Objectives THE NEW SURVEY PROCESS- LESSONS LEARNED Presenter: Shelly Maffia, MSN, MBA, RN, NHA, QCP Director of Regulatory Services Identify significant differences between old and new survey process Describe how the new survey process is conducted Identify the most frequently cited deficiencies in the state since the new survey process began Describe examples of actual survey citations related to the most commonly cited F-Tags in the state Explain strategies for survey success with the new process 2 The New Long Term Care Survey Process Comparison of New Survey Process to Traditional & QIS Process 3 Task Traditional Survey Process QIS (Quality Indicator Survey) Process Automation Sample Selection Survey team collects data and records the findings on paper The computer is only used to prepare the deficiencies recorded on the CMS-2567 Sample size determined by facility census Residents are pre-selected based on QM/QI percentiles (total sample) Sample may be adjusted based on issues identified on tour Maximum sample size is 30 residents Includes complaints Each survey team member uses a tablet PC throughout the survey process to record findings that are synthesized and organized by the QIS software The ASE-Q provides a randomly selected sample of residents for the following: Admission sample is a review of up to 30 current or discharged resident records Census sample includes up to 40 current residents for observation, interview, and record review With QIS 4.04, complaints can be included in census sample New Survey Process Each survey team member uses a tablet or laptop PC throughout the survey process to record findings that are synthesized and organized by new software Sample size is determined by the facility census 70% of the total sample is MDS pre-selected residents and 30% of the total sample is surveyorselected residents. Surveyors finalize the sample based on observations, interviews, and a limited record review. Maximum sample size is 35 residents 1
Task Traditional Survey Process QIS (Quality Indicator Survey) Process Off-Site Preparation Information Needed Upon Entrance Review Casper 3 and 4 reports Survey team uses QM/QIs report offsite to identify preliminary sample of residents areas of concern Roster Sample Matrix Form (CMS-802) Review the Casper 3 report and current complaints Download the MDS data to PCs ASE-Q selects a random sample of residents for Stage 1 from residents with MDS assessments in past 180 days Obtain census number and alphabetical resident census with room numbers and units List of new admissions over last 30 days 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. 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 Task Traditional Survey Process QIS (Quality Indicator Survey) Process Initial Entry Gather information about preselected residents and new concerns Determine whether pre-selected residents are still appropriate 1 3 hours on average No sample selection Initial overview of facility, resident population and staff/resident interactions. 30 45 minutes on average for initial overview 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. Task Traditional Survey Process QIS (Quality Indicator Survey) Process New Survey Process Survey Structure 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 Stage 1: Preliminary investigation of regulatory areas in the admission and census samples and mandatory facility tasks started Stage 2: Completion of indepth investigation of triggered care areas and/or facility tasks based on concerns identified during Stage 1 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 Task Group Interviews Traditional Survey Process Meet with Resident Group/Council Includes Resident Council minutes review to identify concerns QIS (Quality Indicator Survey) Process Interview with Resident Council President or Representative Includes Resident Council minutes review to identify concerns New Survey Process Resident Council Meeting with active members Questions are different from both current processes Includes Resident Council minutes review to identify concerns 2
