Objectives Provide information resources Describe the 2567 and - - PDF document

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Objectives Provide information resources Describe the 2567 and - - PDF document

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06/17/2018 THE LTC SURVEY PROCESS Speaker: Office of Long Term Care Facilities Licensure Unit Public Health Division 402-471-3324 Objectives Provide information resources Describe the 2567 and identify the elements and

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SLIDE 1

06/17/2018 1

THE LTC SURVEY PROCESS Speaker:

Office of Long Term Care Facilities Licensure Unit – Public Health Division 402-471-3324

Objectives

  • Provide information resources
  • Describe the 2567 and identify the elements and

information contained

  • Identify the steps in the LTC survey process
  • Describe how the information obtained is used in

making compliance determinations

  • Identify the components of an acceptable POC

and the steps in the process for submitting submission

  • Discuss the dispute process

THE LTC SURVEY PROCESS AND RESOURCES

  • Medicare.Gov

– Appendix PP – Memos (S&C Letters)

  • qtso.com

– LTCSP directions – LTCSP forms

  • CMS.gov/Nursing Homes

– LTCSP forms

  • DHHS.ne.gov

– Regulations – Reporting forms

  • Contacts:

– Dan Taylor

  • Daniel.taylor@Nebraska.gov
  • 402-471-3324
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SLIDE 2

06/17/2018 2

Tag Number Scope and Severity Licensure Reference Number Deficient Practice Statement Evidence

Licensure Inspection

  • At Least Once Every 5 Years
  • 25% Sample Yearly

Survey Types

  • Standard/Annual

Alternate Special Focused

  • Partial/Complaint
  • Extended
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SLIDE 3

06/17/2018 3

Off-Site Preparation

  • CASPER 3

65 55 55 65 10 45 10 55

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SLIDE 4

06/17/2018 4

Off-Site Preparation

  • MDS information
  • Team Leader assigns units
  • CASPER 3
  • Waivers
  • Complaints
  • Ombudsman Information
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SLIDE 5

06/17/2018 5 Entrance Tasks

  • Introductions
  • Request the following Information:
  • Alphabetical listing of residents residing in

the facility.

  • Matrix for New Admissions
  • Census Number
  • Residents who smoke

Entrance Tasks

  • Entrance Conference Worksheet
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SLIDE 6

06/17/2018 6

Entrance Conference Worksheet Entrance Conference Worksheet Entrance Conference Worksheet

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SLIDE 7

06/17/2018 7

Entrance Conference Worksheet Entrance Conference Worksheet Entrance Conference Worksheet

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SLIDE 8

06/17/2018 8

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SLIDE 9

06/17/2018 9

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SLIDE 10

06/17/2018 10

Sample size Grid Initial Pool

  • Reviewed through
  • Resident Interview
  • Resident Observation
  • Chart Review
  • 3 Resident

Representative Interviews per team

  • Areas Reviewed:

– ADLs – Nutrition – Drug Use – Elimination/Incontinence – Resident Room – Oral Health – Quality of Care – Quality of Life – Skin Care

Resident Observation

  • Activities
  • Dignity
  • Abuse
  • Privacy
  • Accommodations of

Needs

  • Language/Communication
  • Mood/Behavior
  • Restraints
  • Accident Hazards
  • Unsafe Wandering or

Elopement

  • Call lights
  • Resident room
  • Dental
  • Nutrition
  • Edema
  • Hydration
  • Tube Feeding
  • Vision/Hearing
  • ADLs
  • Catheter
  • Psych Meds
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SLIDE 11

06/17/2018 11

Resident Observation

  • Infections
  • Oxygen
  • Positioning
  • Falls
  • Pain
  • Pressure Ulcers
  • Skin Conditions-Other
  • ROM-Limited
  • Hospice
  • Vent/Trach
  • Bowel/Bladder

Incontinence

  • Smoking
  • Other Concerns

Resident Interview

  • Choices
  • Activities
  • Dignity
  • Abuse
  • Resident-to-Resident

Interaction

  • Privacy
  • Accommodation of

Needs (Physical Space)

  • Personal funds
  • Personal Property
  • Sufficient Staffing
  • Care Plan

Participation

  • Community Discharge
  • Environment
  • Food
  • Dental
  • Nutrition
  • Hydration
  • Tube Feeding
  • Vision/Hearing
  • ADLs

Resident Interview

  • ADL Decline
  • Catheter
  • Insulin/Blood Thinner
  • Infections
  • Hospitalizations
  • Falls
  • Pain
  • Pressure Ulcers
  • Skin Conditions-Other
  • ROM-Limited
  • Rehab
  • Dialysis
  • Bowel/Bladder

