the licensors are in the house.pptx [read-only] · 2017-11-02 · 10/27/2017 1 the licensors are in...

10/27/2017

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The Licensors are in the House

The survey process

Authority

RCW 18.20.110Inspection of assisted living facilities—Approval of changes or new facilities.

The department shall make at least every 18 months with an annual average of 15 months, an inspection and investigation of all assisted living facilities.

However, the department may delay an inspection to 24 months if the assisted living facility (ALF) has had three consecutive inspections with no written notice of violations and has received no written notice of violations resulting from complaint investigation during that same time period.

RCS Licensing Inspection Types

New licensure - often called a Pre-occupancy Inspection (only inspection that is announced)

Full licensing inspection - average every 15 months, up to 18 months.

Follow-up (Post) Inspection - following deficiency citations

Complaint investigations

Monitoring visits

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Full Inspection

Unannounced - can enter off hours, or weekends

Field Manager has authority to require early inspections if problems identified

Average length of full inspection, currently 3-5 days

Number of licensors vary depending on RCS staffing and facility size

Inspection Process

RCS Preparation

Look at history

Complaints since last inspection

Contact Ombuds - Any themes, Quality of Care/Life

Contact HCS Case Manager - QoC/L concerns

RCS Prepares –How Do You Prepare?

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Build Relationships:

Field Manager

Ombuds

Case Managers

Families

Physicians

Hospitals

Health Agencies

Anyone else?


Understand or at least be familiar with the inspection process.

What can you do to educate yourself?

Survey Binder- Keep Up To Date

Resident Roster - Delay in getting this to the licensors will prevent them from moving on.

Resident room list - list of residents and roommates. Note if someone is a non-resident individual, i.e., spouse of a resident. They will not be included in the sample

Staff information - position, title, hire dates, day and month of birth

Staffing schedules - 3 weeks

Disclosure of Services

Liability insurance coverage

Menus

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How Do You Prepare?

Keep an inspection ready binder up to date:

Pet records

Changes in physical environment with construction review approvals

Copies of any waivers the facility may have

List of discharged residents in last 6 months and reason for discharge

How Do You Prepare?

Review facility history since the last full inspection:

What is your compliance history?

Review all Statements of Deficiencies (SODs) – Full and Complaint

Know the deficiencies cited

Identify any patterns of repeat and/or isolated deficiencies, attestation of correction and resident identification

Ongoing monitoring to ensure you have maintained compliance

Do you have any open citations?

Are there any conditions on your license? Are you complying with the conditions?

How Do You Prepare?

What changes have been made since the last full inspection?

Changes in number of licensed beds

Specialty designations

Contracts

Current exemptions

Approved new construction- DOH project reports, go to: http://www.doh.wa.gov/crs

Change of Administrator / Change of owner

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How Do You Prepare?

Through your ongoing audits- How do you identify problems for all departments?

Are problems being addressed?

Who is monitoring to ensure approach to resolving identified problems is working?

Are you confident your facility is moving in the right direction? If not, what needs to happen TODAY to change that.

How Do You Prepare?

Inspection prep is always and ongoing

Your facility dynamics are always changing

Staffing - composition and expertise

Resident acuity and mix, families

Technological advantages and disadvantages

Know the extra things you can do when “in your window”

Entrance

The licensor/team coordinator explain the purpose of the visit

Make introductions to the administrator, designee or staff and provide a business card. Have department name tag visible.

Provide the written list of documents needed

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Entrance

Do staff know what they should do once the team enters?

If licensors are waiting they will use the time to observe the residents and the immediate environment and make introductions to any residents or staff in the area and briefly explain the reason for the visit.

Set lines of communication. You should tell the team who should be the point of contact – Adm, DON, and introduce key staff.

Let your staff know how you want them to communicate with you.

Entrance

Licensors will request a place for the team work. Think strategically where you want inspectors to be planted during the process.

They should try to minimize disruption to your normal day of care provision, however, you will need to accommodate their requests.

Tour

PURPOSE

To provide the licensing team with:

An initial observation of physical environment, quality of life and safety.

Introduction to the residents, facility staff, and family that may be visiting.

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What are licensors observing for?

Everything! What things might they be looking for in your facility?

What might they see?

When do you think they start observing?

Tour

Tour should be conducted with staff member(s), who are knowledgeable about the residents

Observations of quality of life, care and services, environmental and safety issues, required postings

Data collection during the tour consists of observations and informal interviews with residents, families, staff

Tour will include common areas, resident rooms, activity areas, laundry room, storage areas, restrooms

The exterior environment

Tour The tour guide should note any environmental issues noticed during

the tour- correct immediately as you are able/appropriate – i.e., cold - check with RDT

Note residents who express concerns or appear to have unmet or special care and service needs. Follow up with these residents as soon as appropriate

Observe the general appearance of residents: grooming and dress -find staff to assist the resident

Observe staff-to-resident interaction related to quality of life, dignity, privacy, and responsiveness to resident needs including verbal communication, eye contact, and touch

Observe residents’ response to staff. If anything seems unusual, follow up. The the licensors will!