FY 2017 STD IL Top 10 Citations Standard Surveys (7/30/18 Data) FY 2018 New LTC Survey Process 1 F441 Infection Control 2 F323 Accident Hazards 3 F371 Food Safety 4 F315 Catheter/UTI/Bladder 5 F312 ADL Care Dependent Residents 6 F314 Pressure Ulcers 7 F309 Quality of Care 8 F465 Environment 9 F329 Unnecessary Drugs 10 F226 Abuse Policies 1 F880 Infection Control 2 F812 Food Safety 3 F689 Accident Hazards 4 F690 Bowel/Bladder Incont. 5 F686 Pressure Ulcers 6 F677 ADL Care for Dependent Res. 7 F758 Unnecessary Psych Meds 8 F657 Care Plan Timing/Revision 9 F761 Label/Store Drugs 10 F656 Develop/Implement Care Plan The New Long Term Care Survey Process Overview of New LTC Survey Process 9 Source: CASPER (03/05/2018) 10 New Survey Process Resources CMS Webpage https://www.cms.gov/medicare/provider-enrollment-and- Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html New Survey Process Three parts to new Survey Process: 1. Initial pool process Sample size based on census: 20% of facility census with cap of 35 residents 70% offsite selected 30% selected onsite by team: o Vulnerable residents who are dependent on staff o New Admissions within last 30 days o Complaints or Facility-reported incidents o FRI (Facility Reported Incidents- federal only) o Identified concerns 2. Sample Selection End of day 1 or beginning of day 2 survey team selects sample 3. Investigation All concerns for sample residents requiring further investigation o Closed records o Facility tasks 11 (CMS, 2017) 3
Mandatory Tasks 1. Dining 2. Infection Control 3. Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review 4. Resident Council Meeting 5. Kitchen 6. Medication administration 7. Medication storage 8. Sufficient and competent nurse staffing 9. QAA/QAPI Recommended Number of Surveyors 13 (LTC Survey Process Procedure Guide) Facility Entrance Team Coordinator (TC) conducts Entrance Conference Brief visit to the kitchen Surveyors go to assigned areas New Entrance Conference Worksheet (CMS, 2017) 15 4
Updated Facility Matrix Initial Pool Process Surveyor request names of new admissions Identify initial pool about eight residents Offsite selected Vulnerable New admissions Complaints or FRIs Identified concern 18 (CMS, 2017) 18 Resident Interviews Screen each resident in initial pool to determine if interviewable Will complete full interview on all interviewable residents in the initial pool Takes about 20 minutes per resident Surveyor can ask questions as they like, but must address all care areas For any concern expressed during interview, will ask additional questions to determine if concern can be ruled out or needs to be investigated further 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 Initial pool residents if possible Investigate further or no issue 19 (CMS, 2017) 20 19 (CMS, 2017) 20 5
Initial Pool Process: Interview Care Areas 1. Choices 2. Activities 3. Dignity 4. Abuse 5. Resident Interactions 6. Privacy 7. Accommodation of Needs 8. Personal Funds 9. Personal Property 10. Sufficient Staffing 11. Participation in Care Planning 12. Community Discharge 13. Environment 14. Food 15. Dental 16. Nutrition 17. Hydration 18. Tube Feeding 19. Vision and Hearing 20. ADLs 21. ADL Decline 22. Catheter 23. Inulin or Blood Thinner 24. Infections 25. Hospitalizations 26. Falls 27. Pain 28. Pressure Ulcer/Skin 29. Limited ROM 30. Rehab 31. Dialysis 32. Incontinence 33. Constipation/Diarrhea 34. Smoking 35. Hospice Initial Pool Process: Interview Guides Surveyor Observations Full resident observation for all resident s in initial pool Cover all care areas and probes listed in software Conduct rounds Complete formal observations Investigate further or no issue Initial Pool Process: Resident Observation Care Areas 1. Activities 2. Dignity 3. Abuse 4. Privacy 5. Accommodation of Needs 6. Language/ Communication 7. Mood/Behavior 8. Restraints 9. Accident hazards 10. Unsafe Wandering/ Elopement 11. Call lights 12. Environment 13. Dental/Nutrition 14. Edema 15. Hydration 16. Tube Feeding 17. Vision/Hearing 18. ADLs 19. Catheter 20. Psych/Opiod Med Side Effects 21. Anticoagulant Side Effects 22. Infections 23. Oxygen 24. Positioning 25. Falls 26. Pain 27. Pressure Ulcers 28. Skin condition 29. Limited ROM 30. Hospice 31. Vent/Trach 32. Incontinence 33. Smoking 23 (CMS, 2017) 23 6
Initial Pool Process: Resident Observations Guide Initial Pool Process: Resident Observations 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 to identify high-risk medications and hospice Extenuating circumstances, interview staff Investigate further or no issue 26 (CMS, 2017) 26 Initial Pool Process: Record Review Care Areas 1. Pressure Ulcers 2. Dialysis 3. Infections 4. Nutrition 5. Falls 6. ADL Decline 7. Low Risk B&B 8. Hospitalization 9. Elopement 10.Change of Condition 11.Insulin 12.Anticoagulant 13.Antipsychotic with Alzheimer's/ Dementia 14.PASARR 15.Advance Directives 16.High Risk Meds 17.Diagnoses 18.Hospice Initial Pool Pool Process: Resident Process: Record Observations Review Guide 7
