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marcumllp.com

The New Long Term Care Survey ProcessMarch 1, 2018

Illinois Council on Long Term CareHealthCare Council of Illinois

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Marilyn Mines RN, BC, RAC‐CT

Marcum LLP

Nine Parkway North Deerfield, Illinois 60015P: (847) 282‐6416 F: (847) 282‐[email protected]

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Objectives

At the end of this session, attendees will know what to expect during the new LTC survey process as it relates to: Surveyor preparations Completion of the required Entrance information and timelines Surveyor observations, interviews, and chart reviews Critical Element Pathways Surveyor tools How citations are determined

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Resourceshttps://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/GuidanceforLawsAndRegulations/Nursing‐Homes.html

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Overview

Best parts of the traditional and QIS survey Because it is computer based, there is less interpretation and more evidence based determinations Compliance will be determined by use of the interpretive guidance, investigative protocols and procedures, CE Pathways, and other observation tools/tasks

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Comparison Between the Traditional and New Survey Process

Traditional New Process

Computers ‐Used to develop the 2567 form: data written on paper

‐Used throughout the survey, with information being entered and synthesized/ organized by newsoftware

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Sample ‐Based on census‐Maximum of 30 ‐Pre‐selected based on QM/QI reports‐Adjusted based on issues identified while on tour‐Includes complaints

‐Based on census‐Maximum of 35‐70% pre‐selected, 30% survey selected based based on observations, interviews and limited chart review‐Includes complaints

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CASPER3 and 4 reports

‐Reviewed with the QI/QMs to further identify preliminary resident sample

‐Each team member reviews the CASPER 3 report on their own‐Review off site selected residents and indicators

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Roster Matrix CMS‐802

Required info

‐Completed for facility census

‐Two are completed (new form) 1) entire census and 2) those admitted within last 30 days‐Alpha resident list‐List of residents who smoke and designated smoke time

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Entranceto facility

‐Initial tour‐Observe for additional concerns‐Determine if pre‐selected residents are still appropriate‐1‐3 hours

‐No tour‐Each team member goes to their assigned unit and begins observations, interview , and limited chart reviews‐8‐10 hours

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Misc. ‐PhasesFocus andComprehensivereviews based on identified issues and QM/QI reportsFocused record review

‐Interview, observations, limited chart review for residents in the initial pool process‐Team meet and discuss/add new concerns

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Misc. ‐Environmental and other tasks during the survey

‐Meet with Resident Council‐Review minutes

‐Investigations with critical element pathways‐Facility tasks and closed record reviews are done‐Meet with Resident Council‐Review minutes

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The Process

There are numerous steps that are involved in the preparation and execution of the new process1. Offsite preparations2. Facility entrance3. Initial pool process4. Sample selection5. Investigation6. Ongoing and other survey activities7. Potential citations

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1. Offsite Preparations The team coordinator (TC) is required to download numerous facility specific files as close to the survey date as possible‐no more than 5 business days prior to the survey Most current MDS information Most recent standard survey Complaint surveys since most recent standard survey Casper 3 report (repeated deficiencies) Facility reported incidents (FRI) Variances and waivers

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Offsite Preparations

The downloaded information allows the survey team to view the facility’s history of

Allegations of abuse Active enforcement cases

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The Team Coordinator (TC) assigns a variety of tasks to the team members Beneficiary Protection Notification Review Dining observation Infection Control Kitchen Medication Administration Medication Storage QAA/QAPI Resident Council meeting Sufficient/competent nurse staffing

The State Ombudsman is informed

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There are several other documents that must be downloading to each surveyor’s computer

a.

b.

c.

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There are several other documents that must be downloading to each surveyor’s computer continuedd. Appendix Q – Guidelines for Determining

Immediate Jeopardy (IJ)https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107ap_q_immedjeopardy.pdf

e. Chapter 7 of the State Operations Manual https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/Downloads/som107c07.pdf


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There are several other documents that must be downloading to each surveyor’s computer continued

f. Psychosocial Outcome Severity Grid https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Transmittals/Downloads/R156SOMA.pdf

g. Principles of Documentationhttps://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/som107 _exhibit_007a.pdf


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70% of the sample is chosen off‐site By reviewing facility information, a determination of concerns/potential concerns is made Closed record review (discharge records) must include one resident in each of the following categories Unexpected death Hospitalization Community

Team members independently review offsite information

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Recently posted for surveyors to use during offsite preparations

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2. Facility Entrance

There is no entrance tour Team surveyors immediately go to their assigned areas Each team member will request the resident roster for their area Residents admitted within the last 30 days must be identified ‐matrix for new admission

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Facility Entrance

The team member assigned to do the kitchen tour visits that area immediately: before proceeding to their assigned area

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Facility Entrance

Prior to going to her/his assigned area, the TC will conduct an entrance conference with the administrator If the entrance is during off‐hours, a short entrance conference will be held with whomever is in charge Once the administrator arrives, a full entrance conference will be conducted