Incontinence

  • Constipation/Diarrhea
  • Smoking
  • Hospice
  • Other Concerns
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SLIDE 12

06/17/2018 12

Family Interview

  • 3 in each Facility
  • In person or phone
  • Most knowledge

about resident/care

  • 2 attempts

Family Interview

  • Same as for resident:

– Choices – Activities – Dignity – Abuse – Resident-to-Resident Interaction – Privacy – Accommodation of Needs (Physical Space) – Personal funds – Personal Property – Sufficient Staffing – Care Plan Participation – Community Discharge – Environment – Food – Dental – Nutrition – Hydration – Tube Feeding – Vision/Hearing – ADLs

Family Interview

  • ADL Decline
  • Catheter
  • Insulin/Blood Thinner
  • Infections
  • Hospitalizations
  • Falls
  • Pain
  • Pressure Ulcers
  • Skin Conditions-Other
  • ROM-Limited
  • Rehab
  • Dialysis
  • Bowel/Bladder

Incontinence

  • Constipation/Diarrhea
  • Smoking
  • Hospice
  • Other Concerns
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SLIDE 13

06/17/2018 13

Initial Pool Limited Record Review

  • For Any Resident Marked:
  • Non-Interviewable
  • Refused
  • Unavailable
  • Out of Facility
  • Review:

– Pressure Ulcers – Dialysis – Infections – Nutrition – Falls – ADL Decline – Bowel/Bladder

  • Low Risk

– Hospitalization – Elopement – Change of Condition

Initial Pool Limited Record Review

  • For All Residents

Reviewed:

– Advance Directives – Other – If Indicator Present Review For:

  • Insulin
  • Anticoagulant
  • Antipsychotic with

Alzheimer’s or Dementia

  • PASARR (LevelI)
  • For New Admissions

Reviewed-Add

– High Risk Meds – Diagnoses – Hospice

Dining – First Full Meal

  • Dining – observe first full

meal

Cover all dining rooms and room trays Observe enough to adequately identify concerns If feasible, observe initial pool residents with weight loss If concerns identified,

  • bserve another meal
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SLIDE 14

06/17/2018 14

Team Meetings

  • Brief meeting at the end of

each day

Workload Coverage Concern Synchronize/share data (if needed)

Sample Selection

  • Select sample based on:

Offsite selection Harm, SQC if suspected, IJ if identified Abuse Concern Identified concerns during Initial Pool Sample Process Unnecessary Medication Review

  • In addition, at least 3 closed record review

Unexpected death Hospitalization Community discharge

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SLIDE 15

06/17/2018 15

Sample Selection Unnecessary Medication Review

  • System selects five residents

for full medication review

  • Based on observation,

interview, record review, and MDS

  • Broad range of high-risk

medications and adverse consequences

Sample size Grid

Resident Investigation General Guidelines

  • Conduct investigations for all concerns that warrant

further investigation for sampled residents using:

– Multiple observations, as required – Interview resident/representative/staff – Record review – Critical Element (CE) pathways

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SLIDE 16

06/17/2018 16

Critical Element Pathways (CE)

  • Components:

– Assessment – Care Planning

  • Develop
  • Revise

– Provision of Care

  • Investigations:

– Observations – Resident/Family Interviews – Staff Interviews – Record Reviews

Facility Task Mandatory

  • Nine Mandatory Tasks

– Dining – Infection Control – SNF Beneficiary – Kitchen – Medication – Med Storage – Resident Council – Nurse Staffing – QAA/QAPI

Dining Observations

  • First full meal

– All dining areas – Room trays

  • Focus on:

– Staff Availability – Positive Experience – Positioning – Interactions – Furnishings

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SLIDE 17

06/17/2018 17

Infection Control

  • Hand washing
  • Glove use
  • Precautions
  • Isolation
  • Laundry Handling
  • Immunization
  • Communicable

Disease

SNF Beneficiary Protection Notification Review

  • SNF Beneficiary Protection Notification Rights

– 3 notices reviewed – Facility given worksheets to complete

  • Medicaid Only Facility Not Given The

Review

Kitchen/Food Service

  • Initial tour
  • Focus on:

– General Sanitation – Cleanliness – Food-borne Illness prevention

  • Meal prep
  • bservation
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SLIDE 18

