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 by CMS as of August 16, 2017: https://www.cms.gov/medicare/provider-enrollment-and- Certification/GuidanceforLawsAndRegulations/Downloads/New-Long-term-Care-Survey-Process%E2%80%93Slide- Deck-and-Speaker-Notes.pptx CMS has not released an update to Appendix P as of August 16, 2017. 2
BACKGROUND Two different survey processes to review facility compliance with the Requirements of Participation (RoPs): 1. Traditional Nursing Home Survey (Traditional) original paper-based 2. Quality Indicator Survey (QIS) customized software CMS set out to build on the best of both the Traditional and QIS processes to establish a single nationwide survey process. 3
GOALS OF THE NEW PROCESS Same survey for entire country Incorporates strengths from Traditional & OIS New innovative approaches Effective and efficient Resident-centered Balance between structure and surveyor autonomy 4
New Survey Process Traditional Survey Process Automation Using an automated process, surveyors will use a tablet or laptop throughout the process to record findings their findings in the new software Data collected by the surveyors are recorded on paper The computer is used ONLY to prepare the deficiencies on the CMS-2567 form Sample Size Determined by the facility census Max sample size is 35 residents 70% - MDS pre-selected 30% - surveyor-selected Determined by facility census Total is pre-selected based on QM/QI percentiles May be adjusted based on issues identified on tour Maximum sample size is 30 residents Includes complaints 5
Offsite New Survey Process Each team member independently reviews the Casper 3 report and other facility history information Review offsite selected residents and their indicators and the facility rates. Traditional Survey Process Review Casper 3 and 4 reports Survey team uses QM/QIs report offsite to identify preliminary sample of residents areas of concern Information Needed Upon Entrance Completed matrix for new admissions over the last 30 days Facility census number Alphabetical list of residents List of residents who smoke and designated smoking times Roster Sample Matrix Form (CMS-802) 6
Initial Entry to Facility New Survey Process No formal tour process Surveyors complete a full observation, interview all interviewable residents, and complete a limited record review for initial pool residents: Offsite selected residents New admissions Vulnerable residents Identified Concern that doesn t fall into one of the above subgroups 8 hours on average for interviews, observations, and screening. Traditional Survey Process Gather information about preselected residents and new concerns Determine whether pre-selected residents are still appropriate 1 3 hours on average 7
Survey Structure New Survey Process Resident sample size is about 20% of facility census Interview, observation and limited record review care areas are provided for the initial pool process; surveyors can ask the questions as they would like Surveyors meet to discuss and select sample, may have more concerns than can be added to the sample; may need to prioritize concerns Investigations are then completed during the remainder of the survey for each sample resident using CE pathways Facility tasks and closed record reviews are completed during the survey Traditional Survey Process Resident sample is about 20% of facility census for resident observations, interviews, and record reviews Phase I: Focused and comprehensive reviews based on QM/QI report and issues identified from offsite information and facility tour Phase II: Focused record reviews Facility and environmental tasks completed during the survey 8
New Survey Process Traditional Survey Process Group Interviews Resident Council Meeting with active members Includes Resident Council minutes review to identify concerns Meet with Resident Group/Council Includes Resident Council minutes review to identify concerns 9
NEW LTC SURVEY PROCESS OVERVIEW Three parts to the new Survey Process: 1. Initial pool process 2. Sample Selection 3. Investigation 10
Initial Pool Process Select Sample Investigations Sample size based on census: 70% offsite selected 30% selected onsite by team: Vulnerable New Admission Complaint FRI (Facility Reported Incidents- federal only) Identified concern Survey team selects sample All concerns for sample residents requiring further investigation Closed records Facility tasks 11
OFFSITE PREPARATION Team Coordinator (TC) completes offsite preparation: Repeat deficiencies Results of last Standard survey Complaints Facility Reported Incidences (FRIs) - federal only Variances/waivers Necessary documents are printed Unit and mandatory facility task assignments: Dining Infection Control Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Resident Council Meeting Kitchen Medication administration and storage Sufficient and competent nurse staffing 12 QAA/QAPI