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Facility Entrance

The entrance begins with a give and take relationship The administrator immediately gives the TC Census number minus bed holds Complete matrix for new admissions (within the last 30 days) who are still residing in the facility An alphabetical list of all residents (note any resident out of the facility) A list of residents who smoke, designated smoking time, and locations

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Facility Entrance

The entrance begins with a give and take relationship The administrator immediately gives the TC continued Information regarding full time DON coverage Information regarding emergency water source Name of Resident Council President Updated floor plan, if necessary Facility Assessment

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Facility Entrance

The entrance begins with a give and take relationship continued The TC gives A copy of the Casper 3 report Signs indicating that surveyors are in the facility, which must be prominently posted Worksheet

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Facility Staff Must Give

Meal times Location of dining roomsMedication pass times Number and location of med storage rooms and cartsWorking schedules for licensed and registered nursing for the survey time period List of key personnel, location, phone numbers If paid feeding assistants are used, their training, names, and residents who receive the service

ONE HOUR

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An admission packet Dialysis information Contracts, agreements, policies and procedures including agreements for transportation List of staff providing dialysis Identification of certified unit

Hospice agreements with each provider Infection prevention and control program standards, policies and procedures Antibiotic stewardship program

FOUR HOURS

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Flu and Pneumococcal immunization policy and procedures QAA committee information QAPI plan Abuse prohibition policy and procedures Description of any experimental research in facility Nurse staffing waivers List of rooms requiring a variance Facility Assessment Completed matrix for entire facility

FOUR HOURS

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Completed Electronic Health Record Information portion of the Entrance Conference Worksheet Tells the surveyor were items for review are located If in the EHR system, how to find specific documents If on “paper” and not scanned into the system, where those items are located

END OF

FIRST DAY

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Entrance Conference Worksheet EHR Access

Care Area Location of info Care Area Location of info

1. Pressure ulcers 9. Elopement

2. Dialysis 10. Change of condition

3. Infections 11. Medication s

4. Nutrition 12. Diagnoses

5. Falls 13. PASARR

6. ADL Status 14. Advance directives

7. Bowel & Bladder 15. Hospice

8. Hospitalization

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Completed CMS Forms 671 and 672 Completed the Beneficiary Notice portion of Entrance Conference Worksheet

24 HOURS

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3. Initial Pool Process

Screening includes all residents in the assigned area, including those on the new admission matrix

All residents must be screened before identifying the 8 per surveyor that will be included in the initial pool

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Initial Pool Process

If the survey team arrives during off hours, the initial pool process will be slightly different Accommodations should be made based on resident activities Observations and screening will be done for those residents who are available If other tasks are appropriate, they will be started

This process requires the surveyors to be on the unit with residents

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Observation by all surveyors of the first full scheduled meal since entrance Must start at the beginning of the meal All dining rooms All room trays

Include those in the initial pool with weight loss, nutritional and/or hydration concerns If an issue is identified, must observe more residents


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The initial pool includes residents from the surveyor’s assigned area who are Offsite selected residents Complaint/facility reported incident (FRI) residents (a limit of 5 in total) Vulnerable residents New admissions within the last 30 days Others with concerns

Residents will be interviewed and observed differently depending on their subcategory

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There are several options on how to conduct the screening, interviews and observations The surveyor may choose whatever way they are more comfortable

Directions are clear: go room to room without staff

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Review resident’s information prior to entering the room Introduce self and have a short conversation Do a head‐to‐toe observation while talking to the person Determine whether the resident is interviewable or not

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Initial Pool Process: Conduct a Full interview on Interviewable Residents

The MDS indicators and active complaint/facility reported incidents residents appear the computer screen Prompted to question these care areas

Choices Activities Dignity Abuse Resident to resident interaction

Privacy Accommodation of Needs Person Funds Personal Property Sufficient Staffing Participation in care planning

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Prompted to question these care areas continued

Community Discharge Environment Food Dental Nutrition Hydration Tube Feeding

Vision and Hearing ADLs ADL Decline Catheter Insulin or Blood Thinner Respiratory infection Urinary Tract Infection


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Prompted to question these care areas continued

Infections other than respiratory or urinary Hospitalizations Falls Pain Pressure Ulcers Skin condition

Limited ROM Rehab Dialysis B&B incontinence Constipation/Diarrhea Smoking Hospice Other concerns

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If concerns are voiced in any of the care areas, the surveyor must determine if further investigation is needed and/or whether the MDS should be reviewed

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Even if the care area doesn’t apply, each item must be reviewed and have a response Although the questions may be asked in any manner comfortable for the surveyor, the intent must be maintained If the MDS must be viewed to identify a discrepancy, it can be done at any time during the process, but it must be confirmed or denied prior to the exit

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Initial Pool Process: Conduct a Full interview for Non‐Interviewable Residents

The interview for resident’s representative has the same questions as the one for residents with one additional question: notification of change These interviews should be conducted on the first day

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Initial Pool Process: Conduct a Full Resident Observation

