1. 2015 State Veterans Homes VA Survey Deficiency Overview For NASVH Summer Conference Sandusky, OH Valarie Delanko JoAnne Parker Office of GEC Operations (10NC4)

2. Discussion Topics Overview of SVH survey deficiencies – January through March 2015 Immediate Jeopardies Sentinel Event Reporting Falls Collaborative Update Recognition Survey Updates 2

3. SVH Program Census Current SVH Program Structure offering three levels of care: – 152 State Veterans Home Facilities 143 Nursing Home Care programs (25, 216 beds) 55 Domiciliary Care programs (6,176 beds 2 Adult Day Health Care programs (85 participant slots) 3

4. # of Recognized SVHs 2008 - 2015 4

5. Surveys Types 2010 – June 2015 5

6. Totals 6 FunctionMarch 2015 20142013 Number of nursing home care surveys47146142 Number of nursing home care deficiencies159464385 Avg. number of deficiencies per survey3.383.182.71 Number of domiciliary surveyed185755 Number of domiciliary deficiencies85355 Avg. number of deficiencies per survey.44.931.00 Number of adult day health care surveys123 Number of adult day health care deficiencies100

7. Nursing Home Citing's - Category CategoryJan. to March 2015 Jan. to March 2014 Jan. to March 2013 Resident Rights 51.70202 Resident Behavior and Facility Practice 51.90 1986 Quality of Life 51.100929 Resident Assessment 51.110283017 Quality of Care 51.120432620 Nursing Care 51.130101 Dietary Services 51.140630 Physician 51.150000 Specialized Rehabilitation Services 51.160000 Pharmacy Service 51.180432 Infection Control 51.190734 Physical Environment 51.200397236 Administration 51.210120 7

8. Domiciliary Citing's - Category CategoryJan. to March 2015 Jan. to March 2014 Jan. to March 2013 Governance and Administration000 Safety41411 Physical Environment100 Medical Care110 Nursing Service010 Rehabilitation000 Social Services000 Dietetics011 Resident Activities100 Pharmacy000 Medical Records000 Quality Assurance000 Quality of Life100

9. Immediate Jeopardy Numbers 9

10. Justification for IJ: 2015 RegulationIssues - 6 51.190 Resident Behavior- Abuse #65 #66 Residents have had multiply verbal and physical altercations with other residents and staff; Bed lowered on resident foot by staff during transfer; (2) Residents with multiple elopements w/ no investigations; Neglect in wake of tornado warning; Referral to Urologist was not submitted. 2014 RegulationIssues - 2 51.190 Resident Behavior- Abuse #65 #66 Resident in fear of care by CNA; New resident with elopement risk but was not accessed in 7 days and had 2 departures from facility. 10

11. Justification for IJ: 2015 RegulationIssues - 5 51.120 Quality of Care - Accidents #108 Residents with multiple falls, in adequate falls program and policy; Resident cognitive impaired with burns from hot liquids; Facility is a no smoking facility, but 3 residents identified as smoking; Residents with 2 nd degree burns from coffee; Resident assessed to need WanderGuard but did not have one. 2014 RegulationIssues - 8 51.120 Quality of Care - Accidents #108 Coffee burn; Widespread falls concerns (2); Eating vs NPO; Unsafe smoking practices(2),; High water temperatures in bathroom sinks; High instances of physical aggression. 11

12. Justification for IJ: 2015 RegulationIssues - 2 51.200 Physical Environment- Life Safety #147 - DOM #167 Fire monitoring company has not received fire alarm signals for 3 months, fire doors held open; Fire alarm not communicating with fire monitoring company for 2 weeks, no fire watch implemented; 2014 RegulationIssues - 2 51.200 Physical Environment- Life Safety #147 - DOM #167 Fire pumps (2) operational for only one (1) hour; Dish machine wash temperature utilized to clean dishes below manufactures required safety temperature. 12

13. Justification for IJ: 2015 RegulationIssues - 1 51.111 Residents with tracheostomy tubes at risk because trach emergency kit not available and no current training for RNs to reinsert. 2014 RegulationIssues - 0 51.111 13

