2015 survey trends and systems review 2015 survey trends and systems review nyshfa audio conference...

2015 Survey Trends and Systems Review

NYSHFA Audio Conference

Presenters:Linda M. Elizaitis, President, CMS Compliance Group James Houle, Life Safety Consultant, CMS Compliance Group

CMS Compliance Group, Inc.T: 631.692.4422

E. [email protected]

W. www.cmscompliancegroup.com

This presentation is property of CMS Compliance Group, Inc. Reuse or distribution without prior written authorization by CMS Compliance Group, Inc. is strictly forbidden.

mailto:[email protected]

http://www.cmscompliancegroup.com/

2015 Top 10 Deficiencies – National vs NYS

www.cmscompliancegroup.com 2

2015 National Top 10 Deficiencies 2015 NYS Top 10 Deficiencies1. F-441 Infection Control, Prevent Spread, Linens 1. F-371 Food Procurement, Store/Prepare/Serve –

Sanitary

2. F-371 Food Procurement, Store/Prepare/Serve - Sanitary

2. F-441 Infection Control, Prevent Spread, Linens

3. F-323 Free of Accident Hazards/Supervision/ Devices


4. F-309 Provide Care/Services for Highest Well Being

4. F-225* Investigate/Report Allegations/ Individuals

5. F-431* Drug Records, Label/Store Drugs & Biologicals

5. F-279 Develop Comprehensive Care Plans

6. F-329 Drug Regimen is Free From Unnecessary Drugs

6. F-282 Services by Qualified Persons/ Per Care Plan

7. F-279 Develop Comprehensive Care Plans 7. F-280* Right to Participate in Care Planning – Revise CP

8. F-514* Resident Records – Complete/ Accurate/ Accessible

8. F-241 Dignity and Respect of Individuality

9. F-241 Dignity and Respect of Individuality 9. F-309 Provide Care/Services for Highest Well Being

10. F-282 Services by Qualified Persons/ Per Care Plan

10. F-329 Drug Regimen is Free From Unnecessary Drugs

NYS 2014 vs 2015 Top 10 Deficiencies2014 NYS Top 10 Deficiencies 2015 NYS Top 10 Deficiencies

1. F-441 Infection Control, Prevent Spread, Linens 1. F-371 Food Procurement, Store/Prepare/Serve – Sanitary (↑)


2. F-441 Infection Control, Prevent Spread, Linens (↓)


3. F-323 Free of Accident Hazards/Supervision/ Devices (↔)

4. F-282 Services by Qualified Persons/Per Care Plan

4. F-225 Investigate/Report Allegations/Individuals (↑)

5. F-279 Develop Comprehensive Care Plans 5. F-279 Develop Comprehensive Care Plans (↔)

6. F-309 Provide Care/Services for Highest Well Being

6. F-282 Services by Qualified Persons/ Per Care Plan (↓)

7. F-253 Housekeeping and Maintenance Services 7. F-280 Right to Participate in Care Planning – Revise CP (↑)

8. F-280 Right to Participate in Care Planning – Revise CP

8. F-241 Dignity and Respect of Individuality (NEW)

9. F-281 Services Provided Meet Professional Standards

9. F-309 Provide Care/Services for Highest Well Being (↓)

10. F-225 Investigate/Report Allegations/Individuals 10. F-329* Drug Regimen is Free From Unnecessary Drugs (NEW)

3

Top 10 Deficiencies – Buffalo


2. F-441 Infection Control, Prevent Spread, Linens3. F-280 Right to Participate in Care Planning – Revise CP4. F-241 Dignity and Respect of Individuality5. F-309 Provide Care/Services for Highest Well Being6. F-323 Free of Accident Hazards/Supervision/Devices7. F-157* Notify of Changes (Injury/Decline/Room, etc)8. F-242* Self Determination – Right to Make Choices9. F-279 Develop Comprehensive Care Plans10. F-312* ADL Care Provided for Dependent Residents


