3 ISDH Progress in Training Staff 17 of 21 Teams TrainedGoal has remained to have all teams trained by the end of 2012Training 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 familiarPhysically challenging carrying a laptop around all dayCRUCIAL TO HAVE 4 SURVEYORS ON A TEAMVacations/Illness/TurnoverWorkload
6 GOAL OF NEW SURVEY PROCESS A SURVEY PROCESS TO MAKE SURVEYS MOREEfficientAccurateConsistent
7 EFFICIENCYA more structured approach to the survey we have been conductingNumber of days to complete a surveyFocus 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 ReviewAsk the same questions the same way at every survey
10 The RESIDENTSInterview RatesInterview RefusalsDining 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 teamWell organized processInterfered minimally with daily routineLove QIS, but tags are odd and different areas are investigated than previous survey processSmooth processCommunication 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 OBSERVATIONAre 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 visibleCover for drainage bagsWait for permission to enter room following knock on doorExplaining care the staff is going to provideIncluding resident in conversation during careLabels such as “feeder” or “honey”Posting personal care instructions for all to seeMimicking or making fun of residentDisplaying disapproving behavior: sighing or rolling eyes
18 GOING FORWARD Monitor time spent on surveys Tags cited Resident Interview PercentagesFollowing protocols
20 From an Industry Perspective…. What We’ve Learned and How to Prepare INDIANA EXPERIENCE WITH QISFrom an Industry Perspective…. What We’ve Learned and How to PrepareRebecca Bartle, RN, MSN, HFARegulatory Affairs DirectorHoosier 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……………
26 Overview of Citations (January 2011- June 2012) 199 surveys1643 total deficiencies102 unique F tags citedMedian number of deficiencies= 7Average number of deficiencies= 8Highest number of deficiencies= 35Most frequent scope and severity= “D” (61%)
27 Citations by Scope and Severity F= 76G= 39J= 1K=2L=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 HandwashingGloves (wearing/changing)Incontinent CarePPE/Transmission Based Precautions (C-Diff)Medication Pass (eye drops)Handling of LinensTracking and Trending of facility acquired and non-facility acquired infectionsBlood glucose monitoring equipment (clean/disinfect)
30 #2-F323- Accidents/Supervision Siderails/assessment/entrapment riskUtilize lift according to manufacturer’s instructionsProper transfers as per plan of careResidents toileted; left unattendedMeds unattended/cart unlockedFall risk identified/interventions implemented/root cause identifiedAlarms per plan of care; not in placeImproper storage of chemicalsElopement risk/supervisionUnsafe water temperatures
31 #3-F309-Quality of CareCoordination of dialysis services (monitoring weight, access site)Abnormal lab results (reporting and treatment)Timely specimen collectionEvaluation and treatment of resident painAssessment of bruising, skin tears (non-pressure related skin conditions)Failure to notify physician of change in condition (deterioration)Failure to follow through with ordered consultationsInadequate bowel monitoring
32 #4-F279- Comprehensive Care Plans Suicidal IdeationsDehydrationCatheter useActivitiesAdvance DirectivesBehaviors/Psychoactive Medication UseRefusals of Care or TreatmentRestraint UseNutritionSkin conditions (pressure and non-pressure related conditions)Discharge planning
33 #5-F282- Qualified Persons Labs and medications not initiated, as orderedDiet not served as ordered; mechanically alteredDressing not in place, as orderedTreatment not provided, as orderedBlood glucose monitoring/insulin coverage not administered as orderedFall interventions not in place, as orderedFailure to monitor and document consumption of supplementsFailure to clarify medication orders to ensure complete medication orders in place….