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Communication During the Tour

Licensors will not communicate about an issue too soon unless it is a serious issue that the ALF must deal with immediately.

Licensors should not communicate issues that may lead to failed practice until they have collected enough information to make that decision.

Communication During the Tour

During the tour find ways to point out to licensor positive things and showcase:

Residents- introduce to council president

Offer good care outcomes about the resident – i.e., came from hospital with pressure injury, all healed and no reoccurrence

No family, depressed now highly involved in activity programs

Weight loss success story after you discovered resident loves tacos

Tell them about special programming you offer

Knock on doors and wait for a response to come in

Keep HIPAA in mind when talking about residents in open areas!

Tour- Exterior Environment

Licensors should focus on egress

Tripping hazards in courtyards or walking paths

Smoking areas

Snow or ice build up in driveway or entrance. Is it safe and accessible for visitors and EMS?

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Tour- Completion

RSC staff will meet to discuss findings from tour and pick a resident sample

What should you do during this time?

Resident Sample

PURPOSE

To select a sample of residents in the ALF that best represents the resident population regarding care and service needs.

The sample selection must occur as soon as possible after the tour.

Sample Selection

Selected based on information gathered during pre-inspection prep, entrance, and tour.

Will review Resident Characteristic Roster during sample selection.

The size of resident sample is based on ALF census and consists of residents selected for review.

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Sample Selection

Depends on census, licensors may expand sample as needed based on issues identified and to determine scope of failed practice

3-6 residents=all

7-15 residents=at least 6





126 residents and higher=at least 19

Sample Selection

Licensors will use the roster and information obtained through observations and interviews to ensure residents selected represent a diversified group

Special care needs- diabetic, modified diet, skin issues, falls

Identified as able to interview and not able to interview

Receive nursing services different medication levels

Identified as having special needs (dementia, mental illness, developmental disability)

Identified as receiving services through Specialized Dementia Services

How Would You Pick A Sample?

Sample your residents for review

Who does your audits – same person or multiple people?

How often do you perform audits?

What do you audit?

Who do you audit?

Do your audits include observations, interviews and record review?

Use your Resident Characteristics Roster- Who stands out when you look at it?

Acute care needs or specialized services provided

“Squeaky Wheels”?

No family and non-interviewable

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Resident Group Interview

PURPOSE

The group meeting provides the opportunity for residents to share information and provide the licensing staff another source of data


Getting the word out about the meeting:

The licensors will inform residents of the meeting during the tour.

Don’t schedule the group meeting during the time a popular activity is currently scheduled.

Select interviewable residents to attend. This does not mean they can’t have cognitive impairments. Even residents with cog impairments add value to a meeting.

Although facility staff is not “invited” have someone close by as the licensing team may need to request the assistance of facility staff to escort residents to and from the meetings.


The interview questions will follow standardized questions but the licensors are not required to ask every question on their form. If residents are focused on a particular issue, they will follow their lead.

Licensors will follow up with residents individually who raise concerns that need more clarification.

No staff members or resident family members are routinely present at the group meeting, unless specifically requested and approved by the residents.

General questions that will always be asked are about the treatment of themselves and others, enough to do, missing items, grievances, food.

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Interviews

PURPOSE

To collect information about resident life in the ALF by speaking with residents, licensee/administrator or designee, facility staff and other contacts.

The focus of the interview is on resident quality of life, safety, and provision of care and services.

Resident Interview

The licensor will conduct both formal and informal interviews during the inspection:

Formal interviews are those that involve residents and their families selected in the complete review and the in-depth limited review samples.

Informal interviews are with residents not selected in the sample and the interviews are not structured or planned.

Interviews

Interview family members or resident representatives of non-interviewable residents in the sample

Licensors will obtain an interpreter if the resident sample includes a non-English speaking resident who is alert

Staff members - all disciplines

Interview contacts other than family members to obtain information that is necessary to support a citation

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Observations

PURPOSE

To ensure the care provided is appropriate for the resident’s needs, consistent with the Negotiated Service Agreement, performed by qualified and trained staff, and upholds

resident rights for quality of life, dignity, privacy, and choice.

Observations

RCS registered nursing staff will conduct all care observations that require looking at a resident’s genitals, rectal area and the breast area for females (bikini area)

Any licensor can observe wound care unless on the areas above or unless they are observing to make a clinical judgment about the status of the wound.

They are not to touch or examine a resident or provide hands-on care. Request the licensee or staff to provide the direct care if the resident agrees.