Based on information input to the computer, areas are identified for further observation with probes being listed Rounds must continue with observations to answer all of the care area items

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Each of the following care areas must be observed

Activities Dignity Abuse Privacy Accommodating of needs Language/ communication

Mood/Behavior Restraints Accident hazards Unsafe wandering/elopement Call light in reach, call system functioning

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Each of the following care areas must be observed continued

Environment Dental Nutrition Edema Hydration Tube Feeding Vision and Hearing

ADLs Catheter Psych med side effects Psych/opioids med side effects Anticoagulant med side effects

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Each of the following care areas must be observed continued

Respiratory Infection Urinary Tract Infection Infections other than respiratory or UTI Oxygen Positioning Falls Pain

Pressure Ulcers Skin conditions Limited ROM Hospice Vent/Trach B&B continence Smoking Other Concerns

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As with the interview process, it is necessary to document if there is no issue, the need for further investigation, and MDS discrepancies

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Initial Pool Process: Limited Record Review

Care area probes look at many of the same areas identified on the interviews and observations Different areas are reviewed based on resident specific circumstances For all residents observed, the record review must be done to confirm the use of high risk medications and PASSAR if they are indicated

Insulin Anticoagulant

PASARR

Antipsychotic with Alzheimer's or dementia

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Different areas are reviewed based on resident specific circumstances continued For any resident marked non‐Interviewable, out of the facility, or unavailable, a record review must be conducted whether the following indicators were identified or not

Pressure ulcers Dialysis Respiratory infection Urinary tract infection Other infections Nutrition

Falls ADL decline Low risk B&B Hospitalization Elopement Change in condition

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Different areas are reviewed based on resident specific circumstances continued For all residents observed during the initial pool process a record review is conducted to verify Advanced Directives Other Concerns

For new admissions added (no MDS) High risk medication Diagnosis Hospice

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Document findings Limited time should be spent on the record review

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Initial Pool Process: End of Day 1 Team Meeting

The computer program includes a “Team Meeting” screen that lists items that must be discussed Should only be 15‐30 minutes Basically the survey team is guided through questions: their responses are entered into the computer to keep the information updated If substandard quality of care is suspected, the sample must be expanded to either rule it out or determine the scope

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Initial Pool Process: Daily Data Sharing

All surveyors share their data at the end of each day via the computer TC accesses information and shares with the team

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4. Sample Selection

The team meets and discusses all potential sample residents – about 1 hour‐ to select the sample Those in the actual sample will have a full blown investigation for any area of concern that was noted and marked for investigation If there are residents with concerns that are not in the actual sample, those concerns will still be investigated through others in the sample If there is no other resident with the concern, include that resident in the sample

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Sample Selection

Total number in the sample does not include discharged or closed records, only active resident Those identified through the initial pool process Those identified during rounds and review

Must include any resident with An abuse concern Potential harm Transmission based precautions All other care areas of concern Up to 5 complaints or FRI residents

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Sample Selection

Software program will ensure that all areas are represented It will select 5 residents for a full medication review of unnecessary medications: may or may not be in the sample Will indicate which facility tasks are triggered and require investigation Environment Personal funds Resident assessments

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Sample Selection

Software program will ensure that all are areas are represented continued Ensures that the correct number of resident are in the sample, based on census information Indicates what areas of care are to be investigated Team discusses concerns for each resident chosen and is mandated to refer to the Sufficient and Competent Nurse Staffing task to determine if any of the concerns indicate staffing issues

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Sample Selection ‐Sufficient and Competent Nurse Staffing

Was updated in November 2017 Although every surveyor observes for compliance, at the end of the day, when the team meets and discusses the days observations and concerns, the one assigned to this task determines whether any further investigation is warranted

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Sufficient and Competent Nurse Staffing

Survey team is asked whether observations, interviews, or resident record reviews conducted during the initial pool process and via general oversight suggested staffing issues might lead to negative outcomes Observations Offensive odors Residents in bed and not dressed after 9am Slow response time to call lights No staff interaction with residents Unsupervised wanderers

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Survey team is asked ….lead to negative outcomes Observations continued

Lack of assistance during meals Licensed staff helping unlicensed staff Sedated residents Use of position alarms Staff rushing to get there work done Delay in receiving medication Repositioning not done on a timely basis Display of pain, combative behavior, crying out, or yelling

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Survey team is asked ….lead to negative outcomes Observations continued

Avoidable accidents, elopement, resident to resident altercations Lack of competency while administering resident care

Interviews Do you feel there is enough staff? Has anything happened while you were waiting for staff to help you?

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Survey team is asked ….lead to negative outcomes Interviews continue Do you eat in your room but want to eat elsewhere? Are you able to make choices regarding dressing, eating, and activities? Get your medications on time? Do they make you sleepy? Do you think the staff is competent? How did staff respond to a concern or problem you expressed? How many residents are you responsible for?

