2012 State Veterans Homes VA Survey Deficiency Overview JoAnne Parker Kelly Mingle Office of GEC...
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![Page 1: 2012 State Veterans Homes VA Survey Deficiency Overview JoAnne Parker Kelly Mingle Office of GEC Operations (10NC4)](https://reader035.fdocuments.in/reader035/viewer/2022062314/56649ea05503460f94ba2be1/html5/thumbnails/1.jpg)
2012 State Veterans Homes VA Survey Deficiency Overview
JoAnne ParkerKelly Mingle
Office of GEC Operations (10NC4)
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Discussion Topics
• All Deficiencies cited in 2012• Top 10 Deficiencies Discussion• Bonus – Recognition updates
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Background Information
• Current SVH Program Structure offering three levels of care:– 143 State Veterans Home Facilities
• 134 Nursing Home Care programs (24,526 beds)
• 53 domiciliary care programs (5,801 beds)
• 2 adult day health care programs (85 participant slots)
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FY12 Types of Surveys
Survey Type Surveys % of Total
Annual 135 90.00%
For Cause 3 2.00%
Recognition 12 8.00%
Total 150 100%
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Comparison – Surveys Types (FY10-12)
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Totals for FY12
Total Number of Nursing Homes Surveyed
150
Total Number of Surveys with Deficiencies
65
Total Nursing Home Deficiencies285
Average Number of Deficiencies Cited per Survey
1.90
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IJs for FY12CFR
#Tag # Times Reason
51.110
87 1 Failure to complete assessment for smoking residents/
51.120
108 8
Accidents: Failure to develop smoking policy and supervise residents smoking/Resident smoking with oxygen and without
supervision/Failure to implement, monitor, and supervise fall interventions
51.110
92 1 Failure to follow care plans/supervise residents that smoke
1C 161 1Failure to ensure three (3) residents from self harm/ Failure to
document attempted suicide51.20
0147 1 Failure to provide adequate fire safety systems
51.210
1 1Failure to use resources effectively to maintain the highest practical,
physical, mental, and psychological well being of each resident.51.21
018 1
Failure to ensure nurse aides able to demonstrate competency to care for residents’ needs
51.210
28 1 Failure to correct quality deficiencies within established time period
51.90 65 1Failure to provide appropriate supervision to the residents while in the
shower room51.20
0149 1 Lack of functional water thermometer on ARJO tubs
51.110
93 1 Failure to ensure safe smoking practices
51.110
94 1 Failure to ensure safe smoking practices
51.210
27 2Failure to implement, monitor and supervise residents that
smoke/Failure to develop and implement appropriate plans of action
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IJs for FY12CFR
#Tag # Times Reason
51.110
87 1 Failure to complete assessment for smoking residents/
51.120
108 8
Accidents: Failure to develop smoking policy and supervise residents smoking/Resident smoking with oxygen and without
supervision/Failure to implement, monitor, and supervise fall interventions
51.110
92 1 Failure to follow care plans/supervise residents that smoke
1C 161 1Failure to ensure three (3) residents from self harm/ Failure to
document attempted suicide51.20
0147 1 Failure to provide adequate fire safety systems
51.210
1 1Failure to use resources effectively to maintain the highest practical,
physical, mental, and psychological well being of each resident.51.21
018 1
Failure to ensure nurse aides able to demonstrate competency to care for residents’ needs
51.210
28 1 Failure to correct quality deficiencies within established time period
51.90 65 1Failure to provide appropriate supervision to the residents while in the
shower room51.20
0149 1 Lack of functional water thermometer on ARJO tubs
51.110
93 1 Failure to ensure safe smoking practices
51.110
94 1 Failure to ensure safe smoking practices
51.210
27 2Failure to implement, monitor and supervise residents that
smoke/Failure to develop and implement appropriate plans of action
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10 Ten Deficiencies FY12
StandardNumber of
Deficiencies - FY 12 Percentage
Physical Environment 97 34.64%
Resident Assessment 61 21.79%
Quality of Care 54 19.29%
Quality of Life 29 10.36%
Residents Behavior and Facility Practices 10 3.57%
Administration 9 3.21%
Infection Control 8 2.86%
Dietary Services 5 1.79%
Resident Rights 5 1.79%
Nursing Services 2 0.71%
