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State of State of MichiganMichiganDepartment of Community Department of Community

HealthHealthBureau of Health SystemsBureau of Health Systems

Division of OperationsDivision of OperationsRoxanne PerryRoxanne Perry

February 28, 2008February 28, 2008

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WelcomeWelcome

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Clinical Process Clinical Process GuidelinesGuidelines

Green BillGreen Bill

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Clinical Process Clinical Process GuidelinesGuidelines

Clarification Work GroupClarification Work Group

Clinical Advisory PanelClinical Advisory Panel

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Purpose of CPGsPurpose of CPGs

To provide a uniform definition of the To provide a uniform definition of the issueissue

To establish clinical/research evidence To establish clinical/research evidence as the basis for managementas the basis for management

To provide a format for analysisTo provide a format for analysis To provide a standard of practiceTo provide a standard of practice To provide a template for action, To provide a template for action,

documentation and monitoringdocumentation and monitoring

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Format of CPGsFormat of CPGs

Care ProcessCare Process

StepStepExpectationsExpectations RationaleRationale

Recognition/Recognition/

AssessmentAssessment

Diagnosis/Diagnosis/

Cause Cause IdentificationIdentification

Treatment/Treatment/

ManagementManagement

MonitoringMonitoring

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Example: CPG-Evaluation Example: CPG-Evaluation of Falls/Falls Riskof Falls/Falls Risk

Memorandum to LTC facilities from Memorandum to LTC facilities from Clinical Advisory PanelClinical Advisory Panel

The Basic Care Process definedThe Basic Care Process defined Process Guideline Process Guideline Documentation ChecklistDocumentation Checklist MDS/Fall RAP Key guidelines Assessment MDS/Fall RAP Key guidelines Assessment

and Problem Definition, Care Planand Problem Definition, Care Plan Tables and illustrationsTables and illustrations Checklist for AssessmentChecklist for Assessment ReferencesReferences

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Clinical Process Clinical Process GuidelinesGuidelines

TopicsTopics

~ Guideline for Use of Bed Rails in Long ~ Guideline for Use of Bed Rails in Long Term Care Facilities (April 2001)Term Care Facilities (April 2001)

~ Evaluation of Falls/Fall Risk (October ~ Evaluation of Falls/Fall Risk (October 2001)2001)

~ Pain Management (March 2002)~ Pain Management (March 2002)~ End of Life Care (March 2002)~ End of Life Care (March 2002)~ Medication Management and Reduction of ~ Medication Management and Reduction of

Adverse Drug Reactions (October 2002)Adverse Drug Reactions (October 2002)~~ Prevention and Management of Pressure Prevention and Management of Pressure

Ulcers (February 2003)Ulcers (February 2003)

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Clinical Process Clinical Process GuidelinesGuidelines

TopicsTopics

~ Behavior Management and Antipsychotic ~ Behavior Management and Antipsychotic Medication Prescribing (October 2003)Medication Prescribing (October 2003)

~ Acute Change of Condition (June 2004)~ Acute Change of Condition (June 2004)

~ Maintaining Hydration/Electrolyte ~ Maintaining Hydration/Electrolyte Imbalance (September 2005) Imbalance (September 2005)

~ Altered Nutritional Status (September ~ Altered Nutritional Status (September 2005)2005)

~ Depression (November 2006)~ Depression (November 2006)

~ Heart Failure (December 2007)~ Heart Failure (December 2007)

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New Applications for UseNew Applications for Use

May be provided as a May be provided as a “recommendation” in enforcement “recommendation” in enforcement letter.letter.