FACILITY ENTRANCE Team Coordinator (TC) conducts an Entrance Conference Updated Entrance Conference Worksheet List of residents who smoke and smoking times, which will be used on the first day The number and location of medical storage rooms and carts, which will be used later in the survey Updated instructions for the list of residents for the beneficiary notices revie Updated facility matrix Brief visit to the kitchen Surveyors go to assigned areas 13
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INITIAL POOL PROCESS Surveyor request names of new admissions Identify initial pool about eight residents Offsite selected Vulnerable New admissions Complaints or FRIs (Facility Reported Incidences- federal only) Identified concern 15
RESIDENT INTERVIEWS Screen every resident Suggested questions but not a specific surveyor script Must cover all care areas Includes Rights, QOL, QOC Investigate further or no issue 16
OBSERVATIONS Cover all care areas and probes Conduct rounds Complete formal observations Investigate further or no issue Facility Task vs. Critical Elements (CE) Pathways Facility Task Pathways Critical Elements Pathways 17
RESIDENT REPRESENTATIVE/FAMILY INTERVIEWS Non-interviewable residents Familiar with the resident s care Complete at least three during initial pool process or early enough to follow up on concerns Sampled residents if possible Investigate further or no issue 18
LIMITED RECORD REVIEW Conduct limited record review after interviews and observations are completed prior to sample selection. All initial pool residents: advance directives and confirm specific information If interview not conducted: review certain care areas in record Confirm insulin, anticoagulant, and antipsychotic with a diagnosis of Alzheimer s or dementia, and PASARR (Pre-Admission Screening and Resident Review) New admissions broad range of high-risk medications Extenuating circumstances, interview staff Investigate further or no issue 19
DINING Observation of first full meal Cover all dining rooms and room trays Observe enough to adequately identify concerns If feasible, observe initial pool residents with weight loss If concerns identified, observe another meal 20
TEAM MEETINGS Brief meeting at the end of each day will be conducted by the survey team to discuss: Workload Coverage Concern Synchronize/share data (if needed) 21
SAMPLE SELECTION Prioritize using sampling considerations: Replace discharged residents selected offsite with those selected onsite Can replace residents selected offsite with rationale Harm, SQC if suspected, IJ if identified Abuse Concern Transmission based precautions All MDS indicator areas if not already included 22
UNNECESSARY MEDICATION REVIEW SAMPLE SELECTION System selects five residents for full medication review Insulin Anticoagulant Antipsychotic with Alzheimer s or dementia diagnosis Based on observation, interview, record review, and MDS Broad range of high-risk medications and adverse consequences all psychotropic medications, insulin, anticoagulants, opioids, diuretics and antibiotics, as well as some adverse consequences, including falls, weight loss, and sedation 23
INVESTIGATION General guidelines Conduct investigations for all concerns that warrant further investigation for sampled residents Continuous observations, if required Interview representative, if appropriate, when concerns are identified Majority of time spent observing and interviewing with relevant review of record to complete investigation Use Appendix PP and Appendix P - critical elements (CE) pathways 24
ONGOING AND OTHER SURVEY ACTIVITIES Closed Record Reviews Completed during the investigation portion of survey System selected Unexpected death, hospitalization, and community discharge within the last 90 days Discharged Resident 25
ONGOING AND OTHER SURVEY ACTIVITIES Facility Task Investigations Completed any time during investigation Uses facility task pathways CE compliance decision 26
ONGOING AND OTHER SURVEY ACTIVITIES Dining Subsequent Meal (if needed) Second meal observation if concerns noted during first full meal observation Use Appendix PP and CE Pathway for Dining Dining task is completed outside any resident specific investigation into nutrition and/or weight loss 27
ONGOING AND OTHER SURVEY ACTIVITIES Infection Control All surveyors will observe for infection control throughout the survey process Review of influenza and pneumococcal vaccinations will be coordinated by assigned surveyor Infection prevention and control, and antibiotic stewardship program will be reviewed by assigned surveyor 28
ONGOING AND OTHER SURVEY ACTIVITIES SNF Beneficiary Protection Notification Review A new pathway has been developed for to make the process more user friendly. A list of residents D/C d from all Medicare Part A services Both in-facility and home Random selection by surveyor Facility completes newly developed worksheet 29
