1. INDIANA EXPERIENCE WITH QIS
Brenda Buroker RN
Survey Manager – QIS State Lead
Indiana State Department of Health

3. ISDH Progress in Training Staff
17 of 21 Teams Trained
Goal has remained to have all teams trained by the end of 2012
Training of staff in QIS will be turned over to the Training Department at ISDH in 2013

4. NOT WITHOUT PAIN LOSS OF SURVEYORS Loss of flexibility of job
Loss of everything familiar
Physically challenging carrying a laptop around all day
CRUCIAL TO HAVE 4 SURVEYORS ON A TEAM
Vacations/Illness/Turnover
Workload

5. NEW SURVEY AREAS

6. GOAL OF NEW SURVEY PROCESS
A SURVEY PROCESS TO MAKE SURVEYS MORE
Efficient
Accurate
Consistent

7. EFFICIENCY
A more structured approach to the survey we have been conducting
Number of days to complete a survey
Focus on problem areas

8. ACCURACY New tags written Following the Critical Element Pathways
Identify Substandard Quality of Care sooner in the process

9. CONSISTENCY Continual state, regional and national comparison
Desk Audit Review
Ask the same questions the same way at every survey

10. The RESIDENTS
Interview Rates
Interview Refusals
Dining Observation

11. IMPORTANT FAMILY INTERVIEWS
Interviews with 3 resident families per survey.
Threshold is low

12. Facility Response REMARKS WE HAVE RECEIVED:
Process worked as described by survey team
Well organized process
Interfered minimally with daily routine
Love QIS, but tags are odd and different areas are investigated than previous survey process
Smooth process
Communication is less, but is as much as possible with QIS

13. ABUSE RESIDENT INTERVIEW Have you ever been treated roughly by staff?
Has staff yelled or been rude to you?
Do you ever feel afraid because the way you or some other resident is treated?
RESIDENT OBSERVATION
Are staff treating the resident in a manner that may indicate abuse?

14. ABUSE FAMILY INTERVIEW
Have you ever noticed any staff member being rough with, talking in a demeaning way or yelled at your family member or any other resident?

15. CHOICES RESIDENT INTERVIEW
Do you choose when to get up in the morning?
Do you choose when to go bed at night?
Do you choose how many times a week you take a bath or shower?
Do you choose whether you take a shower, tub, or bed bath?
Can you have visitors any time during the day or night?

16. CHOICES FAMILY INTERVIEW
Does [resident’s name] get up in the morning according to his/her previous routine?
Does [resident’s name] go to bed according to his/her previous routine?
Does [resident’s name] receive the same number of baths or showers in a week based on past preferences?
Can you visit anytime during the day or nighttime?

17. DIGNITY RESIDENT OBSERVATION
Dressed in hospital gown during the day or name visible
Cover for drainage bags
Wait for permission to enter room following knock on door
Explaining care the staff is going to provide
Including resident in conversation during care
Labels such as “feeder” or “honey”
Posting personal care instructions for all to see
Mimicking or making fun of resident
Displaying disapproving behavior: sighing or rolling eyes

18. GOING FORWARD Monitor time spent on surveys Tags cited
Resident Interview Percentages
Following protocols

20. From an Industry Perspective…. What We’ve Learned and How to Prepare
INDIANA EXPERIENCE WITH QIS
From an Industry Perspective…. What We’ve Learned and How to Prepare
Rebecca Bartle, RN, MSN, HFA
Regulatory Affairs Director
Hoosier Owners and Providers for the Elderly

21. "Those who cannot learn from history are doomed to repeat it."
-George Santayana

22. Syzygy Culture Change MDS 3.0 QIS
The nearly straight-line configuration of three celestial bodies (as the sun, moon, and earth during a solar or lunar eclipse)
Latin conjunction (from Greek origin)
“yoked together”

23. Everything is in align with the Resident’s wishes
However, we must “ask”………
because the answer is not always what “we” think it is……………

25. What We’ve Learned…….

26. Overview of Citations (January 2011- June 2012)
199 surveys
1643 total deficiencies
102 unique F tags cited
Median number of deficiencies= 7
Average number of deficiencies= 8
Highest number of deficiencies= 35
Most frequent scope and severity= “D” (61%)