Dining First Full Meal Dining observe 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 Use Appendix PP and CE Pathway for Dining Dining task is completed outside any resident specific investigation into nutrition and/or weight loss Dining Observation Each survey team member will be assigned a dining area. If there are fewer surveyors than dining areas, observe the dining areas with the most dependent residents. The team is responsible for observing the first meal upon entrance into the facility. Additional observations may be required if the team identifies concerns. Any surveyor assigned a dining location will complete the observations and answer all CEs using Dining Observation FORM CMS 20053 (5/2017) While it is not mandatory, the team member responsible for the Kitchen task should also consider completing the Dining task. Potential nutrition or hydration concerns should be investigated under the resident review. (CMS, 2017) 30 29 Dining Observation Focus Areas Infection Control Dignity Homelike Environment Resident Self- Determination/Preferences Dining Assistance Assistive Devices Positioning Dietary needs Paid Feeding Assistants Food and Drink Quality Food Substitutes Therapeutic Diets Lighting Ventilation Sound levels Comfortable & safe temperature Furnishings Space Frequency of Meals Were any offsite selected residents discharged? Ensure all offsite selected residents were included in the initial pool, unless discharged. Was at least one resident who smokes included in the initial pool? Is each surveyor identifying vulnerable residents? Go over each newly admitted resident listed on the matrix and ensure each resident listed was screened by a team member. How many residents did each surveyor include in the initial pool? How much work does each surveyor have left to do? Any harm, SQC, IJ, or other concern that should be discussed? How many resident representative/family interviews were completed? Day 1 Team Meeting Was at least one resident who is on transmission-based precautions in the initial pool? Ensure any resident on the matrix who has a unique significant concern was included in the initial pool. Discuss any discrepancy between the matrix and information from the interview, observation, and limited record review. What is the status and pertinent information for complaint and FRI residents? Enter the total number of new admissions. 8
Sample Selection Meet, for about 1 hour, after initial pool process is complete to select sample Prioritize using sampling considerations: Replace discharged residents selected offsite with those selected onsite May include up to 5 complaint/fri in sample Can replace residents selected offsite with rationale Harm, SQC if suspected, IJ if identified Abuse Concern Transmission based precautions Hospice Dialysis Ventilator All MDS indicator areas if not already included Sample Selection Unnecessary Medication Review System selects five residents for full medication review Residents may or may not be in sample Use for a resident who has potentially unnecessary medications, is prescribed psychotropic medications or has the potential for an adverse outcome to determine whether facility practices are in place to identify, evaluate, and intervene for potential or actual unnecessary medications. Use also to evaluate the medication regimen review (MRR) process. Residents selected will include (if available): Insulin Anticoagulant Antipsychotic with Alzheimer s or dementia 33 (CMS, 2017) 34 33 (CMS, 2017) 34 Unnecessary Medication Review- Documentation Review Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway (Form CMS 20082) Based on observation, interview, record review, and MDS Review MDS for adverse consequences and/or behaviors Review all medications currently ordered or discontinued going back to the most recent signed recapitulation. Acceptable clinical indication for use Written protocols or resources to guide antibiotic use Appropriate monitoring Appropriate dosing Duration documented Clinical rationale for continued use documented System to monitor and address presence of adverse consequences System for and documentation of psychotropic GDRs Adherence to PRN psychotropic requirements Individualized approaches and non-pharmacological interventions care planned Unnecessary Medication Review Investigation Process Observations Staff Interviews Pharmacist Interview Attending Practitioner, Medical Director, & DON interview Record Review Critical Element Focus 1. Medication Regimen Review process 2. Free from Unnecessary Medications 3. Psychotropic Drug Use 4. Antibiotic Stewardship 5. Baseline/Comprehensive Care Plan 6. Comprehensive Assessment 35 9
