National Regulatory OverviewPDPM Intensive Sessions •Join AHCA/NCAL at the 69th Annual Convention...
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National Regulatory Overview Lyn Bentley, Vice President Quality & Regulatory Affairs September 19, 2018
Transcript of National Regulatory OverviewPDPM Intensive Sessions •Join AHCA/NCAL at the 69th Annual Convention...
National Regulatory Overview
Lyn Bentley, Vice President
Quality & Regulatory Affairs
September 19, 2018
Topics
• The new survey process
oBe prepared
• Frequently cited tags
oNation
oRegion VII
oNebraska
• Compliance tips
• Adjust your approach
Standard Surveys in NebraskaCASPER as of 8/13/2018
• 142 standard surveys ---- 65% of facilities have had a survey since October 1, 2017
Deficiency Levels for Nebraska TagsCASPER as of 8/13/2018
• 1 – B
• 73 – C
• 755 – D
• 334 – E
• 174 – F
• 31 – G
• 16 – H
• 0 – I
• 71 – J
• 26 – K
• 9 - L
CMP data for NebraskaCASPER as of 8/13/2018
• 4 per diem Total $171,992.60
• 3 per instance Total $ 28,553.25
New Survey Process
The New Survey Process
• Goal: more consistency
• Combines QIS and standard
• Critical Element Pathways
• Focus on person - centered care
• Emphasis on interviews
oPatient
oFamilies
oRepresentatives
oStaff
Three Components
• Three Components
oInitial Pool Process
oSample Selection
oInvestigation
Offsite Preparation
• Team Coordinator completes offsite preparation
Repeat deficiencies
Results of last Standard survey
Complaints
Facility Reported Incidents
Variances/waivers• Necessary documents are printed
Facility Entrance
• Team Coordinator conducts Entrance Conference Updated Entrance Conference Worksheet Updated facility matrix
• List of residents who smoke and smoking times (used Day 1)
• Number and location of medication storage rooms and carts
• List of residents for Advance Beneficiary Notices review
• Brief visit to the kitchen
• Surveyors go to pre-assigned areas
Mandatory Tasks
• Unit and facility task assignments
Kitchen
Medication administration
Medication storage
Sufficient and competent nurse staffing
QAA/QAPI (must take place at end of survey)
If triggered: Environment, Personal Funds, Resident Assessment
Needed within One Hour
• Schedule of meal times
• Schedule of Med Administration Times
• Number & location of medication storage rooms and medication carts
• Actual work schedules of LPNs & RNs
Needed within Four Hours
• Complete Matrix of residents
• Admission packet for new admissions
• Dialysis
oContracts, P&P about dialysis
oList of qualified staff to perform dialysis if applicable
oAgreements or policies & procedures for transport to & from dialysis
oDoes facility have onsite certified ESRD unit
Needed within Four Hours
• Hospice
oAgreements, P&P and
oStaff who coordinates services with hospice
• Influenza/Pneumococcal Immunization P&P
• Abuse Prohibition P&P
Needed within Four Hours
• Infection Prevention Plan, P&P, ABX stewardship program
• QAPI plan
• QAA committee information
• Facility assessment
• Description of any experimental research occurring in the facility
• Nurse staffing waivers
Needed within Four Hours
• List of rooms meeting any of the following:
oLess than required square footage
oMore than four residents to room
oBelow ground level
oNo window to the outside
oNo direct access to an exit corridor
Material needed by End of First Day
• EHRs – provide each surveyor with access to all resident EHRs
oDo not exclude anything that should be part of the resident’s medical record
oInformation how surveyors can access the EHRs outside of the conference room
oProvide completed form “Electronic Health Record (EHR) Information”
Materials needed within 24hours of entrance
• Form 671 – Facility staffing data CMS stopped collecting as of June 1, 2018
• Form 672 – completed census and condition information
• Completed form “Beneficiary Notice –Residents Discharged Within the Last Six Months”
Interviews
• Resident/Representative/Family
• Group interview with Resident Council
• Each surveyor covers all care areas
Resident Interviews
• Choices
• Activities
• Dignity
• Abuse
• Resident-to-Resident Interaction (confrontation)
• Privacy
• Accommodation of Needs (physical)
• Personal Funds
• Personal Property
Resident Interviews
• Sufficient Staffing
• Participation in Care Planning
• Community Discharge
• Environment
• Food
• Dental
• Nutrition
• Hydration
• Tube Feeding
• Vision and Hearing
• ADLs
Resident Interviews
• ADL Decline
• Catheter
• Insulin or Blood Thinner
• Respiratory Infection
• Urinary Tract Infection
• Other Infections
• Hospitalizations
• Falls
• Pain
• Pressure Ulcers
Resident Interviews
• Skin Conditions non-pressure related
• Limited Range of Motion
• Rehabilitation
• Dialysis
• Incontinence
• Constipation/Diarrhea
• Smoking
• Hospice
• Other Concerns
Representative/Family Interviews
• Same topics as Resident Interview PLUS
oNotification of Change
Resident Observations
• Surveyors also make observations about all the topics they are asking questions about
oEx: Access to call light; fresh water/drink; assistance to attend activities; if the patient wears glasses or uses a hearing aid, are they being used; if needed is patient receiving needed assistance eating or with activities; etc.
