1. Virginia Survey Process Medical Director’s role Judy Wilhide Brandt, RN, BA, RAC-MT, C-NE judy@judywilhide.com 909-800-9124 www.judywilhide.com

2. Basics Annual survey: Q 9 – 15 months Complaints: PRN Process outlined in SOM Appendix P & PP Very well defined, published survey tasks Structured investigation prescribed by state/federal guidelines – Very subjective decision making/citation assignment

3. Traditional Survey Process Tasks Sample Selection- Offsite Survey Preparation: Used to select initial areas of concern & initial residents for sample ≈60% of residents chosen in Phase 1 & ≈40% in Phase 2 – Quality Measure (QM) Reports If weight loss, dehydration, and/or pressure ulcers trigger as a concern, half the phase 1 sample has to have these issues. – Previous survey/complaint history – Waiver/variance info – Ombudsman info – PASSR info

4. Example of resident sample size CensusPhase 1Phase 2 Compre- hensive Review Focused Review Closed Record Res/Fam ily Interviews WHP 60964924/25 120141051635/27 200+181252237/39

5. Point: Areas of concern should never be a total surprise – Discourage “survey prep” mentality just prior to survey window – Encourage IDT to review QMs monthly Target areas that trigger at 70% to review: – MDS coding – Care concerns – Proper chart documentation to explain whether QM represents an issue or not with appropriate follow up

6. Quality Measures used in Survey Process Long Stay: ADL decline High-risk residents with pressure ulcers Indwelling catheter Physically restrained UTI Self-report moderate to severe pain Fall with major injury Lo Risk Incontinence Weight Loss Antipsychotic Use in absence of psychotic/related condition Depressive Symptoms Antianxiety/Hypnotic Use Falls (all) Behaviors affecting others Short Stay: New/Worsened Pressure Ulcers Self-report moderate to severe pain

7. Comparative Analysis/Benchmarks Compares your facility to: – Other certified facilities in your state – Other certified facilities nationally This comparison is used in traditional surveys Allows you to benchmark your progress and compare yourself to others You Shall Rise and Show Respect to the Aged State Comparison National Comparison/Percentile Ranking

8. Resident Level Report You Shall Rise and Show Respect to the Aged

9. Initial Tour Initial opportunity to observe residents, staff and physical environment including kitchen Identify residents or potential concerns for investigation Facility should have staff member who can discuss the resident accompany all surveyors Very common for most of the worst citations to begin development on the initial tour

10. 109/2/2015 Residents: new admissions have no or infrequent visitors. psychosocial, interactive, and/or behavioral needs. bedfast and totally dependent on care. dialysis or hospice Psychotropics Room variances MI/DD Communication issues: Non-oral, languages Special Considerations for Sample:

11. Information Gathering 5A General Observations of the Facility 5B Kitchen/Food Service Observations 5C Resident Review – Observation, Interview, Record review 5D Quality of Life Assessment 5E Medication Pass and Pharmacy Services 5F Quality Assessment and Assurance Review 5G Abuse Prohibition Review

12. Major Areas Reviewed: Resident Rights Admission, transfer, discharge rights Resident behavior & facility practices Quality of life Resident assessment Quality of care Nursing services Dietary services Physician services Rehab services Dental services Pharmacy services Infection control Physical environment Administration (QA)

14. Official Top 10 Virginia list 2013 F-309 Quality of Care F-514 Clinical records - order F-280 Care plan 7-days/team/periodic review F-329 Unnecessary drugs F-323 Accident prevention - environment F-502 Laboratory Services F-278 Accuracy of assessment F-431 Drugs labels/expired drugs F=441 Infection Control Program F-279 Care plan, comprehensive

15. Most frequent high level citations Virginia 2013 F-329: Antipsychotics mostly: Need actual behaviors, actual reasons, MD ordering and general statements not sufficient. “dementia with behaviors” certainly not sufficient F-502: Screwed up labs: Not ordered, not done, not responded to, not done as ordered, not reported, etc. Diabetic Management: Screwed up with bad outcomes Injuries: Falls, elopement, physical plant hazards F441: infection control: Mostly watching med passes, dressing changes, incontinence care, not washing hands by CNAs

16. P HYSICIAN S ERVICES F385 Residents’ Care Supervised by Physician F386 Physician Responsibilities During Visits F387 Frequency/Timeliness of Physician Visits F388 Visits by Physician/Phys Assistant/Etc F389 Emergency Physician Services 24 Hr/Day F390 Phys Delegation of Tasks in SNFs/NFs

17. The Medical Director – can help ensure that appropriate systems exist to facilitate good medical care, – establish and apply good monitoring systems and effective documentation and follow up of findings – help improve physician compliance with regulations, including required visits. During and after the survey process, the medical director can – clarify for the surveyors clinical questions or information about the care of specific residents, – request surveyor clarification of citations on clinical care, – attend the exit conference to demonstrate physician interest and help in understanding the nature and scope of the facility's deficiencies, – help the facility draft corrective actions.

18. Care coordination A medical director should establish a framework for physician participation, and physicians should believe that they are accountable for their actions and their care. – Ensure primary attending and backup physician coverage; – Ensure that physician/NPP are available to help residents attain and maintain their highest practicable level of functioning, consistent with regulatory requirements; – Develop a process to review basic MD/NPP credentials (e.g., licensure and pertinent background); – Address and resolve concerns and issues between the physicians, health care practitioners and facility staff – Resolve issues related to continuity of care and transfer of medical information between the facility and other care settings.

19. Common NF Issues in poor survey outcomes Lack of clinical education by clinical management – Lack of on-going educational development of CNAs, LPNs, RNs, therapists Perceived or real inadequate staffing Lack of a robust activities department Lack of leadership experience/knowledge by administrator/nursing management Budgetary decisions that do not support quality of care/life

20. How you can help Lead the team Do comprehensive assessments, document legibly your conclusions and plan, every time – Tips: Diagnose, describe and stage pressure ulcers (yourself) Diagnose, describe other types of wounds Avoid simply listing diagnoses without current status and plan Follow up on resident injuries: Demand careful review by IDT of falls, fractures, etc. Follow up on infections, changes of condition: Did staff properly recognize and report? Do they know what they are doing clinically? Prescribe psychotropics when needed and document justification. – Don’t prescribe when not indicated

21. Demand quality of care – Sanitation, hygiene, nutritious, delicious meals Do you ever eat the food? How about the pureed food? – Restorative nursing – Skin – Dental – Foot care Demand continuity of care – Shift to shift – Across transitions: Hospital, home health Pain control During high risk times: – Newly admitted: Does the staff know how to assess a new resident? Skin, pain, preferences, functional status (falls) How you can help

22. Demand appropriate staffing for acuity Actively engage in QA efforts Realize that a little pain for the IDT during a survey may result in lasting improvements – Don’t buckle to pressure in survey to ‘write something to make it better’ – Admit your shortcomings, demand the IDT admit theirs: make it better (QAPI) – Stay the course – Tell the truth How you can help

23. Plan of correction: Be actively involved in survey Attend exit conference Assist in implementing realistic POC for lasting change – Root cause analysis Develop/educate staff – CNA, LPN, RN – Dietary – OT, ST, PT

24. Questions/discussion