation of Need F250 Social services 34
Hospitalization or Death Professional standards ID acute issues Vital signs, pain, ID potential contributing and/or causal factors such as meds, falls, labs Appropriate staff available Notified physician & family F tags F309 Quality of care F241 Dignity F242 Self determination F353 Sufficient staff F385 Physician services F501 Medical director Nutrition, Hydration, Tube Feed Assessment F tags Baseline status F321 Naso-gastric Diet calculation tubes Intake issues F322 Naso-gastric Weight history tube Terminal illness F325 Nutrition Care Planning F327 Hydration Prevent and/or address weight F328 Parenteral and issues and dehydration concerns enteral fluids Prevent unnecessary tube feeding Restorative dining End of life consistent with wishes and address decreased appetite Pain Assessment History including conditions, risks and contributing factors Identify functional limitations Care Planning Address impact of pain on function Monitoring for sign and symptoms Intervention strategy F tag considerations F309 Quality of care F157 Notification of changes F172 Access and visitation F242 Self determination F246 Accommodation of Need F250 Social services F 353 Sufficient staff F385 Physician F501 Medical director 35
Physical Restraints Assessment Medical symptoms Function Risk and benefit Care planning Goals for use and intended improvement in function Type of restraint and in what circumstances for use Frequency and monitoring Interventions/ services when not in use Interventions to limit functional decline F tags F221 restraints F242 self determination and participation F246 accommodation of need F248 activities F323 accidents F353 sufficient staff F385 physician services F406 specialized rehab Pressure Sores Assessment Resident function, medications, skin condition, cognitive status, nutrition Identifies factors that increase risks for development or healing Care planning Developed to address the specific conditions, risks, needs, behaviors, and preferences (and standards of practice) F tag considerations F157 Notification of changes F309 Quality of Care F314 Pressure Ulcers F325 Nutrition F327 Hydration F353 sufficient staff F406 specialized rehabilitation F385 physician services Rehabilitation and Community Discharge Assessment Resident status including overall health and psychosocial status Identifies risks, strengths, weaknesses Care planning Goals, needs and strengths Care plan known by staff responsible and delivered consistently Preparations for discharge F tag considerations F250 social services F 311 Activities of daily living F406 specialized rehabilitation F241 dignity F246 accommodation of needs F 309 quality of care F318 range of motion F353 sufficient staff F385 physician services 36
Ventilator Dependant Assessment Potential weaning, psychosocial issues, advanced directives, ADLs Care planning Vent equipment Alarms (power failure) Ventilator use Ventilator setting Type of airways Adjunctive interventions Psychosocial issues Monitoring for use/changes Emergency issues F tag considerations F157 Notification of changes F325 Nutrition F327 Hydration F328 Special care F353 sufficient staff F406 specialized rehabilitation F385 physician services Extended Survey Extended Survey is not part of the QIS standard survey Surveyor-initiated before the exit conference or within two weeks of completion of the standard survey When the survey team determines during the standard survey that substandard quality of care exists. One or more deficiencies with scope/severity levels of F, H, I, J, K, or L in any of these regulatory groupings: Nursing Services (F353-354) Physician Services (F385-390) Administration (F490-F522) Regulatory Compliance Potential citations are agreed too and statement of deficiency is developed by with integration of findings Combine stage I and II findings across residents by F-tag Identify deficiencies Scope and severity Exit conference 37
Quality Management Quality management must deliver bottom-line Measure true impact of time and investment Quality is everyone s job Practices and understanding of the continuous nature of quality Quality management will increasingly be absorbed in each of our jobs Moving from doing quality to coaching for quality Customer expectations are increasing Customers are accustomed to speed, efficiency, and excellent customer service will demand that of long term care too Core Principles We want a better future than the future we have If we do what we have always done, we will get what we always had Know the truths and share them Core changes is a function of new truth There are things that we know that are the exact opposite of what the public believes Honesty We are change agents Educate vs. telling Person-centered Care? What does the nursing home do to make residents feel comfortable Do They take a person's personal habits into consideration when developing plans of care Do residents make choices about When they wake up, eat meals, bathe, or take medications? What they do with their day? Does nursing home have any house pets? And do you allow residents to have pets of their own? What types of programs or activities does nursing home offer that allow residents to feel like contributing members of society? 38
Compliance Versus Quality Improvement Compliance Floor is goal Crisis management High stress High costs Turn around effect? Quality Goals increase/change Success is planned for Manageable challenge Manageable challenge Recruitment/retention A Case for Preparation: Look, I really want the fancy scroll work on the rails. In a hundred years, who ll know I scrimped on the soil samples? S&C Memos Survey and certification memo inform state and regional offices of CMS Google Survey and Certification memo 39
Resources www.cms.com www.med-pass.com Quality Indicator Survey: Process Tools and Resources Manual Kenneth Daily, LNHA kenn@qissurvey.com Consulting and education focusing on quality improvement, survey compliance, and facility management. Comprehensive Traditional and QIS technical assistance, Mock surveys and audits Standard/traditional and QIS preparation Directed Plan of Correction development and implementation Immediate Jeopardy Assistance Quality/Performance Improvement Program development and implementation Corp Compliance Plans END 40