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Survey team is asked ….lead to negative outcomes Interviews continue How many residents are you assigned? Have enough time to complete your assignment? How often are you asked to work overtime? Any devices available to prevent falls, wandering, etc.? Able to complete restorative interventions? Do you have input into staffing schedules and numbers? How are care plans updated and changes in resident’s needs communicated?

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Survey team is asked ….lead to negative outcomes Interviews continue How do you identify resident’s change in condition How are they communicated?

How often, and why, are resident’s sent to the hospital? Have you been trained to do your job? Are there in‐services on abuse, dementia care, resident rights, etc.? Are agency staff used? How often?

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Survey team is asked ….lead to negative outcomes Interviews continue Does the Facility Assessment include levels and competency of staff needed? Did (do) you have input in the Facility Assessment? How often is the Facility Assessment updated? How does resident acuity, needs, and diagnosis influence staffing requirements and assignments? Does census influence staffing levels?

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Survey team is asked ….lead to negative outcomes Interviews continue Have there been concerns regarding staffing levels brought to your attention? How was this handled? How does staff identify resident’s change in condition? Most common reason for hospitalization? How do you assure that competent staff is assigned to meet residents’ needs? How do you assure that care plan interventions are implemented?

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Survey team is asked ….lead to negative outcomes Interviews continue Use of temporary or contract staff? How do you know their skill set?

How are staff competencies assessed? Record reviews If position alarms are used, is there sufficient documentation to indicate the justification for its use and its impact on the resident? If sedating medications are used, does the clinical record support its use?

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Survey team is asked ….lead to negative outcomes Record reviews continue If there were changes in condition, does documentation indicate they were reported and timely? Does document suggest that a transfer to the hospital could have been avoided? Nursing schedules include 24 hour licensed nurse coverage 8 hours RN coverage daily Full‐time DON

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Sample Selection

Should there be a need to add residents (to meet the required sample size) the following guidelines are used Residents with the most concerns or those with concerns related to QOL and resident rights Residents who computer selected for the unnecessary med review but who are not in the sample Prior survey and complaint results Unrepresented area(s) of the building

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Sample Selection

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5. Investigation

Each surveyor is mandated to conduct an investigation on the residents identified in their sample The investigations may be conducted By resident By care area

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Investigation

Software guides the surveyor through the investigation to determine compliance decisions and FTag citations Critical Element Pathways will be triggered for any care area of concern

All “questions” on the Critical Element Pathways must be answered If there is no Critical Element Pathway for an identified concern, the surveyor is instructed to use Appendix PP

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Investigation

The Facility Assessment must be reviewed if there are concerns related to Hospice Ventilators Nutrition Dementia

Dialysis Activities Behavioral/emotional Lack of resources

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Investigation

Observation Staff, residents, representative Consistent implementation of the care plan all shifts, at all times Any deviations from the care plan

AM care, wound care, restorative, incontinent care and transfers as indicated by the areas of concern There is a body map in the computer which is used to draw observations of wounds Nutrition or weight concerns require use of a weight calculator

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6. On‐going and Other Survey Activities

Assigned tasks using pathway tools may be completed at any time during the survey process Closed record reviews It is recommended that is review takes place early in the survey process to allow time for investigation of identified concerns Sample selection is done by the software Review unexpected deaths, hospitalizations, and discharges to the community for last 90 days using the appropriate pathways

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On‐going and Other Survey Activities

Additional dining observation A second one is done if any concerns were identified during the initial full meal observation After reviewing other surveyor’s notes, the decision to cite or not will be made

Infection Control All surveyors are responsible for observing throughout their observations One is assigned to coordinate and review other’s notes when completing this task

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SNF Beneficiary notification review Using the info on the Beneficiary Notification worksheet, 3 residents are randomly selected The worksheet, one for each resident in the sample, will be given to the facility for completion Findings will be reviewed with the provider if issues are noted

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Kitchen Observations are made throughout the survey process One item on the Kitchen task requires unit refrigerators to be observed for temperature and labeling of food items This may be done by one person or by each surveyor–information will be shared with the person assigned to complete this form

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Medication administration‐25 medication opportunities Should be conducted by a nurse or pharmacist Although the preference is to observe residents in sample, any resident may be observed if the opportunity arises Different shifts, different units, different routes should be observed

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Medication storage May be done by any surveyor Observation of half the medication carts and storage rooms (defined by software) If concerns are noted, the review will be expanded

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Resident council meeting Group interview with active members should be conducted by day 2‐ allows time to pursue problems identified Any resident can attend but should be limited to 12 Include ombudsmen if requested

If no council exists, identify attempts to get one started

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Resident council meeting continued With permission of president, 3 months of council minutes should be reviewed Identify whether issues brought up have been resolved

Sufficient and Competent Nurse Staffing Throughout the entire survey process, all surveyors will be observing for problems or complaints that might be related to staffing One surveyor responds to the questions of the pathway

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Triggered Tasks: Only To Be Done if a Concern Is Identified

If any of these are triggered for review, only the applicable section is to be completed

