Quality Indicator Survey S 4 by Cindy Luxem, CEO/President, Kansas Health Care Association, Topeka, KS and LuMarie Polivka-West, Vice President, Chief of Clinical Services, Florida Health Care Association 2007 American Health Care Association Annual Convention

Background  A revised survey process  Contract awarded in 2005 with University of Colorado to conduct demonstration  Independent evaluation of demonstration (Abt Associates)  Florida is participating in demonstration to evaluate training model with the statewide roll out of the QIS

2 Stages of the Quality Indicator Survey  Stage I: Preliminarily investigate all regulatory areas and determine care areas for in-depth Stage II review  Stage II: Determine if deficient practice, and document deficiencies including F tags, scope and severity

Stage I Entrance  Entrance Conference held during which necessary information is requested from facility (see Entrance Conference Facility Worksheet), i.e. alphabetical roster (this has been identified as a problem by AHCA)  Abbreviated Tour (concurrent to entrance conference) to provide orientation; goals are different than traditional survey tour (no selection of resident sampling)

Within One Hour  Key personnel and locations  Name of resident council president  Meal time schedule and dining room location  All admission sample closed records List provided to facility after entrance conference

Within Four Hours  Ventilator/Dialysis/Hospice Worksheet  Dialysis contract and related policies; overview of how care is coordinated  For facility dialysis: List of residents, room, and ESRD caregiver and who provides the service (internal or external provisions)  Day and times for dialysis treatment  Flu/Pneumococcal P&P

Within 4 Hours cont.  Rooms with less than required square footage that have a variance  Lists of rooms: >4 residents (variance)  Rooms below grade; no window to outside or access to a corridor  QA&A committee info: Contact persons, members, frequency of meetings  PASSAR information  Any experimental research in the facility  Complaint/Abuse/Grievance info; contact person and P&P

Within 24 Hours…  Medicare residents that have requested demand billing since lasty survey (9-15 mo)  Medicare/Caid application (671)  Resident Census and Condition (672)  Copy of the OSCAR 3  Query: Is full time DON coverage provided?

Stage I Sampling  MDS sample – drawn offsite and includes all residents with an MDS assessment within the past 6 months of the survey  Census sample - random sample of current residents (n=40)  Admission sample - random sample of new admissions (n=30)

Stage I Resident Level Investigation  Resident Interviews  Resident Observations  Staff Interviews  Medical Record Reviews  Family Interviews

Stage I Facility Level Investigation  Resident Council Interviews  Observations of Dining and Kitchen  Infection Control Practices  Demand Bill Procedures  Quality Assessment and Assurance Program

Stage I Synthesis Onsite data are combined with MDS data to create resident-centered outcome and process indicators, called Quality of Care Indicators (QCIs) QCIs and Facility-level Tasks MDS (includes the 24 QI) Census Admission Facility

Admission Sample Review  Prognosis  DX  LOS  Discharge info (if applicable)  Within 60 days of admit: Any PT, OT, ST?  Pressure ulcer, weight loss, Terminal prognosis

Census Sample  Comatose  Bed mobility  Transfer  ICD 9 codes that focus on nutrition  Stability  Pressure Ulcers  Psycho tropics  Weight Loss

Family Interview  “Want to understand why it is like to live in this nursing home”  Determine through screening the level of resident knowledge  Prior Hx  Preferences; Are they honored?  Choices  Activities  Dignity Interactions

Family Interviews  Staffing - Is it sufficient?  ADL  Oral Health  Abuse  Personal property  Environment  Rights  Costs/Funds  Admission  Notice of changes  Care plan participation

Resident Interview Openers: How long have you been here, are you from around here, what is the food like? Cognitive determination If cognitively appropriate the questions entail quality of life and care

Resident Interview Cont.  Abuse: Do you ever feel afraid…  Personal property  Skin condition  Potential restraints: device in place that may potentially restrict movement or access to one’s body  Pain*; observations also done  Food

Resident Interviews  Staffing  Oral Health  Positioning  Privacy  Exercise of rights  Funds  Room

