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ThisprogramismadepossiblybythegeneroussupportoftheNYStateHealthFoundation

TheNewSurveyProcessforNursingHomesPresentedbyRichardMollot

LongTermCareCommunityCoalition

www.nursinghome411.org

+ WhatistheLongTermCareCommunityCoalition?

n LTCCC:Nonprofitorganizationdedicatedtoimprovingcare&qualityoflifefortheelderly&adultdisabledinlongtermcare(LTC).HometotheHudsonValleyLTCOmbudsmanProgram.

n Ourfocus:Peoplewholiveinnursinghomes&assistedliving.

n Whatwedo:n PolicyanalysisandsystemsadvocacyinNYS&nationally;n Educationofconsumersandfamilies,LTCOmbudsmenandother

stakeholders.

n CoalitionmembersincludeseveralLTCOmbudsmanPrograms,theCenterforIndependenceoftheDisabled,AARPNY,severalAlzheimer’sAssociationchapters,othersenioranddisabledorganizations.Alsoindividuals,includingombudsmen,whojoininourmissiontoprotectresidents.

n RichardMollot:JoinedLTCCCin2002.Executivedirectorsince2005.

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+ WhatWillWeBeTalkingAboutTODAY?3

nBriefBackground:

OverviewoftheNursingHomeSystem

nFocus:

TheNew NursingHomeSurvey(Inspection)System

+ TheNursingHomeSysteminaNutshelln VirtuallyallnursinghomesparticipateinMedicaidand/orMedicare.

n InordertoparticipateinMedicaid/Medicare,afacilityagreestomeetthestandardsprovidedforinthefederalNursingHomeReformLaw.

n Statesmayhaveadditional protections,butnostatecanhavelessprotections.

n Federalprotectionsareforallresidentsinafacility,whethertheircareispaidforbyMedicare,Medicaidorprivatepay.

n Thefederalagency,CMS,contractswiththestateDOHtoensurethatresidentsareprotectedandreceivetheservicestheyneedanddeserve.

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+n Thefederallawrequiresthatevery nursinghomeresidentisprovidedthecareandqualityoflifeservicessufficienttoattainandmaintainherhighestpracticablephysical,emotional&socialwell-being.

n Thelawemphasizesindividualized, patient-centeredcare.

n Importantly,thelawlaysoutspecificresidentrights,fromgoodcareandmonitoringtoaqualityoflifethatmaximizeschoice,dignity&autonomy.

n Thelawpassedin1987.Regulatorystandardscameoutin1991.

5TheNursingHomeReformLaw

+ What IsHappeningNow?Forthefirsttimein25years,thefederalregulatorysystemhasbeensignificantlyrevisedandupdated.

Thiswillaffecteveryaspectofcare&qualityoflife.

n AlloftheRegulations arechanging.For25yearseveryone– nursinghomes,surveyors,ombudsmenandadvocates– knewwhattheruleswereandwheretofindthem.Thatentirestructurehaschanged.

n AlloftheGuidelines havechanged. Theguidelinesdetailwhatisexpectedofnursinghomesinrelationtoeachstandard– whattheyaresupposedtodoandhowtheyaresupposetodoit.

n Thenation’sSurveySystemhaschanged.AsofNovember2017,allstatesurveyagencieswillbeutilizinganewsurveyprocess.

n TheF-tagsystem,usedbynursinghomeinspectors,haschanged. Whenasurveyoridentifiesaproblemincareorlivingconditionsinanursinghome,shecitesthenursinghomeusingasystemcalled“F-tags”– numbersthatcorrelatewiththeregulatoryrequirements.

