Seminar for providers and persons in charge of designated centres 2012 Session 4 October 2012
Question and Answer session Central Seminar HIQA panel members: Niall Byrne, Vicky Blomfield, Finbarr Colfer, Aileen Keane North Seminar HIQA panel members John Farrelly, Florence Farrelly, Damien Woods, Brid McGoldrick South Seminar Niall Byrne, Tony Christie, Catherine O Keefe and Cathleen Callanan Date: October 2012
Annual fees Why does HIQA continue to charge for occupancy at the original fee when they instruct providers to reduce capacity in line with requirements of HIQA on space? The annual fees are set out in the Regulations (Registration regulations) and are determined by the Department of Health not by HIQA. HIQA administer these regulations however it is not within HIQAs power to change the regulations. For all centres which h are registered by HIQA - The annual fees are based on the number of beds which the centre is registered for (i.e. the capacity) not the actual occupancy.
Staffing levels What assessment tool does HIQA suggest/recommend for determining staffing levels? HIQA does not suggest or recommend specific assessment tools for determining staff levels. It is the person in charge s responsibility to ensure the staffing levels and skills mix meet the dependency needs of people living at the designated centres at all times. Persons in charge should review staffing levels and skills mix regularly and change them as and when necessary to meet the assessed needs of its own particular residents. Staffing levels and skills mix should be driven primarily by the need to achieve optimal health and quality of life outcomes for the resident. There are numerous tools for determining staffing levels and skills mix and different countries use different methods. There are no detailed specifications for staffing to cover all situations. Inspectors make a judgment about staffing levels based on information they have about a Inspectors make a judgment about staffing levels based on information they have about a centre and whether the individual needs of residents are being met. Inspectors look for evidence of a formal, informed process for deciding the staffing levels.
Behaviours that Challenge What does HIQA suggest in the management of a resident with behaviours that challenge that continues to be aggressive when all interventions have failed, including one-to-one care, activities, GP/ Psychiatry review? Nursing homes do not want to sedate residents or terminate their contract. What options do HIQA suggest? The Authority does not provide suggestions on the specific care needs of individual residents, and it would be inappropriate to do so. While the Authority acknowledges that at times care of some residents can be very complex. It is the responsibility of the provider to ensure that residents receive suitable and sufficient care based on a high standard of evidence based nursing care. The provider should look at their Statement of Purpose and what they are set up to do. Providers should also look at their pre-admission assessments. The responsibility does rest with the provider to ensure they have the adequate staffing to meet the needs of residents.
Inspections/ Inspection process Will all future inspections be utilising the 18 outcomes? No, not all future inspections will be 18 outcome inspections. There are currently four different types of inspections. These will be carried out in order to monitor ongoing compliance with regulatory requirements and ensure continual improvement, as follows: Full 18 outcome inspections which set out the centre s compliance with all of fthe standards d and regulations. Ten outcome monitoring inspections which monitor ongoing compliance with key regulations and standards. Follow-up inspections which assess whether the provider has implemented required actions. Single/specific issue inspection, based on a notification or on information received.
Inspections/ Inspection process At the commencement of inspections HIQA inspectors have been asking for a Primary and Secondary diagnosis for each resident. Could they clarify this. Is it historical diagnosis or reason for admission to a nursing home? Is it a medical diagnosis and who should diagnose? Inspectors can ask different questions about the assessment and care needs of residents. While this may be asked on some inspections, it is not asked on all. The information from these types of questions is used to determine whether the person in charge has information on the needs of current residents and is responding to those needs. On inspection inspectors will ask: How does the provider establish the needs of the residents? and inspectors will look for evidence that the planning and care is based on the information that is gathered.
Inspections/ Inspection process Why do HIQA inspectors challenge the findings of other statutory organisations? E.g. Environmental Health, Fire, Health and Safety HIQA does not challenge the findings of other bodies with statutory responsibilities which may sometimes cross over with HIQA. HIQA has a broader duty. HIQA are aware of the remit of other statutory organisations and do not set out to inspect those areas which other agencies are responsible for regulating. HIQA is however entitled to review copies of reports from other agencies. The Authority does have liaison arrangements with other regulatory bodies and also has a memorandum of understanding with the Health and Safety Authority and the Pharmaceutical Society of Ireland, a liaison group with the fire authorities etc and if a situation arises where an inspector feels that some further clarification or follow up is required in relation to an area covered by another agency the inspector can bring this to the attention of the relevant agency in question. HIQA does work together in the public interest with other statutory organisations.
