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The Quality Debate: How to Rise Above Contents Who Are You?

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4/4/14
The Quality Debate:
How to Rise Above
OHCA Conference
Wednesday April 30, 2014
Session W31
Wednesday 2:00PM to 5:00 PM
Shane Craycraft
scraycraft@gmecc.com
1
Contents
тАвтАп
Who are You?
тАвтАп
The Quality Discussion
тАвтАп
тАвтАп
Satisfaction and Choice
тАвтАп
3rd Party Ideas
тАвтАп
Survey Regulatory Ideas
тАвтАп QA Setup
тАвтАп Survey Prep
Quality Components
тАвтАп
Payment 4 Performance
тАвтАп
ICDS
тАвтАп
5 Star/Nursing Home Compare
тАвтАп
QAPI
ODH Quality Nursing Home
Reports and IJтАЩs
2
тАвтАп
Who Are You?
3
1
4/4/14
4
Age Distribution
Age
Less than 25 years
State Average
National Average
Less than 1%
Less than 1%
25 to 54 years
7.8%
5.9%
55 to 64 years
12.5%
10.2%
65 to 74 years
18.1%
17.5%
75 to 84 years
27.4%
28.1%
34%
38%
Greater than 84
5
Gender Distribution
Gender
State Average
National Average
Male
36.2%
36.2%
Female
63.8%
63.8%
6
2
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Payment Sources
Payment Sources
Peer Group Percentage
Medicaid or Medicaid Pending
68%
Medicare
19%
Private Pay
11%
Other
2%
7
Length of Stay
Length of Stay
Peer Group Percentage
Less than 3 months
19%
3 to 12 months
29%
13 to 70 months
32%
Greater than 70 months
6%
Unknown
14%
8
Census Changes:
Hospital Data
The National average as of June 2010
for Medicare Discharges to SNFтАЩs was
9
21.7%
3
4/4/14
Market Share
Calculation
Categories
Numbers
Hospital Discharges
1200
Admissions to your SNF
250
Percentage of Your SNFтАЩs Market Share
21%
Number of SNFтАЩs in Your Market
5
Even Distribution of Market Share Discharges
240
Percentage of Even Distribution of Market Share Discharges
20%
10
Census Changes:
Hospital Data
11
Entered Facility From:
Entered Facility From
State Average
National Average
Community
9.0%
10.6%
Another Nursing Home
7.4%
6.4%
Acute Hospital
79.9%
78.7%
Psychiatric Hospital
1.8%
2.1%
Inpatient Rehab
0.4%
0.7%
ID/DD Facility
0.1%
0.1%
Hospice
0.5%
0.3%
LTAC
0.3%
0.2%
Other
0.5%
0.8%
4
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13
The Quality Discussion
14
Is Quality
Personal Satisfaction?
" тАп
Resident and Family Satisfaction?
" тАп
" тАп
General Satisfaction with facially
Choices
" тАп
Can I choose when I get Up?
" тАп
Can I choose when I go to bed?
" тАп
Personalization- Can I decorate my room the
way I want?
15
5
4/4/14
Is Quality Based Simply
on Personal Choice?
" тАп
Choice in Dining
"
Restaurant-style dining in which food is brought
from the food preparation area to residents per the
residents' orders;
"
Buffet-style dining in which residents obtain their
own food or have the facility's staff bring food to
them, per the residents' directions, from the buffet;
"
Family-style dining in which food is customarily
served on a platter and shared by residents;
"
Open dining in which residents have at least a twohour period to choose when to have a meal;
"
Twenty-four-hour dining in which residents may
order meals from the facility any time of the day.
16
Is Quality Based Simply
on Personal Choice?
" тАп
" тАп
Choice in Bathing
The facility's residents must be able to take a
bath or shower as often as they choose.
Advance Care Planning
The facility's residents have the opportunity to
discuss their goals for the care they are to
receive at the facility, including their preferences
for advance care planning, with a member of the
residents' healthcare team that the facility,
residents, and residents' sponsors consider
appropriate.
17
Is Quality Based Simply
on Personal Choice?
" тАп
" тАп
Private Rooms
A certain percentage of the facility's Medicaidcertified beds must be in private rooms.
Eliminate Overhead Paging
To receive the quality incentive point for this
measure, the facility must maintain a written
policy that prohibits the use of overhead paging
systems or limits the use of overhead paging
systems to emergencies, as defined in the policy.
The facility must communicate the policy to its
staff, residents, and families of residents.┬а
18
6
4/4/14
Is Quality Found in
Advancing Excellence?
" тАп
The Advancing Excellence in AmericaтАЩs Nursing
Homes Campaign is a major initiative of the
Advancing Excellence in Long Term Care
Collaborative. The Collaborative assists all
stakeholders of long term care supports and
services to achieve the highest practicable level of
physical, mental, and psychosocial well-being for
all individuals receiving long term care services.