Total 280 100%
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Deficiencies by Type FY 12
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Deficiencies by Type FY 11
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Deficiencies by Type FY 10
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DOM Totals FY12
Total Number of Domiciliary Surveyed 59
Total Number of Surveys with Deficiencies Cited
23
Total Domiciliary Deficiencies Cited 27
Average Number of Deficiencies Cited per Survey
0.46
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Top DOM standards FY12Tag
Regulation Number
Standard Frequency% of All
Tags
4E 181.4 ePrimary care medical services are provided for domiciliary patients as needed
2 7.41%
11A 219.11 aMedical records are completely legible and accurately documented, readily accessible, and systematically organized to facilitate retrieving and compiling information
2 7.41%
4F 182.4 f Each patient has a complete medical re-evaluation annual and as needed 1 3.70%
5C 190.5 c Nursing services rendered are documented in the patient's medical record 1 3.70%
5D 191.5 dNursing service participates in the establishment and maintenance of a treatment plan for each domiciliary patient
1 3.70%
7A 196.7A qualified social worker is on staff or the facility has a written agreement with a qualified social worker or recognized social agency for consultation on a regularly scheduled basis
1 3.70%
7B-C 197.7 b-cA written psychosocial assessment is maintained in each patient's medical record
1 3.70%
7C 198.7 cResults of social services rendered are documented in the patient's medical record
1 3.70%
7D 199.7 d The facility has an organized procedure for discharge and transfers 1 3.70%
9D 210.9 d Each patient's activity plan is a part of the overall treatment plan 1 3.70%
10A 213.10 a A registered pharmacist is responsible for pharmacy services 1 3.70%
13A 226.13 a Patients are treated with respect and dignity 1 3.70%
13E 230.13 ePatients are oriented to the policies and procedures concerning the rights and responsibilities of the domiciliary patient
1 3.70%
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DOM Comparison FY10 - 13
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A Closer Look
• Based on frequency of issue:– Physical Environment– Assessments– Quality of Life– Quality of Care
• Based on level of improvement:– Dietary
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Physical Environment
TagRegulation Number
Standard FY11 FY12 % change
147 51.200a Life Safety from Fire
97 80 -17.5%
148 51.200 b1-4 Emergency Power
10 7 -30.0%
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Assessments
TagRegulation Number
Standard FY11 FY12 % change
87 51.110b1 Resident Assessment: Comprehensive Assessments of residents needs
2 3 +50.0%
92 51.110d1 Resident Assessment: Comprehensive Care Plan
8 12 +50.0%
93 51.110d2 Resident Assessment: Comprehensive Care Plan
16 12 -25.0%
94 51.110d3 Resident Assessment: Periodic Review
12 15 +25.0%
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Quality of Care
TagRegulation Number
Standard FY11 FY12 % change
96 51.120a1-3 Quality of Care: Reporting of Sentinel Events
6 3 -50.0%
102 51.120d Quality of Care: Pressure Sores
10 3 -70.0%
108 51.120i1-2 Quality of Care: Accidents 25 24 -4.0%
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Quality of Life
TagRegulation Number
Standard FY11 FY12 % change
67 51.100a/b Quality of Life: Dignity
10 11 +10.0%
72 51.100g1 Quality of Life: Patient Activities
10 7 -30.0%
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Dietary
TagRegulation Number
Standard FY11 FY12 % change
123 51.140d Food 18 1 -94.4%
127 51.140h Sanitary Conditions
11 3 -72.7%
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Recognition Update
New State Veterans Homes
06/29/2012 Tyler, TX 100-Bed NHC
07/12/2012 Tucson, AZ 120-Bed NHC
Pell City, AL 174-Bed NHC, 80-Bed DOM
Black Mountain, NC 100-Bed NHC
Changes to Existing State Veterans Homes
03/09/2012 Marshalltown, IA 180-Bed Replacement
03/22/2012 Bangor, ME New Therapy Unit and Transitional Wing
08/12/2012 Milford, DE 30-Bed Addition
08/02/2012 Charlotte Hall, MD Converted 8 DOM beds to NHC
10/25/2012 Spring City, PA 120-Bed NHC Replacement
08/23/2012 Minneapolis, MN 100-Bed NHC Replacement 35-Participant ADHC
02/01/2013 Scranton, PA Converted 12 DOM beds to NHC
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Take Away
• SVHs hard working to secure Veterans Safety
• Relationship between SVHs and VA is important
• Moving Forward