Inspections/ Inspection process Why do announced inspections not proceed at the time agreed/ provided? E.g. Planned for 9am but inspectors arrive on the premises at 6am. In most cases for announced inspections inspectors do aim to stick to the planned inspection time however inspection start times may change due to information received or other reasons which warrant a change to the inspection timetable. Inspectors may want to see a particular aspect i.e. staffing levels at night, start of a medication round, first meal etc
Inspections/ Inspection process What is the process for challenging an inspector or ceasing an inspection where the provider believes that the inspector has not followed due process or complied with the HIQA Code of Conduct? The provider does not have the legal authority to prevent or stop an inspection proceeding. HIQA inspectors have the authority to enter premises at any time However, the HIQA website contains the Authority s current Complaints Procedure and providers should feel free to utilise this process. Complaints are treated t seriously and are acted upon. In summary the procedure is for use by any person or organisation that may have a complaint about employees or practices of the Authority. This procedure sets out how the Authority will deal with complaints.
Inspections/ Inspection process Why do discrepancies occur between what is reported in the closing meeting and what appears in the inspection report? Is it possible to tape these meetings or ask inspectors to sign a copy of the minutes? Most inspections include a feedback meeting at the conclusion of inspection where the main or critical findings are highlighted so that the provider/pic can have a sense of how well they are complying with the regulations. This allows the provider to identify the main areas for improvement and allow them to start the corrective actions without having to wait for receipt of the report. Following the inspection and feedback meeting, further work will be done by the inspector to review all the evidence gathered and draw together their findings of both compliance and non compliance, The inspection report is the definitive iti summation of all the findings on inspection. Providers are welcome to take notes during the feedback meeting however inspectors are not required to sign copies of any notes taken by providers. Taping of these meetings is not permitted
Inspections/ Inspection process Can inspectors request staff (that have completed their shift) to remain in the nursing home for further questioning? Inspectors would aim to complete any questions with staff during their shift. If a situation did arise where an inspector requested staff (that have completed their shift) to remain in the nursing home for further questioning the staff member has the choice as to whether they choose to remain in the centre. We don t want to disrupt the staff and we have no powers to keep the staff We don t want to disrupt the staff and we have no powers to keep the staff in the nursing home but we may want to meet with them at another time at their convenience.
Advocacy by HIQA What is the role of HIQA in advocating with external agencies on behalf of residents who are not receiving their entitlements? E.g Access to allied health professionals from the HSE for residents in private and voluntary nursing homes and GPs refusing to keep adequate records. Depending on the issue at hand HIQAs does and has raised issues (many of which have been identified through inspection and when regional variations have been identified) ed) with external agencies es regarding g residents not receiving their entitlements. HIQA is limited in what they can achieve in this area we can (and do) bring it to the attention of the relevant agencies/departments For example HIQA has in the past contacted the HSE in relation to the medical card scheme, HIQA also speaks regularly to the Pharmaceutical society of Ireland in relation to medication management.
Advocacy by HIQA What relationship does HIQA have with the NTPF? It is critically important that HIQA and the NTPF address funding and standards together as they are intrinsically linked. The role of the Authority is to regulate designated centres for dependent persons. This is done under the Health Act 2007 and the relevant regulations. Our role is to inspect whether registered providers are adhering to the regulation; that charges are clearly specified in the contract of care and that alterations to fees charged are notified in accordance with the regulations. The Authority has no role in relation to the setting of charges for services. The cost charged in a nursing home is a matter for the individual providers. Authority has no legislative mandate to intervene in this matter unless the provider is failing to comply with the Health Act 2007 and the associated regulations. HIQA does have a relationship with the NTPF and we do talk to them in our advocacy role and will discuss this issue with them again. It is up to the NTPF to determine the pricing. There is a review of the Fair deal scheme ongoing at the moment.
Complaints Do all verbal complaints which are resolved locally in the nursing home need to be documented in the complaints register or should this be for formal complaints only? All complaints, including verbal complaints, should be documented in the complaints register inline with article 39 (7) and (9). (7) The registered provider shall ensure that the nominated person maintains a record of all complaints detailing the investigation and outcome of the complaint and whether or not the resident was satisfied. (9) The registered provider shall ensure that all complaints and the results of any investigations into the matters complained and any actions taken on foot of a complaint are fully and properly recorded and that such records shall be in addition to and distinct from a resident s individual care plan. Complaints relate to quality improvement and providers need to investigate all complaints as they are a good indicator of how the provider can resolve these issues.