06/17/2018 18

Kitchen/Food Service

  • Food Storage
  • Food Preparation
  • Sanitization

Medication Pass

Actual Preparation and Administration 25 Opportunities

Medication Pass

Reconcile Orders 25 Opportunities Multiple Individuals Multiple Times Multiple Routes

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SLIDE 19

06/17/2018 19

Medication Storage

  • Any surveyor can do Task
  • Half Med Storage Rooms reviewed
  • Half Med Carts reviewed

Resident Council Meeting

  • Completed with 12 or so residents
  • Staff can not attend
  • Questions for meeting about:

– How often meet – Room availability to meet – Room size appropriate – Grievance procedure – Staff Treatment – Facility Rules

Sufficient and Competent Nurse Staffing

  • All Surveyors conduct
  • Compliance based on Care
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SLIDE 20

06/17/2018 20

Quality Assessment and Assurance and Quality Assurance and Performance Improvement

  • Committee

Members

  • Leader
  • Frequency of

Meeting

Facility Tasks Triggered

  • Four Triggered Tasks

– Personal Funds – Environment – Resident Assessment – Extended Survey

Personal Funds

  • Notification
  • Accounting

Process

– Interest bearing – Pooled/Separate – Reconciliation – Statements

  • Charges for

Medicare/Medicaid

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SLIDE 21

06/17/2018 21

Environmental Observations

  • Required Postings
  • Resident Areas

– Pests/Cleanliness – Ventilation/Temperature – Handrails/Furnishings – Lighting/Sound

  • Bathing Areas
  • Water temperatures
  • Care Equipment
  • Laundry
  • Disaster Planning

Resident Assessment

  • Concerns with:

– MDS Completion – MDS submission – MDS Discrepancy

Extended Survey

  • SQC
  • Due within 14

Days after survey

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SLIDE 22

06/17/2018 22

Potential Citations

  • Investigations

Complete

  • Concerns

Shared/Data Sharing

  • Team Discussion

EXIT CONFERENCE

  • Daily Discussions

– Once issue resolved

  • Exit Conference

– Public

  • Concerns resolved

shared

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SLIDE 23

06/17/2018 23

Immediate Jeopardy

  • Based on:

– Harm – Culpability – Immediacy

  • Results in:

– Abatement – 23 day termination

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SLIDE 24

06/17/2018 24

Remedy Categories

Category 2 (Cat. 2) Denial of Payment for New Admissions Denial of Payment for All Individuals imposed by HCFA; and/or Civil Money penalties; $50 - $3,000/day $1,000 - $10,000/ instance Category 1 (Cat. 1) Directed Plan of Correction Sate Monitoring; and/or Directed In-Service Training Category 3 (Cat. 3)

  • Temp. Mgmt.

Termination Optional: Civil Money Penalties 3,050-$10,000/day $1,000-$10,000/instance

  • Probation

Licensure Only:

  • Fines
  • Prohibition of Admission
  • Partial
  • Full
  • Limitation of Care
  • Revocation

Life Safety Code

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SLIDE 25

06/17/2018 25

Access to ePOC ePOC Submission

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SLIDE 26

06/17/2018 26

Acceptable Plan of Correction

  • Corrective Action for:

– Cited – Potentially affected

Acceptable Plan of Correction

  • Corrective Action for:

– Cited – Potentially affected

  • Systemic change

Acceptable Plan of Correction

  • Corrective Action for:

– Cited – Potentially affected

  • Systemic change
  • Monitoring System

– Method – Frequency – Person Responsible

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SLIDE 27

06/17/2018 27

Acceptable Plan of Correction

  • Corrective Action for:

– Cited – Potentially affected

  • Systemic change
  • Monitoring System

– Method – Frequency – Person Responsible

  • Compliance Date

Revisit and Correction

  • Determine compliance status
  • Type

– Administrative/Paper – On-site

  • Number allowed

– 1st within 60 days – 2nd within 90 days – 3rd CMS RO approval – 4th CMS CO approval

  • Termination at 6 months

Dispute Process

Informal Dispute Resolution/Conference

  • Certification – IDR
  • Licensure – IC
  • Type

– In person – Telephonic – Written

  • Informal – no attorney
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SLIDE 28

06/17/2018 28 Dispute Process

Administrative Hearing

  • Certification

– Completed by RO – Only monetary imposed

  • Licensure

– State attorneys – Any deficiency – Not impact website

Internet Access

  • 2567
  • POC
  • Letters

– Federal Action – State Action

  • http://dhhs.ne.gov/pu

blichealth/Pages/lis_li sindex.aspx

THE END