19
Is Quality Found in
Advancing Excellence?
Does a Quality Process equal Quality?
" тАп
" тАп
Consistent Assignment
" тАп
Hospitalization/Re-Hospitalization
" тАп
Person Centered Care
" тАп
Staff Stability (Turnover vs Retention)
20
Is Quality Found in
Advancing Excellence?
" тАп
Do Quality Clinical Outcomes equal Quality?
" тАп
Infection Rates are kept low
" тАп
Medication utilization is monitored
" тАп
Mobility- Focus on therapy. Mobility equals
freedom
" тАп
Pain- Low percentages of pain
" тАп
Pressure Ulcers- Low percentages of ulcers
21
7
4/4/14
AHCA Quality
Initiative
http://www.ahcancal.org/
quality_improvement/qualityinitiative/Pages/
default.aspx
22
AHCA Quality
Initiative
1.тАп
2.тАп
3.тАп
4.тАп
Safely Reduce Hospital Readmissions: By March 2015,
reduce the number of hospital readmissions within 30
days during a SNF stay by 15%.
Increase Staff Stability: By March 2015, reduce turnover
among┬аnursing staff (RN, LPN/LVN, CNA) by 15%.
Increase Customer Satisfaction: By March 2015, increase
the number of customers who would recommend the
facility to others up to 90%.
Safely Reduce the Off-Label Use of Antipsychotics: By
December 2012, reduce the off-label use of antipsychotic
drugs┬аby 15%.┬а┬а
23
Is Quality Found in
CMS Quality Measures?
" тАп
" тАп
" тАп
" тАп
Pain
Not more than 13.35% of the facility's long-stay residents report
severe to moderate pain.
Pressure Ulcers
Not more than 5.73% of the facility's long-stay, high-risk
residents may have been assessed as having one or more stage
two, three, or four pressure ulcers.
Restraints
Not more than 1.52% of the facility's long-stay residents may be
physically restrained.
Urinary Tract Infections
Less than 7.78% of the facility's long-stay residents may have
had a urinary tract infection.
24
8
4/4/14
Is Quality a Good
Survey?
"
"
No health deficiency with a scope and severity
greater than F.
No deficiency that constitutes a substandard
quality of care.
25
What is Quality?
" тАп
Is it satisfaction?
" тАп
Is it choice?
" тАп
" тАп
Is it about having the right processes
in place?
Is it about clinical outcomes?
26
Harvard Medical
School Defines Quality
" тАп
Staffing Levels
" тАп
Staffing mix
" тАп
"тАп
Hospitalizations
"тАп
Urinary Incontinence
Staff Turnover
"тАп
Functional status change
Assists with ADLтАЩs
"тАп
Pain Control
" тАп
Infections Resident Services
"тАп
Depression
" тАп
"тАп
Injuries
"тАп
Pressure Ulcers
" тАп
Physical/Chemical Restraints
" тАп
Delivery of тАЬhotelтАЭ services
"тАп
Weight Loss
" тАп
use of urinary catheters
"тАп
Patient/Family Satisfaction
" тАп
Resident centeredness
"тАп
Staff Satisfaction
" тАп
Survey Deficiencies
"тАп
Medicare/Medicaid Spending
27
9
4/4/14
28
Attempts at Better
Quality
" тАп
Historic Approach- Increased regulation and oversight
" тАп
" тАп
OBRA, MDS, Minimum Staffing StandardsтАж
New Approaches
" тАп
Pay for Performance/Quality Incentives
" тАп
Report Cards- 5 Star
" тАп
ACO/Managed Care Networks
" тАп
Integrated Care Delivery System (ICDS)
29
Payment 4 PerformanceMedicaid Financial Incentives
30
10
4/4/14
Werner Nursing
Home Study 2013
31
Managed Care Ideas (AHCA)
32
Dual Eligible Proposals
33
11
4/4/14
34
The Integrated Care
Delivery System
The Affordable Care Act in Action
http://www.medicaid.gov/AffordableCareAct/Provisions/Dual-Eligibles.html
35
ICDS Dual Eligibles
" тАп
тАЬThe Affordable Care Act creates a new
office within CMS, the MedicareMedicaid Coordination Office, to
coordinate care for individuals who are
eligible for both Medicaid and Medicare.
The office is charged with making the
two programs wok together more
effectively to improve care and lower
costsтАжтАЭ
36
12
4/4/14
ICDS:
Areas of Interest
" тАп
Integrating Care for MedicareMedicaid enrollees
" тАп
Medicare Data
" тАп
State Demonstrations
" тАп
Waiver Period
37
38
ICDS Background
" тАп
" тАп
" тАп
" тАп
It is part of the Affordable Care Act.