Personal funds if residents indicate they do not have access to their funds Environment concerns only if they are identified with the sampled resident Not to be redundant of the LSC, will not investigate disaster and emergency preparedness, oxygen storage, or generator

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Triggered Tasks: Only To Be Done if a Concern Is Identified

Resident Assessment will only be investigated by each surveyor if there are concerns with Timing Discrepancies for care areas

If any of these are triggered for review, only the applicable section is to be completed continued

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7. Potential Citations

Team meets to determine compliance

4‐Immediate Jeopardy J K L

3‐Actual Harm‐not IJ G H I

2‐No actual harm/potential for more

than minimal harmD E F

1‐No actual harm potential for minimum A B C

Isolated Pattern Wide Spread

ScopeSeverity

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Potential Citations

Team will determine scope and severity for all the potential deficiencies The meeting for these decisions should take about an hour Every tag that was identified by the individual surveyors must have a compliance decision made

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Exit Conference

With administration and leadership team Ombudsman, president or officer of resident council, and one or two residents should be invited May conduct two separate exits with an abbreviated one for residents who may be in attendance Ombudsman may go to either or both

Indicate the observations and preliminary findings while keeping the resident’s identity hidden

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Exit Conference

Provider will be informed that deficiencies may be amended following new findings in the event that the survey is expanded Facility will be allowed opportunity to discuss and give more information if appropriate Resident roster information can be given at this time

Surveyor Investigation/Observation Tools and Tasks

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Mandatory Tasks

Beneficiary Notices Dining Infection Prevention Control KitchenMed AdministrationMedication Storage Resident Council Sufficient and Competent Nursing Staff

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Triggered Tasks

Environment Personal Funds Resident Assessment Extended Survey If there is any suspicion of SQC the survey must be extended to determine whether there is SQC or not

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F602Misappropriation of Resident Property and Exploitation

F603 Involuntary Seclusion

F608Reporting Of Reasonable Suspicion Of A Crime

F620 Admissions

F678 Regarding Basic Life Support, CPR

F700 Bed Side Rails

A few refer to the appropriate Critical Element Pathway

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F740 Behavioral Health Services

F741 Sufficient Staff

F743 Decreased socialization

F757 & F758

Chemical Restraints Use

F949 Use of paid feeding assistants

A few refer to the appropriate Critical Element Pathway

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F622 Transfer and discharge

F684 Quality of Care (End of Life)

686 Pressure Ulcer

F690 Bowel and Bladder

F692 Nutrition and hydration

A few that refer to the appropriate Critical Element Pathway

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Investigative Procedures

F660 Effective discharge planning process

F694 IV oversite and observations

F760 Medication Administration‐med errors

F842 Medical Records

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Facility Responsibilities and Preparation

Familiarize staff with investigative protocols and procedures, FTags, and the survey process

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PROACTIVE

REACTIVE

Dale Carnegie

Knowledge isn’t power until it is applied

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Prepare

Educate staff on new survey process, new FTags, investigative protocols and procedures, and survey tools Identify staff’s responsibility prior to and during the survey process Assist staff in the proper ways to respond to surveyor interviews Have all the required information available

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Interdisciplinary Team

Review the new survey process elements Know your function in interviews, observations, and record reviews Study the Investigative Protocols related to the interdisciplinary team and your specific discipline Learn all the requirements of the Critical Element Pathways related to your discipline Understand how the CE Pathways Facility Tasks will be used Prepare as if you were the surveyor

FTags

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Tag # (As of

Nov. 28, 2017)

SQC Tag?

X = YesTag Title CFR Regulatory Groupings

Tags / Subparts Implemented in Phase 3

Old Tag(Taken from

App PP 03‐08‐2017)

Regulation Text that was Moved toNew Tag

F540 Definitions 483.5 F150 483.5

F550 XResident Rights/Exercise of Rights

483.10(a)(1)(2)(b)(1)(2)

483.10 Resident Rights

F151 483.10(b)(1)(2)

F551Rights Exercised by Representative

483.10(b)(3)‐(7)(i)‐(iii)


F152 483.10(b)(3)‐(7)

F573Right to Access/Purchase Copies of Records

483.10(g)(2)(i)(ii)(3)483.10 Resident Rights

F153 483.10(g)(2)(3)

F552Right to be Informed/Make Treatment Decisions

483.10(c)(1)(4)(5)483.10 Resident Rights

F154 483.10(c)(1)(4)(5)

F553Right to Participate in Planning Care

483.10(c)(2)(3)483.10 Resident Rights

F154 483.10(c)(2)(iii)

F578Request/Refuse/Discontinue Treatment;Formulate Adv Directives

483.10(c)(6)(8)(g)(12)(i)‐(v)


F155 483.10(c)(6)(8)(g)(12)

F678 XCardio‐Pulmonary Resuscitation(CPR)

483.24(a)(3) 483.24 Quality of Life F155 483.24(a)(3)

F572 Notice of Rights and Rules 483.10(g)(1)(16)483.10 Resident Rights

F156 483.10(g)(1)(16)

