A SYSTEMS APPROACH TO SURVEY PREPARATION

4/15/2015 A SYSTEMS APPROACH TO SURVEY PREPARATION Laying a Strong Foundation Demi Haffenreffer, RN MBA Email: demi@consultdemi.net Phone: 1-800-7336590 Survey Preparation Overall Year round systems and processes more on this in a minute A good (at least basic) understanding of the requirements Sort through what is the actual rule, the interpretive guideline, your policies, standards of practice and just plain old common sense Keep a three year history Complaint investigations whether substantiated or not Your health deficiency score and your surveys Trend / analyze the data Use the tools CMS provides you: Run your Casper reports monthly more on this later Check Nursing Home compare at least quarterly Survey Preparation Overall QAPI IS A MUST! More on this later Consider using AHCA Long Term Trend Tracker Consider using Interact Tools Two to three months prior Make a survey plan conduct drills Put together a team Obtain your Oscar reports Perform a Mock survey Educate staff have question drills Begin work on your survey book Hire an outside consultant to assist 1

4/15/2015 Some Additional Thoughts to Begin With.. Characteristics of a facility that does well on survey: Decisions for care based on resident needs All systems & processes are person-centered (resident, family & staff) Not fixed changes can be made based on new standards, staff/resident needs, and/or new requirements Requirements are guidelines only we can do better! Survey does not serve as an indicator of quality but rather serves as a catalyst to find out if there is truly systemic problems that require action A strong QAPI approach in this way preparation is ongoing Person-centered care Begins with the assessment Resident informed of data collected, options, risks and benefits of each option Resident decision Documentation of assessment & resident choices Care planning Reevaluation & care plan updates Systems and Processes are Building Blocks to Quality & Successful Surveys 2

4/15/2015 System Thinking Work Systems How the work of your organization is accomplished; coordinate the internal work processes and external resources necessary for you to develop, produce, and deliver your health care services; involve entire workforce. Work Processes Your most important internal value creation processes such as, health care system design & delivery, supply chain management, business processes and more; frequently and relate core competencies. Core Competencies Your organization s areas of greatest expertise; central to fulfilling your mission; may involve unique service offerings and more. Workforce refers to people actively involved in accomplishing the work of your organization all levels; all departments; all paid contractors or outside agents. Process Work is process goal directed activity System A system is a group of process interacting to achieve a goal 3

4/15/2015 A Brief At Systems & Processes Where are You Most Vulnerable? Top Citations F157 Notification of Changes F225 Abuse (especially as it relates to investigations & reporting F272 Comprehensive Assessment F278 MDS Accuracy F279 & 280 Care Planning F309 Quality of Care (Pain; Hospice; Dementia Care) F314 Pressure Ulcers F315 Urinary Incontinence F323 Prevention of Accidents F325 Nutrition F329 Unnecessary Drugs F371 Food Preparation and Storage F431 Drug Storage and Labeling F441 Infection Control 4

4/15/2015 Assessment and Care Planning How well trained and competent are your staff in performing assessments? Are your systems and processes easy to use & follow MDS/CAA s RAI manual is the bible Are you keeping it updated Electronic records and throwing the baby out with the bathwater While important, the MDS is not the only assessment tool your staff need. If not a tool then at least a guideline to follow. Is the resident / family / ancillary staff part of the assessment process Are you OVER meeting? Are you staffed for your systems and processes? Do staff know resident need and preferences? The 25 page care plan trap CHANGES IN RESIDENT CONDITIONS Using the survey criteria for avoidable vs. unavoidable F309 says it all! The foundation of quality of care Assessment of risk and needs; implementation; monitoring; evaluation Going electronic throwing the baby out with the bath water Observation & reporting (24-hr. report) Good evaluation & assessment techniques Documentation & ongoing monitoring Notification of family & physicians Further assessment of at risk areas for decline related to current condition change Care planning (temporary & ongoing) Procedures for investigation Are procedures easy to follow? How much paperwork is associated with your procedures? Are responsibilities clearly defined? Procedures include initial data gathering Procedures include overall root/cause analysis? Employees need to understand overall goals of the program & when to complete incident reports Closely aligned with condition change protocols A good understanding of abuse definitions and when to report what Accidents & incidents Specific to F225 & 323 5

