Risk Management Preparation - Prevention - Response Janice Sumner, RN VP of Clinical Operations HMRVSI, Inc. July 30, 2015

Risk The possibility that something bad or unpleasant (such as injury or loss will happen) Someone or something may cause something bad or unpleasant to happen A person that someone judges to be a bad choice for many things

Preparation Quality assurance program Current information Education

Prevention The act or practice of stopping something bad from happening

Response Something done as a result to something that has happened An incident that constitutes a reply or reaction

MDS Focused Survey Targeted Survey Specialized onsite surveys to access adequacy of a resident’s assessment as related to information reported to CMS Can not be combined with a normal recertification survey Can be conducted immediately after or before a compliant survey

Three areas to be evaluated Compliance with regulatory requirements Timeliness Compare MDS with the medical record

MDS Survey Request Policies and Procedures for MDS and Quality Measures Staffing schedule: MDS and Quality Assurance Resident Information

Top 5 Deficiencies Follow up from injury Pressure Ulcers Restraints Diagnosis for indwelling catheter Late loss ADLs

MDS Survey Results Increased compliance with timeliness of assessments Decreased compliance with supporting documentation

Electronic Staffing PBJ Must transmit timely and efficiently Requires electronically submission – Includes agency and contract staff – Based on payroll/verification – Must be auditable – Uniform format Staffing data must include hours worked by each staff every day

Dates to Remember Fiscal quarter 1October 1 – December 31 Fiscal quarter 2January 1 – March 31 Fiscal quarter 3April 4 – June 30 Fiscal quarter 4July 1 – September 30

Additional Dates Mandated July 1, 2016 Voluntary registration August 15, 2015

Registration QIES System – Quality Improvement &Evaluation System

Job Descriptions Administrator Nursing Services Restorative Services Dietary Services Social services Activity Services

Additional Job Descriptions Physician Services Nursing Services Dietary Services Therapeutic Services Dental Services Mental Health Services Clinical Laboratory Services Diagnostic X-ray Services Housekeeping Services Additional Services

Food for Thought Create policy and procedure Communication with providers Process for information – Timeliness – Format of information – Compliance to accuracy

Final Rule Biggest change to nursing home rules in 24 years Published July 13, 2015 Open for comments

Goal of Final Rule To achieve improvement in quality of health care and resident safety through federal programs while reducing the procedural burden on providers

Significant Requirements Implementation of a Comprehensive Quality Assurance and Performance Program Required facility compliance and ethics program

Additional Changes Resident’s Rights Pharmacy Services Behavioral Health Diagnostic Services Dental Services Food & Nutritional Services Specialized Rehab Services Physical Environment

QAPI Requirements Facility will be required to present a comprehensive QAPI to state agency surveyors during the first annual survey after the effective date of the regulation Facility must develop, implement, and maintain effective comprehensive data driven QAPI program with a focus on indicators of the outcomes of care and quality of life

Elements of a QAPI Program activities Leadership QAA committee Disclosure of information Sanctions

Compliance and Ethics

Components Posted information related to reporting Policies for disciplinary standards

Facility Assessment and Staffing

How Will the Facility Maintain the Assessment? List of resident current census and facility capacity Care provided by resident population EthicCulturalReligious Facility Resources Facility based and community based assessment

Reporting Requirements for Suspicious Crimes Suspicion of bodily harm must be reported in 2 hours Suspicion of a crime without bodily harm must be reported in 24 hours Suspicion of a crime must be reported to state and law enforcement

Transition of Care Dr Order for Transfer Demographic Responsible Party Advanced Directives Reason for Transfer Past Medical History Active Diagnosis Pertinent Lab Reports Functional Status Psychosocial Issues Social Supports Behavioral Issues

Transitional Care Medications Allergies Immunizations Smoking Status Vital signs Unique device identifiers Comprehensive care plan

Transition Care Form Recapitulation of stay Final summary Reconciliation of all medications Post discharge care plan

Comprehensive Care Plan Initial care plan within 48 hours of admission Goals based upon admission orders PASARR recommendations if applicable

ICPO Infection Control & Prevention Officer Must have specialized training in infection prevention and control Will be responsible for identifying, reporting and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors

Physician Services Must have a Physician, NP, or Clinical Nurse Specialist to evaluate resident before a nonemergency transfer to hospital Physician must delegate task of writing dietary orders to a RD or other clinically qualified nutritional professional Physician must delegate the task of writing therapy orders to a qualified therapist

September 14,