Review of Surveyor Tools
• Mapping for All Areas
Find at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html
Survey Resources – zip file
“LTSCP MappingDocument_Streamlined”
• Interview and observation surveyor tools
Top Ten Tags in Nation
as of July 30, 2018 CASPER DATA
• F 880 Infection Prevention & Control
• F 689 Free of Accident Hazards; Supervision; Devices
• F 656 Develop/Implement Comprehensive Care Plan
• F 812 Food Procurement, Store/Prepare/Serve Sanitary Conditions
• F 684 Quality of Care
Top Ten Tags in Nation, cont.as of July 30, 2018 CASPER DATA
• F 657 Care Plan Timing and Revision
• F 761 Label/Store Drugs
• F 686 Pressure Ulcers
• F 758 Psychotropics/PRN use
• F 842 Resident Records: Identifiable Information
Top Ten Tags in Region 7as of July 30, 2018 CASPER Data
• F 880 Infection Prevention & Control
• F 689 Free of Accident Hazards; Supervision; Devises
• F 812 Food Procurement, Store/Prepare/Serve Sanitary Conditions
• F 656 Develop/Implement Comprehensive Care Plan
• F 684 Quality of Care
• F 658 Services provided – Professional Standards
Top Ten Tags in Region 7, cont.as of July 30, 2018 CASPER DATA
• F 657 Care Plan Timing and Revision
• F 690 Bowel/Bladder Incontinence, Catheter, UTI
• F 686 Pressure Ulcers
• F 584 Safe, Clean/Comfortable/Homelike Environment
Top Ten Tags in NebraskaAs of July 30, 2018 CASPER Data
• F 689 Free of Accident Hazards/Supervision
• F 880 Infection Prevention & Control
• F 812 Food Procurement, Store/Prepare/Serve Sanitary Conditions
• F 656 Develop/Implement Comprehensive Care Plan
• F 609 Reporting of Alleged Violations
• F 584 Safe, Clean/Comfortable/Homelike Environment
Top Ten Tags in NebraskaAs of July 30, 2018 CASPER Data
• F 657 Care Plan Timing and Revision
• F 684 Quality of Care
• F 550 Resident Rights/Exercise of Rights
• F 755 Pharmacy Services; Procedures; Pharmacist; Records
Real outlier tag----
13th most frequently cited:
• F 923 Ventilation
F880 – Infection Prevention & Control
• Handwashing – between glove changes; during medication pass
• Cleaning reusable equipment: glucometers, lift slings
• Cleaning/disinfecting patient rooms, shower rooms, bathrooms
• Use of PPE’s
• Consistent use of facility’s infection control log
• Staff competencies – have process in place and use it!!!!
F880 – Infection Prevention & Control
• Water management plan
• Use current CDC guidelines
• Use current P&Ps – make sure everyone who needs to know about them does know about them
• Scabies and use of infection control log for patients and staff
• Communication
F689 – Free From Accident Hazards/Supervision
• Fall interventions were removed however nothing replaced those interventions
• Standard of practice:oAide left room with bed in highest position –
patient with a fall risk in bedoAide went in the bathroom to wash hands and the
door was partially shut – couldn’t observe patient
• Unsupervised smoking and no assessment for safe smoking and risk for elopement
• Causal factors for falls not determined and no interventions put in place
F609- Reporting Alleged Violations
• Failure to complete and submit results of investigation of abuse for 2 patients
• Failure to report fall after calling Adult Protective Services after a all and failure to complete and submit results of investigation
• Resident to resident altercation: failed to report incident of abuse to state
• Failure to report potential misappropriate of resident medications
F923 - Ventilation
• 41 citations in the country; 23 in Nebraska
• Bathroom ventilation systems were not working
• Resident rooms had no working ventilation systems
F812 – Food Procurement, Store; Prepare; Serve; Sanitary
• Runny eggs
oProcurement
oServing
• Containers in refrigerator: contents not identified; no date; not consistent with facility P&Ps
• Hand washing/gloves
• Not reporting illness to Food Service Director (person in charge)
F812 – Food Procurement, Store; Prepare; Serve; Sanitary
• Roaches
• Temperatures
oFood
oDishwasher
• Sanitizing cleaner – mixture
Adjusting the Approach
• Consideration
oIncreased amount of time surveyors are talking to patients/families/staff
• Approach
oTake a walk and ask questions
oUse observation and interview questions the surveyors will use
oAsk your staff how they would “fix” a problem
Adjusting the Approach
• Audits
oInternal
oPeer
oExpectations
• Come into your center and pretend you have never been here before
oSights
oSounds
oSmells
Strategies for Survey and Compliance
• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html
• LTC Survey Pathways
• LTCSP Initial Pool Care Areas
• LTCSP Procedure Guide (eff. 8/5/2018)
• LTC Survey FAQs (updated 7/11/2018)
Resources for New Requirements of
Participation
www.educate.ahcancal.org
ROP Playbook and Overview Checklist
PDPM Intensive Sessions • Join AHCA/NCAL at the 69th Annual Convention &
Expo for the most up-to-date payment reform information
• Two opportunities to attend an intensive session:• Sunday, October 7 – 1:00pm – 5:00pm • Wednesday, October 10 – 10:30am – 3:30pm
(repeat of Sunday session)
• Early bird registration ends July 20
• Advance registration ends September 21
• For more information and to register visit www.ahcaconvention.com or www.ncalconvention.com
Contact Information
• Lyn Bentley, MSW
• Vice-President, Quality & Regulatory Affairs
• 202-898-6304