Top 10 Deficiencies - Rochester

1. F-280 Right to Participate in Care Planning – Revise CP2. F-225 Investigate/Report Allegations/Individuals3. F-312* ADL Care Provided for Dependent Residents 4. F-323 Free of Accident Hazards/Supervision/Devices5. F-441 Infection Control, Prevent Spread, Linens6. F-329 Drug Regimen is Free From Unnecessary Drugs7. F-431* Drug Records, Label/Store Drugs & Biologicals8. F-241 Dignity and Respect of Individuality9. F-282 Services by Qualified Persons/ Per Care Plan10. F-371 Food Procurement, Store/Prepare/Serve -

Sanitary


Top 10 Deficiencies – Capital District

1. F-371 Food Procurement, Store/Prepare/Serve - Sanitary2. F-441 Infection Control, Prevent Spread, Linens3. F-241 Dignity and Respect of Individuality4. F-309 Provide Care/Services for Highest Well Being5. F-225 Investigate/Report Allegations/Individuals6. F-514* Resident Records – Complete/Accurate/ Accessible7. F-282 Services by Qualified Persons/Per Care Plan8. F-323 Free of Accident Hazards/Supervision/Devices9. F-279 Develop Comprehensive Care Plans10. (Tie) F-253* Housekeeping and Maintenance Services and F-

314* Treatment/Svcs to Prevent/Heal Pressure Ulcers


Top 10 Deficiencies – Central NY

1. F-225 Investigate/Report Allegations/Individuals2. F-371 Food Procurement, Store/Prepare/ Serve -

Sanitary3. F-309 Provide Care/Services for Highest Well Being4. F-441 Infection Control, Prevent Spread, Linens5. F-314* Treatment/Svcs to Prevent/Heal Pressure Ulcers6. F-323 Free of Accident Hazards/Supervision/Devices7. F-279 Develop Comprehensive Care Plans 8. F-241 Dignity and Respect of Individuality9. F-253* Housekeeping and Maintenance Services10. F-325* Maintain Nutritional Status Unless Unavoidable


Top 10 Deficiencies – Hudson Valley

1. F-279 Develop Comprehensive Care Plans2. F-282 Services by Qualified Persons/Per Care Plan3. F-371 Food Procurement, Store/Prepare/Serve - Sanitary4. F-280 – Right to Participated in Care Planning – Revise CP5. F-315* No Catheter, Prevent UTI, Restore Bladder6. F-329 Drug Regimen is Free From Unnecessary Drugs7. F-431* Drug Records, Label/Store Drugs & Biologicals8. (3-way tie at #8/#9/#10) F-309 Provide Care/Services for

Highest Well Being9. F-441 Infection Control, Prevent Spread, Linens10. F-456* Essential Equipment, Safe Operating Condition


Top 10 Deficiencies - NYC


2. F-282 Services by Qualified Persons/Per Care Plan3. F-431* Drug Records, Label/Store Drugs & Biologicals4. F-441 Infection Control, Prevent Spread, Linens5. F-253* Housekeeping and Maintenance Services6. F-279 Develop Comprehensive Care Plans7. F-280 Right to Participate in Care Planning – Revise CP8. F-281* Services Provided Meet Professional Standards9. F-329 Drug Regimen is Free From Unnecessary Drugs10. F-323 Free of Accident Hazards/Supervision/Devices


Top 10 Deficiencies – Long Island

1. F-282 – Services by Qualified Persons/Per Care Plan2. F-280 Right to Participate in Care Planning – Revise CP3. F-329 Drug Regimen is Free From Unnecessary Drugs4. F-253* Housekeeping and Maintenance Services5. F-441 Infection Control, Prevent Spread, Linens6. F-514* Resident Records – Complete/Accurate/

Accessible7. F-323 Free of Accident Hazards/Supervision/Devices8. F-241 Dignity and Respect of Individuality 9. F-371 Food Procurement, Store/Prepare/Serve -