Complaints Does the Quality Assurance Questionnaire document form part of the complaints process in HIQA? What is the process for reviewing/ responding to these questionnaires? All Quality Assurance Questionnaires are reviewed by a member of our Quality team. The feedback from the questionnaires is one way HIQA gets feedback on the experience of providers and this is useful when we review our systems and processes. Where specific feedback is provided in relation to an inspection this is also provided to the relevant inspector manager The Quality Assurance Questionnaire i document does not form part of the complaints process in HIQA there is a separate complaints process for HIQA as outlined on the HIQA website. If you don t get a feedback form at the end of an inspection please ask your inspector for one pr call the office and we will send one out to you.
Competency/ Training of inspectors How can inspectors without a professional nursing background review and inspect nursing practices? Inspectors come from a range of professional backgrounds. They are provided with training on how to inspect against the regulation and standards. Inspectors make a judgement on whether the care is delivered based on the centre s own policies and whether these policies are based on informed, evidence based knowledge. It is possible, appropriate and reasonable for professional people to inspect against regulations and standards and we absolutely discourage inspector from making snap judgements. If a situation i arises where additional i expertise is required in any area there is always the option for an inspector to get this assistance as required- either in house or using the option of appointing someone with specific expertise e under section 72 of the Health Act 2007.
Garda Vetting What is the suggested frequency of Garda vetting for staff? Regulation 18 of the Health Act 2007 (Care and Welfare of residents in designated centres for Older People) Regulations 2009 (as amended) states that all staff working in the centre are required to have undergone garda vetting. There is no specification in this regulation in relation to the frequency of garda vetting for staff. However, under the registration regulations, the providers, persons in charge and any other persons participating in or proposed to be participating in the management of the designated centre are required to undergo garda vetting at registration and at each registration renewal.
Garda Vetting Does the nursing home have to keep a copy of garda clearance for contracted services under service level agreements? It is the responsibility of the provider to ensure that t the measures in place protect the residents in the designated centre. It is the responsibility of the provider to demonstrate to the inspectors how they are satisfied that people working in the centre are vetted appropriately. An inspector may ask to review this information.
Criteria for the Person in Charge What is the criteria for the PIC in relation to regulation 15 (2)? What is deemed acceptable in terms of experience in the area of geriatric nursing? Regulation 15 (2) of The Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) states: Subject to article 15(3), the post of person in charge, where that is not the registered provider, shall be full-time and the registered provider or the person in charge, where that is not the registered provider, shall be a nurse with a minimum of three years experience in the area of geriatric nursing within the previous six years. It is the responsibility of the provider to ensure that at the time of appointment, the proposed person in charge satisfies all the requirements of Regulation 15. While it is not possible to be prescriptive in terms of the specific type of experience, it is likely that the proposed person in charge has, for three of the previous six years, been wholly employed as a nurse in one of the following indicative areas: Designated Centre for Older People Older Person Day care setting (centre/hospital) Dementia Unit Geriatric/Psychogeriatric Unit Medical ward for older people this can be a grey area inspectors will look for evidence that t the majority of the nursing is for older people. Community Nurse or Community Psychiatric Nurse for Older People Clinical Nurse Specialist for Older People Answer continued on next slide
Criteria for the Person in Charge (continued from previous slide) Where a proposed person in charge has being working in a part-timetime capacity with older persons, that time should be measured pro-rata to ensure he/she has a minimum of three years experience in the area of geriatric nursing within the previous six years. Where the experience is ambiguous Where there is ambiguity i regarding experience, the inspector will obtain written confirmation from the provider (including relevant supporting documentation) on the nature of that experience. This includes references or other similar il documentation obtained from a previous line manager (or other relevant senior manager) within the identified area/s to confirm experience of the person in charge in the area of geriatric nursing. HIQA has been asked on a number of occasions by providers to indicate whether a prospective PIC is suitable for the position HIQA does not approve PICS for employment/recruitment t etc.
Additional questions re: PIC Can the post of PIC be shared by two people? Yes job share is allowed. Can a PIC overlap a couple of centres? Yes, as long as there is robust governance in place.