4/15/2015 SKIN - F314 COMPONENTS OF A GOOD PROGRAM Thorough examination of skin 2-6 hours after admission Assessment of risk with implementation of interventions in keeping with identified risk Weekly skin checks Daily and weekly documentation of current wounds with consideration of change in treatment when wound not progressing towards healing Clear physician orders Consideration to one treatment nurse Monthly QAPI analysis Specific consistent processes when wound found Training and competency checks Comprehensive Nutrition Program F325 Person-centered procedures for dining QAPI for weight changes and dining Audits of monthly weights, assessment, care planning Monthly trending & root-cause analysis Assessment & care planning Communication systems for special needs (such as thickened liquids; cueing) Restorative dining Training on hire & annually Procedures for I & O Overall Kitchen environment Behavioral and Unnecessary Drugs F329 Behavior / intervention tracking & root-cause analysis Proactive & aggressive interventions to prevent resident to resident behaviors Assessment using CAA s 8 (Mood), 9 (Behavior),17 (Drugs) & F329 Investigative Protocol Interdisciplinary (social services and activities) Rule out pain & depression as cause for behaviors Attempt medications other than Antipsychotics Make a QAPI goal to reduce Antipsychotic use Assist your pharmacist with drug reviews by providing specific resident information Develop documented goals for medications 6

4/15/2015 Infection Control Continuous and aggressive monitoring daily closely aligned with changes of condition and that system Don t wait to an outbreak is obvious before taking aggressive action It is more than just tracking info on a log It is cross referencing labs, bugs and meds It is trending and analyzing It is conducting outcome and process auditing Staff training and competency testing is key WELL 0RGANIZED MEDICAL RECORDS Physician orders and monthly review (recap) procedures All areas (sections) well defined consider a table of contents If Electronic where are things located and what is still on paper Care plans that are easy to review & follow Staff communications Focus on intra and inter departmental Keep it simple What does this resident want & need? Daily stand-up meetings Weekly floor staff meetings Make it safe to report mistakes Don t cut budget in the training category 7

4/15/2015 TALK TO YOUR PEOPLE! Conduct overall SATISFACTION surveys at least on admission or beginning employment, with discharge or leaving employment & annually Consider family satisfaction as well Includes ongoing grievance procedures Follow-up & documentation of Trended & analyzed at least quarterly See all grievances as an opportunity to improve QUALITY ASSURANCE & PERFORMANCE IMPROVEMENT OVERALL Core Components of QAPI Methodology Identify the process to improve Either project wise or you did not reach a goal Can be resident specific or system/process specific Identify the team Clarify what is known about the process and how it currently works Identify and verify root cause(s) of the problem(s) 8

4/15/2015 Determine the solution Implement plan Core Components of QAPI Methodology Check to see if plan worked (evaluate) Maintain improvements and / or determine next steps Document and communicate Performance Measures and Indicators Refers to numerical information that quantifies performance dimensions of processes, programs, projects, services and the overall organizational outcomes 9

4/15/2015 Why Measure? YOU CAN T IMPROVE WHAT YOU DON T MEASURE! Know how processes are performing Know if you are achieving results Identify areas for improvement Determine the effect of a change you made Provide data for decision making Management oversight Meet regulatory requirements Provide evidence of quality Example of a Measure / Goal Definition All falls that occurred in the past month define fall All Medication errors define medication error All residents receiving an antipsychotic medication with only the diagnosis of Dementia All residents with unexpected transfer to the hospital / ER within the last thirty days Overall Measure Falls no greater than 25% of average daily census. No greater than 3 medication errors in a quarter. Will decrease current antipsychotic use in residents with dementia by 15% of current rate in 2015 (35%) to 32% Will decrease current avoidable hospital transfers by 15% in 2015 (35%) to 32% Example of a Measure / Goal Numerator Total number of falls based on our definition Total number of medication errors based on our definition Total number of residents receiving antipsychotics with only the diagnosis of Dementia for the year (2015) measured monthly Total number of residents transferred to hospital / ER within last thirty days Denominator For falls = Average daily census for the past 30 days X 100 For medication errors = Number of medication errors For Meds & Hospital readmissions: Average daily census for the month and year (2015) X 100 10

4/15/2015 Example of a Measure / Goal Exclusions Falls related to resident:resident behaviors Blanks on Medication sheets after careful analysis & evidence medication was provided as ordered Residents receiving antipsychotics with diagnosis of schizophrenia Residents who required discharge due to extreme medical conditions. How / When will data be collected Data will be collected monthly from incident reports / review of medication sheets / pharmacy reports / census information by the 5 th of the next month Who is responsible Administrator, Director of Nursing or other LET S END THIS SESSION WITH A REVIEW OF A CASPER REPORT! Discussion and Questions 11