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+ WhyisCMSChangingtheLTCSurveyProcess?

n Twodifferentsurveyprocessesexistedtoreviewforanursinghome’scompliancewiththeRequirementsofnursinghomecare(TraditionalandQIS)

n Strengthsandweaknesseshavebeenidentifiedintheefficiencyandeffectivenessofbothsurveyprocesses.

n Thetwoprocessesappearedtoidentifyslightlydifferentqualityofcare/qualityoflifeissues.

n CMSsetouttobuildonthebestofboththeTraditionalandQISprocessestoestablishasinglenationwidesurveyprocess.

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+ GoalsoftheNewProcess

nSamesurveyforentirecountry

nCombinestrengthsfromTraditional&QIS

nAddnewinnovativeapproaches

nMoreeffectiveandefficient

nMoreresident-centered

nImprovebalancebetweenstructureandsurveyorautonomy

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+ WhatisintheNewSurveyProcess?Basicchangesinclude:

n Automationofsurveyortasks

n Changesinhowresidentsareselectedforsamplingbysurveyors

n Changesinoff-sitevson-sitesurveyoractivities

n Changestoexpectedactivitieswhensurveyorsenterandtourfacility

n Changestosurveystructure

n Changestoexpectationsforengagingresidentcouncil

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+ HowWillStateSurveyorsKnowWhattoDo?Thereweremandatory,live,computer-basedtrainingsforallstatesurveyorsoverthesummerof2017.

Inaddition,CMSisproviding:

n Computer-BasedTrainingModules– Availableon-demand

nNationalCallsandQ&As– Summer/Fall2017

n AccesstoSurveyorTrainingMaterials(RO/SAmanagementwebinar)

n VideosonHighlightsoftheInterpretiveGuidance

n TrainingToolsaccesstoSurveyFormsandCE(CriticalElement)Pathways

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+ OverviewoftheNewSurveyProcess

Threeparts:

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+ InitialPoolProcessResidentsamplesizebasedonfacilitycensus:n70%offsiteselectedn30%selectedonsitebythesurveyteam:

o Vulnerableresidentswhoaredependentonstaffo NewAdmissions(within30days)o ComplaintsorFRI(FacilityReportedIncidents)o Identifiedconcern(anyresidentwhohasasignificantconcernbutdoesnotfallintoanyoftheabovesub-groups)

Whyisthisimportant?Toaddressconcernsthat,toooften,residents&familiesarenotspokentoandhavelittleinputduringtheannualsurvey.

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Day1ofSurvey:Spentconductingobservations,interviews,andalimitedrecordreviewfortheresidentsintheinitialpool.

+ SampleSelection&Investigation 13

Day2ofSurvey&Beyond:“[T]heremainderofthesurveyisspentinvestigatingallconcernsrequiringfurtherinvestigationfortheresidentsinthesample.Facilitytasksandclosed-recordinvestigationswillalsobeconducted.”

+ SampleSelection:nBasedonresidentcensusnThesurveyteamshould“includeanyresidentwhohasapotentialharmidentified”

nPrioritizeusingsamplingconsiderations:§ Replacedischargedresidentsselectedoffsitewiththoseselectedonsite§ Canreplaceresidentsselectedoffsite withrationale§ Harm,SQCifsuspected,IJifidentified§ AbuseConcern§ Transmissionbasedprecautions§ AllMDSindicatorareasifnotalreadyincluded.

nSampleincludesUnnecessaryMedicationReview:§ Considersallpsychotropicmedications,insulin,anticoagulants,opioids,

diureticsandantibiotics[Someexceptions,suchasforresidentswithschizophrenia.]

§ Considersadverseconsequences,includingfalls,weightloss,andsedation.

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+ RelevantDetailsoftheNewSurvey…

OffsitePreparation&Review:

nFacilitydatatoidentifypatternsofrepeatdeficiencies

n ResultsofthelastStandardsurvey

nComplaintssincethelastsurvey,includingactivecomplaints

nFacilityreportedincidents

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+ RelevantDetailsoftheNewSurvey…

MandatoryTasksfortheSurveyTeam:

nDining

n InfectionControl

n SkilledNursingFacility(SNF)BeneficiaryProtectionNotificationReview

nResidentCouncilMeeting

nKitchen

nMedicationadministrationandstorage

n Sufficientandcompetentnursestaffing

nQAA/QAPI

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+ FacilityCompletes&ProvidestoSurveyTeama“FacilityMatrix”

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Note:Followingisadraftwhichmaychange.