Sanitary10. F-431* Drug Records, Label/Store Drugs & Biologicals


Upstate Area Offices Top Cited Deficiencies

Buffalo•F-371•F-441•F-280•F-241•F-309•F-323•F-157*•F-242*•F-279•F-312*

Rochester•F-280•F-225•F-312*•F-323•F-441•F-329•F-431*•F-241•F-282•F-371

Capital•F-371•F-441•F-241•F-309•F-225•F-514*•F-282•F-323•F-279•F-253* / F-314*

Central•F-225•F-371•F-309•F-441•F-314*•F-323•F-279•F-241•F-253*•F-325


Downstate Area Offices Top Cited Deficiencies

Hudson Valley

•F-279•F-282•F-371•F-280•F-315*•F-329•F-431*•F-309•F-441•(Tie) F-456* / F-309 / F-441

NYC•F-371•F-282•F-431*•F-441•F-253•F-279•F-280•F-281*•F-329•F-323

Long Island•F-282•F-280•F-329•F-253*•F-441•F-514*•F-323•F-241•F-371•F-431*


#1 F-371 Food Procurement, Store/Prepare/ Serve- Sanitary

Citations◦ CNA observed taking bread out of

wrapper with bare hands and buttering, then touching trays, resident’s hair and then assisted another resident with unwrapping sandwich and touching bread, breaking it up and putting into soup (S/S: D)

◦ Fish cooked for previous day’s meal observed in walk-in but no cooling/ reheating logs to show food was properly cooled (S/S: E)

◦ Undated spoiled milk in activities room, food not maintained at hot holding temps, disposable ware/napkins stored on floor (S/S: F)


F-371

Systems to Review: Food Procurement, Store/Prepare/ Serve- Sanitary

Kitchen Cleaning

Cooling

Remote Kitchens

Refrigerator Temperatures

Holding food temperatures


#2 F-441 Infection Control, Prevent Spread, Linens

Facility cat observed walking on dining table while residents waited for meals and the table was not disinfected prior to meal service (S/S: D)

Shower trolleys on multiple units were soiled, potentially affected all residents who used this equipment (S/S: E)

No handwashing supplies were available for staff to use before leaving soiled utility room (S/S: F)


F-441

Systems to Review: Infection Control, Prevent Spread, Linens

Handwashing during medication and/or treatment administration

Contact precautions

Flu vaccinations


#3 F-323 Free of Accident Hazards/ Supervision/Devices

Resident exited the facility through resident room window and reentered through front of building without staff knowledge (S/S: D)

Residents received the wrong liquid consistency, resulting in aspiration (S/S: E)

On 2 occasions resident was observed with back buckled seat belt across her chest (S/S: G)


F-323• (1) The resident environment

remains as free from accident hazards as is possible; and

• (2) Each resident receives adequate supervision and assistance devices to prevent accidents.

Systems to Review: F-323 Free of Accident Hazards/ Supervision/Devices

Risk Management and Accident Prevention Programs

Falls Prevention

Elopement Protocols

Safe Smoking Program

Side rail PMP and gaps


#4 F-225 Investigate/Report Allegations/ Individuals

Facility failed to report and investigate incident where resident wearing oxygen attempted to light a cigarette, burning himself on the face (S/S: D)

Failure to report resident-to- resident physical and verbal abuse that resulted in roommate asking for a room change (S/S: D)

Inconsistencies found in staff reports regarding resident falling and thorough investigation not completed to determine reason for inconsistencies (S/S: E)


F-323

The facility must— •§483.13(c)(1)(ii) Not employ individuals who have been-- (A) Found guilty of abusing, neglecting, or mistreating residents by a court of law; or (B) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and (iii) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities •§483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). • §483.13(c)(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. •§483.13(c)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Systems to Review: F-225 Investigate/Report Allegations/Individuals

Resident Observation & Reporting ◦ Bruises/Scratches

Background checks

Investigations◦ Staff Statements


#5 F-279 Develop Comprehensive Care Plans

No care plan to address multiple falls and injuries of a resident with self-injurious behavior (S/S: D)

Self-inflating resuscitation bag with tracheotomy attachments and mask not made available to resident on ventilator ( S/S: D)

No CCPs developed for palliative care and restraint use and use of psychoactive medications for multiple residents (S/S: E)


F-282• §483.20(d) (A facility must..) use

the results of the assessment to develop, review and revise the resident’s comprehensive plan of care.

