Post Survey Protocol Kenny williamson keith Harbuck keith & holmes llc kkeith@hkh.law 205-547-5557

Post Survey Protocol Begins at the Exit Conference Assign at least one person to take detailed notes and one to be fully engaged in discussion. After the surveyor exits, discuss the conference to ensure that the exit notes are as complete as possible

Begin to Formulate a Plan of Attack Most serious alleged deficiency? Most complex corrective action required? Are policy revisions necessary? Are discharges necessary? Distinguish: Is there a training need or a re-training need? Who are the key individuals to implement the plan of attack? What resources are needed to implement the plan? What is the time frame for implementation?

What Is the Most Serious alleged deficiency? Investigation Issues Resident Care Issues Retention of residents beyond the scope of assisted living or specialty care assisted living. Harm or serious risk of harm based on failure to appropriately assess and care plan. The Big Three: Falls, Elopements, and Medication Awareness Danger Zones: Special Diets, Mobility, and Restraints Handling allegations of abuse, neglect, or misappropriation. Incident analysis and determination of root cause for accidents.

Retention of residents beyond the scope of alf or scalf Two categories of concern: Discharge notice not issued in a timely manner Discharge not completed in a timely manner

Harm or Risk of Harm Related to Failure to Assess and/or Adequately Care Plan: Thinking About the Big Three Falls Elopements Medication Awareness Points of Most Vulnerability Change in Condition, One Size DOES NOT Fit All, Too Little, Too Late

Danger, Will Robinson Special Diets and Food Assistance Mobility and Safety Restraints

Investigation and Reporting Allegations of Abuse and Neglect Definitions of Abuse and Neglect What Controls the Duty to Report? Resident Protection During Investigation Living with the Gray Areas What constitutes a thorough investigation? Answer the major questions: What When Where Who How

Incident Investigation: One Size Does Not Fit All What happened? When did it happen? Who was involved? Why did it happen? Dig for all information. Compare previous incidents: time, place, caregiver, activity, clothing, toileting needs, patterns. Don’t hesitate to re-interview, reassess if things don’t add up. Make sure your findings and recommendations/revisions to care plan FIT the WHY.

Policy Revisions: Revise Before You Teach/Monitor Don’t get the cart before the horse. If policy revisions are necessary for the plan of correction, those must be made before you in-service. Likewise, you must in-service before you start to monitor.

Putting it all together: Writing the poc Kenny’s first law of poc development: give yourself credit for all that you do!!!!!!

The Five Required Elements of a POC Each of the five required elements must be addressed under each individual tag Identification of the Tag (Example: A-402) Corrective actions taken with respect to the residents identified in the statement of deficiencies. Corrective actions taken to ensure that (a) there are no similar issues with similar residents and (b) if any similar issues are identified, that they have been corrected. Systemic changes implemented to ensure that the alleged deficient practice does not re- occur. This is where policy revisions and teaching and training activities are listed. Monitoring plan to ensure that the systemic actions you took are successful.

Required Element #2 For each resident identified in the statement of deficiencies, the facility must identify exactly what was done to correct the alleged deficient practice involving that resident. Corrective actions should contain both the date the action was completed and the job title of the individual responsible for the corrective action: On May 23, 2015, the clinical services director updated RI#2’S CARE PLAN WITH THE FOLLOWING INTERVENTIONS and instructions for observation and health supervision for weight loss, including addition of double protein at each meal and provision of high calorie snacks of resident preference at bedtime.

Required element #3 The plan of correction must address the actions taken to ensure that no other resident is affected by the alleged deficient practice. Corrective actions should contain both the date the action was completed and the job title of the individual responsible for the corrective action: By may 27, 2015, the facility wellness nurse/designee reviewed all resident records to ensure that no other resident had experienced weight loss and that any resident who had experienced weight loss had an appropriate care plan in place. Also by may 27, 2015, the facility wellness nurse/designee updated any resident care plans as needed based on the above review.

Element #4: Systemic changes This section includes any policy revision necessary for implementation of the plan of correction and any training provided as part of the plan of correction. Corrective actions should contain both the date the action was completed and the job title of the individual responsible for the corrective action: BY JUNE 1, 2015, THE ADMINISTRATOR/DESIGNEE WILL INSERVICE ALL FACILITY DIRECT CARE STAFF, INCLUDING FOOD PREPARATION STAFF, REGARDING MONITORING FOR, PREVENTING, RECOGNIZING AND RESPONDING TO WEIGHT LOSS. ANY DIRECT CARE STAFF MEMBER WHO HAS NOT COMPLETED THE REQUIRED TRAINING BY JUNE 1, 2015 WILL BE REMOVED FROM THE SCHEDULE AND WILL NOT BE ALLOWED TO RETURN TO WORK UNTIL THE TRAINING IS COMPLETE.

Element #5: monitoring This section describes how the facility will monitor its corrective actions to ensure that there are not repeats of the same deficient practice. Monitoring activities need to be person and time specific and should include start and stop dates as well as how ongoing concerns are addressed. Beginning on June 2, 2015, the Administrator/Designee will review the care plans for all residents experiencing a weight loss to ensure that appropriate interventions are documented. This review will be conducted daily for three weeks. At the end of three weeks, the Administrator/Designee will review 10% of care plans for residents experiencing weight loss every other week for three weeks. At the end of this second three week period, the Administrator/Designee will review 10% of care plans for experiencing weight loss monthly for two months. The Administrator/Designee will be responsible for additional correction action, if needed. Results of monitoring and documentation of corrective action, if needed, will be maintained in the POC notebook in the office of the Administrator.

The Part I don’t want to talk about The Really Difficult survey……. What happens now?

Questions? Invitations to lunch? Rotten tomatoes? Kenny Williamson Keith Harbuck keith & holmes llc 205-547-5557 kkeith@hkh.law