1. National Association of State Veterans Homes State Veterans Home Program Office of Geriatrics and Extended Care, Patient Care Services, Department of Veterans Affairs

2. 2 CLINICAL & SURVEY OVERSIGHT  Current program structure –140 State Veterans Homes facilities –132 nursing home care programs 24448 beds –55 domiciliary care programs –6110 beds –1 adult day health care program 50 participant slots

3. 3 CLINICAL & SURVEY OVERSIGHT  FY 2010 new survey implemented –Phase I consisted of 6 surveys –Phase II consisted of 91 surveys  Types of surveys –Recognition surveys = 4 –Annual surveys = 87 –For Cause surveys = 6 Totals surveys 97

4. 4 CLINICAL & SURVEY OVERSIGHT  Survey length in days –7 surveys averaged 4 days –88 surveys averaged 3 days –1 survey averaged 2 days –1 survey averaged 1 day

5. 5 CLINICAL & SURVEY OVERSIGHT NURSING HOME SURVEY RESULTS  Number of surveys without deficiencies 22  Number of surveys with deficiencies 75  Total number of deficiencies 381  Average number of deficiencies per survey 5.08

6. 6 CLINICAL & SURVEY OVERSIGHT Standard #StandardFrequency 51.200 aPhysical Environment: Life Safety from fire40 51.120 iQuality of Care: Accidents34 51.200 bPhysical Environment: Emergency Power22 51.110 b Resident Assessments: Comprehensive Assessments of residents needs 21 51.110 2 Resident Assessments: Comprehensive Assessments must be developed within 7 day by an Interdisciplinary team and periodically reviewed 19 51.140 dDietary Services: Food15 51.190 aResidents Behavior and Facility Practices: Restraints12 51.90 4 Resident Behavior and Facility Practices: Staff Treatment of Resident 12 51.120 dQuality of Care: Pressure Sores12

7. 7 CLINICAL & SURVEY OVERSIGHT Standard #StandardFrequency 51.110 d Resident Assessment: Comprehensive plans need to be individualized 11 51.110 3 Resident Assessment: Services provided or arranged by facility must meet professional standards of quality and provided in accordance with Residents care plan 11 51.120 aQuality of Care: Reporting of Sentinel Events10 51.100 a/bQuality of Life: Dignity/ Self-determination and participation8 51.190 aInfection Control: Infection Control Program8 51.190 bInfection Control: Preventing spread of Infection8 51.120 fQuality of Care: Range of Motion7 51.100 gQuality of Life: Patient Activities6 51.120 j Quality of Care: Nutrition based on residents comprehensive assessment 6

8. 8 CLINICAL & SURVEY OVERSIGHT  Deficiencies identified on 5 or fewer surveys –Administration: Clinical Records –Residents Rights: Notification of Changes –Dietary Services: Menus and nutritional adequacy –Administration: Governing body –Quality of Care: Medication Errors –Dietary Services: Frequency of meals –Dietary Services: Sanitary conditions

9. 9 CLINICAL & SURVEY OVERSIGHT IMMEDIATE JEOPARDY / FOR CAUSE SURVEYS  Ten (10) Immediate Jeopardy determinations –Smoking while using oxygen –Modified diets, thickened liquids –Falls with significant injuries  Six (6) For Cause Surveys –Significant increase in falls - 2 –Complaints of a serious nature from residents, residents’ families and staff – 3 –Significant number of deficiencies identified during annual survey - 1

10. 10 CLINICAL & SURVEY OVERSIGHT DOMICILIARY SURVEY RESULTS  Number of surveys without deficiencies 26  Number of surveys with deficiencies 12  Total number of deficiencies 63  Average number of deficiencies per survey 5.25

11. 11 CLINICAL & SURVEY OVERSIGHT  Deficiencies identified on 4 surveys –Medical Care: A patient treatment plan is established and maintained for each domiciliary patient. –Medical Care: Each patient has a complete medical re-evaluation annually and as needed.  13 standards were cited as deficient on 2 surveys  29 standards were cited as deficient on 1 survey

12. 12 CLINICAL & SURVEY OVERSIGHT QUESTIONS