34 Cont. F282 Positioning devices Geri-sleeves Adherence with fluid restrictionsSplint/orthotic application, as orderedObtaining blood pressures, as ordered
35 #6-F329- Unnecessary Drugs Antipsychotics without medical justification and/or lacking monitoring for side effectsHypnotics without adequate justificationAnticoagulant medication and laboratory monitoringAdequate indications for PRN anti-anxiety medication administrationLack of attempted non-pharmacological interventionsLack of review for Gradual Dose Reduction
36 #7-F371- Dietary Sanitation Labeling and dating food in refrigeratorsBeard restraints/hair coveringsSoap dispensersSanitizing chemicals/testing stripsIce machine/cleanlinessHandwashingHandling food/containers on trays improperlyPans clean and in good repairCross contaminationDishes stored with lime build upRefrigeration temps
37 #8-F253- Housekeeping/Maintenance Marred and paint chipped wallsDusty ceiling vents/blindsMissing floor tileBroken or missing cove baseBedside tables in poor conditionSoiled shower chairsSpillage on feeding pumpsMarred and scratched furnitureUrine odors, strong musty odor, objectionable odor………….Malodorous scent
38 #9-F314- Pressure Sores Lack of skin assessment Dressing not changed, as orderedFailure to obtain treatment (wound worsened)Lack of position changesCushions/devices not in useTreatment not done in accordance with physician’s orders
39 #10-F315- Urinary Incontinence Lack of proper perineal/incontinence careDecline in bladder function- lacking assessment, training, etc.Lack of order for use and care of an indwelling catheterUTIs and catheter utilizationDrainage bag/tubing maintenance (below bladder level)Obtaining timely UAs, as orderedLack of medical justification for catheter use
44 Resident Rights 166-Resolve Grievances* 151-Exercise of Rights 167-Examination of Survey Results168-Receiving Information170-Mail172-Access and Visitation Rights174-Telephone176-Self-Administration of Drugs203-Notice Before Transfer205-Notice of Bed hold Policy & Readmission151-Exercise of Rights153-Adjudged Incompetent155-Refusal of Treatment156-Notice of Rights & Services157-Notfication of Changes159-Management of Personal Funds160-Conveyance upon Death161-Assurance of Financial Security164-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, Neglect226-Development and Implementation of Procedures
46 Quality of Life 241-Dignity* 242-Self-Determination and Participation* 244-Facility Listen/Act on Grievances246-Accommodation of Needs*247-Notice of Room/Roommate Change248-Activities*249-Activities Director Qualifications250-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 Days278-Accuracy/Coordination279-Comprehensive Careplans*280-Timing and Participation281-Standards of Professional Practice282-Qualified Persons*285-PASRR/Coordination286-Assessments 15 months in Active Record
48 Quality of Care 309-Quality of Care* 325-Nutrition/Parameters* 311-Treatment to Maintain or Improve Abilities312-Receives Necessary Services to Maintain Abilities313-Vision and Hearing314-Pressure Sores*315-Urinary Incontinence*317-Range of Motion-No reduction318-Range of Motion- Maintenance/Improve*322-Naso-gastric Tubes323-Naso-gastric Tubes- Treatment and Services*325-Nutrition/Parameters*327-Hydration*328-Special Needs329-Unnecessary Drugs*332-Free of Medication Error Rate of 5% or Greater*333-Free of Significant Med Errors334-Influenza & Pneumococcal Immunizations
55 Infection Control441-Preventing Spread of Infection, Employees with Communicable Disease, Handwashing, Linens*
56 Physical Environment 456-Maintain all Essential Equipment* 458-Resident Rooms 80/100 square feet463-Resident Call System*464-Dining and Resident Activity Rooms465-Other Environmental Conditions*467-Adequate Outside Ventilation468-Firmly Secured Handrails469-Effective Pest Control Program*
57 Administration 490-Administration 498-Proficiency of Nurse Aides 500-Use of Outside Resources502-Laboratory Services503-Facility Based Lab/Blood Work505- Notify the Physician of Lab Results507-Lab Reports in Resident Files508-Diagnostic Services/Agreement514-Clinical Records*516-Safeguard of Records Against Loss, Destruction and Unauthorized Use518-Training in Emergency Procedures520-Quality Assessment and Assurance*
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 censusNew Admission Information (30 day period before survey)Staffing schedules for licensed and registered nursing staffList of key personnel and their locationsName of Resident Council President/active council memberSchedule of meal times and location of dining roomsSchedule of medication administration timesWorksheet 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 waiverQuality Assessment and Assurance Committee informationName of contact person for abuse prohibition policies/complaints/grievance proceduresList of Medicare beneficiaries who requested a demand bill in the past 6 monthsInformation about the facility’s emergency water sourceMedicare/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 UlcersUnnecessary MedicationsResident 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 LossCurrent, 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 columnAlong 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 SupplementsPressure UlcersSide rail use/ capable of getting out of bed on own/ do rails prevent resident from voluntarily getting out of bedContractures/ROM or splint useFall 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 DischargeWas 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. DeathDid resident expire within 30 days of admission?
