2013 state veterans homes va survey deficiency overview valarie delanko joanne parker office of gec...
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2013 State Veterans Homes VA Survey Deficiency Overview
Valarie DelankoJoAnne Parker
Office of GEC Operations (10NC4)
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Discussion Topics
• Deficiencies cited in 2013• Top Deficiencies Discussion – NH &
DOM• Recognition updates
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Background Information
• Current SVH Program Structure offering three levels of care:– 146 State Veterans Home Facilities
• 137 Nursing Home Care programs (24,898 beds)
• 54 domiciliary care programs (5,876 beds)
• 2 adult day health care programs (85 participant slots)
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Surveys Types 2010 -2013
2010 2011 2012 20130
20
40
60
80
100
120
140
160
87
134 135 140
411 12 106 3 3 1
Total Survey Types
Annual Recognition For Cause
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Totals for 2013
Total Number of Nursing Homes Surveyed 151
Total Number of Surveys with Deficiencies
91 (60%)
Total State Veteran Home Deficiencies 441
Average Number of Deficiencies Cited per Survey
2.92
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NH Totals for 2013
Total Number of Nursing Homes Surveyed
97
Total Number of Surveys with Deficiencies
68 (70%)
Total State Veteran Home Deficiencies385
Average Number of Deficiencies Cited per Survey
3.96
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DOM Totals 2013
Total Number of Domiciliary Surveyed 54
Total Number of Surveys with Deficiencies Cited
23 (42%)
Total Domiciliary Deficiencies Cited 56
Average Number of Deficiencies Cited per Survey
1.03
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IJs for 2013
Total Cited 6
Accidents & Supervision: Smoking with Oxygen; burns from hot coffee
Falls with Injury
Accurate Care Plan Assessments: Failure to follow care plans/supervise residents that smoke
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Top NH standards 2013Regulation
NumberStandard Frequency
% of All Tags
51.200 a.Facility meets applicable provisions of the Life Safety Code of National Fire Protection Association.
167 43%
51.120 i. 1-2Residents environment remains free of accidents, hazards and receives adequate supervision and assistance.
23 6%
51.110 d. 2.Comprehensive care plan developed in 7 calendar days after completion of comprehensive assessments, prepared by IDT, and periodically reviewed and revised.
16 4%
51.200 b. 1-4An emergency electrical power system, in accordance with NFPA, on-site emergency standby generator of sufficient size to serve connected load.
15 3.9%
51.110 d.3.Services provided or arranged by facility must meet professional standards of quality or by qualified persons in accordance with the care plan.
13 3.4%
51.110 d.1.Assessments' are conducted with appropriate participation of health professionals, registered nurse and certification of that assessment.
11 2.9%
51.90 b.The resident has the right to be free from mental, physical, sexual, and verbal abuse or neglect, corporal punishment and involuntary seclusion.
6 1.6%
51.90 c.Facility management must develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse and misappropriate of property.
6 1.6%
51.100 a. b.Facility management must promote care in a manner in an environment that maintains or enhanced dignity, respect, self-determination and participation.
5 1.3%
51.120 b. 3.Residents receive proper treatment and assistive devices to maintain vision and hearing abilities.
5 1.3%
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Top DOM standards 2013Regulation
NumberStandard Frequency
% of All Tags
167 C.There is evidence reported that life safety deficiencies have been or are corrected.
29 61.7%
165 2. A.The facility has a current State Fire Marshall certificate or documented evidence of compliance with life safety codes.
7 14.9%
168 2. D.Facility has available an emergency source of electrical power to provide essential service when normal electricity supply is interrupted.
3 6.4%
176 3. C.Acceptable practices are employed for maintenance and repair of equipment, buildings and grounds.
1 2.13%
177 4. A. Facility ensures provision of professional medical services for residents. 1 2.13%
179 4. C. Residents are classified according to domiciliary care required. 1 2.13%
180 4. D.Resident treatment plan established and maintained for each domiciliary resident.
1 2.13%
189 5. B. Primary care nursing services are provided for domiciliary residents. 1 2.13%
190 5. C. Nursing services rendered are documented in the medical record. 1 2.13%
206 8. G. The nutritional status of each resident is monitored on a regular basis. 1 2.13%
226 13. A. Residents are treated with dignity and respect. 1 2.13%
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Functional Deficiencies 2013
Functional Standard GroupsNumber of
Deficiencies - 2013 Percentage
Physical Environment 219 57%
Resident Assessment 60 16%
Quality of Care 43 11%
Quality of Life 24 6%
Residents Behavior and Facility Practices 16 4%
Resident Rights 8 2%
Infection Control 6 2%
Dietary Services 4 1%
Pharmacy Services 3 1%
Nursing Services 2 .5%
Total 385 100%
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Physical Environment
TagRegulation Number
Standard FY 11 FY12 2013% change from FY 12
147 51.200a Life Safety From Fire
97 80 187 >100%+
148 51.200 b1-4 Emergency Power
10 7 15 >100%+
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Resident Assessments
TagRegulation Number
Standard FY 11 FY12 2013% change from FY
1287 51.110b1 Resident Assessment:
Comprehensive Assessments of residents needs
2 3 1 <66%
92 51.110d1 Resident Assessment: Comprehensive Care Plan
8 12 11 <8%
93 51.110d2 Resident Assessment: Comprehensive Care Plan
16 12 16 >33%
94 51.110d3 Resident Assessment: Periodic Review
12 15 13 <13%
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Quality of Care
TagRegulation Number
Standard FY 11 FY12 2013% change from FY
1296 51.120a1-3 Quality of Care:
Reporting of Sentinel Events
6 3 1 <66%
102 51.120d Quality of Care: Pressure Sores
10 3 4 >33%
108 51.120i1-2 Quality of Care: Accidents
25 24 23 <4%
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Quality of Life
TagRegulation Number
Standard FY 11 FY12 2013 % change
67 51.100a/b Quality of Life: Dignity
10 11 5 <55%
72 51.100g1 Quality of Life: Patient Activities
10 7 4 <43%
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Resident Behaviors/Facility Practice
TagRegulation Number
Standard FY 11 FY12 2013 % change
64 51.90 a. Restraints 9 5 4 <20%
65 51.90 b. Abuse 5 3 6 >100%
66 51.90 c. Staff treatment of residents
6 2 6 >100%
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Recognition Update
New State Veterans Homes
5/29/2013 Chippewa Fall, WI 72-Bed NHC
Changes to Existing State Veterans Homes
06/25/2013 Hanson, KY 156-Bed NHC (36-Bed Addition)
11/01/2013 Silver Bay, MN 83-Bed NHC (4-Bed Reduction)
11/05/2013 Spring City, PA 54-Bed DOM Renovation
11/18/2013 Union Grove, WI 76-Bed DOM and 158-Bed NHC
Minneapolis, MN 50-Bed DOM (Addition)
Recognition Packages in VA Concurrence
Kinston, NC 100-Bed NHC
Ivins, UT 108-Bed NHC
Payson, UT 108-Bed NHC
Bennington, VT 171-Bed NHC (6-Bed Reduction)
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Take Away
• Opportunity to improve in the Physical Environment.
• Many clinical functions have demonstrated improvement.
• Relationship between SVHs and VA is key to high quality and safety of Veterans.
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Contacts
• Valarie Delanko, RDN, LDN, CPHQ National Program Manager SVH Quality &
Survey Oversight
• Jo Anne Parker, MHA National Program Manager SVH Survey
Process