F758 Unnecessary Psych Drugs #7 most frequently cited 96 citations Complaint Surveys = 14 Standard Surveys = 82 D level = 79 E level = 16 G level = 1 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08/07/2018) 37 #7 F758 Unnecessary Drugs G Level Citation Example Facility failed to provide documentation to support the use of the anti-psychotic medications in dementia residents, failed to have documentation on targeted behaviors being treated and failed to provide documentation of non-pharmacological interventions prior and during the use of the anti-psychotic medications for 3 residents reviewed for anti-psychotic medication. This failures have resulted in residents exhibiting Tardive Dyskinesia (side affects) symptoms and exhibiting excessive sleepiness. 38 #7 F758 Unnecessary Drugs E Level Citation Example Facility failed to complete initial and quarterly psycotropic medication assessments, attempt/document Gradual Dose Reductions, document targeted behaviors, monitor for side effects of psychotropic medication, and complete psychotropic medication consents for 6 of 6 sampled residents. No medication assessments, AIMS assessments, or GDR attempts in over 6 months to 2 years No behavior documentation present for these residents on psychotropics No evidence of monitoring for side effects in record or MAR No completed consents Sample Selection 1. Unexpected death in last 90 days who was not on hospice 2. Resident who went to hospital in last 90 days and has not returned 3. Resident who was discharged back to community in last 90 days Closed Record Reviews Critical Element Pathways Death (Form CMS 20074) Circumstances surrounding the death Practices related to changes in condition Discharge (Form CMS 20132) Discharge planning processes Hospitalization (Form CMS 20123) Practices related to changes in condition Transfer/Discharge Practices 39 40 10
Infection Control Infection Prevention and Control CE Pathway (CMS-20054) Investigates compliance with F880, F881, & F883 One surveyor coordinates the facility task to review for: The overall Infection Prevention and Control Program (IPCP); The annual review of the IPCP policies and practices; The review of the surveillance and antibiotic stewardship programs; and Tracking influenza/pneumococcal immunization of residents. Team assignments must be made to include the review of: Laundry services; A resident on transmission-based precautions, if any; Five sampled residents for influenza/pneumococcal immunizations; Other care-specific observations if concerns are identified. Every surveyor assesses IPCP compliance throughout the survey and communicates any concerns to the team. F880 Infection Control #1 cited tag in IL & Nationally 247 citations Complaint Surveys = 45 Standard Surveys = 202 C level = 1 D level = 152 E level = 69 F level = 24 Glevel = 1 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30//18 Source: S&C QCOR (08/07/2018) 41 42 #1 F880 Infection Control G Level Citation Examples Facility failed to establish & maintain an ICP program designed to provide an environment for its residents which was free from potential exposure to the Legionella bacteria. The facility failed to have a water management program based on industry standard of practice. R8 tested positive for Legionella pneumophila and subsequently expired due to bilateral pneumonia. #1 F880 Infection Control F Level Citation Examples Facility failed to perform hand hygiene during incontinence care for 3 residents reviewed for incontinence care. The facility also failed to maintain and monitor an employee illness log. Facility failed to follow contact precautions during routine blood glucose testing, identify and institute transmission-based precautions, and perform hand hygiene during incontinent care for 3 residents. Facility failed to implement active surveillance for residents infections. Facility failed to follow established infection control measures to prevent the spread of infection, for 8 resident O2 tubing on floor Un-labeled co-mingled personal care items in shared bathrooms Bed pan containing soiled towels on floor Urine collection bag directly touching floor 43 44 11
SNF Beneficiary Protection Notification Review Completed for residents who received Medicare Part A Services. This protocol is intended to evaluate a nursing home s compliance with the requirements to notify Original (Fee-For-Service) Medicare beneficiaries when the provider determines that the beneficiary no longer meets the skilled care requirement. This review confirms that residents receive timely and specific notification when a facility determines that a resident no longer qualifies for Medicare Part A skilled services when the resident has not used all the Medicare benefit days for that episode. This review does not include Admission notifications or Medicare Part B only notifications. SNF Beneficiary Protection Notification Review The two forms of notification that are evaluated in this review are: 1. Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS-10055. 2. Notice of Medicare Non-coverage--Form CMS 10123-NOMNC, also referred to as a generic notice. 45 (CMS, 2017) 46 45 SNF Beneficiary Protection Notification Review SNF Beneficiary Protection and Notification Review Pathway FORM CMS-20052 (11/2017) Information requested during the Entrance Conference: A list of Original (Fee for Service) Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months prior to the survey. Does not include: Beneficiaries who received Medicare Part B benefits only. Beneficiaries covered under Medicare Advantage insurance. Beneficiaries who expired during the sample date range. Beneficiaries that were transferred to an acute care facility or another Randomly select three residents from list One who went home Two who remained in facility, if available Surveyor Scenarios 47 48 12