4/15/2015 Resources Carey, R & Lloyd, R (2001). Measuring Quality Improvement in Healthcare: A guide to Statistical Process Control Applications. Quality Press: Milwaukee, WI.* Dana, B. (2006). Developing a Quality Management System (2 nd edition). AHCA: DC* DeFeo, J & Barnard, W. (2004). Juran Institute s Six Sigma. McGraw Hill: NY. Fox, N. (2007). The Journey of a Lifetime: Leadership Pathways to Culture Change in Long-Term Care. Eden Alternative. Gawande, A. (2007). Better: A Surgeon s Notes on Performance. Picador: NY. Gawande, A (2010). The Checklist Manifesto: How to Get Things Right. Metropolitan Books: NY. Gawande, A (2014). Being Mortal. Metropolitan Books: NY. www.consultdemi.net Resources Senge, P. M. et al (2004). Presence: An Exploration of Profound Change in People, Organizations, and Society. Random House: NY. Senge, P. M. (1990). The Fifth Discipline: The Art & Practice of The Learning Organization. Doubleday: NY. Senge, P. M. et al (1994). The Fifth Discipline Fieldbook. Doubleday: NY. www.consultdemi.net: 2-day Quality Improvement Workshop 3-day RN Management in Long Term Care Survey Management including Mock Surveys Survey Management www.consultdemi.net www consultdemi net 12

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Haffenreffer & Associates, Inc. SNF Mock / Presurvey Procedures Standard Survey 1. Consists of: First reviewing Quality Indicators (Measures) / Casper report and select residents (may also use last survey & facility request in selecting residents). In addition to QI s select weight losses, skin problems, drugs (especially hypnotics), restraints, and declines in ADL/ROM. You may also choose QI s below the 75 th percentile as a check, such as depression without treatment. We normally look at 10 residents comprehensively and 5 residents as a focus review. Go to Nursing Home Compare to obtain a three year history and compare staffing / other measures. - Chart review: Thoroughness is the key go to purged records if necessary Stay with one topic at a time drugs, pain etc. When complete then go on to next topic. Chart review includes all disciplines quarterlies, etc. Look back 3 6 months Use investigative protocols or our audit tools (pressure sore investigation, fecal impaction audit, etc.) - Interview 5-6 residents and 1-2 families use QIS interview tools - Kitchen review twice. Second visit watch tray service on tray line. Use QIS audit tool - Hot water temperatures in at least five rooms and one shower room. - Baseboard heaters if used need a temperature check see environmental safety - Two medication passes and one dressing change - PLEASE OBSERVE TF & CBG. - The drug audit must be used choose two to four medications. - Resident care on two shifts watch turning and repositioning and restraint rel. Care observed must include transfers, peri care, privacy, handwashing and at least one or two care plan items. - Observe two meals. Stress homelike stay for the entire meal use QIS audit tool - Abuse questions at least 5 employees (different shifts) and include housekeepers in the mix. - Overall environmental safety, cleanliness & homelike. Fire and disaster safety see logs & interview staff. - Activity programs watch an entire activity see audit tool - Notice as much as you possibly can what is it like for the resident living at this facility? - Try to interview the resident if possible. How do you like it here? - Glucometer check - Choose one or two residents on sliding scale and check correct insulin - Look at 6 employee files: New aide (< 4 months), old aide (> 1 year), kitchen employee, and one nurse and you choose other two. - If they have resident council minutes look at last two meeting minutes -? follow-up to grievances. - Look at immunization protocols see QIS audit tool - Check out staffing if there are many quality of care problems - Do they have a procedure for QA talk to someone about it this is important if there are many quality of care problems. - Other things include: Res. Involved in DNR, behaviors assessed, physician order recap problems & signatures, call lights answered, Postings, RD aware of skin & wt. loss problems and PPS, Quality Assurance Review, PIF accounts, AED. Appendices - 1

Appendices - 2 Antibiotics Facility: Pharmacy Referral Form Week / Month Ending: Weight Change Behavioral Changes Bleeding or Bruising Bowel Problems Fluid / Electrolyte Imbalance Mood Dysphagia Falls, dizziness Gastrointestinal Problems Pain Mental status changes Rash, pruritus Respiratory difficulty Sedation, insomnia Seizures Urinary problems Changes that have occurred - symptoms, signs, and conditions that may be associated with medications. New infections treated with antibiotics. Document Resident name and check all appropriate boxes. Copyright 2009 by Haffenreffer & Associates, Inc. All rights reserved. Reproduction of this work, in whole or in part, without prior written permission is prohibited. For more information, call (800) 733-6590