May be used as developmental May be used as developmental structure by Clinical Advisorstructure by Clinical Advisor

May be included in Directed Plan of May be included in Directed Plan of Correction/Directed In-serviceCorrection/Directed In-service

May be used as a framework for May be used as a framework for establishing compliance (and past establishing compliance (and past non-compliance)non-compliance)

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Past Non-Past Non-ComplianceCompliance

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Criteria for Past Non-Criteria for Past Non-ComplianceCompliance

To cite past non-compliance, all three(3) To cite past non-compliance, all three(3) criteria must be met:criteria must be met:

1. The facility must not have been in 1. The facility must not have been in compliance compliance

with a regulatory requirement at with a regulatory requirement at the time the situation occurred, i.e. the time the situation occurred, i.e. the facility must have had a the facility must have had a violation; andviolation; and

2. The situation of non-compliance 2. The situation of non-compliance must have occurred after the exit must have occurred after the exit date of the last survey, and before date of the last survey, and before the current survey (standard, the current survey (standard, complaint, revisit); andcomplaint, revisit); and

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Criteria for Past Non-Criteria for Past Non-ComplianceCompliance

cont’dcont’d

3. There must be specific evidence 3. There must be specific evidence that the facility corrected the non-that the facility corrected the non-compliance (at the time of the compliance (at the time of the incident) and is in substantial incident) and is in substantial compliance at the current survey.compliance at the current survey.

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Facility Past Non-Facility Past Non-Compliance FormCompliance Form

Date of Report:Date of Report: Administrator Administrator Name:Name:

Facility name:Facility name: Address:Address: Phone #: Phone #: Resident Name: Resident Name: Date of Birth: Date of Birth: Room #:Room #: Diagnosis: Diagnosis: Date of event:Date of event: Was the resident injured?Was the resident injured? If yes –Describe injury:If yes –Describe injury:

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Facility Past Non-Facility Past Non-Compliance FormCompliance Form

cont’dcont’dDescription of deficient practice: (Why and how did it Description of deficient practice: (Why and how did it happen?)happen?)

Plan of Correction:Plan of Correction: In-depth analysis of how the deficiency occurred.In-depth analysis of how the deficiency occurred. How facility identified resident affected and residents How facility identified resident affected and residents

having potential to be affected by the same deficient having potential to be affected by the same deficient practice.practice.

Corrective action taken for resident affected.Corrective action taken for resident affected. Measures or systemic changes made to ensure that Measures or systemic changes made to ensure that

deficient practice will not occur and affect others.deficient practice will not occur and affect others. How facility monitors its corrective actions to ensure How facility monitors its corrective actions to ensure

deficient practice is corrected and will not recur.deficient practice is corrected and will not recur.

Date of completion of plan of correction. Attach Date of completion of plan of correction. Attach documents for evidence of compliance.documents for evidence of compliance.

Name (printed) and Signature of person completing formName (printed) and Signature of person completing form

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Documentation of Past Documentation of Past Non-ComplianceNon-Compliance

1.1. Past non-compliance that is not Immediate Jeopardy Past non-compliance that is not Immediate Jeopardy and for which a quality assurance program has and for which a quality assurance program has corrected the non-compliance, should not be cited. corrected the non-compliance, should not be cited. Note: The facility needs to bring this to the attention of Note: The facility needs to bring this to the attention of the surveyor. The facility must provide the evidence to the surveyor. The facility must provide the evidence to the surveyor who will contact his/her manager to the surveyor who will contact his/her manager to review the information and make a determination if the review the information and make a determination if the evidence meets the criteria for past non-compliance. evidence meets the criteria for past non-compliance.

2.2. Past non-compliance identified as immediate jeopardy Past non-compliance identified as immediate jeopardy is entered on CMS 2567 under the specific deficiency is entered on CMS 2567 under the specific deficiency tag, scope and severity with supporting documentation.tag, scope and severity with supporting documentation.

3.3. The CMS 2567 should include the appropriate F-tag, The CMS 2567 should include the appropriate F-tag, date of deficiency, the date of past non-compliance, the date of deficiency, the date of past non-compliance, the evidence of past non-compliance and implementation of evidence of past non-compliance and implementation of a plan of correction so that the civil money penalty can a plan of correction so that the civil money penalty can be determined.be determined.