F582 MCD/MCR Coverage/Liability Notice 14 citations Complaint Surveys = 0 Standard Surveys = 14 D level = 12 E level = 2 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08/07/2018) F582 MCD/MCR Coverage/Liability Notice E Level Citation Examples Facility failed to issue the CMS SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) to residents discharged from Medicare Part A Services. This failure affected 15 of 15 residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past six months All were provided NOMNC, but facility was not using ABN Facility failed to provide proper written Notices of Medicare Non-coverage and an Advance Beneficiary Notice of Non-coverage for Medicare non-covered services. This failure has the potential to affect 4 residents outside the sample by precluding residents their right to appeal the decision to end Medicare covered services. NOMNC provided did not include the name and toll-free telephone number for the QIO (Quality Improvement Organization) to file an appeal for the decision to end Medicare covered services & ABNs not provided as indicated 49 50 Resident Council Meeting Group interview with active members of the council Try to keep at 12 or less residents Will ask president to assist with arranging the meeting Will obtain consent from President to review last 3 months council minutes Complete early to ensure investigation if concerns identified- Preferably day 2 Resident Council CE Pathway- FORM CMS 20057 Different questions than Traditional & QIS Focus: Functioning of the council Grievance Process Abuse Sufficient Staffing Identified concerns from survey Kitchen Observation Kitchen Observation CE Pathway- FORM CMS 20055 Initial brief tour of kitchen upon entrance Foods stored & prepared under sanitary conditions Handling, preparing, distributing food in manner that prevents foodborne illness Conduct full kitchen investigation in future trips to kitchen 51 51 52 (CMS,2017) 52 13
#2 most frequently cited 147 citations Complaint Surveys = 9 Standard Surveys = 138 B level = 1 C level = 3 D level = 3 E level = 13 F level = 126 L level = 1 F812 Food Safety The is valid for the subset of providers for which there are survey records in CASPER as of 3/26/18 Source: S&C QCOR (04/02/2018) #2 F812 Food Safety F Level Citation Example Facility failed to ensure dishes were effectively sanitized in the hot water sanitizing machine A test strip designed to turn black when the water is hot enough to sanitize did not turn black during 3 different checks. Facility staff was not aware the machine was not sanitizing until surveyors requested a strip be sent through the machine. Facility failed to follow their policy and procedures to ensure the proper dishwasher machine sanitation temperatures and chemical concentrations in their three compartment sinks to prevent the spread of food-borne illnesses. In addition, the facility failed to label, date, and dispose of expired food items in resident pantry refrigerators. Facility log titled Sample High Temperature Dishwasher Form Heat Sanitation shows temperatures on the log with no evidence showing actual strips were used to determine the sanitizing effectiveness of the dishwashing machine. Staff report they only record temperature from gauge on machine. Staff washing dishes in 3 compartment sink could not explain how to test for effective sanitation, nor had strips available to her Expired milk & cream cheese in pantry fridge & unlabeled items 53 54 Medication Administration & Storage Medication Administration- FORM CMS 20056 (11/2017) Make random observations of several staff over different shifts/units & multiple routes Oral, enteral, intravenous (IV), intramuscular (IM), subcutaneous (SQ), topical, ophthalmic Observe minimum of 25 medication opportunities Observe and document all of the resident s medications for each observed medication administration If possible, observe medications for a sampled resident whose medication regimen is being reviewed. Otherwise, observe medications for any resident to whom the nurse is ready to administer medications. Reconcile controlled medications if observed during medication administration Medication Storage - FORM CMS-20089 Observe half of medication storage rooms and half of medication carts, covering different units Review half of the med carts on units where the storage room was not observed. If issues, expand medication room/cart F761 Label/Store Drugs #9 most frequently cited 86 citations Complaint Surveys = 9 Standard Surveys = 77 C level = 3 D level = 51 E level = 21 F level = 11 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08/07/2018) 55 55 56 14
