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Presentation on theme: "INDIANA EXPERIENCE WITH QIS"— Presentation transcript:

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



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

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?

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?

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?

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?

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
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….


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