1. 2015 State Veterans Homes VA Survey Deficiency Overview Valarie Delanko JoAnne Parker Office of GEC Operations (10NC4)

2. Discussion Topics 2014 SVH survey deficiencies overview Recognition survey updates Appeals updates 38 CFR Part 53 Falls Collaborative Update Satisfaction Survey Standard Operating Procedures 2

3. SVH Program Census Current SVH Program Structure offering three levels of care: – 150 State Veterans Home Facilities 140 Nursing Home Care programs (25, 163 beds) 55 Domiciliary Care programs (6,039 beds) 2 Adult Day Health Care programs (85 participant slots) 3

4. Number of SVHs 2008 - 2015 4

5. Surveys Types 2010 -2014 5

6. Totals 6 Function20142013 Number of nursing home care surveys146142 Number of nursing home care deficiencies464385 Avg. number of deficiencies per survey3.182.71 Number of domiciliary surveyed5755 Number of domiciliary deficiencies5355 Avg. number of deficiencies per survey1.081.00 Number of adult day health care surveys23 Number of adult day health care deficiencies00

7. Immediate Jeopardy Numbers 7

8. Reasons for IJ: 51.120 Quality of Care -Accidents #108 (8): Coffee burn; widespread falls concerns (2); eating vs NPO; unsafe smoking practices(2), high water temperatures in bathroom sinks, high instances of physical aggression. 51.120 Quality of Care -Reporting Sentinel Events #96 – (1) Necrotic tissue in a wound with no assessment and care plan. 51.190 Resident Behavior-Abuse #65 – (2) Resident in fear of care by CAN; New resident with elopement risk but was not accessed in 7 days with 2 departures. 51.120 Quality of Care -Incontinence #103 – (1) Improper care of residents who have Foley Catheters. 51.120 Quality of Care -Unnecessary Medication #112 – (1) Deep vein thrombosis (DVT), which is being treated with a blood thinner (Coumadin). 51.120 Quality of Care -Mental and Psychosocial Functioning #106 – (1) Physical and verbal aggression, 20 total incidents. 51.200 Physical Environment-Life Safety #147 – (1) Fire pumps (2) operational for only one (1) hour. DOM Safety- (1) Dish machine wash temperature utilized to clean dishes below manufactures required safety temperature. 8

9. Top NH standards Line # Regulation Number Standard Frequency % 14751.200 a. Facility meets applicable provisions of the 2009 Life Safety Code of National Fire Protection Association. 19241% 10851.120 i. 1-2 Ensure environment remains free of accident hazards as is possible and residents receive adequate supervision and assistance devices to prevent accidents. 409% 9451.110 e. 3 Services provided or arranged by facility must meet professional standards of quality and by qualified persons in accordance with the care plan. 337% 9351.110 e. 2 Comprehensive care plan is: developed within 7 calendar days after assessments, prepared by an interdisciplinary team and periodically reviewed and revised after each assessment. 276% 14851.200 b. 1-4 An emergency electrical power system is provided in accordance with NFPA; on-site emergency standby generator of sufficient size to serve connected load. 245% 9251.110 e. Comprehensive care plan is: individualized that includes measurable objectives and timetables to meet residents physician, mental and psychosocial needs that are identified in the comprehensive assessment. 122.5% 102 51.120 d. 1- 2. Pressure sores: Based on comprehensive assessment, resident enters facility without sore does not develop one unless clinical condition is unavoidable and having one receives necessary tx and services to promote healing. 112% 6651.90 c. Facility management must ensure all alleged violations are reported immediately to administrator/officials per state law; have evidence violations are thoroughly investigated; results reported back to administrator with appropriate corrective action if verified. 112% 9

10. Top DOM standards Line # Guideline Number Standard Frequency % 1672. Safety C. There is evidence reported that reported life safety deficiencies have been or are being corrected. 3260% 1682. Safety D. Facility has available an emergency source of electrical power to provide essential service when normal electricity supply is interrupted. 815% 181 4. Medical E. Primary Care medical services are provided for domiciliary patients as needed. 24% 10