#9 F761 Label/Store Drugs E Level Citation Example Facility failed to label eye drop (medication) bottles with resident's names for 6 residents Failed to store medication that required refrigeration in a clean refrigerator. The refrigerator in the medication room had food particles and dried liquid splatters on the inside walls of the refrigeration unit. Facility failed to follow the facility policies for labeling and storage of medications Inhalers stored with no opened date on label Insulin vial with open date >28 days on med cart #9 F761 Label/Store Drugs F Level Citation Example Facility failed to ensure medications were stored at proper temperatures and away from food for two of two medication storage refrigerators located within the facility. Applesauce stored in medication refrigerator & thick, tan, sticky buildup on bottom of refrigerator Med room refrigerator temperature not checked & documented per policy 57 58 Sufficient and Competent Nurse Staffing Review Sufficient and Competent Nurse Staffing Review - FORM CMS 20062 Considerations: Surveyor observations Resident/Resident Rep/Family Member Interviews Nurse Aide & Licensed Nurse Interviews DON/Staff Development Interviews Record Reviews Other Facility documents: Facility Assessment, Schedules, Posted Staffing, etc. Throughout the survey, consider if staffing concerns can be linked to QOL and QOC concerns (CMS, 2017) 59 F725 Sufficient Nursing Staff 32 citations Complaint Surveys = 23 Standard Surveys = 9 D level = 7 E level = 19 F level = 5 GLevel = 1 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08/7/2018) 59 60 15
F726 Competent Nursing Staff 7 citations Complaint Surveys = 3 Standard Surveys = 4 D level = 5 Flevel = 1 L level = 1 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08//07/2018) F725 Sufficient Staffing G Level Citation Example Facility failed to provide a sufficient number of effective staff to meet the care needs of 4 residents. Resident was put in the wheelchair and changed at 5:55 am and at 11:23 am had not been checked or changed since 5:55 am due to not having enough time to get it done. He was found to have newly facility acquired Moisture Associated Skin Deterioration (MASD) when changed at 11:23 am. At 11:11 AM Nursing Assistant provided incontinence care to Resident. She stated resident was last changed at 8 am and confirmed residents are to be checked and changed every 2 hours. She further stated, We are doing the best we can-not enough Nursing Assistants. At 12:22 PM, Resident stuck his right hand in his incontinence briefs and removed hand which then had stool on the side of his right hand and fingers. At 12:41 PM nurse aide brought him into the shower room to provide incontinence care after she noticed the stool on his fingers and hand. She confirmed this was the first time incontinence care was provided to him since 6 am. Between 12:40-1:11 PM nurse was assisting in one of the dining rooms. She stated they were short and only had 2 CNA's and that she had one noon medication left to give and it would be late if she was unable to get another staff to assist in the dining room- supervising in the dining room was a priority over timely medication administration. She stated medications are to be administered no more than one hour before or after the prescribed time. She administered the noon med at 1:24 pm. Residents, Ombudsman & staff voiced concerns regarding staffing levels. 61 62 F726 Competent Staffing L Level Citation Example Facility failed to ensure that facility staff has current healthcare provider CPR (cardiopulmonary resuscitation) certification, failed to ensure that nursing staff was trained and knowledgeable of facility procedures for identifying resident code status, failed to ensure staff was competent in assessing the need for CPR and able to correctly implement CPR. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin when facility staff failed to initiate CPR on a resident. QAA/QAPI Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Plan Review - Form CMS 20058 Review occurs at end of survey after investigations complete Concerns identified during offsite preparation Systemic issues or shared concerns QAA meeting frequency and committee members Identification of system issues and good faith attempts to correct QAPI plan review 63 64 16