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Documentation of Past Documentation of Past Non-ComplianceNon-Compliance

cont’dcont’d NOTENOTE: The generic F698 has been : The generic F698 has been

discontinueddiscontinued

Enforcement Action on Immediate Enforcement Action on Immediate Jeopardy Past Non-ComplianceJeopardy Past Non-Compliance

1. Civil money penalty is required for 1. Civil money penalty is required for immediateimmediate

jeopardy. Usually a per instance CMP isjeopardy. Usually a per instance CMP is imposed.imposed.

NOTE:NOTE: Past non-compliance does not apply to Past non-compliance does not apply to State Nursing Home Rules and the Public State Nursing Home Rules and the Public Health Code. A State of Michigan-tag (M-tag) Health Code. A State of Michigan-tag (M-tag) may be cited.may be cited.

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Documentation of Past Documentation of Past Non-ComplianceNon-Compliance

cont’dcont’d IDRIDR

1. Will be allowed for past non-compliance 1. Will be allowed for past non-compliance cites. cites.

i.e.: To contest whether a deficiency i.e.: To contest whether a deficiency occurred. occurred.

2. Can IDR whether a past non-compliance 2. Can IDR whether a past non-compliance citation is acitation is a

deficiency. deficiency.

3. Cannot IDR whether a deficiency (cite) is 3. Cannot IDR whether a deficiency (cite) is past past non-compliance. non-compliance.

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Putting it all togetherPutting it all together Use the Clinical Process Guidelines as a Use the Clinical Process Guidelines as a

problem solving tool and to assure problem solving tool and to assure ongoing compliance. ongoing compliance.

Identify the use of the CPGs when Identify the use of the CPGs when offering evidence of past non-compliance. offering evidence of past non-compliance.

Maintain a clear file of QA efforts in a Maintain a clear file of QA efforts in a manner that can be provided to manner that can be provided to surveyors. surveyors.

Continually monitor and document the Continually monitor and document the monitoring of all QA efforts.monitoring of all QA efforts.

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RevisitsRevisits

Revisits may be conducted at any Revisits may be conducted at any time for any level of non-compliance.time for any level of non-compliance.

Revisits are required for:Revisits are required for:

1) Non-compliance at F (substandard 1) Non-compliance at F (substandard quality of care)quality of care)

2) Harm level citations2) Harm level citations

3) Immediate Jeopardy3) Immediate Jeopardy

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Evidence in Lieu of Evidence in Lieu of RevisitRevisit

In some cases, acceptable level of In some cases, acceptable level of compliance may be submitted in lieu compliance may be submitted in lieu of a revisit.of a revisit.

Evidence of compliance in lieu of a Evidence of compliance in lieu of a revisit is not acceptable after a revisit is not acceptable after a second revisit has been conducted.second revisit has been conducted.

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Evidence in Lieu of Evidence in Lieu of RevisitRevisit

Examples of acceptable evidence Examples of acceptable evidence are:are:

1) Invoice or receipt verifying 1) Invoice or receipt verifying repairs, purchases, etc.repairs, purchases, etc.

2) Sign-in sheets for in-service 2) Sign-in sheets for in-service training verifying attendancetraining verifying attendance

3) Contact with resident council3) Contact with resident council

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Resources Resources

Bureau of Health SystemsBureau of Health Systems

http://www.michigan.gov/bhshttp://www.michigan.gov/bhs

State Operations Manual (CMS)State Operations Manual (CMS)

Appendix PAppendix Phttp://cms.hhs.gov/manuals/Downloads/http://cms.hhs.gov/manuals/Downloads/

som107ap_p_ltcf.pdfsom107ap_p_ltcf.pdf

Appendix PPAppendix PPhttp://cms.hhs.gov/manuals/Downloads/http://cms.hhs.gov/manuals/Downloads/

som107ap_pp_guidelines_ltcf.pdfsom107ap_pp_guidelines_ltcf.pdf

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ResourcesResourcescont’dcont’d

Clinical Process GuidelinesClinical Process Guidelines

Deborah Ayers, DCH QI Nurse Deborah Ayers, DCH QI Nurse Consultant:Consultant:

517-241-2656517-241-2656

dayers@michigan.govdayers@michigan.gov