BLENDED SURVEY PROCESS UPDATE OF LESSONS LEARNED UNDER THE NEW SURVEY PROCESS KATHY CREEGAN-TEDESCHI DIRECTOR LTC VDH APRIL PAYNE, LNHA VP OF QUALITY IMPROVEMENT & DIRECTOR OF VCAL VHCA-VCAL NEW LONG TERM CARE SURVEY 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 1
Seven Parts: 1) Offsite preparation 2) Facility entrance 3) Initial pool process 4) Sample selection 5) Investigation 6) Ongoing and other survey activities 7) Potential citations OFFSITE PREPARATION Each team member independently reviews: Casper 3 report for pattern of repeat deficiencies Results of last standard survey Complaints since last standard survey FRI s since last standard survey Facility variances/waivers (if applicable) Active enforcement cases TC makes contact with the Ombudsman Review offsite selected residents and their indicators and the facility rates. TC makes assignments for each member of the survey team and each member reviews the offsite prep work (no meeting required). 2
ASSIGNED MANDATORY FACILITY TASKS Beneficiary Protection Notification Review Dining Observation* Infection Control* Medication Administration Medication Storage QAA/QAPI Resident Council Meeting Sufficient and Competent Nurse Staffing * * assigned to all surveyors, but one surveyor has primary responsibility SURVEY RESOURCES LTCSP Procedure Guide List of Revised FTags/Substandard Quality of Care (SQC) Ftags Appendix PP Guidance to Surveyors for LTC Facilities Appendix Q Guidelines for Determining Immediate Jeopardy (IJ) Chapter 7 of the State Operations Manual Psychosocial Outcome Severity Grid Principles of Documentation 3
FACILITY 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 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. INITIAL POOL PROCESS The first eight to ten hours onsite are primarily spent completing initial pool process 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 4
SAMPLE SELECTION Survey team meets to choose residents from the initial pool to include in the sample based on concerns identified from the interview, observations, and/or limited record review, and consideration of resident-specific data. Once onsite, surveyors DO NOT need to consider maintaining a 70/30 split between offsite and onsite selected residents the focus is on identifying residents for the initial pool and sample based on concerns. UNNECESSARY MEDICATION System selects five residents for full medication review 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 Based on observation, interview, record review, and MDS 5
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 11 INVESTIGATION Closed Record Reviews Completed during the investigation portion of survey System selected Unexpected death, hospitalization, and community discharge within the last 90 days Facility Task Investigations Completed any time during investigation Uses facility task pathways CE compliance decision 12 6
Dining Subsequent Meal (if needed) Second meal observation if concerns noted during first full meal observation Infection Control All surveyors will observe for infection control throughout the survey process Review of influenza and pneumococcal vaccinations Review of infection prevention and control and antibiotic stewardship 13 SNF Beneficiary Protection Notification Review A list of residents D/C d from all Medicare Part A services Both in-facility and home Random selection by surveyor Facility completes worksheet Kitchen Observation Full Kitchen Observation will be conducted in addition to the brief kitchen observation upon entrance 14 7
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 carts15 If issues, will expand and review more medication rooms and medication carts. 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 16 8
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 17 Eliminates duplicative LSC areas Disaster and Emergency Preparedness Oxygen Storage Generator 18 9
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 One or two residents may be invited to attend 19 EMERGENCY PREPAREDNESS (EP) Completed during standard survey inspection Upon entrance Emergency Preparedness Items Needed During inspection interview with facility leadership and a review of the EP program to include: Risk Assessments/Planning, Communication Plan, relevant Policies and Procedures, Training Documentation, and Testing Documentation ETags 10
THANK YOU! Questions? 11