F865 QAPI Program/Plan 6 citations Complaint Surveys = 1 Standard Surveys = 5 C level = 4 F level= 2 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08/7/2018) F867 QAA/QAPI Improvement Activities 2 citations Complaint Surveys = 0 Standard Surveys = 2 F level= 2 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08/7/2018) 65 66 F868 QAA Committee 9 citations Complaint Surveys = 1 Standard Surveys = 8 C level = 7 F level= 2 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08/07/2018) F865 & F868 C level Example Based on interview and record review the facility failed to develop a Quality Assurance and Performance Improvement Program (QAPI). This failure has the potential to affect all 120 residents currently in the facility. Findings include: Interview with V1 (Administrator) on 02/05/18 at 3:30pm stated, I've only been here for about a month. I will ask to see what we do. Since I've gotten here we are in the process of developing things. We have ideas of what we are going to be doing. V1 stated that she has not attended any QAPI meetings since she has been at the facility. Surveyor asked for evidence that the facility has been conducting meetings for their quality assurance committee and all that was provided was a list of the committee members but no evidence that meetings have been held. Surveyor was provided with a copy of the facility's Quality Assessment and Assurance Plan (undated). The plan does not address required components of the QAPI Plan, including but not limited to, the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved, how the QAPI and QAA committee functions, scope of the QAA committee's responsibilities and activities, and the process addressing how the committee will conduct the activities necessary to identify and correct quality deficiencies. 67 68 17
Abuse Environment* Personal Funds* Activities ADLS Behavioral-Emotional Urinary Catheter-UTI Communication & Sensory Dental Dialysis General QOC concerns Hospice/End of Life Nutrition Pain Management Triggered Pathways/Tasks Physical Restraints Pressure Ulcers Rehab and Restorative Respiratory Care PASARR Extended Survey Hydration Tube Feeding Positioning, Mobility, & ROM Incontinence Accidents Neglect Resident Assessment* Dementia Care End of Day Meetings Team members share data Meet for 30-45 minutes Software has Team Meeting Screen Surveyors discuss areas noted on Team Meeting Screen System populated areas include: Newly identified harm or IJ concerns Follow up to ensure 3 resident representative interviews completed 70 Potential Citations Team makes compliance determination. Compliance decisions reviewed by team Scope and severity (S/S) Conduct exit conference and relay potential areas of deficient practice The New Long Term Care Survey Process Review of Citation Frequency & Examples (CMS, 2017) 71 71 72 18
National Standard Surveys 2018 1 F880 Infection Control 2 F812 Food Safety 3 F656 Develop/Implement Care Plan 4 F689 Accident Hazards 5 F761 Label/Store Drugs 6 F657 Care Plan Timing/Revision 7 F684 Quality of Care 8 F758 Unnecessary Psych Meds 9 F641 Accuracy of Assessments 10 F550 Resident Rights Top 10 Deficiencies Standard Surveys 2018 Illinois Standard Surveys 2018 1 F880 Infection Control 2 F812 Food Safety 3 F689 Accident Hazards 4 F690 Bowel/Bladder Incont. 5 F686 Pressure Ulcers 6 F677 ADL Care for Dependent Res. 7 F758 Unnecessary Psych Meds 8 F657 Care Plan Timing/Revision 9 F761 Label/Store Drugs 10 F656 Develop/Implement Care Plan F689 Accident Hazards #3 most frequently cited 280 citations Complaint Surveys = 151 Standard Surveys = 129 D level = 187 E level = 31 F level = 1 G level = 57 J level = 3 K level = 2 (3 IJs one facility) The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (8/07/2018) 74 #3 F689 Accidents IJ Citation Example Facility failed to remove a tray of food from the vicinity of a resident assessed at risk for choking and with known impulsive eating behaviors. This failure resulted in resident being found unresponsive in his room after taking food off an unmonitored tray of food near the nurse's station. He subsequently died. On mechanical soft diet, fed by staff, 30 min checks, not to be left alone with food d/t impulsive eating/risk for choking Staff noted tray in disarray with water tipped over at nurse desk. Followed trail of food to his room where found him unresponsive. Initiated CPR & expired at hospital. #3 F689 Accidents IJ Citation Example Facility failed to transcribe an order for 1:1 supervision with meals. Resident choked and was subsequently hospitalized where he expired. These failures resulted in an Immediate Jeopardy Resident choked on food while his mother was in room assisting him with meal. Staff and resident s mother were not aware of the order and need for 1:1 supervision. Mother stated staff had never supervised him while eating & his door was often closed when he ate his meals. 75 76 19