27. Citations by Scope and Severity
F= 76
G= 39
J= 1
K=2
L=2

28. Top Ten Tags Cited 441- Infection Control (89) (45%)
323- Accidents/Supervision (80) (38%)
309- Quality of Care (76) (37%)
279- Comprehensive Care plans (74) (37%)
282- Qualified Persons (71) (36%)
329-Unnecessary Drugs (66) (33%)
371-Dietary Sanitation (57) (29%)
253-Housekeeping and Maintenance (56) (28%)
314-Pressure Sores (44) (22%)
315-Urinary Incontinence (35) (18%)

29. #1-F441- Infection Control
Handwashing
Gloves (wearing/changing)
Incontinent Care
PPE/Transmission Based Precautions (C-Diff)
Medication Pass (eye drops)
Handling of Linens
Tracking and Trending of facility acquired and non-facility acquired infections
Blood glucose monitoring equipment (clean/disinfect)

30. #2-F323- Accidents/Supervision
Siderails/assessment/entrapment risk
Utilize lift according to manufacturer’s instructions
Proper transfers as per plan of care
Residents toileted; left unattended
Meds unattended/cart unlocked
Fall risk identified/interventions implemented/root cause identified
Alarms per plan of care; not in place
Improper storage of chemicals
Elopement risk/supervision
Unsafe water temperatures

31. #3-F309-Quality of Care
Coordination of dialysis services (monitoring weight, access site)
Abnormal lab results (reporting and treatment)
Timely specimen collection
Evaluation and treatment of resident pain
Assessment of bruising, skin tears (non-pressure related skin conditions)
Failure to notify physician of change in condition (deterioration)
Failure to follow through with ordered consultations
Inadequate bowel monitoring

32. #4-F279- Comprehensive Care Plans
Suicidal Ideations
Dehydration
Catheter use
Activities
Advance Directives
Behaviors/Psychoactive Medication Use
Refusals of Care or Treatment
Restraint Use
Nutrition
Skin conditions (pressure and non-pressure related conditions)
Discharge planning

33. #5-F282- Qualified Persons
Labs and medications not initiated, as ordered
Diet not served as ordered; mechanically altered
Dressing not in place, as ordered
Treatment not provided, as ordered
Blood glucose monitoring/insulin coverage not administered as ordered
Fall interventions not in place, as ordered
Failure to monitor and document consumption of supplements
Failure to clarify medication orders to ensure complete medication orders in place….

34. Cont. F282 Positioning devices Geri-sleeves
Adherence with fluid restrictions
Splint/orthotic application, as ordered
Obtaining blood pressures, as ordered

35. #6-F329- Unnecessary Drugs
Antipsychotics without medical justification and/or lacking monitoring for side effects
Hypnotics without adequate justification
Anticoagulant medication and laboratory monitoring
Adequate indications for PRN anti-anxiety medication administration
Lack of attempted non-pharmacological interventions
Lack of review for Gradual Dose Reduction

36. #7-F371- Dietary Sanitation
Labeling and dating food in refrigerators
Beard restraints/hair coverings
Soap dispensers
Sanitizing chemicals/testing strips
Ice machine/cleanliness
Handwashing
Handling food/containers on trays improperly
Pans clean and in good repair
Cross contamination
Dishes stored with lime build up
Refrigeration temps

37. #8-F253- Housekeeping/Maintenance
Marred and paint chipped walls
Dusty ceiling vents/blinds
Missing floor tile
Broken or missing cove base
Bedside tables in poor condition
Soiled shower chairs
Spillage on feeding pumps
Marred and scratched furniture
Urine odors, strong musty odor, objectionable odor………….
Malodorous scent

38. #9-F314- Pressure Sores Lack of skin assessment
Dressing not changed, as ordered
Failure to obtain treatment (wound worsened)
Lack of position changes
Cushions/devices not in use
Treatment not done in accordance with physician’s orders

39. #10-F315- Urinary Incontinence
Lack of proper perineal/incontinence care
Decline in bladder function- lacking assessment, training, etc.
Lack of order for use and care of an indwelling catheter
UTIs and catheter utilization
Drainage bag/tubing maintenance (below bladder level)
Obtaining timely UAs, as ordered
Lack of medical justification for catheter use

40. Widespread Deficiencies…
F371- Dietary Sanitation (approximately 50%; 30+ deficiencies)
F441- Infection Control (approximately 15%; 10+ deficiencies)
F520 - Quality Assessment and Assurance (approximately 10%; 7+ deficiencies)