14. Sentinel Events §51.120 Quality of care. Sentinel Event Reporting State Veterans Homes must report sentinel events to the VA Medical Center of Jurisdiction as outlined in 38 CFR Part 51 and 52. (a)Reporting of Sentinel Events—(1) Definition. A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function. (2) Examples of sentinel events are as follows: (i) Any resident death, paralysis, coma or other major permanent loss of function associated with a medication error; or (ii) Any suicide of a resident, including suicides following elopement (unauthorized departure) from the facility; or (iii) Any elopement of a resident from the facility resulting in a death or a major permanent loss of function; or (iv) Any procedure or clinical intervention, including restraints, that result in death or a major permanent loss of function; or (v) Assault, homicide or other crime resulting in patient death or major permanent loss of function; or (vi) A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall. 14

15. Sentinel Events §51.120 Quality of care. (3) The facility management must report sentinel events to the director of VA medical center of jurisdiction within 24 hours of identification. The VA medical center of jurisdiction must report sentinel events by calling VA Network Director (10N 1-22) and Chief Consultant, Office of Geriatrics and Extended Care (114) within 24 hours of notification. (4) The facility management must establish a mechanism to review and analyze a sentinel event resulting in a written report no later than 10 working days following the event. The purpose of the review and analysis of a sentinel event is to prevent injuries to residents, visitors, and personnel, and to manage those injuries that do occur and to minimize the negative consequences to the injured individuals and facility. 15

16. Falls Collaborative: 2015 Preventing Falls and Fall Related Injuries for Veterans Continuing collaboration between NASVH and the National Center for Patient Safety (NCPS). AIM: Reduce preventable falls & reduce injurious falls. Special thank you to Eric Jordon, Julia Neily and Pat Quigley. Program caped at 30 SVHs due to resources and availability of coaches from NCPS. 5 total coaches. 3 SVH facilities returned from 2014 program. Participating States: WA, SC, NC, WI, VA, TX, LA, OK, CA, MI, NM, KY, ME, UT, NJ, NY Utilization of Survey Monkey tool for immediate feedback. 16

17. Falls Collaborative: 2015 Formal Program Outline May 1– applications had to be submitted to be a part of total 30. June 1 & 5 – Pre-work calls – 90% participation June 30 – SVH baseline reports due (PP template) - 67% July & August – Meet & greet calls between NCPS coaches and the assigned SVHs. September 10 – “Overview of the Science for Fall Prevention in LTC” October 8 – “VeHU Preventing Fall Related Injuries” November 5 – “Types of Falls and Decision Tree” December 3 – “Injury Reduction Strategies” January 31, 2016 – SVH submits final summary of changes 17

18. Falls Collaborative: 2015 Informal Program Outline September 24 – Open forum, discussion and implementation October 10 – SVH facilities submit monthly report of progress October 22 - Open forum, discussion and implementation November 10 – SVH facilities submit monthly report of progress November 19 - Open forum, discussion and implementation December 10 - SVH facilities submit monthly report of progress December 17- Evaluation of Post Falls Huddles 18

19. Recognition Update: 2/2015 – 7/ 2015 Approved Recognitions Redding, CA60-Bed NH West Los Angeles, CA 84-Bed DOM Addition (Total of 168 DOM Beds) 72-Bed NH Marshalltown, IA509-Bed NHC (66-Bed Reduction) Fresno, CA 180-Bed DOM West Lafayette, IN 337-Bed NH (128-Bed Reduction) 80-Bed DOM (35-Bed Reduction) Lebanon, OR154-Bed NH Bennington, VT130-BH NH (41-Bed Reduction) Pending Recognition Hilo, HI24-Participant ADHC 19

20. Questions? 20

21. Contacts Valarie Delanko, RDN, LDN, CPHQ National Program Manager SVH Quality & Survey Oversight 814-860-2201 Jo Anne Parker, MHA National Program Manager SVH Survey Process 202-623-8328 21