Observation Of Care

Formal observations are specific to a resident and/or care issue. Licensors will observe for the following:

The resident response to the care provided:

Behavior

Level of comfort

The caregiver/staff performing the care

Technique and knowledge

Staff-to-resident interaction

Infection control practices

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Observation Of Care

Does the level of assistance provided match what is identified in the negotiated care plan?

Is physical care provided using safe practices and appropriate handling?

Is inclusion of the resident’s participation in the care task to the maximum of their ability or care planned potential or as identified in the negotiated care plan?

How Do You Observe?

Abuse/Neglect Prevention Review

PURPOSE

To determine if licensee practices are in compliance with the regulations and statutes regarding mandated reporting and prevention of abuse in the assisted living facility

The primary focus of the abuse prevention task is on ensuring the quality of life, dignity, welfare and safety for all residents

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Abuse/Neglect Prevention Review

Conduct interviews with:

Residents to follow up for any possible identification of abuse revealed during the resident group meeting, resident interviews or from observational data. If the resident is unable to be interviewed licensors will contact the resident’s representative.

Staff regarding abuse:

What constitutes physical, mental and emotional abuse?

Steps to take in the event of suspected abuse, neglect, use of restraints, involuntary seclusion and/or financial exploitation

Notification and reporting requirements

Medication Services

Medication services data collection includes review of:

Medication storage: safety, labeling, organizers

Medication delivery system: documentation, assistance/ administration, alterations, appropriate for resident needs

Medication prescriptions received timely

Respect of resident rights: right to refuse, individual choice and preference

Disposal of medications

Conduct interviews with contacts including outside the ALF regarding medication services if further data needed to verify non-compliance

Medication Services

Observe medication storage area during tour and at other times during the inspection for the following:

Medications are secure for residents not capable of self-storage;

Medication is properly labeled;

Medications for a specific resident are stored together and are kept separate from other resident medications and/or food or toxic chemicals;

Storage area is locked, accessible only to designated, responsible staff; and

Medications are stored according to medication label recommendations, (example: KEEP REFRIGERATED).

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Medication Services

For residents on nurse delegation licensors will interview staff regarding nurse delegation practices for the resident.

For residents doing self-med program licensors will observe resident room for medication issues such as medications on floor or inappropriately stored, such that residents may gain access to another resident’s medications.

Observe whether staff confirmed the resident’s identity prior to giving medications.

Identify medications not being given in a timely manner, such as antibiotics and pain medications.

Review how emergency medication issues are handled. If a resident is out of medication, what does the facility do to obtain in a timely manner?

Environmental Observation

The Licensor will:

Conduct observations regarding the appearance of the ALF beginning with the entrance and tour process and throughout the inspection.

Conduct observations in the common areas and resident rooms.

Check water temperature in half of resident rooms of the residents who were selected in the resident sample. They will expand the sample if there are concerns.

Environmental Observation

If smoking is permitted for residents, is there shelter, is it fire safe, what is the supervision, are residents assessed for safety?

The team will share observations with each other to continue to look for any patterns of areas of concern that were identified.

They will notify the Field Manager and contact CRU to report to State Fire Marshall if a fire safety issue is identified.

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Food Services

The Licensor will:

Use the tour as the first opportunity to observe the food service environment and general food service practices including proper food handling skills and handwashing.

Observe food safety to include: personal hygiene, employee health, temperature control, and potential cross-contamination during food preparation and service.

Food Services

Residents will be asked during dining observations, resident interview and group interview about:

Preferences;

Alternate choices;

How they express their comments on food services;

Prescribed diets;

Prescribed nutrient supplements and concentrates;

A variety of daily food choices;

Temperature of food; and

Assistance with eating, if needed.

Food Services

During Dining Observation, licensors will:

Observe for timeliness of meal service;

Observe for sufficient time and staff provided to meet resident needs. Observe meal for attractively-served meals that are nourishing and palatable;

Observe sample residents if needing eating assistance as per resident needs;

Observe residents receiving meals in their room, noting why they are in their rooms, and if they are assisted per care needs.

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Resident Record Review

Conduct a complete resident record review for residents in the sample

Resident assessment;

Monitoring of resident’s well-being;

Negotiated service agreement; and

Medication record and other information

Determine if information obtained from record review will require further interviews and observations

Expand record review only if necessary to make a compliance decision

Facility Record Review

When licensors review facility records:

Incident/accident documentation

Policies and procedures (rarely)

Financial records (rarely) as they are related to specific complaints/concerns

Outside Record Review

When licensors review other records:

Review of outside records, such as hospital records, police records, agency records, and other records not associated with the ALF will rarely be done, and is only done when necessary to determine failed practice

Licensors should initiate the review of outside records as soon as possible. The inspection is not complete until the last date of data collection.