67 C. HospitalizationWas the resident hospitalized, for other than a planned elective surgery, within 30 days of admission?D. Pressure UlcerDid 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 admissionWhether 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/doseAdministered without an orderFailure to take pulse or blood pressure, when indicatedFailure to “shake well”Inhaler not administered per manufacturerInadequate time sequence between eye drops
70 Resident Council President/Representative Interview (CMS 20057) Focus:CouncilGrievancesRulesRightsMail 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 terminatedFailure 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/preferencesServices to prevent decline in eating abilitiesFood palatability and substitutesProvision of meal service with dignity and respectNapkins, clothing protectors if desired, served concurrentlyTimely provision of meals in a safe/sanitary mannerEnvironmental conditions (space, lighting, ventilation, furnishings)Quality of life accommodations (noise level)
74 Infection Control & Immunization (CMS 20054) Evaluation of the facility’s infection control programHandwashing/glove useFree of communicable disease/infected skin lesionsDisposal of contaminated itemsHandling and transport of laundryIsolation precautionsInfluenza/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 illnessPHF thawing at room temperatureUnlabeled/undated items in refrigeratorPHF (uncooked meat) not stored separatelyAppropriate handwashing facilities with soap and waterFood stored at appropriate temperaturesFood preparation and serviceSanitization and storageEquipment safe/clean
77 Critical Element Pathways UseProcedureObservationsInterviewResident/Representative; StaffAssessmentCareplanningCare Plan Revision
78 ActivitiesADL and/or ROM statusBehavioral and Emotional statusUrinary Incontinence, Urinary Catheter, UTICommunication and Sensory ProblemsDental status and servicesDialysisGeneralHospice and/or Palliative CareHospitalization or DeathPain Recognition and ManagementUse of Physical RestraintsPressure UlcersRehabilitation and Community DischargeVentilator-Dependent ResidentsUnnecessary Medication ReviewPreadmission Screening and Resident ReviewHydrationTube Feeding Status
79 Dialysis (CMS 20071) Observations: Care needed and provided for shunts/fistulas, dressings, nutritional/fluid needs, and restrictionsKnowledge 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 needsRisk for adverse medication effectsCare of the access siteInfection control measuresSkin care measuresMonitoring of V/S, weights, such as before and after dialysis treatmentInstructions 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, vomitingPreferences and choices acknowledged and respectedCoordinated plan of care that identifies which provider (hospice or facility) is responsible for various aspects of careProcess 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 pharmacistResident may trigger based on taking one or a combination of the following medications:AntipsychoticAntianxietyAntidepressantHypnoticMood stabilizerAnticoagulantAntibioticDiureticInsulin
83 Preparation for QIS Understand the process Conduct resident, family and staff interviewsEnsure that you are addressing key issues in care plan meetingsRecognize the importance of quality assurance and customer satisfactionUnderstand that quality must be delivered daily throughout the year
84 Sometimes, we all need to implement a little Quality Assurance….