41. Actual Harm Deficiencies…..
F309- Quality of Care (approximately 22%)
F323- Accidents/Supervision (approximately 19%)
F314- Pressure Sores (approximately 11%)

42. Immediate Jeopardy Deficiencies
F314 (J)- Pressure Sores
F309 (K)- Quality of Care
F323 (K)- Accidents/Supervision
F323 (L)- Accidents/Supervision
F490 (L)- Administration

43. Deficiencies by Category…..

44. Resident Rights 166-Resolve Grievances* 151-Exercise of Rights
167-Examination of Survey Results
168-Receiving Information
170-Mail
172-Access and Visitation Rights
174-Telephone
176-Self-Administration of Drugs
203-Notice Before Transfer
205-Notice of Bed hold Policy & Readmission
151-Exercise of Rights
153-Adjudged Incompetent
155-Refusal of Treatment
156-Notice of Rights & Services
157-Notfication of Changes
159-Management of Personal Funds
160-Conveyance upon Death
161-Assurance of Financial Security
164-Privacy and Confidentiality*
165-Grievances

45. Resident Behavior & Facility Practices
221-Physical Restraints*
223-Abuse*
224-Mistreatment, Neglect or Misappropriation of Resident Property*
225-Not Employ Individuals Guilty of Abuse, Neglect
226-Development and Implementation of Procedures

46. Quality of Life 241-Dignity* 242-Self-Determination and Participation*
244-Facility Listen/Act on Grievances
246-Accommodation of Needs*
247-Notice of Room/Roommate Change
248-Activities*
249-Activities Director Qualifications
250-Social Services*
252-Environment*
253-Housekeeping and Maintenance*
254-Clean Bed and Bath Linens*

47. Resident Assessment 272-Resident Assessment*
273-Comprehensive Assessment within 14 Days
278-Accuracy/Coordination
279-Comprehensive Careplans*
280-Timing and Participation
281-Standards of Professional Practice
282-Qualified Persons*
285-PASRR/Coordination
286-Assessments 15 months in Active Record

48. Quality of Care 309-Quality of Care* 325-Nutrition/Parameters*
311-Treatment to Maintain or Improve Abilities
312-Receives Necessary Services to Maintain Abilities
313-Vision and Hearing
314-Pressure Sores*
315-Urinary Incontinence*
317-Range of Motion-No reduction
318-Range of Motion- Maintenance/Improve*
322-Naso-gastric Tubes
323-Naso-gastric Tubes- Treatment and Services*
325-Nutrition/Parameters*
327-Hydration*
328-Special Needs
329-Unnecessary Drugs*
332-Free of Medication Error Rate of 5% or Greater*
333-Free of Significant Med Errors
334-Influenza & Pneumococcal Immunizations

49. Nursing Services 353-Sufficient Staff* 354- Nursing Waivers
356-Nursing Staffing Information

50. Dietary Services 362-Dietary Sufficient Staff
363-Menus and Nutritional Adequacy
364-Food Appearance/Palatability*
365-Food Prepared for Individual Needs
366-Substitutes Offered*
367-Therapeutic Diets*
368-Frequency of Meals
371-Sanitation, Store, Prepare, Distribute and Serve Food*

51. Physician Services 385-Physician Supervision* 386-Physician Visits
387-Frequency of Physician Visits

52. Specialized Rehab
406-Provision of Services

53. Dental
411-Dental Services
412-Obtaining Dental Services

54. Pharmacy 425-Services 428-Drug Regimen Review
431-Licensed Pharmacist Consultation

55. Infection Control
441-Preventing Spread of Infection, Employees with Communicable Disease, Handwashing, Linens*

56. Physical Environment 456-Maintain all Essential Equipment*
458-Resident Rooms 80/100 square feet
463-Resident Call System*
464-Dining and Resident Activity Rooms
465-Other Environmental Conditions*
467-Adequate Outside Ventilation
468-Firmly Secured Handrails
469-Effective Pest Control Program*

57. Administration 490-Administration 498-Proficiency of Nurse Aides
500-Use of Outside Resources
502-Laboratory Services
503-Facility Based Lab/Blood Work
505- Notify the Physician of Lab Results
507-Lab Reports in Resident Files
508-Diagnostic Services/Agreement
514-Clinical Records*
516-Safeguard of Records Against Loss, Destruction and Unauthorized Use
518-Training in Emergency Procedures
520-Quality Assessment and Assurance*