ONGOING AND OTHER SURVEY ACTIVITIES Kitchen Observation Full Kitchen Observation will be conducted in addition to the brief kitchen observation upon entrance Appendix PP and Facility Task Pathway will be used to completed kitchen investigation 30
ONGOING AND OTHER SURVEY ACTIVITIES Medication Administration If opportunity presents itself, observation of medication administration for a sampled resident whose medication regimen is being reviewed. Reconciliation of any controlled medications observed during medication administration Observation of 25 medication opportunities Observation of different routes, units, and shifts Medication Storage Observation of half of medication storage rooms and half of medication carts If issues, will expand and review more medication rooms and medication carts. 31
ONGOING AND OTHER SURVEY ACTIVITIES Resident Council Meeting Should occur early in the survey Questions asked of residents are different from Traditional and QIS Areas related: Functioning of the council A few resident specific areas (i.e. abuse) Sufficient staffing 32
ONGOING AND OTHER SURVEY ACTIVITIES Sufficient and Competent Nurse Staffing Review Mandatory task to be investigated on every survey to verify sufficient numbers and competency of staff per the RoPs Consideration to staffing concerns being linked to QOL and QOC concerns 33
ONGOING AND OTHER SURVEY ACTIVITIES Increased efficiency Will investigate just the relevant concerns that cause the task to trigger Eliminates duplicative LSC areas Disaster and Emergency Preparedness Oxygen Storage Generator 34
ONGOING AND OTHER SURVEY ACTIVITIES Potential Citations Survey team will meet to review individual compliance decisions made by assigned surveyor to determine compliance and S/S for all potential deficiencies. Exit conference will be conducted with facility staff. 35
OPERATIONAL CONSIDERATIONS F-Tag renumbering, designation and definition Current survey process has 176 possible F-Tags; effective 11/28/2017 there are 179 possible F-Tags with more to come with implementation of Phase 3 In the Resident Right category there are currently 27 possible tags but in November there will be 35 possible tags under the Resident Rights Category Some F-tags that were under Quality of Care have been moved to other categories but the old F-309 has been broken down into specific tags for pain, dialysis, hospice, etc. 36
OPERATIONAL CONSIDERATIONS These types of splits will create more opportunities for multiple citations; HOWEVER They provide opportunity for more focused and acceptable plans of action that could be classified as past non-compliance They provide opportunity for more successful IDRs because the reasons for citations will have more commonality and not be as broad as current survey process 37
OPERATIONAL CONSIDERATIONS -- SQC Substandard QOC 49 possible F-tags a across 8 different regulatory groupings when cited at F, H, I, J, K, or L Classification is based on specific tag and not the regulatory grouping All 10 tags in the regulatory grouping of Freedom from Abuse may be classified as SQC 4 of the 7 possible F-tags under Pharmacy Services may be cited as SQC F757 (Drug Regimen is Free From Unnecessary Drugs); F758 (Free From Unnecessary Psychotropic Meds/PRN Use); F759 (Free of Medication Error Rates of 5% or More); and F760 (Residents Are Free of Significant Med Errors). 38
OPERATIONAL CONSIDERATIONS Facility Task vs. Critical Elements (CE) Pathways Facility Task Pathways focuses on processes and required tasks, i.e. kitchen observation, resident / staff interview; medication administration, dining observations, etc. Critical Elements Pathways -- focuses on care and services, i.e. hydration, nutrition, end of life, dialysis, catheters, etc. https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/qis-survey-forms.html 39
OPERATIONAL CONSIDERATIONS Appendix P Unsure when this will be published Watch for additional S&C letters S&C: 17-41 NH -- Survey Team Composition and Investigation of Complaints S&C: 18-38 LSC -- Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies 40
OPERATIONAL CONSIDERATIONS Survey Readiness Educate staff and residents in new survey process Develop and keep current a survey ready book Be proactive use the Facility Task Tools and Critical Element Pathways as part of your QAPI process Create systems to ensure MDS accuracy and optimize flexibility im MDS schedule and completion of assessments Create systems that validate the medical record is telling the story Be prepared to share your action plans when appropriate so that a deficiency may be classified as past non-compliance 41
QUESTIONS? APRIL PAYNE, LNHA VICE PRESIDENT OF QUALITY IMPROVEMENT DIRECTOR OF THE VIRGINIA CENTER FOR ASSISTED LIVING april.payne@vhca.org O: 804.212.1698 M: 804.212.9917