F574Required Notices and Contact Information

483.10(g)(4)(i)‐(vi)483.10 Resident Rights

F156 483.10(g)(4)

F Tag Crosswalk

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FTags

Hundreds of tags, associated with the various paragraphs of the Requirements of Participation (Appendix PP)Must know what they are and how to achieve and maintain compliance Assign various staff and team members to review and outline the contents to educate others in their department Staff must know which tags impact their discipline

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Interdisciplinary Team (IDT)

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IDT

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IDT

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115

IDT

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IDT

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Discipline Specific/Shared

Crosses over several disciplines but primarily is the responsibility of physical engineer and housekeeping

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118


Admissions Billing Nursing Social Services Physician

Nursing Medical Director Physicians/non and physician practitioners

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Administration NursingMedical Director Human Resources/ Personnel

Nursing Administration Social Services Physicians/ Medical Director

120


Nursing Dietary Dentist/physician

Nursing PhysiciansMedical Director Administration

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121


Administration Nursing Dietary Physician Dentist Activities

Administration Board of Directors

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Therapies Nursing Physician Restorative

Administration

CE Pathways and Facility Tasks

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127

***

*

*

*

*

*

*

*

**

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Initial Pool Process Interviews, Observations, and Record Review

The interdisciplinary team and specific disciplines must be familiar with the facility tasks

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Surveyor Facility Tasks

Interdisciplinary Team Environment QAA/QAPI Dining Infection Prevention and Control Extended Survey

Social Services Beneficiary Notices Personal Funds Resident Council

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Surveyor Facility Tasks

Dietary Kitchen

Nursing Medication Administration Medication Storage and Labeling Sufficient and Competent Nursing Staff

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Critical Element Pathways

Pain Management

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Dietary/NursingDietary/Nursing

• Dental

• Hydration

• Nutrition

• Tube feeding


Social ServicesSocial Services

• Death

• Discharge

• Hospitalization

• PASARR (Admissions)

ActivitiesActivities

• Activities

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Dialysis

Pressure Ulcer (Laundry & Dietary)

Respiratory Care

Unnecessary Medications

Urinary Catheter‐UTI


Nursing

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Activities of Daily Living

Bowel and Bladder Incontinence

Physical Restraints

Positioning, Mobility and ROM

Rehabilitation and Restorative


Nursing/Therapy/Restorative

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Mapping for All Areas

26 pages of information that tells the surveyor what to look at and how to do their observations and investigations

4. Investigative tools Pathway Investigative Protocol

5. Critical Element and Tag number

6. Description of tag

1. Initial Pool Area2. Probing words3. Initial information source RI=resident interview RO=resident observation RRI=resident representative interview RR=resident record

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Example

Initial Pool Area

Initial Pool IntentKey Probing Words

Initial Pool Source

Investigative Tool CE # Tag# Tag Description

Accident Hazards

Bed rails or mattress entrapmentRestraint appliedcorrectlyUnsafe cords, outlets, handrailsInadequate safety equipment or lighting (grab bars, ambulation, transfer, or therapyChemicals/other hazardsExposure to unsafe heating surfacesLocks disables, propped fire doors, irregular walking surfacesResidents adequately supervised

RO

Accidents Pathway for all CEs

Additionally, Investigative Protocol for CE 2 (F700)

1F689

Free of accidenthazards/supervision/devices

2 F700 Bedrails

3 F909 Resident bed

4 F655 Baseline care plan

5 F636Comprehensive Assessment and timing

6 F637Comprehensive Assessment after significant change

7 F641 Accuracy of assessment

8 F656Development/implementation of comprehensive care plan

9 F657 Care plan Timing and Revision

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Example

Accident Hazards Pathway for all CEs Interviews Resident, resident representative or family interview asks questions related to all items on the pathway Nurse Aides are asked their knowledge of the resident's care and circumstances around the accident Therapy/Restorative nursing personnel are asked about the interventions, their implementation, and response to the accident

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Example

Accident Hazards Pathway for all CEs Interviews continued Nurses are asked about resident care, risk factors, specifics about the incident Social Service personnel are questioned about behaviors and care planning to manage the concerns

Record review of all notes to determine Whether risks were identified Whether the risks were properly managed Investigation of the incident

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Example

Critical Element Decisions1) Based on observation, interviews, and record

review, did the facility ensure the resident’s environment is free from accident hazards and each resident receives adequate supervision to prevent accidents? If No, cite F689

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Example

Critical Element Decisions continued2) Based on observations, interviews, and record

review, did the facility assess each resident for risk of entrapment and only use bed rails after trying other alternatives and explaining the risks and benefits to the resident or the resident’s representative? If No, cite F700NA, bed rails were not investigated.