58. How to Prepare…………….

59. Obtain the CMS Forms https://www.qtso.com/qisforms.html
Entrance Conference Worksheet (CMS 20045)
Census Sample Record Review (CMS 20048)
Resident Interview & Observation (CMS 20050)
Family Interview (CMS 20049)
Staff Interview (CMS 20051)
Admission Sample Record Review (CMS 20047)

60. Entrance Conference Worksheet (CMS 20045)
Alphabetical resident census
New Admission Information (30 day period before survey)
Staffing schedules for licensed and registered nursing staff
List of key personnel and their locations
Name of Resident Council President/active council member
Schedule of meal times and location of dining rooms
Schedule of medication administration times
Worksheet listing residents who receive PASRR Level II services, hospice services, dialysis care (have written contract/agreement; coordination of care)

61. Influenza and Pneumococcal Policies and Procedures
List of rooms requiring a waiver
Quality Assessment and Assurance Committee information
Name of contact person for abuse prohibition policies/complaints/grievance procedures
List of Medicare beneficiaries who requested a demand bill in the past 6 months
Information about the facility’s emergency water source
Medicare/Medicaid Application (CMS-671) and Resident Census and Condition Report (CMS-672)

62. Census Sample Record Review (CMS 20048)
40 individuals who currently live at the facility and have been there more than six months.
Pressure Ulcers
Unnecessary Medications
Resident received any of the following at least one time in the last 30 days:
antipsychotic, antianxiety, antidepressant, hypnotic, mood stabilizer, anticoagulant, antibiotic, diuretic, insulin,
Weight Loss
Current, 30, 90 and 180 days prior

63. Resident Interview & Observation (CMS 20050)
The interview questions are designed to gain insight into the resident’s perspective of quality of care and/or quality of life.
Found in the left column
Along with the interviews, the surveyors complete a series of structured observations of the resident.
Found in the right column

64. Family Interview (CMS 20049)
These interviews are typically conducted with individuals who know the resident well and who have knowledge of the resident’s stay at the facility.
The purpose of the family interview is to obtain information from the interviewee about whether the facility is honoring the preferences of residents in areas such as schedules, activities, and choices.

65. Staff Interview (CMS 20051) Catheter Use/reason
Nutritional Supplements
Pressure Ulcers
Side rail use/ capable of getting out of bed on own/ do rails prevent resident from voluntarily getting out of bed
Contractures/ROM or splint use
Fall and/or fracture in the last 30 days
* The interview is designed to determine the care the resident receives daily but may also reveal where inconsistencies occur between the resident’s plan of care and the care received.

66. Admission Sample Record Review (CMS 20047)
The Admission Sample review focuses on the quality of care within the first six months for short-stay residents (30 residents)
A. Community Discharge
Was length of stay less than 60 days?
Discharge location?
Rehabilitation (Within 60 days of admission, did the resident receive any PT, ST or OT services beyond the initial evaluation?)
B. Death
Did resident expire within 30 days of admission?

67. C. Hospitalization
Was the resident hospitalized, for other than a planned elective surgery, within 30 days of admission?
D. Pressure Ulcer
Did the resident develop a pressure ulcer in the first 30 days following admission to the nursing facility?
Was resident admitted with a pressure ulcer? If so, was there an increase in the stage of the ulcer?
E. Weight Loss
-Weight closest to admission date; 15, 30 and 60 days after admission
Whether the resident is on planned weight loss

68. Mandatory Facility Tasks
Medication Administration Observation (CMS 20056)
Resident Council President/Representative Interview (CMS 20057)
Quality Assessment and Assurance (CMS 20058)
Medication Storage (CMS 20089)
Liability Notices & Beneficiary Appeal Rights (CMS 20052)
Dining Observations (CMS 20053)
Infection Control & Immunization (CMS 20054)
Kitchen/Food Service Observation (CMS 20055)

69. Medication Administration Observation (CMS 20056)
A minimum of 50 medication administrations to at least 10 different residents.
Incorrect med/dose
Administered without an order
Failure to take pulse or blood pressure, when indicated
Failure to “shake well”
Inhaler not administered per manufacturer
Inadequate time sequence between eye drops

70. Resident Council President/Representative Interview (CMS 20057)
Focus:
Council
Grievances
Rules
Rights
Mail on Saturdays, survey results available, knowledge of ombudsman, medical record review upon request, informed of right to formally voice a complaint to the State about care

71. Quality Assessment and Assurance (CMS 20058)
Includes questions related to the committee makeup, meeting schedule, and how the committee functions to determine whether the facility is effectively identifying and handling quality concerns.
“Does the facility have a QAA committee that has developed and implemented appropriate plans of action to correct identified quality deficiencies?”

