1. Besides Xanax, What is the CNP’s Role in the Survey Process

3. The survey process is probably one of the most stressful times for the nursing home staff. Most facilities attempt to manage the process as much as possible, however there are ingrained processes that they must follow in the survey. The survey process is probably one of the most stressful times for the nursing home staff. Most facilities attempt to manage the process as much as possible, however there are ingrained processes that they must follow in the survey.

5. The CNP roles begins prior to the actual survey Always ensure that the documentation is complete and clear and concise. Always ensure that the documentation is complete and clear and concise. It goes without sayings, I am sure, but ensure that there are no departmental battles in your notes. This will send red flags out to the surveyors. It goes without sayings, I am sure, but ensure that there are no departmental battles in your notes. This will send red flags out to the surveyors.

6. General Survey Protocol Every facility is different in how they manage the process, however it is common practice not to provide any copies of information to the surveyor directly. The surveyor should be directed to request information from the Administrator or DON. Every facility is different in how they manage the process, however it is common practice not to provide any copies of information to the surveyor directly. The surveyor should be directed to request information from the Administrator or DON.

7. It is wise to have a witness with you if asked to speak with the surveyor. It is wise to have a witness with you if asked to speak with the surveyor. Only answer the question asked, do not provide additional information. Only answer the question asked, do not provide additional information.

9. CNP/MD visits Residents are required to be seen by the doctor every 30 days for the first 90 days. It is recommended that the visits alternate between the CNP and MD. Residents are required to be seen by the doctor every 30 days for the first 90 days. It is recommended that the visits alternate between the CNP and MD. They must be seen every 60 days after. They must be seen every 60 days after. A visit is timely if it is within 10 days after the due date. A visit is timely if it is within 10 days after the due date.

10. Quality Measures All nursing homes are rated based on Quality Measures. These are broken down between long term care and short term residents. For the long term residents, the following are the items looked at: All nursing homes are rated based on Quality Measures. These are broken down between long term care and short term residents. For the long term residents, the following are the items looked at: The percentage of residents experiencing one or more falls with a major injury The percentage of residents experiencing one or more falls with a major injury Percent of long-stay residents with UTI Percent of long-stay residents with UTI

11. Percent of long-stay residents who self- report moderate to severe pain. Percent of long-stay residents who self- report moderate to severe pain. Percent of long-stay residents with pressure ulcers Percent of long-stay residents with pressure ulcers Percent of long-stay residents who lose control of their bowels or bladder. Percent of long-stay residents who lose control of their bowels or bladder. Percent of long-stay residents who have/had a catheter inserted and left. Percent of long-stay residents who have/had a catheter inserted and left. Percent of long-stay residents who were physically restrained Percent of long-stay residents who were physically restrained

12. Percent of long-stay residents whose need for help with daily activities has increased. Percent of long-stay residents whose need for help with daily activities has increased. Percent of long-stay residents who lose too much weight. Percent of long-stay residents who lose too much weight. Percent of long-stay resident who have depressive symptoms Percent of long-stay resident who have depressive symptoms Percent of long-stay residents assessed and given, appropriately the seasonal influenza vaccine. Percent of long-stay residents assessed and given, appropriately the seasonal influenza vaccine.

13. Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine Percent of long-stay residents who are administered antipsychotic medications. Percent of long-stay residents who are administered antipsychotic medications.

15. Short-Stay Residents Percentage of short-stay resident who self-report moderate to severe pain Percentage of short-stay resident who self-report moderate to severe pain Percentage of short-stay residents who new or worsening Stage II to Stage IV pressure ulcers Percentage of short-stay residents who new or worsening Stage II to Stage IV pressure ulcers Percentage of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine. Percentage of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine.

16. The percentage of short-stay residents assessed and given, appropriately, the pneumococcal vaccine The percentage of short-stay residents assessed and given, appropriately, the pneumococcal vaccine The percentage of short-stay residents who are newly administered antipsychotic medications. The percentage of short-stay residents who are newly administered antipsychotic medications.