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QM/FTAG CROSSWALK QM FTAG CAA Other related QM s Pressure sores, Moderate to Severe Pain 19 - Pain Antipsychotic / (L & S) F309, F272, F279, F280 Antianxiety / Hypnotic meds, Depression, Wt. Loss, Increase ADL help Pressure Ulcer High risk or new / worse (L & S) F314, F272, F279, F280 16 Pressure Ulcers Physical Restraints F221, F323, F272, F279, F280 18 Physical Restraints Falls and Falls with Major Injury Antipsychotic / Antianxiety Med (L & S) Behavior Symptoms Affecting Others and Depressive Symptoms F323, F329, F225, F272, F279, F280 11- Falls F329, F272, F279, F280, F425 17 Psychotropic Drug Use F309, F319, F329, 241 (all quality of life tags) 7 Psychosocial Well- Being 8 Mood 9 Behavior 17 Psychotropic 19 - Pain Restraints, Pain, Meds, Low Risk Incontinence, Wt. Loss, Increase ADL help Pain, Pressure sores, Falls, Meds, Depression, Wt loss, Increase ADL help Pain, Restraints, Meds, UTI, Incontinence, Increase ADL help Pain, Falls, Behaviors, Depression, Incontinence, Wt. Loss, Increase ADL help Pain, UTI, Behavior (if depression only triggered on QM) and Depression if only Behavior triggered on QM) UTI F441 6 Urinary Incontinence Pain, Falls, Behaviors, Wt Loss Catheter Inserted / left in Bladder and Lo-Risk Incontinence F315, F272, F279, F280 6 Urinary Incontinence Appendices - 7 Falls, Meds, Restraints, Pressure sores, UTI 1

QM/FTAG CROSSWALK QM FTAG CAA Other related QM s Excess Wt. Loss F325, F272, F279, F280 12- Nutritional status Pain, Restraints, Meds, Depression, UTI, Increase ADL help Increase ADL help F309, F310, F311, F312 5 ADL Functional / Rehab Potential Pain, Pressure sore, Falls, Meds, Depression, Incontinence, Wt. Loss Copyright 2010 by Haffenreffer & Associates, Inc. All rights reserved. Reproduction of this work, in whole or in part, without prior written permission is prohibited. For more information, call (800) 733-6590 2 Appendices - 8

GUIDELINE FOR ANSWERING SURVEYOR QUESTIONS 1. Listen carefully to the question Take a moment to answer and collect your thoughts. Stop what you are doing. a. Does it pertain to your role? If not, direct the surveyor (accompany the surveyor) to the person who can better answer the question. b. Do you understand the question? If not, ask the surveyor to rephrase the question. Say, "I don't understand your question." c. Do you definitely know the answer? Please don't guess at the answer. Make sure the information you are giving is exact and correct. Go to the care plan if you need to or direct the surveyor (accompany) to a person who can answer OR find out the answer and then follow-up with surveyor. 2. Only give the surveyor the information they are seeking - you don't need to embellish. 3. Answer only questions, not general comments. 4. Be confident - the surveyor needs to trust in your ability to provide this resident care. 5. If you have a complaint - the surveyor should not be the first person you tell. Facility management staff should have heard it first. 6. Let management staff know that you were interviewed and what was discussed. a. If a red area was found during care or a resident complained and the surveyor was in attendance, please be sure to let the RCM or Charge Nurse know as the surveyor may not pass-on that information. 7. Examples: "Does this resident still have an open area?" Answer (right): "Yes." Answer (right): "No." Answer (wrong): Anything else. "The facility seems noisy." Answer (wrong): "Yes, it does." Answer (wrong): "It doesn't seem as noisy as usual." Answer (right): No comment at all is needed as surveyor only made a comment. "How often are you providing ROM to this resident?" Answer (wrong): "I don't normally work with this resident so I am not the person to ask." Answer (right): "The care plan says. I haven't performed this on this res. in awhile, so I'm getting another CNA to help." "Do you know the facility policy on?" Answer (wrong): "I think it says." Answer (right): "I would not want to misquote it. I can show you where the policy book is." Appendices - 9

Survey Book Contents 1. List of key personnel and locations 2. Written material provided to residents on their rights 3. Meal times and dining locations by unit 4. Copies of all menus 5. Medication pass times by unit 6. List of admissions past month 7. List of residents transferred or discharged during the past three months with destinations 8. Facility map, indicating nursing stations, common areas, rooms, etc. 9. Facility admission packet (including admission contracts) 10. Abuse prevention policies and procedures include a name of a person to talk to about abuse prevention 11. Accident/incident monitoring and prevention at the facility s discretion a copy of accident and incident reports 12. Activity schedule & calendar (optional facility is not required to have) 13. The names of residents under 55 14. The names of residents who communicate with non-oral communication services 15. A list of Medicare residents who requested demand bills in the last 6 months 16. Be ready to answer the following questions or provide in this book: - rooms with less square footage than required - rooms that have more than four residents - Does each room have an outside window - Any rooms not above ground level - Do all rooms have access to the corridor - What procedures are there to ensure water is available to essential areas when there is loss of normal supply 17. Forms that must be completed: - By the end of task 3 the initial tour: Roster/sample matrix HCFA form 802 modifications can be made up to 24 hours after giving to surveyors - Within 24 hours: Application for Medicare & Medicaid HCFA form 671; Resident Census & Conditions HCFA form 672; Ownership documents HCFA form 1513 or HCFA form 855. 18. Consider introductions to all team members at entrance conference Appendices - 10