Staff Interviews  Catheter use; reason; diagnosis  Neurogenic bladder must be verified in medical record  Nutrition; supplements and reasons for  Skin Care Protocols

Facility Survey Tasks  Demand Billing  Dining Frequency of meals Assistance Meal service and proper handling Dignity and independence Adequate time Positioning (maximized eating ability)

Facility Survey Tasks cont. Atmosphere Substitutes Furnishing/space Food quality and sufficient liquids; adequate assist as needed

Infection Control  Observations for hand washing (Competency tool)  Glove use  Staff with lesions?  Soiled laundry process  Isolation  Functioning infection control program  Staff adherence to P&P

Kitchen/Food Service  Tour  Storage  Food Infection control guidelines  Storage temperatures and process  Food prep and service; includes snacks, leftover storage, etc.  Sanitization  Equipment

Stage II Sampling  Computer identifies sample such that all triggered care areas are included with as few residents as possible  The more care areas triggered, the larger the sample  All sentinel events and complaints

Stage II Resident Level Investigation  Each surveyor evaluates care process in relation to Stage I findings  Both resident-level and facility-wide investigations  Use of Critical Elements Pathways to structure investigative process  Rate severity for each resident where deficient practice is found

Stage II Facility Level Investigations If triggered in Stage I:  Abuse Prohibition  Environment  Nursing service  Sufficient staff  Resident funds  Admission, transfer, and discharge

Stage II Synthesis  Combine Stage II findings across residents into single computer by F tag  Integrate survey team findings into single statement  Use documentation recorded in Stage I and Stage II  Identify deficiencies and determine severity and scope  Upload directly to 2567

Surveyor Initiative At any time in the process, surveyors can initiate the addition of:  Residents  Care areas  F tags

Medication Observation  Medication administration observation is assigned to specific surveyors during offsite preparation  Medication administration observation is conducted throughout the survey  Documentation is completed during Stage II

Medication  10 resident sample  Preparation  Administration: correct dose, order, and given per ; appropriate technique and order  Storage  Staff need a working knowledge of medications  Beyond the med cart = survey success

CMS: QIS Process Strengths  Larger Sample Sizes To identify patterns of poor care, it requires a sample of adequate size to infer about facility population. To identify patterns of poor care, it requires a sample of adequate size to infer about facility population. Different samples (e.g., admission and census) emphasize different types of residents. Different samples (e.g., admission and census) emphasize different types of residents.  Comprehensive Past studies demonstrated that some surveyors targeted only selected deficiencies while missing the big picture Staged approach requires surveyors to examine all regulations

Structured Approach  Systematic observations and questions are comparable across sites and replicable  Providers could use the tool to reliably assess and improve quality on an ongoing basis

Quality Assurance Assessment  QA & A: How do staff know their role in QA? How are they kept in the loop?  How are problems identified and addressed?  How does the facility review practices to identify concerns; Committee function  Do action plans relate to the analysis of data?

Enhanced Documentation  Information collected throughout the process is collated by computer for development of 2567  Trail of findings available to follow on-site decision-making  Should be more defensible because of rates and structured findings

Citations  On average modest increase in number from previous annual survey under QIS  Greater variation in citations across surveys (higher standard deviation and interquartile range)  Zero deficiencies still occur  Citations have been well documented and infrequently overturned

Types of Deficiencies Cited at Higher Rate in QIS  Quality of Life Dignity Activity program meets individual needs  Resident Assessment Comprehensive assessments Develop comprehensive care plans  Quality of Care Facility is free of accident hazards Provide necessary care for highest practicable well being Drug regimen is free from unnecessary drugs Proper treatment to prevent/heal pressure sores  Resident Behavior and Facility Practices Persons guilty of abuse not employed Right to be free from physical restraints not required for treatment Staff treatment of residents

Concluding Remarks  Varied QIS outcomes but according to providers, slightly higher level of deficiencies.  Resurvey protocol supposed to be similar to current survey process with a focus on deficiencies from first survey.  Complaint surveys  CMS has contracted for nationwide training of surveyors in all states over the next four years.