17. Based on these measure, we can obviously control some of them, however, not all. Most facilities try to manage these situations as much as possible, however there are always situations we cannot control. This is when the ongoing documentation to “prove” the actual situation becomes vital. Based on these measure, we can obviously control some of them, however, not all. Most facilities try to manage these situations as much as possible, however there are always situations we cannot control. This is when the ongoing documentation to “prove” the actual situation becomes vital.

19. Falls We would all love to have a “fall free facility”, however that is impossible. This is why we need to review each fall on an ongoing basis and add some type of interventions. It truly takes a team approach to be as creative as we need to with interventions related to fall. It is important as well, to rule out medical issues. We would all love to have a “fall free facility”, however that is impossible. This is why we need to review each fall on an ongoing basis and add some type of interventions. It truly takes a team approach to be as creative as we need to with interventions related to fall. It is important as well, to rule out medical issues.

21. Urinary Tract Infections Again, we really cannot control this area 100% ! Again, we really cannot control this area 100% ! As the CNP, you need to ensure that treatment is rendered as needed and appropriate and that for the resident with frequent UTI’s all appropriate interventions are in place. As the CNP, you need to ensure that treatment is rendered as needed and appropriate and that for the resident with frequent UTI’s all appropriate interventions are in place. Educate residents, families and staff. Educate residents, families and staff.

22. Pain Management This is always a challenging area to ensure that triggers do not occur. We all have the resident who will smile, show absolutely no s/s of pain, but will rate their pain at 9 – 10. We basically need to show that we are attempting to assess and address the pain, and again educate residents on pain and document. This is always a challenging area to ensure that triggers do not occur. We all have the resident who will smile, show absolutely no s/s of pain, but will rate their pain at 9 – 10. We basically need to show that we are attempting to assess and address the pain, and again educate residents on pain and document.

24. Loss of Bowel or Bladder Control Again, we wish we could control ones muscle control, however……. Again, we wish we could control ones muscle control, however……. This is related to low risk residents who do not have severe memory losses and/or severe limitations in mobility This is related to low risk residents who do not have severe memory losses and/or severe limitations in mobility We always need the appropriate documentation to explain why declines have occurred and to show that we have made all appropriate referrals and attempts to control what we can. We always need the appropriate documentation to explain why declines have occurred and to show that we have made all appropriate referrals and attempts to control what we can.

25. Catheters I certainly don’t need to tell you about the risks related to catheters! I certainly don’t need to tell you about the risks related to catheters! The CNP/MD need to ensure that all attempts have been made to discontinue the use of a catheter. If unable, we need to show that the urologist was involved, that appropriate medications were attempted and that the appropriate diagnosis is in place. The CNP/MD need to ensure that all attempts have been made to discontinue the use of a catheter. If unable, we need to show that the urologist was involved, that appropriate medications were attempted and that the appropriate diagnosis is in place.

26. Appropriate Diagnoses Obstructive uropathy Obstructive uropathy Neurogenic bladder Neurogenic bladder Treatment of stage III or IV pressure ulcer for an incontinent resident. Treatment of stage III or IV pressure ulcer for an incontinent resident.

28. Physical Restraints Most facilities refuse to use any physical restraints. Most facilities refuse to use any physical restraints. If there is a situation where a restraint is used, please ensure that there is appropriate documentation to justify the temporary use of and removal of the restraints. If there is a situation where a restraint is used, please ensure that there is appropriate documentation to justify the temporary use of and removal of the restraints.

29. ADL’s Obviously, the need for assistance with ADL’s is one of the main reasons residents are admitted to facilities. When a resident needs more assistance with eating, transferring, changing position in bed and toileting, our quality measures change. Obviously, the need for assistance with ADL’s is one of the main reasons residents are admitted to facilities. When a resident needs more assistance with eating, transferring, changing position in bed and toileting, our quality measures change. We need to ensure that we are doing everything possible to maintain their level of functioning with either therapy referrals or restorative nursing programs. We need to ensure that we are doing everything possible to maintain their level of functioning with either therapy referrals or restorative nursing programs.