(Medicare-Medicaid Coordination Office)
Designed to Integrate Dual Eligibles (Medicare
and Medicaid) into one payment system.
Intent of any MCO (Managed Care
Organization) is to save money.
Nine states were approved.
39
13
4/4/14
Ohio ICDS
" тАп
" тАп
It is a тАЬdemonstrationтАЭ through 2017
5 MCOтАЩs were selected in 7 metro areas have
been selected
" тАп
Estimated 114,000 dual eligible people in Ohio
" тАп
There is some ability to opt out.
" тАп
All Medicare and Medicaid Services are
included (Part A, B, D, state plans and waiver)
40
My Care Ohio
41
42
14
4/4/14
ICDS Plans by
Region
43
44
45
15
4/4/14
46
47
48
16
4/4/14
ICDS Thoughts
" тАп
MCOтАЩs will attempt to reduce cost.
" тАп
MCOтАЩs Are Using Existing Networks
" тАп
" тАп
MD Enrollment?
" тАп
Adequate Market Coverage?
5 Star will be used to determine future
eligibility.
49
CMS 5 Star Rating
тж┐тАп
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/
CertificationandComplianc/Downloads/brieffivestartug.pdf
What Is the 5-Star Rating?
" тАпTool for consumers and caregivers to compare nursing homes more easily
" тАпSummarized information into an easy- to-understand rating system
How Did CMS Design the 5-Star?
" тАпDetermined Key Information
" тАпEmployed Use of Technical Expert Panel
" тАпStakeholder Comments
17
4/4/14
What Do the Stars Mean?
Much Above Average
Above Average
Average
Below Average
Much Below Average
5 Star Rating Methodology
" тАп Step 1: Start with the Health Inspection Rating.
" тАп Step 2: Add one star if the Staffing rating is 4 or 5 stars and also greater
than the Health Inspection Rating. Subtract one star if the Staffing rating is
1 star. The rating cannot go above 5 stars or lower than 1 star.
" тАп Step 3: Add one star if the Quality Measure rating is 5 stars; subtract one
star if the Quality Measure is 1 star. The rating cannot go above 5 stars or
lower than 1 star.
" тАп Step 4: If the Health Inspection rating is 1 star, then the Overall Quality rating
cannot be upgraded by more than one star based on the Staffing and Quality
Measure ratings.
" тАп Step 5: If a nursing home is a Special Focus Facility that has not graduated,
the maximum Overall Quality rating is 3 stars.
18
4/4/14
5 Star Health Inspection (1 of 2)
" тАп Ratings are calculated from points that are assigned to the results
of nursing home surveys over the past three years, as well as
complaint surveys from the past three years and survey revisits.
More recent surveys are weighted more heavily.
" тАп Points are assigned based on the number, scope and severity of a
nursing home's health deficiencies. If multiple revisits are
required to ensure that major deficiencies are corrected,
additional points are added to the health inspection score.
" тАп Lower health inspection scores result in a better 5-Star rating on
Nursing Home Compare.
5 Star Health Inspection (2 of 2)
" тАп Nursing homes are ranked within their state based on their
score, and the number of stars is based on where the nursing
home falls within the state ranking.
" тАп The top 10% of nursing homes get 5 stars, the bottom 20% get 1
star, and the middle 70% of nursing homes receive 2, 3 or 4
stars, with equal proportions (23.33%) in each category.
" тАп Health Inspection ratings are re-calculated every month to
account for new survey results entering into the system.
Health Inspections
Table 1 Health Inspection Score: Weights for Different Types of Deficiencies
Severity
Scope
Isolated
Pattern
" тАп 3 years of annual
and complaint
surveysWidespread
Immediate jeopardy to resident health
or safety
J
50 points
(75 points)
K
100 points
(125 points)
L
150 points
(175 points)
Actual harm that is not immediate
jeopardy
G
20 points
H
35 points
(40 points)
I
45 points
(50 points)
No actual harm with potential for actual
harm that is not IJ
D
4 points
E
8 points
F
16 points
(20 points)
No actual harm with potential for
minimal harm
A
0 point
B
0 points
C
0 points
Scores in parentheses = if substandard quality of care
Shaded boxes = substandard quality of care if the requirement which is not met is one that falls under: resident behavior and nursing home
practices; quality of life; quality of care.