72. Liability Notices & Beneficiary Appeal Rights (CMS 20052)
Involves reviewing the demand notices to determine whether the facility provided such notices to Medicare beneficiaries in a timely and appropriate manner.
Failure to provide detailed information as to why Medicare coverage was being terminated
Failure to ensure residents were informed of possible charges that could be incurred as a result of the lack of Medicare coverage

73. Dining Observations (CMS 20053)
Purpose:
Resident choice/preferences
Services to prevent decline in eating abilities
Food palatability and substitutes
Provision of meal service with dignity and respect
Napkins, clothing protectors if desired, served concurrently
Timely provision of meals in a safe/sanitary manner
Environmental conditions (space, lighting, ventilation, furnishings)
Quality of life accommodations (noise level)

74. Infection Control & Immunization (CMS 20054)
Evaluation of the facility’s infection control program
Handwashing/glove use
Free of communicable disease/infected skin lesions
Disposal of contaminated items
Handling and transport of laundry
Isolation precautions
Influenza/Pneumococcal immunizations

75. Kitchen/Food Service Observation (CMS 20055)
The primary focus of this task is to measure the facility’s compliance with regard to protecting residents from foodborne illness
PHF thawing at room temperature
Unlabeled/undated items in refrigerator
PHF (uncooked meat) not stored separately
Appropriate handwashing facilities with soap and water
Food stored at appropriate temperatures
Food preparation and service
Sanitization and storage
Equipment safe/clean

76. Triggered Facility Tasks
Admission, Transfer, and Discharge Review (CMS 20060)
Environmental Observations (CMS 20061)
Sufficient Nursing Staff (CMS 20062)
Personal Funds Review (CMS 20063)
Abuse Prohibition Review (CMS 20059)

77. Critical Element Pathways
Use
Procedure
Observations
Interview
Resident/Representative; Staff
Assessment
Careplanning
Care Plan Revision

78. Activities
ADL and/or ROM status
Behavioral and Emotional status
Urinary Incontinence, Urinary Catheter, UTI
Communication and Sensory Problems
Dental status and services
Dialysis
General
Hospice and/or Palliative Care
Hospitalization or Death
Pain Recognition and Management
Use of Physical Restraints
Pressure Ulcers
Rehabilitation and Community Discharge
Ventilator-Dependent Residents
Unnecessary Medication Review
Preadmission Screening and Resident Review
Hydration
Tube Feeding Status

79. Dialysis (CMS 20071) Observations:
Care needed and provided for shunts/fistulas, dressings, nutritional/fluid needs, and restrictions
Knowledge of emergency complications (bleeding/hemorrhage, infection, septic shock)
How information is communicated between the facility and the dialysis center; where communication is recorded

80. Cont. Dialysis Elements of the care plan:
Special nutritional and volume needs
Risk for adverse medication effects
Care of the access site
Infection control measures
Skin care measures
Monitoring of V/S, weights, such as before and after dialysis treatment
Instructions for giving medications (to prevent dialysis treatments removing medication from the resident’s system)

81. Hospice and/or Palliative Care (CMS 20073)
Interventions used if the resident exhibited or verbalized pain or other symptoms (apprehension, restlessness)
Interventions used if the resident exhibits constipation, nausea, vomiting
Preferences and choices acknowledged and respected
Coordinated plan of care that identifies which provider (hospice or facility) is responsible for various aspects of care
Process by which hospice and the facility can exchange information

82. Unnecessary Medication Review (CMS 20082)
Two components: to review for unnecessary medications; and to review for the monthly medication review conducted by the pharmacist
Resident may trigger based on taking one or a combination of the following medications:
Antipsychotic
Antianxiety
Antidepressant
Hypnotic
Mood stabilizer
Anticoagulant
Antibiotic
Diuretic
Insulin

83. Preparation for QIS Understand the process
Conduct resident, family and staff interviews
Ensure that you are addressing key issues in care plan meetings
Recognize the importance of quality assurance and customer satisfaction
Understand that quality must be delivered daily throughout the year

84. Sometimes, we all need to implement a little Quality Assurance….