1. 2014 State Veterans Homes VA Survey Deficiency Overview Valarie Delanko JoAnne Parker Office of GEC Operations (10NC4)

2. Discussion Topics Top Deficiencies cited: January 2014 thru May 2014 for Nursing Home Care and Domiciliary. Recognition survey updates 2

3. SVH Program Census Current SVH Program Structure offering three levels of care: – 149 State Veterans Home Facilities 140 Nursing Home Care programs (24,163 beds) 54 Domiciliary Care programs (5,865 beds) 2 Adult Day Health Care programs (85 participant slots) 3

4. Surveys Types 2010 -2014 (May) 4

5. Totals FunctionJan – May 20142013 Number of nursing home care surveys7197 Number of surveys with deficiencies47 (66%)68 (70%) Number of nursing home care deficiencies220385 Avg. number of deficiencies per survey3.103.96 Number of domiciliary surveyed3054 Number of surveys with deficiencies10 (33%)23 (42%) Number of domiciliary deficiencies2856 Avg. number of deficiencies per survey.931.03 5

6. IJs -2011 to present Total Cited 201411 Accidents #108 (4): Coffee burn; widespread falls; eating vs NPO; safe smoking practices Necrotic tissue; Dish machine temperatures; Foley catheter Staff/resident incident; elopement risk; drug/drug interaction 6

7. Top NH standards Line # Regulation Number Standard Frequency % 14751.200 a. Facility meets applicable provisions of the 2009 Life Safety Code of National Fire Protection Association. 9443% 148 51.200 b. 1-4 An emergency electrical power system is provided in accordance with NFPA; on-site emergency standby generator of sufficient size to serve connected load. 167% 108 51.120 i. 1- 2 Ensure environment remains free of accident hazards as is possible and residents receive adequate supervision and assistance devices to prevent accidents. 199% 9351.110 e. 2 Comprehensive care plan is: developed within 7 calendar days after assessments, prepared by an interdisciplinary team and periodically reviewed and revised after each assessment. 136% 9451.110 e. 3 Services provided or arranged by facility must meet professional standards of quality and by qualified persons in accordance with the care plan. 136% 9251.110 e. Comprehensive care plan is: individualized that includes measurable objectives and timetables to meet residents physician, mental and psychosocial needs that are identified in the comprehensive assessment. 63% 102 51.120 d. 1-2. Pressure sores: Based on comprehensive assessment, resident enters facility without sore does not develop one unless clinical condition is unavoidable and having one receives necessary tx and services to promote healing. 42% 6651.90 c. Facility management must ensure all alleged violations are reported immediately to administrator/officials per state law; have evidence violations are thoroughly investigated; results reported back to administrator with appropriate corrective action if verified. 42% 7

8. Top DOM standards Line # Guideline Number Standard Frequency % 1672. Safety C. There is evidence reported that reported life safety deficiencies have been or are being corrected. 1968% 1682. Safety D. Facility has available an emergency source of electrical power to provide essential service when normal electricity supply is interrupted. 311% 180 4. Medical D. A patient treatment plan is established and maintained for each domiciliary patient. 14% 181 4. Medical E. Primary Care medical services are provided for domiciliary patients as needed. 14% 216 10. Pharmacy D. Patient on self-medication are instructed by qualified personnel on proper use of drugs. 14% 191 5. Nursing D. Nursing Service participates in the establishment and maintenance of a treatment plan for each domiciliary patient. 14% 204 8 Dietetics E. Dietetic Service personnel practice safe and sanitary food handling techniques. 14% 218 10. Pharmacy F. There is an established system for monitoring the outcome of drug therapy or treatment. 14% 8

9. NH Line # Regulation Number Standard 14751.200 a. Facility meets applicable provisions of the 2009 Life Safety Code of National Fire Protection Association. YEAR:2011201220132014 # Deficiencies: 978018794 Examples: Automatic fire alarm control panel (FACP) reports a supervisory visual notification trouble signal on the panel, but no action taken. Fail to maintain the automatic sprinkler systems, complete and document required inspection, testing, and maintenance services in accordance with established code inspection frequency. No documented weekly no-flow churn test for the fire pump. No documentation of biannual smoke detector sensitivity testing for the smoke detectors. Fail to maintain smoke barrier doors that would close and resist the passage of smoke and provide rated doors for hazardous areas - edge gaps on doors exceeding the permissible 1/8” inch clearance, doors fire ratings are insufficient for a hazardous area. Exits shall terminate directly at a public way or at an exterior exit discharge that is safe. Fail to provide a Digital Alarm Communicator Transmitter (DACT) system in an area where the alarm is likely to be heard by staff. 9