#3 F689 Accidents IJ Citation Example Facility failed to ensure that a mechanical lift sling was safe for use prior to transfer of one resident. This failure resulted in R1 falling from the mechanical lift on two separate occasions, the second time sustaining a Subarachnoid Hemorrhage (brain bleed), and a Subdural Hemorrhage (brain bleed). R1 was subsequently hospitalized then transferred to another long term care facility where R1 expired. (R1) was being transferred via mechanical lift. (R1) sustained a fall with injury when the (mechanical lift) sling sustained a tear. Loop on sling tore allowing resident to slip out of sling onto the floor. Nurse aide stated she didn't have help so she performed lift without assistance. Resident was still over the bed when the sling broke and he went through the side and over (mechanical lift sling) to the ground. There was another incident where loop broke off sling the prior week & aide reported to supervisor, but no one took the sling out of service or inspected slings. Laundry supervisor revealed that sometimes slings were washed with bleach & they were purchased over 2 years ago. F690 Bowel & Bladder, Catheter, UTI #4 most frequent citation 154 citations Complaint Surveys = 39 Standard Surveys = 115 D level = 143 E level = 9 G level = 2 The is valid for the subset of providers for which there are survey records in CASPER as of7/30/18 Source: S&C QCOR (08/07/2018) 77 78 #4 F690 Bowel & Bladder, Catheter, UTI G Level Citation Example Facility failed to provide timely incontinence care to 3 of 5 residents reviewed for bowel and bladder incontinence. This failure resulted in R57 developing Moisture Associated Skin Deterioration (MASD) to the scrotum and R20 to the buttocks area. This is same example reviewed for Sufficient Staffing G level citation #4 F690 Bowel & Bladder, Catheter, UTI D Level Citation Example Facility failed to maintain a resident's indwelling catheter bag below a resident's waist and ensure a catheter bag is not positioned on the floor, to prevent a urine tract infection 2 observations of catheter bag on floor Observed staff holding catheter bag up above level of bladder during mechanical lift transfer 79 80 20
F686 Treatment/Services to Prevent/Heal Pressure Ulcers #5 most frequently cited 201 citations Complaint Surveys = 90 Standard Surveys = 111 D level = 156 E level = 12 G level = 31 H level = 1 J level = 1 The is valid for the subset of providers for which there are survey records in CASPER as of 7/30/18 Source: S&C QCOR (08/07/2018) #5 F686 Treatment/Services to Prevent/Heal Pressure Ulcers IJ Level Citation Facility failed to document initial skin assessments upon admission, failed to measure identified wounds upon admission, failed to conduct weekly measurements and assessments of pressure ulcers, failed to document dressing changes on the treatment record, failed to implement preventative measures for a resident admitted with pressure ulcers, failed to obtain physician orders for a new admission with a Stage 2 pressure ulcer, failed to develop and implement individualized care plans for residents with known pressure ulcers and the facility failed to identify a pressure ulcer prior to a Stage 4. These failures resulted in an Immediate Jeopardy (IJ). The Immediate Jeopardy began when R4 was found to have a Stage 4 pressure ulcer under a leg immobilizer. The facility failed to perform an initial assessment of the wound when it was reported by the Nurse Practitioner, including obtaining measurements and description of the wound. R4's pressure ulcer risk assessment was last completed over one year ago. R4's care plan does not indicate use of a leg immobilizer or interventions to prevent pressure ulcers. The care plan interventions for a Stage 4 pressure ulcer were not implemented. 81 82 Survey Preparedness Tips The New Long Term Care Survey Process Strategies for Survey Success Staff education Resident/Family education On-going process for interviews Identify high-risk residents Matrix Quality Measures CE Pathway use Mock Survey Keep Matrix updated Maintain Survey Binder 83 84 21
References 1.Centers for Medicare and Medicaid Services. (2017). Nursing homes Centers for Medicare and Medicaid Services. Retrieved from https://www.cms.gov/medicare/provider Enrollment and Certification/GuidanceforLawsAndRegulations/Nursing Homes.html 2.Centers for Medicare & Medicaid Services. (2017). S&C QCOR Home Page. Retrieved from https://pdq.cms.hhs.gov/report_select.jsp?which=0 Thank you for attending! Shelly Maffia, RN, MSN, HFA, MBA, QCP smaffia@proactivemedicalreview.com Proactive partners with providers for regulatory compliance, training, & medical review solutions. 85 85 22