3 most recent annual inspections тАУ weighted in favor of most recent surveys
19
4/4/14
5 Star- Quality Measures
Long-stay Prevalence Measures:
Short-Stay Prevalence Measures:
ADL change*
Mobility change*
High-risk pressure ulcers
Long-term catheters
Physical restraints
Urinary Tract Infection (UTIs)
Pain
Delirium
Pain
Pressure Ulcers
Points for QMs тАУ ADL QMs* are scored statewide, others nationally
The 2 ADL measures* are weighted 1.6667 times heavier than the others
ADL QMs
Other QMs
<20th percentile
20
12
20 - < 40th percentile
15
9
40th - < 60th percentile
10
6
60 тАУ 80th
5
3
80th percentile or greater
0
0
5 Star- Quality Measures (1 of 2)
" тАп ADL Decline and Mobility Decline contribute more heavily
(each weighted at 1.667 times) than the other QMs.
" тАп A nursing home's performance on the ADL Decline and
Mobility Decline QMs is ranked against all other nursing homes
in the state.
" тАп A nursing home's performance on the other 8 measures is ranked
against all other nursing homes in the nation.
5 Star- Quality Measures (2 of 2)
" тАп Points are assigned for each QM based on what quintile the
nursing home falls into, in comparison to other nursing homes.
For the 2 ADL QMs, these quintile thresholds were set in March
2011; for the other 8 QMs, fixed quintile boundaries (from
January 2009) are used. Points for each QM are added together
for a total point score.
20
4/4/14
5 Star- Staffing Ratings (1 of 2)
" тАп Ratings are calculated from two case mix adjusted measures: RN
hours per resident day and total staffing hours (RN, LPN, Nurse
Aide) per resident day. These two measures contribute equally to
the Staffing rating.
" тАп Staffing measures are derived from OSCAR data that is then
case mix adjusted based on the nursing home's distribution of
MDS assessments by RUG-III group, based on the number of
RN, LPN, and nurse aide minutes associated with each RUG-III
group.
" тАп The source data is the CMS for CMS-671.
" тАп Other staff, such as clerical, administrative, and housekeeping
staff, are not included in the calculation of the Staffing ratings.
5 Star- Staffing Ratings (2 of 2)
" тАп For each staffing measure, a 5-Star rating is assigned based on
where the nursing home ranks compared to the adjusted staffing
hours for all freestanding nursing homes AND where the
nursing home ranks compared to optimal staffing levels
identified in the 2001 CMS Staffing Study.
" тАп To earn 5 stars on the Staffing rating, the nursing home must
meet or exceed the CMS staffing study thresholds for both RN
and total nursing hours per resident day.
" тАп The Nursing Home Compare website will include a "drill down"
that shows the nursing home's rating for RN Staffing.
Table 3: Scoring Method & Thresholds for Staffing Measures
Rating
Definition
1
<25th percentile of distribution for freestanding
facilities
2
at least 25th percentile but less than median of the
distribution for freestanding facilities
3
Range тАУ RN adjusted hrs. per Range тАУ all staff adjusted
resident day
hrs. per resident day
<0.220
< 2.946
0.220 - 0.297
2.946 - 3.316
greater than or equal to the median but less the
75th percentile of the distribution for freestanding
facilities
0.298-0.403
3.317 тАУ 3.774
4
greater than or equal to the 75th percentile of the
distribution for freestanding facilities but less than
the CMS staffing study threshold
0.404-0.549
5
at or exceeding the thresholds identified in the
CMS staffing study
> 0.55
3.775 тАУ 4.079
> 4.08
CMS plans to use these percentile cut points for 2 years
Staffing is compared nationally
RN & All Staff are equally weighted
21
4/4/14
Staffing Data Source
" тАп CASPER Staffing Report: The CASPER Staffing Report provides
a synopsis of the facilityтАЩs reported staffing hours, as reported on
the┬а CMS 671 form that is completed at time of the Annual
Health Inspection.┬а┬а The information found in this report
includes PPD Hours for all departments, percentage of FullTime, Part-Time and Contract Hours.┬а┬а
5 Stars Concerns
" тАп 5 Star is based on a flawed survey system
" тАп 5 Star provides little useful information for the consumer, and may
confound the already difficult decision of which facility best serves
the consumerтАЩs needs.
" тАп 5 Star staffing ratings are built on the findings of a study completed
eight years ago тАУ one that does not take into account the adoption
of culture change within long term care (e.g., where a facility has
trained all staff within a facility to serve as CNAs) nor the
significant shifts in the health care market overall. Furthermore,
CMS determined that it was impossible to require these staffing
ratios because of the exorbitant cost.
22
4/4/14
Nursing Home Compare
http://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1
Nursing Home Compare
" тАп What is it?
" тАп Nursing Home Compare allows consumers to compare
information about nursing homes. It contains quality of care
information on every Medicare and Medicaid-certified nursing
home in the country, including over 17,000 nationwide.
Nursing Home Compare
" What Information Can I Get from It?