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Example

Critical Element Decisions continued

3) Based on observations, interviews, and record review, did the facility appropriately install and inspect the bed rails, use compatible bed mattresses, bed rails and frames, and identify any risks of entrapment?If No, cite F909NA, bed rails were not investigated

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Example

Critical Element Decisions continued4) For newly admitted residents and if applicable

based on the concern under investigation, did the facility develop and implement a baseline care plan the care within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident? Did the resident or resident representative receive and understand the baseline care plan?If No, cite F655

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145

Example

Critical Element Decisions continued5) If the condition or risks were present at the time

of the required comprehensive assessment, did the facility comprehensively assess the resident’s physical, mental, and psychosocial needs to identify the risks and/or to determine underlying causes, to the extent possible, and the impact upon the resident’s function, mood, and cognition?If No, cite F636

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Example

Critical Element Decisions continued6) If there was a significant change in the resident’s

status, did the facility complete a significant change assessment within 14 days of determining the status change was significant?If No, cite F637

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Example

Critical Element Decisions continued7) Did staff who have the skills and qualifications to

assess relevant care areas and who are knowledgeable about the resident's status, needs, strengths and areas of decline, accurately complete the resident assessment (i.e., comprehensive, quarterly, significant change in status)? If No, cite F641

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148

Example

Critical Element Decisions continued8) Did the facility develop and implement a

comprehensive person‐centered care plan that includes measureable objectives and timeframes to meet a resident’s medical, nursing, mental, and psychosocial needs and includes the resident’s goals, desired outcomes, and preferences? If No, cite F656NA, the comprehensive assessment was not completed.

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Example

Critical Element Decisions continued9) Did the facility reassess the effectiveness of the

interventions and review and revise the resident’s care plan (with input from the resident or resident representative, to the extent possible), if necessary to meet the resident’s needs?If No, cite F657NA, the comprehensive assessment was not completed OR the care plan was not developed OR the care plan did not have to be revised.

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Example

This Accident Hazards CE Pathway also suggest further investigation 1. Tags2. Care areas3. Facility tasks 4. Investigative protocol

IF THEN

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Example

1. Tags

F580 Notification of Change

F552 Right to be Informed

F635 Admission Orders

F658 Professional Standards

F710 Physician‐ Supervision

F906, F907, F909 thru F918, F920, F922, F925

Physical Environment

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Example

2. Care Areas Restraints Abuse Choices General Pathway ADLs Behavioral‐Emotional Status Unnecessary Medications Dementia Care

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Example

3. Tasks Environment Sufficient and competent staffing QAA/QAPI Rehabilitation and Restorative

4. Investigative Protocol if F700 is cited A sampled resident who has MDS data that indicates a bed/side rail is used; Surveyor observation of the use of a bed/side rail for a resident; and/or An allegation of inappropriate use of a bed/side rail received by the State Survey Agency.

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Investigative Protocol Bed/Side Rails

Protocol has many elements quite similar to the critical element pathway Once the assessment, care plan, and orders are reviewed, with interventions identified, observations will be made, with interviews and record reviews conducted to corroborate what was observed

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Investigative Protocol Bed/Side Rails

Protocol has many elements quite similar to the critical element pathway continued

A resident may have a device in place that the facility has stated can be removed by the resident. For safety reasons, do not request that the resident remove the bed rails, but rather request that staff ask the resident to demonstrate how he/she releases the bed rails Must answer what medical need is met by using the bed rail

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Matrix

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Matrix Categories

1 Date of admission if admitted within past 30 days

2 Alzheimer’s /dementia diagnosis

*3 MD, ID or BC, & no PASARR Level II

*4Medications: Insulin, Anticoagulant, Antibiotic, Diuretic, Anti anxiety, Antipsychotic, Antidepressant, Respiratory

5 Facility acquired pressure ulcer

6 Worsened pressure ulcer

7 Excessive weight loss without prescribed program

8 Tube feeding

9 Dehydration

10 Physical restraint

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Matrix Categories

*11 Fall with injury or major injury

12 Indwelling catheter

*13 Dialysis

14 Hospice

15 End of life/comfort care/palliative care

16 Tracheostomy

17 Ventilator

18 Transmission based precautions

19 IV therapy

*20 Infections

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Status in Illinois

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IDPH on the New Survey Process

Since this is a new process, there is a learning curve for both the provider and surveyors Surveyors will explain the process to providers as they conduct the survey The use of laptops and tablets makes this a slower process than before Although regulations regarding complaints are new, the survey is conducted as in the past

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Surveyor have been instructed to Not hold facilities responsible for issues prior to 11‐28‐17 with the new regulations and survey process Communicate with staff concerns related to resident care, not staff management (staff is to notify management of the issues raised) Focus on quality of care and quality of life for the resident

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Medication Pass Various surveyors will conduct random observations rather than just one person doing them all There is a higher medication error rate noted with the new process

The in‐depth med review, whose residents are chosen by the computer from MDS data, still concentrates on psychotropic and anti‐psychotic medications Emergency preparedness is evaluated during the annual survey

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Exit conference will only relate the areas of concerns, not the tag numbers Tag numbers will be on the 2567 If the facility requests the potential tag numbers, the surveyors will tell them