30. If there is a sudden decline in ones abilities, is there a medical reason for this which obviously needs addressed. If there is a sudden decline in ones abilities, is there a medical reason for this which obviously needs addressed. If there is a slow steady decline, it may be the normal aging process. If there is a slow steady decline, it may be the normal aging process. Or, there may be a temporary decline related to an acute medical situation. Or, there may be a temporary decline related to an acute medical situation. DOCUMENT WHAT YOU FIND DOCUMENT WHAT YOU FIND

32. Weight Loss Obviously with weight loss, the CNP will work closely with the facility Dietician to ensure all appropriate interventions are in place to prevent weight loss. Obviously with weight loss, the CNP will work closely with the facility Dietician to ensure all appropriate interventions are in place to prevent weight loss. Rule out medical issues that could be associated with the weight loss. Rule out medical issues that could be associated with the weight loss. Document Document

33. Influenza and Pneumococcal Vaccines The primary role of the CNP in this area is education of residents and family to encourage the use of the vaccines. Again, it certainly does not hurt to document the reasons for the refusals, however this area is basically documented in numbers. The primary role of the CNP in this area is education of residents and family to encourage the use of the vaccines. Again, it certainly does not hurt to document the reasons for the refusals, however this area is basically documented in numbers.

34. Depressive Symptoms This is a very difficult area. On one end of the spectrum, a facility get reimbursed more for residents with s/s of depression being present. This is a very difficult area. On one end of the spectrum, a facility get reimbursed more for residents with s/s of depression being present. We all know that with all of life losses that our residents are facing, depression is very prevalent. We all know that with all of life losses that our residents are facing, depression is very prevalent. This measure monitors the increase in signs and symptoms, therefore the appropriateness of treatment is very important. This measure monitors the increase in signs and symptoms, therefore the appropriateness of treatment is very important.

35. Most social workers will notify the CNP/MD of significant scored on the PHQ9. This is the assessment we use for mood. Most social workers will notify the CNP/MD of significant scored on the PHQ9. This is the assessment we use for mood. We need to show that we have made attempts both non-pharmacy related and pharmaceutical as needed. We need to show that we have made attempts both non-pharmacy related and pharmaceutical as needed. We need to show the team approach to attempts at treatment and again the appropriate documentation needs to be in place. We need to show the team approach to attempts at treatment and again the appropriate documentation needs to be in place.

37. Psychoactive Medications The nursing facility is mandated to decrease the use of psychoactive medications by 25% by the end of 2015 and by 30% by the end of 2016. The nursing facility is mandated to decrease the use of psychoactive medications by 25% by the end of 2015 and by 30% by the end of 2016. This being said, we also have behaviors that need to be treated. The goal is to reduce the use of medication with the black box warning. This being said, we also have behaviors that need to be treated. The goal is to reduce the use of medication with the black box warning.

38. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used : (i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued

39. That is great but……. The CNP need to monitor PRN meds and discontinue when they are not needed. The CNP need to monitor PRN meds and discontinue when they are not needed. Consult with the MD about the medications and document the effects. Consult with the MD about the medications and document the effects. If a dose reduction is attempted and is not successful, you need to ensure that there is adequate documentation to justify failure of the attempted reduction. If a dose reduction is attempted and is not successful, you need to ensure that there is adequate documentation to justify failure of the attempted reduction.

40. Pressure Ulcers Ensure that your notes indicate that the ulcer/s are unavoidable. Ensure that your notes indicate that the ulcer/s are unavoidable. You are encouraged to document all known attempts at avoiding the development of ulcers as well as non- compliance on the part of the residents. You are encouraged to document all known attempts at avoiding the development of ulcers as well as non- compliance on the part of the residents.