National Regulatory Overview Lyn Bentley, Vice President Quality & Regulatory Affairs September 19, 2018
Topics The new survey process obe prepared Frequently cited tags onation oregion VII onebraska Compliance tips Adjust your approach
Standard Surveys in Nebraska CASPER as of 8/13/2018 142 standard surveys ---- 65% of facilities have had a survey since October 1, 2017
Deficiency Levels for Nebraska Tags CASPER as of 8/13/2018 1 B 73 C 755 D 334 E 174 F 31 G 16 H 0 I 71 J 26 K 9 - L
CMP data for Nebraska CASPER as of 8/13/2018 4 per diem Total $171,992.60 3 per instance Total $ 28,553.25
New Survey Process
The New Survey Process Goal: more consistency Combines QIS and standard Critical Element Pathways Focus on person - centered care Emphasis on interviews opatient ofamilies orepresentatives ostaff
Three Components Three Components oinitial Pool Process osample Selection oinvestigation
Offsite Preparation Team Coordinator completes offsite preparation Repeat deficiencies Results of last Standard survey Complaints Facility Reported Incidents Variances/waivers Necessary documents are printed
Facility Entrance Team Coordinator conducts Entrance Conference Updated Entrance Conference Worksheet Updated facility matrix List of residents who smoke and smoking times (used Day 1) Number and location of medication storage rooms and carts List of residents for Advance Beneficiary Notices review Brief visit to the kitchen Surveyors go to pre-assigned areas
Mandatory Tasks Unit and facility task assignments Kitchen Medication administration Medication storage Sufficient and competent nurse staffing QAA/QAPI (must take place at end of survey) If triggered: Environment, Personal Funds, Resident Assessment
Needed within One Hour Schedule of meal times Schedule of Med Administration Times Number & location of medication storage rooms and medication carts Actual work schedules of LPNs & RNs
Needed within Four Hours Complete Matrix of residents Admission packet for new admissions Dialysis ocontracts, P&P about dialysis olist of qualified staff to perform dialysis if applicable oagreements or policies & procedures for transport to & from dialysis odoes facility have onsite certified ESRD unit
Needed within Four Hours Hospice oagreements, P&P and ostaff who coordinates services with hospice Influenza/Pneumococcal Immunization P&P Abuse Prohibition P&P
Needed within Four Hours Infection Prevention Plan, P&P, ABX stewardship program QAPI plan QAA committee information Facility assessment Description of any experimental research occurring in the facility Nurse staffing waivers
Needed within Four Hours List of rooms meeting any of the following: oless than required square footage omore than four residents to room obelow ground level ono window to the outside ono direct access to an exit corridor
Material needed by End of First Day EHRs provide each surveyor with access to all resident EHRs odo not exclude anything that should be part of the resident s medical record oinformation how surveyors can access the EHRs outside of the conference room oprovide completed form Electronic Health Record (EHR) Information
Materials needed within 24 hours of entrance Form 671 Facility staffing data CMS stopped collecting as of June 1, 2018 Form 672 completed census and condition information Completed form Beneficiary Notice Residents Discharged Within the Last Six Months
Interviews Resident/Representative/Family Group interview with Resident Council Each surveyor covers all care areas
Resident Interviews Choices Activities Dignity Abuse Resident-to-Resident Interaction (confrontation) Privacy Accommodation of Needs (physical) Personal Funds Personal Property
Resident Interviews Sufficient Staffing Participation in Care Planning Community Discharge Environment Food Dental Nutrition Hydration Tube Feeding Vision and Hearing ADLs
Resident Interviews ADL Decline Catheter Insulin or Blood Thinner Respiratory Infection Urinary Tract Infection Other Infections Hospitalizations Falls Pain Pressure Ulcers
Resident Interviews Skin Conditions non-pressure related Limited Range of Motion Rehabilitation Dialysis Incontinence Constipation/Diarrhea Smoking Hospice Other Concerns
Representative/Family Interviews Same topics as Resident Interview PLUS onotification of Change
Resident Observations Surveyors also make observations about all the topics they are asking questions about oex: Access to call light; fresh water/drink; assistance to attend activities; if the patient wears glasses or uses a hearing aid, are they being used; if needed is patient receiving needed assistance eating or with activities; etc.