11. 38 CFR Part 53 Payments to States for Programs to Promote the Hiring and Retention of Nurses at State Veterans Homes. Goal is to reduce nursing shortages at a SVH for an employee incentive program. Must have documented credible evidence of a nursing shortage. Request for 1 year of funds up to a total of 3 years. Applications must be submitted between July – September to Director, Geriatrics and Extended Care Operations. Funds request cannot exceed 2% of the total per diem paid to the SVH in the federal fiscal year. Cannot be used for: benefits, salary, health insurance, retirement plan or construction, expansion, or remodeling. 11

12. Falls Collaborative Preventing Falls and Fall Related Injuries for Veterans: a collaboration between SVHs and the National Center for Patient Safety (NCPS). February 2014 – shared the opportunity with NASVH to work with NCPS. Many expressed interest in a breakthrough series project. Began in April 2014 introducing national practice innovations and strategies for implementation and adoption. Between June 2014 and January 2015, pre-work was completed by SVHs; monthly webinars by NCPS, educational presentations from SMEs; networking calls and project team information was shared. NSPC provided consultation and coaching to individual SVHs. At closure, each SVH submitted a final summary of improvements and results. 12

13. Falls Collaborative Results 6 increased falls education with all staff 6 added post fall huddles 3 incorporated hip protectors 3 used multidisciplinary consulting and fall related referrals 2 developed methods to classify falls 2 added intentional rounding 2 provided feedback to staff 2 added an environmental assessment of the residents room and ordered concave mattresses 13

14. Falls Collaborative Ten State Veteran Homes that participated in the collaborative: Ohio Veterans Home - Georgetown (VISN 10) Ohio Veterans Home – Sandusky (VISN 10) Mississippi Veterans Home - Collins (VISN 16) Mississippi Veterans Home - Kosciusko (VISN 16) Mississippi Veterans Home - Jackson (VISN 16) Clyde W. Cosper Texas State Veterans Home - Bonham (VISN 17) Alfredo Gonzales Texas State Veterans Home - McAllen (VISN 17) Ussery-Roan Texas State Veterans Hospital - Amarillo (VISN 18) Lamun-Lusk-Sanchez Texas State Veterans Home- Big Spring (VISN 18) Ogden Veterans Home - Ogden (VISN 19) 14

15. Recognition Update: 9/2014 – 2/2015 Recognition Packages in VA Concurrence Redding, CA 90-Bed DOM 60-Bed NH West Los Angeles, CA84-Bed DOM Addition Marshalltown, IA509-Bed NHC (66-Bed Reduction) Fresno, CA 180-Bed DOM West Lafayette, IN 337-Bed NH (128-Bed Reduction) 80-Bed DOM (35-Bed Reduction) Upcoming Recognitions Lebanon, OR154-Bed NH Hilo, HI24-Participant ADHC 15

16. Satisfaction Surveys Responded to your request Developed a satisfaction survey utilizing Survey Monkey: – 10 questions for VA Team – 10 questions for Ascellon Team OMB approved survey on January 7, 2015 Launched with February 2015 surveys Survey Links: Link to give feedback on VA Team: https://www.surveymonkey.com/s/SVH-VA_Team https://www.surveymonkey.com/s/SVH-VA_Team Link to give feedback on Ascellon: https://www.surveymonkey.com/s/SVH-Ascellon https://www.surveymonkey.com/s/SVH-Ascellon Aggregate reports will be given starting with the Summer meeting and quarterly reports will be sent to the NASVH President 16

17. Standard Operating Procedures Cancelling of State Veterans Home (SVH) On-Site Surveys Weather - the State or Ascellon has travel restrictions regarding weather related conditions that prohibit surveyor travel to include, snow, hurricane, flood, tornado Infectious disease outbreak - an infectious disease outbreak confirmed anytime one or more of these events occur: The SVH closes certain sections of a facility, restricts visitation, reports to state health department or begins preventative treatment on other residents and/or staff. 17

18. Contacts Valarie Delanko, RDN, LDN, CPHQ National Program Manager SVH Quality & Survey Oversight 814-860-2201 Jo Anne Parker, MHA National Program Manager SVH Survey Process 202-623-8328 18