"
"
"
"
"
Five-Star Quality Ratings of overall and individual star performance on
health inspection surveys, quality measures, and hours of care provided per
resident by staff performing nursing care tasks.
Health inspection results and complaints give detailed and summary
information about deficiencies found during the 3 most recent state
inspections and recent complaint investigations.
Nursing home staffing information about the number of registered nurses,
licensed practical or vocational nurses, physical therapists and nursing
assistants in each nursing home.
A set of quality measures that describe the quality of care in nursing homes
including percent of residents with pressure sore, percent of residents with
urinary incontinence and more.
Penalties and enforcement actions against a nursing home.
23
4/4/14
Quality Assurance/
Performance Improvement
" тАп
" тАп
Know as QAPI
тАЬQAPI is a data-driven, proactive approach to improving the
quality of life, care, and services in nursing homes. ┬аThe
activities of QAPI involve members at all levels of the
organization to: identify opportunities for improvement; address
gaps in systems or processes; develop and implement an
improvement or corrective plan; and continuously monitor
effectiveness of interventions.тАЭ ┬а
" тАп
Expansion of F520 Quality Assurance and Assessment
" тАп
Five Elements
72
24
4/4/14
CMS Interpretive
Guidelines
Identify effectiveness and modifying
interventions as necessary;
Evaluating and analyzing hazards and
risks;
Implementing interventions to reduce
hazards and risks; and
Monitoring for effectiveness and
modifying interventions when
necessary.
The тАЬExecution GapтАЭ
The тАЬExecution GapтАЭ usually occurs
when there is a failure to implement
planned interventions, or when the
work process outputs are not
translated and incorporated into the
actual hands-on delivery of service
or the resident outcomes process.┬а
The lack of follow through or break
in the process is the source of
lawsuits, regulatory deficiencies, poor
quality indicator/quality measure
outcomes and unsatisfied customers.┬а
QAPI Element 1:
Design and Scope
75
25
4/4/14
QAPI Element 2:
Governance & Leadership
76
QAPI Element 3:
Feedback, Data Systems, Monitoring
77
QAPI Element 4:
Performance Improvement
Projects (PIPтАЩs)
78
26
4/4/14
QAPI Element 5:
Systematic Analysis and Action
79
Most Important
Focus?
Survey rules the current Quality environment!
ODH Nursing Home
Reports
81
27
4/4/14
Quarterly Nursing Home
Report
" тАп
" тАп
This report provides information on selected
indicators of care and services being provided to
nursing home residents in Ohio.
Data will be pulled each calendar year (CY)
quarter and added to the current data in order
to assess trends and determine if changes across
quarters indicate an actual change in care being
provided to residents or if the changes are due
to confounding factors, such as seasonal changes
or a change in survey process.
82
Quarterly Nursing Home
Report
" тАп
Comments about QIS from ODH:
"
"
"
It is a resident-centered, outcome-oriented quality
review which entails structured resident, family,
and staff interviews, resident observations, record
reviews, and analysis of health assessment data.
Data from the QIS will be used to track certain
quality of care, quality of life and personcentered tags as well as deficiencies constituting
immediate jeopardy.
Staffing data collected as part of the QIS will also
be monitored.
83
Quarterly Nursing Home
Report
" тАп
Philosophy of the Report:
"
"
"
"
ODH believes that three quality of care survey tags pertaining to
pressure ulcers, nutrition and weight loss, and hydration merit
monitoring because they are indicative of worsening health
status.
The quality of life and person centered care tags pertaining to
resident neglect and mistreatment, resident self-determination
and participation, accommodation of needs and housekeeping
and environment also bear monitoring.
These tags were chosen because they relate to basic fundamental
aspects of resident well-being.
We are also monitoring deficiencies constituting immediate
jeopardy, and violations of federal staffing requirements.
84
28
4/4/14
Quarterly Nursing Home
Report
Key Indications selected by ODH:
" тАп
"
"
"
"
Falls
Pressure Ulcers
Nutrition/Weight Los
Hydration
These тАЬwere chosen because they are indicative of
worsening health conditions. Although we are
tracking deficiencies in these areas, monitoring
of the resident assessment data will provide a
more global picture of residentsтАЩ conditions in
nursing homes.тАЭ
" тАп
85
Enforcement
Actions
" тАп
Enforcement actions are taken against facilities to
encourage prompt correction. We are monitoring the
imposition of civil money penalties because an
increase in the number of civil money penalties or in
the number of facilities receiving a civil money
penalty could indicate that facilities are out of
compliance for longer periods of time, there are
repeat deficiencies, or the deficient practices are of a
more serious nature.
86
Complaint Intake
Data
Complaint intake was chosen to
monitor trends in the residentsтАЩ and
their familiesтАЩ perception of quality
of care in the long term care
facility. The allegation categories
that were chosen provide a snapshot
of the overall stay of a resident in
the facility. A complaint is the initial
indication of a potential problem.