Review of Surveyor Tools Mapping for All Areas Find at: https://www.cms.gov/medicare/provider- Enrollment-and- Certification/GuidanceforLawsAndRegulations/Nursi ng-homes.html Survey Resources zip file LTSCP MappingDocument_Streamlined Interview and observation surveyor tools
Top Ten Tags in Nation as of July 30, 2018 CASPER DATA F 880 Infection Prevention & Control F 689 Free of Accident Hazards; Supervision; Devices F 656 Develop/Implement Comprehensive Care Plan F 812 Food Procurement, Store/Prepare/Serve Sanitary Conditions F 684 Quality of Care
Top Ten Tags in Nation, cont. as of July 30, 2018 CASPER DATA F 657 Care Plan Timing and Revision F 761 Label/Store Drugs F 686 Pressure Ulcers F 758 Psychotropics/PRN use F 842 Resident Records: Identifiable Information
Top Ten Tags in Region 7 as of July 30, 2018 CASPER Data F 880 Infection Prevention & Control F 689 Free of Accident Hazards; Supervision; Devises F 812 Food Procurement, Store/Prepare/Serve Sanitary Conditions F 656 Develop/Implement Comprehensive Care Plan F 684 Quality of Care F 658 Services provided Professional Standards
Top Ten Tags in Region 7, cont. as of July 30, 2018 CASPER DATA F 657 Care Plan Timing and Revision F 690 Bowel/Bladder Incontinence, Catheter, UTI F 686 Pressure Ulcers F 584 Safe, Clean/Comfortable/Homelike Environment
Top Ten Tags in Nebraska As of July 30, 2018 CASPER Data F 689 Free of Accident Hazards/Supervision F 880 Infection Prevention & Control F 812 Food Procurement, Store/Prepare/Serve Sanitary Conditions F 656 Develop/Implement Comprehensive Care Plan F 609 Reporting of Alleged Violations F 584 Safe, Clean/Comfortable/Homelike Environment
Top Ten Tags in Nebraska As of July 30, 2018 CASPER Data F 657 Care Plan Timing and Revision F 684 Quality of Care F 550 Resident Rights/Exercise of Rights F 755 Pharmacy Services; Procedures; Pharmacist; Records Real outlier tag---- 13 th most frequently cited: F 923 Ventilation
F880 Infection Prevention & Control Handwashing between glove changes; during medication pass Cleaning reusable equipment: glucometers, lift slings Cleaning/disinfecting patient rooms, shower rooms, bathrooms Use of PPE s Consistent use of facility s infection control log Staff competencies have process in place and use it!!!!
F880 Infection Prevention & Control Water management plan Use current CDC guidelines Use current P&Ps make sure everyone who needs to know about them does know about them Scabies and use of infection control log for patients and staff Communication
F689 Free From Accident Hazards/Supervision Fall interventions were removed however nothing replaced those interventions Standard of practice: oaide left room with bed in highest position patient with a fall risk in bed oaide went in the bathroom to wash hands and the door was partially shut couldn t observe patient Unsupervised smoking and no assessment for safe smoking and risk for elopement Causal factors for falls not determined and no interventions put in place
F609- Reporting Alleged Violations Failure to complete and submit results of investigation of abuse for 2 patients Failure to report fall after calling Adult Protective Services after a all and failure to complete and submit results of investigation Resident to resident altercation: failed to report incident of abuse to state Failure to report potential misappropriate of resident medications
F923 - Ventilation 41 citations in the country; 23 in Nebraska Bathroom ventilation systems were not working Resident rooms had no working ventilation systems
F812 Food Procurement, Store; Prepare; Serve; Sanitary Runny eggs oprocurement oserving Containers in refrigerator: contents not identified; no date; not consistent with facility P&Ps Hand washing/gloves Not reporting illness to Food Service Director (person in charge)
F812 Food Procurement, Store; Prepare; Serve; Sanitary Roaches Temperatures ofood odishwasher Sanitizing cleaner mixture
Adjusting the Approach Consideration oincreased amount of time surveyors are talking to patients/families/staff Approach otake a walk and ask questions ouse observation and interview questions the surveyors will use oask your staff how they would fix a problem
Adjusting the Approach Audits ointernal opeer oexpectations Come into your center and pretend you have never been here before osights osounds osmells
Strategies for Survey and Compliance https://www.cms.gov/medicare/provider- Enrollment-and- Certification/GuidanceforLawsAndRegulations/ Nursing-Homes.html LTC Survey Pathways LTCSP Initial Pool Care Areas LTCSP Procedure Guide (eff. 8/5/2018) LTC Survey FAQs (updated 7/11/2018)
Strategies for Survey and Compliance https://qcor.cms.gov/main.jsp
Resources for New Requirements of Participation www.educate.ahcancal.org
ROP Playbook and Overview Checklist
PDPM Intensive Sessions Join AHCA/NCAL at the 69 th Annual Convention & Expo for the most up-to-date payment reform information Two opportunities to attend an intensive session: Sunday, October 7 1:00pm 5:00pm Wednesday, October 10 10:30am 3:30pm (repeat of Sunday session) Early bird registration ends July 20 Advance registration ends September 21 For more information and to register visit www.ahcaconvention.com or www.ncalconvention.com
Contact Information Lyn Bentley, MSW Vice-President, Quality & Regulatory Affairs lbentley@ahca.org 202-898-6304