You need to know the last date of data collection!

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Staff Sample Record Review

Selection criteria for facility staff sample:

If the administrator has changed since the last inspection, licensors will review that record to ensure qualification and training requirements are met.

Review of staff list for hire dates and titles:

Select 3 employees who have been hired since the last inspection and review training and qualifications.

Review 1 or 2 employees who have worked over 2 years to ensure a system is in place to conduct background re-checks and continuing education requirements.

Disaster Plans are generally reviewed as part of this task.

Exit Preparation

The licensor will:

Communicate with the administrator to ensure no “surprises” at the exit conference.

Review information for deficiencies and identify any negative resident outcomes or the potential for a negative outcome.

The team should meet with the administrator to discuss any final findings related to the inspection just prior to the exit conference.

Schedule the exit conference with the administrator and invite the Ombuds and interested residents to attend.

Tips For A Good Inspection Experience

Respect for the value of each other’s position

Understanding of the process and the regulations

Be prepared to have an inspection at any time

Communication, Communication, Communication!

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Exit Conference

The exit conference occurs at the end of the full/complaint inspection

However sometimes they will say they have not completed “data collection”

Important to know if this is the final exit or will there be an additional follow up/call to the on-site exit

An exit can occur over the phone. Most often a telephone exit will be seen in a complaint inspection vs a full inspection

Exit Conference

Deficiencies identified by RCS staff at the exit must be regulatory based. Because the licensors have communicated with the administrator throughout the inspection, the identified deficient practices should not be a surprise.

If, after the exit, licensors make changes or additions to the information presented at the exit, a licensor will contact the administrator with information about the changes prior to sending the Statement of Deficiencies. Again no surprises.

Exit Conference

Inform the administrator of the process following the exit and what to expect, including further data collection, Statement of Deficiencies (SOD) report, Attestation of Correction, and the Informal Dispute Resolution (IDR) process.

If you submit information after the exit the administrator will be contacted by telephone if there are any additions or significant changes to the deficiencies discussed at the exit.

Take good notes.

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At This Point You Should Clearly Know

Which residents are included in the deficient practice.

The regulations being cited or at least a specific explanation of the failed practice.

If they have identified harm to any residents and if potential enforcement action will be recommended.

If there is a condition placed on the license during the inspection process – Do you have a written copy? Are you clear about what the condition requires of you?

Is the inspection completed or will there be further data collection after the team leaves the facility?

If there is further data collection to be done off site- when can you expect to hear the results of that and when will the inspection be officially completed?

At This Point You Should Clearly Know

If there were complaints completed during the full inspection- do you know if any citations were a result of the complaints? Did you get a better description of the nature of the complaint?

If you cannot answer these questions you should ask for clarification. Don’t be afraid to ask!

If you have questions about the process, (possible) enforcement action recommendations, team dynamics not resolved with the team leader, contact the field manager.

After the Exit- What You Should Do?

Gather any additional information you have that you wish to have considered and send to the Field Manager or Team Leader.

Begin working on correction-

Correction should start when the facility becomes aware of the problem, don’t wait completely until you get the SOD.

The licensors/complaint investigator should give you enough information at exit in order to start taking immediate action and evaluate the facility’s systems.

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What If My SOD Is Late?

If you don’t receive your SOD by when you think you should have it contact the Field Manager. They SHOULD notify you if they will not meet the 10wd time frame.

Sometimes they started their 10 working day clock differently from when you started counting (based on last day of data gathering)

If they say it will be late they should give you an idea of when you will receive it.

Things that can delay a SOD getting to you timely…

Staffing, scheduling, enforcement

Post-Survey Timeline

SOD/Attestation to department within 10 calendar days

IDR- Written intent within 10 days to the department

Appeal- Written intent within 28 days to office of appeals

POC/Attestation- Correction within 45 calendar days from when they leave your facility

Longer period may be allowed if reasonable- usually this is for construction projects that take much longer to complete or is seasonal work

Reading Your SOD

Don’t become defensive when reading the SOD- be open to improving your systems and operations

Look for things that may be inaccurate but be open to where there are problems

Are they making linkages that are not really there- i.e. A Tb test was late putting all the residents at risk for Tb.

If there are inaccuracies, mis-quotes, missing information, wrong resident identifiers, poor choice of wording- think about each item-

By fixing the concerns would it-

still be a deficiency?

change from harm to no harm?

just sound better and be a better end product

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Reading Your SOD--Hmmmm

I got cited for this and my competitor did not--- Not Fair

When I read this each citation sounds the same – I am being double cited

It has always been this way and this year I am being cited for it

I submitted my POC dates but I am not ready- can I change them

Questions?

the licensors are in the house.pptx [read-only] · 2017-11-02 · 10/27/2017 1 the licensors are in...

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