10. NH Line # Regulation Number Standard 14851.200 b. 1-4 An emergency electrical power system is provided in accordance with NFPA; on- site emergency standby generator of sufficient size to serve connected load. YEAR:2011201220132014 # Deficiencies: 1071516 Examples: Fail to perform the weekly inspection and document monthly load tests of the Emergency Power Supply System (EPSS). Generator did not have a remote manual emergency stop station installed outside of the generator compartment as required by code. Generators load bank test not completed. 10

11. NH Line # Regulation Number Standard 10851.120 i. 1-2 Ensure environment remains free of accident hazards as is possible and residents receive adequate supervision and assistance devices to prevent accidents. YEAR:2011201220132014 # Deficiencies: 25242319 Examples: Fail to provide adequate supervision and/or safety devices. Fail to provide adequate supervision/monitoring of the proper feeding techniques specified by Speech Therapy to prevent aspiration. Fail to ensure that adequate supervision provided while attempting to self- transfer and left unattended in the bathroom. 11

12. NH Line # Regulation Number Standard 9351.110 e. 2 Comprehensive care plan is: developed within 7 calendar days after assessments, prepared by an interdisciplinary team and periodically reviewed and revised after each assessment. YEAR:2011201220132014 # Deficiencies: 16121613 Examples: Fail to review and revise the resident care plan to prevent accidents i.e., adjust for dysphasia. Failed to revise care plans, i.e., resident’s inappropriate behaviors that caused the burn with interventions to prevent re occurrence, as needing close monitoring to prevent altercations with other residents. 12

13. NH Line # Regulation Number Standard 9451.110 e. 3 Services provided or arranged by facility must meet professional standards of quality and by qualified persons in accordance with the care plan. YEAR:2011201220132014 # Deficiencies: 121513 Examples: Interventions on resident care plan were not being followed, i.e. failed to provide toileting assistance as care planned, failed to ensure the fall alarm equipment functioned properly, failed to utilize hipsters as care planned and failed to provide appropriate monitoring for safety after administration of an as needed medication during an acute episode of anxiety. Fail to ensure assessments met professional standards of quality and were provided in accordance with each resident’s written plans of care; i.e. shunt not assessed returned from dialysis, no monthly labs, pressure ulcer tx not provided as ordered. nurse failed to document the nature of the burns, failed to complete an incident report to include measures to prevent further occurrence of such accidents, and failed to report to the physician for examination of the injury and possible treatment orders. 13

14. DOM Line # Regulation Number Standard 1672. Safety C. There is evidence reported that reported life safety deficiencies have been or are being corrected. YEAR:2011201220132014 # Deficiencies: 203419 Examples: Does not have quarterly automatic (wet & dry) sprinkler system's inspection and test reports. Fail to properly maintain the automatic fire sprinkler system fire pump, complete or document weekly inspection services, and recalibrate or replace system pressure gauges. Fire pump pressure gauges overdue for a 5 year calibration or replacement inspection. No weekly fire pump inspection services. No-flow churn test were not being performed. No documented fire drills for each shift in each quarter. Fail to establish an inspection, testing and maintenance program for the battery-powered illumination devices installed within the facility - no monthly 30 second or annual 90 minute program for the inspection. Lack of annual inspection, testing and maintenance services for the portable fire extinguishers. 14

15. DOM Line # Regulation Number Standard 1682. Safety D. Facility has available an emergency source of electrical power to provide essential service when normal electricity supply is interrupted. YEAR:2011201220132014 # Deficiencies: 1043 Examples: Fail to perform the weekly inspection and document monthly load tests of the Emergency Power Supply System (EPSS). Generator did not have a remote manual emergency stop station installed outside of the generator compartment as required by code. Generators load bank test not completed. 15

16. Recognition 1-1-14 to 7-28-14 New State Veterans Homes Effective Per Diem Date Date Letter Signed SVHBeds 11/06/1301/07014Payson, UT108-BED NHC 10/17/1301/06/14Kinston, NC100-Bed NHC 10/24/1302/24/13Ivins, UT108-Bed NHC Changes to Existing State Veterans Homes 08/15/1306/13/14Bennington, VT171-Bed NHC (6-Bed Reduction) Recognition Packages in VA Concurrence Redding, CA90-Bed DOM West Los Angeles, CA84-Bed DOM Addition Marshalltown, IA509-Bed NHC (64-Bed Reduction) 16

17. Contacts Valarie Delanko, RDN, LDN, CPHQ National Program Manager SVH Quality & Survey Oversight Jo Anne Parker, MHA National Program Manager SVH Survey Process 17