• ResidentsAdmittedwithinthePast30days

• Alzheimer’s/Dementia• MentalIllness,DevelopmentalDisability,orIntellectualDisability&NoPASARRLevelII

• Medications– certainmedicationssuchasinsulin,anticoagulants

• FacilityAcquiredPressureUlcers(anystage):

• WorsenedPressureUlcer(s)atanystage

• ExcessiveWeightLoss

• TubeFeeding• Dehydration• PhysicalRestraints• Fall(s)• IndwellingUrinaryCatheter• Dialysis• Hospice• EndofLife/ComfortCare/PalliativeCare• Tracheostomy• Ventilator• Transmission-BasedPrecautions• Centralvenousline/Intravenoustherapy• Infections

+ FacilityCompletes&ProvidestoSurveyTeama“FacilityMatrix”

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Note:Followingisadraftwhichmaychange.

+ ComponentsofResidentInterview:Surveyorsmustcompleteafullobservation,interview,andlimitedrecordreviewforeachresidentincludedintheinitialpool.n Screeningtoseeifresidentisinterviewablen Suggestedquestionsareavailable,butsurveyorshavediscretionn However,allcareareasshouldbeaddressedn Careareascoverqualityoflife,residentrights&qualityofcareScenariofromCMSsurveyortraining:Foranyconcernexpressedbytheresident,youwillaskadditionalquestionsuntilyoucandeterminewhethertheconcerncanberuledoutorneedstobeinvestigatedfurther,whichmeansyouthinktheremaybedeficientpractice.Forexample,iftheresidentsaystheyhadanissuewiththeirroommatebutthefacilityaddressedtheconcerntotheirsatisfaction,youwouldnotneedtoinvestigatefurther;conversely,youwouldwanttoinvestigateaconcerniftheresidentsaystheyhavelostweightrecentlybecauseoftheirloosedenturesunaddressedbythefacility.

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Interviewsare

expectedtotakeabout20minutes.

+ ResidentRepresentativeorFamilyInterview:

nTobedoneifresidentisnot interviewablenTheindividualshouldbefamiliarwiththeresident’scare

nThegoalistocompleteatleastthreeinterviewsfortheteamonthefirstday

NoteinCMSsurveyortraining:Ifyouareunabletocompletethreerepresentative/familyinterviewsduringtheinitialpoolprocess,youhaveuntiltheendofthesurveytocompletethem;however,theteamshouldcompletetheinterviewsearlyenoughinthesurveytohaveenoughtimetofollowuponanyconcerns.

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+ LimitedReviewofResidentRecords:Afterobservationsandinterviewsarecompleted,surveyorswillcompletea“limitedrecordreviewforcertainconditions.”Theintentistoensurethatthesurveyteamspendsthemajorityofitstimeoninterviewandobservation.

§ Forallresidentsininitialpool:abriefreviewfor“advancedirectivesortoconfirmorclarifyspecificinformationbasedonyourinterviewsandobservations,suchasconfirmingthepresenceofapressureulcer.”

§ Foranyresidentnotinterviewed:reviewrelevantcareareasintheresident’srecord.Example:“ifaresidentisnotinterviewable… reviewtherecordforpressureulcers,infections,andelopements.”

§ “Foranyresidentintheinitialpoolwhoisreceivinginsulin,ananticoagulant,oranantipsychoticwithadiagnosisofAlzheimer’sordementia,orifaresidenthasanappropriatediagnosisbutisnotreceivingPASARRLevelIIservices,…reviewtherecordtoconfirmtheinformation.”

