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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.
+ [email protected] orcall212-385-0355 ifyouwouldliketo…
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nSignupforournewsletterandactionalerts.
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Youcanalso…
[email protected]/ltccc.
[email protected]/LTCconsumer.
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Questions?Comments?