• §483.20(k) Comprehensive Care Plans (1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.25; and (ii) Any services that would otherwise be required under §483.25 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

Systems to Review: F-279 Develop Comprehensive Care Plans

Individualized plan of care◦ Measurable goals◦ EMR

Timely implementation

Revision/Review after changes in condition

All care areas & major diagnosis


#6 F-282 Services by Qualified Persons/Per Care Plan

Resident who required assistance with ADLs left by sink unattended and found on floor later by another resident (S/S: D)

Resident found without shoes or heel protectors for physical therapy even though family had brought sneakers for him to use (S/S: D)

Services not provided in accordance with written plan of care for resident observed with greasy hair, unshaven and dry skin (S/S: D)


F-282

Systems to Review: F-282 Services by Qualified Persons/Per Care Plan

Assistive devices not observed to be in use

Consults not completed per physician order

Lab/Diagnostic tests


#7 F-280 Right to Participate in CarePlanning – Revise CP

No revision to CCP for resident who was independent with setup help for ADLs and then required extensive assist from staff member (S/S: D)

CCP not revised for resident with UTI who was on a daily diuretic and experienced a decline in continence and oral intake at meals (S/S: D)

Resident’s spouse was not invited to care planning meetings despite being at facility nearly every day to visit (S/S: D)


F-280

Systems to Review: F-280 Right to Participate in Care Planning – Revise CP

Family/Resident interviews◦ Invitation/review of care plan

Decline in ADLs

Significant Change


#8 F-241 Dignity and Respect of Individuality

Resident refused to wear clothing protector and said he had his own but CNA forced him and fed him without speaking to him or explaining to him what she was doing (S/S: D)

LPN said loudly that residents needed a staff member to sit with them during meals because they are “feeders.” Residents were served last because they required assistance (S/S: D)

Staff did not knock on residents’ doors and announce themselves or ask permission to enter resident rooms (S/S: E)


F-241

Systems to Review: F-241 Dignity and Respect of Individuality

Staff education and monitoring

Exposure

Privacy

Dining


#9 F-309 Provide Care/Services for Highest Well Being

RN assessment not completed for more than a week after resident complained of not feeling well and having trouble breathing (S/S: D)

Incorrect treatment to buttocks completed by CNA, and correct treatment was signed as being administered by LPN (S/S: E)

Stool sample not tested for blood as ordered, resulting in intestinal bleed and no follow up consults were provided (S/S: G)


F-309

Systems to Review: Provide Care/Services for Highest Well Being

Hemodialysis

Anticoagulants

Advance Directives

Pain

Care of the resident with dementia


#10 F-329 Drug Regimen is Free From Unnecessary Drugs

Antianxiety meds administered without nonpharmacological interventions attempted first, and no monitoring documented (S/S: D)

Medication administered without adequate medical indication because physician forgot to put it in record (S/S: D)

Psych consult did not provide notes on suicidal ideation or behaviors but recommended a dosage increase that was signed off on by physician even though no documented behaviors existed in medical record (S/S: D)


F-329• 1. General. Each resident’s drug

regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:

• (i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above.

• 2. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Systems to Review: F-329 Drug Regimen is Free From Unnecessary Drugs

Rationale for use

Nonpharmacological interventions

Documentation

Consultant Pharmacist recommendations


Things to Think About

Immediate Jeopardy Citation Areas:◦ Advance Directives◦ Anticoagulants◦ Physician Notification of Changes◦ Side Rails