29
4/4/14
88
30
4/4/14
Quality of Care
Deficiencies
91
Quality of Life/
Person Centered Care
92
Nursing Home
Staffing
93
31
4/4/14
94
95
G and Above
Deficiencies
96
32
4/4/14
Immediate Jeopardy
97
Immediate Jeopardy:
Abuse & Restraints
" тАп
Cited at F221, F223 F225 & F226
" тАп
F221- Restraints
" тАп
Types of Abuse (Verbal, Physical Sexual)
"
"
"
Resident to Resident
Staff to Resident
Visitor to Resident
98
Immediate Jeopardy:
Coumadin
" тАп
F329 Drug Regimen is
Free from Unnecessary
Drugs (J) тАУCoumadin
99
33
4/4/14
Immediate Jeopardy:
CPR
" тАп
" тАп
F309 Provide Care/Services
for Highest Well Being
CPR
10
0
Immediate Jeopardy:
Choking
" тАп
" тАп
F309 Provide Care/Services for
Highest Well BeingтАУ
Choking
10
1
Immediate Jeopardy:
Accidents & Supervision
" тАп
Facility #1 F323 Free from Accident Hazards- Bed
Rails
" тАп
Facility #2 F323 Elopement
" тАп
Facility #3- F323 Elopement
" тАп
Facility #4- F323 Supervision
" тАп
Case Study- BiPAP and Emergency Generators
10
2
34
4/4/14
Civil Money
Penalties
35
4/4/14
10
7
10
8
36
4/4/14
109
Tracking Nursing Home Self
Reported Incidents
& Complaints
Data from July 1, 2011 to December 31,
2012
11
0
111
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Self Reported Incidents (SRI)
112
Abuse Allegations
by Category
113
ODA SATISFACTION SURVEYS
Resident and Family
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ODA Satisfaction
Surveys Links
http://aging.ohio.gov/ltcquality/nfs/
performance/
http://aging.ohio.gov/ltcquality/inc/
docs/
consumer_01_SatisfactionSurveys.pdf
2011 Resident
Satisfaction Survey
2012 Family
Satisfaction Survey
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Things to Consider
IMMEDIATE JEOPARDY
PREVENTION
CMS Guidelines
Immediate Jeopardy - тАЬA situation in
which the providerтАЩs noncompliance
with one or more requirements of
participation has caused, or is likely
to cause, serious injury, harm,
impairment, or death to a resident.тАЭ
тАЬHarm does NOT have to occur before
considering Immediate Jeopardy. тАЬ
тАЬThe Entity knows or should have
known about the situation.тАЭ
PRINCIPLES
The Entity
тЧЖтАп knows
or
тЧЖтАп should have known about
the situation
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IJ General
Comments
Have an active Quality Assurance/Improvement
Program in place
Routine Auditing is an essential element
Most IJтАЩs are appear in the same categories- Start
auditing in those areas.
Use Regulatory Language for P&P- Quote the Regs.
Make P&PтАЩs simple
Utilize Trade Association Support
Educate, Educate, Educate!
CMS Interpretive Guidelines
Identify- the process through which the
facility becomes aware of potential
hazards;
Evaluating and analyzing hazards and
risks;
Implementing interventions to reduce
hazards and risks; and
Monitoring for effectiveness and
modifying interventions when necessary.
The тАЬExecution
GapтАЭ
The тАЬExecution GapтАЭ usually occurs when
there is a failure to implement planned
interventions, or when the work process
outputs are not translated and
incorporated into the actual hands-on
delivery of service or the resident
outcomes process.┬а The lack of follow
through or break in the process is the
source of lawsuits, regulatory
deficiencies, poor quality indicator/
quality measure outcomes and
unsatisfied customers.┬а
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General QA System
тАвтАп Prioritize the known risk areas
throughout the state.
тАвтАп Prioritize the Risk areas in your building
тАвтАп Make High Risk areas a permanent part
of your QA Program
тАвтАп Make Low Risk areas a less frequent part
of your QA Program
QA Areas of Focus
тАвтАп Education тАУ Teachers or Disciplinarians?
тАвтАп On the Resident as an Individual
тАвтАп Systems and Process
тАвтАп Measurement of Success
тАвтАп Inter-Disciplinary Approach
Getting Started
What are the high risk areas in any facility?