Roster key and other key Resident key will be included with the 2567; names those residents cited in deficiencies Other key includes names of others (staff, physician, family, etc.) that are included in deficiency information

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Facility staff must focus on the Matrix completion and information since the medical conditions identified on the matrix drive the surveyors review Doing a good job with the residents identified on the Matrix assumes the facility is doing a good job in other areas

Emergency Preparedness These ETags citations are on a separate 2567 Will be conducted as part of the healthcare annual survey

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Emergency Preparedness Relate to Emergency plan Policies and procedures in the plan Communication plan Staff training Conducted the 2 mandated exercises

Differs from the Life Safety survey where the focus is on E15 Policies & Procedures E22 Implementation of policies and procedures E41 Emergency power systems

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The number of deficiencies cited is similar to the traditional survey results, with the citations being the same top ten as the traditional survey Compare Illinois to the other states Quality, Certification & Oversight Reports https://pdq.cms.hhs.gov/ Search criteria CY 2017 December and January 2018 Illinois and National Standard Health survey Any F Tag cites

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National Results Illinois Results

Total of 559 Surveys Completed Total 26 Surveys Completed

F880 Infection Prevention & Control F812Food Procurement, Store/Prepare/Service Sanitary

F656 Develop/Implement Comprehensive Care Plan F880 Infection Prevention & Control

F812Food Procurement, Store/Prepare/Service Sanitary

F689 Free of Accident Hazards/Supervision/Devices

F689 Free of Accident Hazards/Supervision/Devices F656 Develop/Implement Comprehensive Care Plan

F657 Care Plan Timing and Revision F693 Tube Feeding Management/ Restore Eating Skills

F761 Label/Store Drugs and Biologicals F686 Treatment/Svcs to Prevent/Heal Pressure Ulcers

F550 Resident Rights/Exercise of Rights F657 Care Plan Timing and Revision

F684 Quality of Care F677 ADL Care Provided for Dependent Residents

F758 Free from Unnec Psychotropic Meds/PRN Use F690 Bowel/Bladder Incontinence, Catheter, UTI

F641 Accuracy of Assessments F692 Nutrition/Hydration Status Maintenance

F578Request/Refuse//Discontinue Treatment; Adv. Directives

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In Summary

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Be Prepared

Have a notebook with all required information available on a daily basis Continually update matrix information, in particular for those admitted within the last 30 days Education ALL staff on the Care Areas FTags as appropriate Documentation Specific responsibilities Interview techniques

Investigative protocols and procedures Infection control Service in dining rooms Etc.

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Moratorium

You will still be cited though may not get civil monetary penalties for noncompliance with certain Phase 2 requirements 18 months to allow for education and implementation Involves forbidding the imposition of civil monetary penalties and denial of payment for new admissions Citations in all Phase 1 and Phase 2 requirements not exempt will be subject to mandatory denial of payments for new admission and termination if compliance is not achieved

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Moratorium F Tags

F655 Baseline care plan

F740 Behavioral Services

F741Sufficient/competent staff/access staff‐behavioral health

F758 Psychotropic medications related to PRN limitation

F838 Facility assessment

F881 Antibiotic Stewardship Program

F865QAPI program and plan related to the development of the QAPI plan

F926 Smoking policies

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Moratorium

Directed Plan of Correction or Directed In‐Service Training may be required for Phase 2 elements that are included in the moratorium If citations are written for both a Phase 1 and a Phase 2 requirement in the same “area, ” enforcement may only be on the Phase 1 requirement Be aware that statutorily mandated remedies are not included by federal law Correction within 3 month Termination after 23 for immediate jeopardy

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5‐Star Implications

The star for health inspection surveys will be frozen for 1 year to allow time for compliance and understanding of the new survey process Only those occurring after November 28, 2017 Applies to annual and complaint surveys

Health inspection methodology also changing Will only include the two most recent survey data The most recent is weighted at 60% The prior cycle data is weighted at 40%

The number of deficiencies cited and the highest scope and severity will be posted on NHCompare

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Questions?

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About Marcum LLP

Marcum LLP is one of the largest independent public accounting and advisory services firms in the nation, with offices in major business markets throughout the U.S., Grand Cayman and China. Headquartered in New York City, Marcum provides a full spectrum of traditional tax, accounting and assurance services; advisory, valuation and litigation support; and an extensive range of specialty and niche industry practices. The Firm serves both privately held and publicly traded companies, as well as high net worth individuals, private equity and hedge funds, with a focus on middle‐market companies and closely held family businesses. Marcum is a member of the Marcum Group, an organization providing a comprehensive array of professional services. For more information, visit www.marcumllp.com.

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Disclaimer

This Presentation has been prepared for informational purposes only from sources believed accurate and reliable as of the date of preparation. It is intended to inform the reader about the subject matter addressed. This is not to be used or interpreted as tax or professional advice.

Those seeking such advice should contact a Marcum professional to establish a client relationship.

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