Nursing Staffing Data


NYS 2015 – Top 10 K-tags

2015 Top 10 K-tags

1. K-56 Automatic Sprinkler System – Throughout

2. K-147 Electrical Wiring & Equipment

3. K-62 Automatic Sprinkler System – Maintained

4. K-29 Hazardous Areas – Construction, Protection, Separation

5. K-38 Exit Access – Accessible at All Times

6. K-25 Smoke Barriers – Fire Resistance Rating

7. K-18 Corridor Doors

8. K-69 Commercial Cooking Equipment

9. K-50 Fire Drills

10. K-20 Vertical Openings – Fire Resistance Rating


NYS Top 10 K-tags – 2014 & 2015

35

2014 Top 10 K-Tags1. K-56 Automatic Sprinkler System – Throughout

2. K-62 Automatic Sprinkler System – Maintained

3. K-29 Hazardous Areas -Construction, Protection, Separation

4. K-25 Smoke Barriers – Fire Resistance Rating

5. K-38 Exit Access – Accessible at all times

6. K-18 Corridor Doors

7. K-147 Electrical Wiring & Equipment

8. K-50 Fire Drills

9. K-76 Medical Gas Storage & Admin Areas

10. K-20 Vertical Openings – Fire Resistance Rating

2015 Top 10 K-Tags1. K-56 Automatic Sprinkler System – Throughout2. K-147 Electrical Wiring & Equipment3. K-62 Automatic Sprinkler System – Maintained4. K-29 Hazardous Areas – Construction, Protection, Separation5. K-38 Exit Access – Accessible at All Times6. K-25 Smoke Barriers – Fire Resistance Rating7. K-18 Corridor Doors8. K-69* Commercial Cooking Equipment9. K-50 Fire Drills10. K-20 Vertical Openings – Fire Resistance Rating

#1 K-56 & #3 K-62 Sprinklers Throughout/ Maintained

Sprinklers◦ Sprinkler pipes in ceiling with wires attached to/supported by

sprinkler pipe◦ Paint on sprinklers◦ Sprinkler hangers◦ Full fabric shower curtains obstructing sprinkler flow in showers◦ Duct work >4’◦ Elevator machine rooms


#2 K-147 Electrical Wiring and Equipment

Electrical◦ Electrical panels lacking directory◦ Electrical boxes lacking covers◦ Extension cords, cube taps and power strips


#4 K-29 Hazardous Areas – Construction,Protection, Separation

Hazardous Areas◦ Room storage >502

◦ Self-closing doors◦ Storage within 3’ of panels


#5 K-38 Exit Access – Accessible at All Times

Exit Access◦ Storage in corridor◦ Door locking, delayed egress◦ Dual lamps


#6 K-25 Smoke Barriers – Fire ResistanceRating

Smoke Barriers◦ Penetrations not sealed with approved fire stop


#7 K-18 Corridor Doors

Corridor Doors◦ Obstructions to closing of doors on corridor◦ Doors positive

Stairwells◦ Self-closing doors◦ Door latching◦ Doors propped open


#8 K-69 Commercial Cooking Equipment

Commercial Cooking Equipment◦ “K” extinguisher with no signage◦ Ansul system monthly inspection◦ Hood cleaning documentation


#9 K-50 Fire Drills

Fire Drills were:◦ Not quarterly and not on each shift◦ Not under varied conditions and times

Fire Procedures◦ Fire extinguishers mounted more than 5’ from finished floor◦ Kitchen staff unfamiliar with:

Fire Procedures Code phrase Ansul system “K” extinguisher


#10 K-20 Vertical Openings – Fire ResistanceRating

Vertical Openings◦ Floor-Floor◦ Floor-Roof


Other Areas to Pay Attention To

Emergency Generators◦ Documentation◦ Required load bank

Combustibles◦ Hand Sanitizers

Alcohol-based sanitizers mounted adjacent to or over ignition source (light switches, electrical receptacles)

Storage of more than 10 gallons of alcohol-based hand sanitizer in one smoke compartment

Miscellaneous◦ Portable Heaters◦ Manometers not provided on filter banks◦ Smoking regulations◦ Oxygen storage


2012 Life Safety Code

Anticipated Changes from 2000 LSC to 2012 LSC


Thank You!

Thank you to NYSHFA for having CMS Compliance Group present on 2015 Survey Trends & Systems to Review!

To learn more about CMS Compliance Group, please visit our website: www.cmscompliancegroup.com


http://www.cmscompliancegroup.com/

2015 survey trends and systems review 2015 survey trends and systems review nyshfa audio conference...

Documents

adl care

comprehensive care plansf

comprehensive care plans6

comprehensive care plans7

comprehensive care plans5

care planning revise

care planning revise

food procurement