тАвтАп Accidents and Supervision
тАвтАп Abuse & Neglect
тАвтАп Medication Errors
тАвтАп Dietary- Choking
тАвтАп CPR Protocols
тАвтАп Pressure Ulcers
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Getting Started
тАвтАп Educate on high priority areas
тАвтАп Conduct Audits
тАвтАп Staff Awareness and education on
subject
тАвтАп Staff performance
тАвтАп Resident- Potential Involvement
тАвтАп Systemic overview
Identifying Problems
тАвтАп Audit the Nurses Notes
тАвтАп Audit the Treatment Administration Records
тАвтАп Audit the Medication Administration Records
тАвтАп Audit the Ancillary/Appliance Records
тАвтАп Audit the environment- Walk the Building
тАвтАп Observe the Residents
тАвтАп Conduct Morning Meeting/Report
Nurses Notes:
A Place of True Enlightenment
тАвтАп Units of
Measurement
тАвтАп What are you
trying to say??!!??
тАвтАп The English Major
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Latest Trend in Facility
Development
Consistency is All That
Matters
Additions to:
Funny Things Found in
NurseтАЩs Notes
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QAA- Resident
Level
Identify
Assessments- Admission, Risk, Event/Incident
Implement
POCтАЩs (Both LT and ST), Interventions, Flow Records,
Administration Records
Evaluate
NurseтАЩs Notes, Specific Discipline Notes, Inter-Disciplinary
Team Notes (IDT)
Monitor
Audits, Chart Reviews , Inter-Disciplinary Team Notes (IDT)
Documentation Recommendations
тАвтАп Initial Nurses/Discipline Note
тАвтАп Short Term Plan of Care with interventions
тАвтАп IDT Note- Initial
тАвтАп Ongoing Nurses/Discipline notes
тАвтАп Long Term POC updated with intervention
тАвтАп IDT Note- Conclusion
QA Monitoring Tool
Nurses Notes
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Case Study:
Maintenance- Hot Water
Review Maintenance Process
тАвтАп Identify Problem- Elevated water temp
тАвтАп Evaluate Circumstances- Inspection found
leak in water pipe and damaged mixing
valve
тАвтАп Implement Intervention- Adjusted mixing
valve, replaced water pipe, replaced mixing
valve.
тАвтАп Monitor for Effectiveness- Monitor Water
temps after each adjustment and repair
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Hot Water Temps
тАвтАп Citation? Yes or No?
тАвтАп Discussion regarding involved resident
population (Dementia Unit verses General
population)
тАвтАп Discussion of process
тАвтАп Discussion of the quality of the process.
тАвтАп Cited at Exit
тАвтАп Not present on Statement of Deficiencies
тАвтАп Suggestions on Improving the process?
Elopement
тАвтАп Review Admission process- Can this
facility adequately meet the needs of
this resident?
тАвтАп Assess Resident and take protective
actions for prevention. Cognitive level
must be taken into consideration
тАвтАп Review LOA Policies- Who requires
supervision with outings? Who is
qualified to Supervise?
Elopement
тАвтАп Secure Unit P&P
тАвтАп Equipment and alarms must be
functioning correctly and used
properly
тАвтАп Interventions must be attainable
тАвтАп Conduct frequent elopement drills
тАвтАп Use the тАЬElopement Prevention and
Management Planning
GuideтАЭ (
www.ohca.org/content/view/320)
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Elopement
тАвтАп Focus on 3 areasтАвтАп Elopement Prevention
тАвтАп Elopement Assessment and Care
Planning
тАвтАп Elopement Follow Up
тАвтАп This is a high profile problem
QA Monitoring Tool
Elopement Assessment & POC
Case Study
Elopement
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Elopement Case Study
Points of Interest
тАвтАп Assessed as High Risk, but no follow
through with warning signs of potential
elopement
тАвтАп Dependence upon locked doors
тАвтАп Nursing Process- Execution Gap
тАвтАп Update POC after occurrence
Case Study Elopement
Follow Up
тАвтАп State plans to revoke license of care
facility
тАвтАп Toledo nursing home found
noncompliant in abuse prevention,
response
тАвтАп BY JESSICA SHOR
BLADE STAFF WRITER
Abuse
тАвтАп When Reported, Take Immediate Action
тАвтАп Protect the Victim from the aggressor
(resident, staff, visitor)
тАвтАп Notify appropriate people (Admin, MD,
LE, Family, ODHтАж) ODH notification is
within 24 hours, if required.
тАвтАп Develop specific plan of prevention of
future occurrences.
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Case Study
Abuse
Medication Errors
тАвтАп Anti-coagulantsтАвтАп Review OHCA Coumadin White Paper
тАвтАп Auditing and Oversight of Lab Ordering process.
тАвтАп Faxing PT/INR results are not recommended
тАвтАп Educate Nurses:
тАвтАп To check for lab results when administering an
anti-coagulant
тАвтАп To monitor for drug interactions (ATBтАЩs)
QA Monitoring Tool
Medication ErrorsCoumadin
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QA Monitoring- CPR/DNR
тАвтАп CPR Protocols
тАвтАп Educate, Educate, Educate
тАвтАп Take random tests of your Nurses
тАвтАп Develop a consistent and easily understood
method of identifying Code Status
тАвтАп At this point and time, only and Physician
can stop a code.