§ Fornewlyadmittedresidents:reviewforhigh-riskmedications.

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+ Dining:Surveyorsarerequired toobservethefirstscheduledfullmealthattakesplaceinthefacility.

n Expectedtohavesurveyorscoveringalldiningareasinthefacilityandroomtrays.Iftherearemorediningareasthansurveyors,prioritizethediningareaswiththemostdependentresidents.

nObserveenoughofthediningexperiencetoadequatelyidentifyconcerns.

n Iffeasible,observethemealforinitialpoolresidentswhohaveweightloss.

n Ifconcernsareidentified,observeasubsequentmeal.

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+ Investigations:nMajorityoftimeshouldbespentobserving andinterviewing, withrelevantreviewofrecordtocompleteinvestigation

nUseAppendixPPandcriticalelements(CE)pathways

InstructionsfromCMSonCEpathways:Thepathwaysincludeguidanceontheareas(e.g.,MDS,physician’sordersandcareplan)thatshouldbereviewedinitiallytohelpguideyourobservationsandinterviews.Thepathwaysincludeobservation,interview,andrecordreviewinvestigativeprobesforanumberofcareareas,includingpressureulcersanddialysis.

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“TheCEsarecriticalcomponentsofcare—theycoverprovisionofcareandservices,aswellasthefacilityassessmentandcareplanning.”

+ Medication§ Recommendbeingdonebynurseorpharmacist§ Ifpossible,observemedicationadministrationforasampledresidentwhosemedicationregimenisbeingreviewed

§ Otherwise,observemedicationsforanyresidenttowhomthenurseisreadytoadministermeds

§ Observeduringdifferentunitsandshifts§ Observe25medicationopportunities§ Ifobservingadministrationofcontrolledmedications,reconcilethecountofthemedication&ensurethemedicationshaven’texpired

§ Observehalfofmedicationstoragerooms+halfofmedicationcarts.Ifissueidentified?– Expandsample.

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+ ResidentCouncilInterview§ ConductagroupinterviewwithactivemembersoftheResidentCouncil

§ Interviewshouldoccurearlyenoughinthesurveytoaffordenoughtimetoinvestigateanyconcerns

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§ interviewisfocusedonspecificareasrelatedtothefunctioningofthecouncilandafewresidentspecificareas,suchasabuseandsufficientstaffing

§ Inaddition,askthegroupaboutanyidentifiedconcernsfromthesurvey.

+ Sufficient&CompetentCareStaff

§ Itisa“mandatorytask”thatsurveyorsreviewtoensurethatfacilityhassufficientandcompetentnursestaffing

§ CMSsays…”surveyorsarealwaysconsideringwhetherstaffingissuescanbelinkedtoresidentcomplaints,orqualityoflife(QOL)andcare(QOC)concerns”

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CareStaffRequirements

SufficientNumber AppropriateTraining&Competency

+ WhenWillWeSeeTheResults? 27

CMSissuedamemoranduminNovember2017stating thatthehealthinspectionstarratingwillbefrozenforoneyear.

Memorandum Summary• Freeze Health Inspection Star Ratings: Following the implementation of the

new Long-Term Care survey process, the Centers for Medicare & Medicaid Services (CMS) plans to hold constant the current health inspection star ratings on the Nursing Home Compare (NHC) website for a period of one year, surveys occurring between November 28, 2017 and November 27, 2018.

• Findings Available: The findings from the new Long-Term Care survey process will be reported on NHC but will not yet be incorporated into the Five-Star Quality Rating System. CMS will add indicators to NHC that summarize survey findings and deficiency free survey findings.

• Methodological Changes: In early 2018, NHC health inspection star ratings will be based on the two most recent cycles of findings for standard health inspection surveys and the two most recent years of complaint inspections.

+ ThankYou!Emailinfo@ltccc.org orcall212-385-0355 ifyouwouldliketo…

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nSignupforournewsletterandactionalerts.

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