тАвтАп Board of Nursing Ruling
TRANSITIONFROM ONE TO MANY
QAA is involved on a resident level on a day to day
basis.
QAA is also involved on a facility level reviewed on
at least a monthly basis.
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52
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Analysis- Falls
Analysis- Pressure
Ulcers
Unit
Name
Location
Stage
Acquired
I/O
1
John
Coccyx/L Heel
II / II
O / O
2
Joe
Coccyx
II
I
3
Judy
R 4th Finger
II
I
4
Jill
B Heels/
Coccyx
III / IV
O / O
Facility Level
тАвтАп Even at the facility level the process is the
same
тАвтАп Identify problems
тАвтАп Evaluate Circumstances regarding
problem
тАвтАп Implement Facility wide interventions
тАвтАп Monitor for effectiveness
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Facility Focus
тАвтАп F279- Comprehensive Care Plans
тАвтАп F323- Accident/Supervision
тАвтАп F309- Quality of Care/Highest Practable Level
тАвтАп F329- Unnecessary Medications
тАвтАп F253- Housekeeping & Maintenance
тАвтАп F371- Food Sanitation
Review
тАвтАп You are responsible for what you know and
what your should have known
тАвтАп CMS states QA has 4 components:
тАвтАп Identify
тАвтАп Evaluate
тАвтАп Implement
тАвтАп Monitor
тАвтАп Do not fall into the Execution Gap!
Preparation is the Key
SURVEY PREPARATION
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Survey Management
Survey Preparation
тАвтАп Survey Entrance Conference Worksheet (Facility)
тАвтАп Survey Entrance Conference Worksheet (QIS Team Copy)
тАвтАп Interviews
тАвтАп Staff
Survey
Binder
тАвтАп Residents
тАвтАп Resident Council President/Representative Interview
тАвтАп Family
тАвтАп Kitchen/Food Service Observation
тАвтАп Dining Observation
Survey Observation- Nursing
Medication Administration Observation
Medication Storage
Quality Assessment and Assurance
(QA&A) Review
Infection Control & Immunizations
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Survey- Record
Review
тАвтАп Admission Sample Record Review
тАвтАп New Admission Information Form
тАвтАп Census Sample Record Review
тАвтАп Liability Notices & Beneficiary Appeal Rights
Review
тАвтАп Surveyor Notes Worksheet
тАвтАп Resident Census and Condition CMS672
тАвтАп Roster/Sample Matrix CMS802
The Survey is Here! It is time.
SURVEY MANAGEMENT
QIS Stage II Critical
Element Pathways
Activities
Activities of Daily Living, and/
or Range of Motion Status
(Includes Cleanliness/
Grooming and Positioning)
Behavioral and Emotional
Status
Bowel or Bladder Function /
Use of an Indwelling Catheter
Communication and Sensory
Problems (Includes Hearing and
Vision)
Dental Status and Services
Dialysis Services
General Critical Element
Pathway
Hospice and / or Palliative
Care
Hospitalization or Death
Nutrition, Hydration and
Tube Feeding
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QIS Stage II Critical
Element Pathways
Pain Management
Physical Restraint Use
Pressure Ulcers
Psychoactive Medications
Rehabilitation for
Community Discharge
Ventilator Dependent
Residents
Unnecessary Drug Review
QIS Extended Survey
Survey Management
Top 10 Things Not to Do During
Survey
1. Give surveyors free roam of the facility.
2. Admit to working short staffed.
3. Tell surveyors тАЬSorry, thatтАЩs not my job.тАЭ
4. Answer тАЬNo, we donтАЩt do that here,тАЭ when
surveyors inquire about the facilityтАЩs care
planning or other care protocols.
5. Put the survey before residents.
Survey Management
Top 10 Things Not to Do During
Survey
6. Talk about residents in their presence or
within earshot of other patients or visitors.
7. Let surveyors leave the facility without
knowing what documents they have copied
to build their case against you.
8. Get heavy-handed with a survey thatтАЩs
going well.
9. Overdo the hospitality.
10. Accept incorrect findings
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What to do after the best week of your year.
POST SURVEY
Survey Process
Review the Statement of Deficiencies
Online 2567L- As of today, it is currently in testing. It is
expected to be released around 10/1/2012
Write the Plan of Correction
Ask legal about opening statement
Submit within allotted Time
Receive confirmation of acceptance
Prepare for Re-visit if necessary
Receive letter of substantial compliance
Thank You!
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