virginia survey process
DESCRIPTION
Virginia Survey Process. Medical Director’s role Judy Wilhide Brandt, RN, BA, RAC-MT, C-NE [email protected] 909-800-9124 www.judywilhide.com. Basics. Annual survey: Q 9 – 15 months Complaints: PRN Process outlined in SOM Appendix P & PP Very well defined, published survey tasks - PowerPoint PPT PresentationTRANSCRIPT
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Virginia Survey Process
Medical Director’s role
Judy Wilhide Brandt, RN, BA, RAC-MT, [email protected]
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Basics
• Annual survey: Q 9 – 15 months• Complaints: PRN• Process outlined in SOM Appendix P & PP• Very well defined, published survey tasks• Structured investigation prescribed by
state/federal guidelines– Very subjective decision making/citation
assignment
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Traditional Survey Process Tasks
• Sample Selection- Offsite Survey Preparation: Used to select initial areas of concern & initial residents for sample
• ≈60% of residents chosen in Phase 1 & ≈40% in Phase 2
– Quality Measure (QM) Reports• If weight loss, dehydration, and/or pressure ulcers
trigger as a concern, half the phase 1 sample has to have these issues.
– Previous survey/complaint history– Waiver/variance info– Ombudsman info– PASSR info
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Example of resident sample sizeCensus Phase 1 Phase 2 Compre-
hensive Review
Focused Review
Closed Record
Res/Family
Interviews
WHP
60 9 6 4 9 2 4/2 5120 14 10 5 16 3 5/2 7
200+ 18 12 5 22 3 7/3 9
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Point:
• Areas of concern should never be a total surprise– Discourage “survey prep” mentality just prior to
survey window– Encourage IDT to review QMs monthly
• Target areas that trigger at 70% to review:–MDS coding–Care concerns–Proper chart documentation to explain whether
QM represents an issue or not with appropriate follow up
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Quality Measures used in Survey Process
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Comparative Analysis/Benchmarks
• Compares your facility to:– Other certified facilities in
your state– Other certified facilities
nationally• This comparison is used in
traditional surveys
• Allows you to benchmark your progress and compare yourself to others
You Shall Rise and Show Respect to the Aged
State ComparisonNational Comparison/Percentile Ranking
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Resident Level Report
You Shall Rise and Show Respect to the Aged
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Initial Tour
• Initial opportunity to observe residents, staff and physical environment including kitchen
• Identify residents or potential concerns for investigation
• Facility should have staff member who can discuss the resident accompany all surveyors
• Very common for most of the worst citations to begin development on the initial tour
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1004/19/23
Residents: new admissions have no or infrequent visitors. psychosocial, interactive, and/or behavioral
needs. bedfast and totally dependent on care. dialysis or hospice Psychotropics Room variances MI/DD Communication issues: Non-oral, languages
Special Considerations for Sample:
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Information Gathering• 5A General Observations of the Facility
• 5B Kitchen/Food Service Observations
• 5C Resident Review– Observation, Interview, Record review
• 5D Quality of Life Assessment
• 5E Medication Pass and Pharmacy Services
• 5F Quality Assessment and Assurance Review
• 5G Abuse Prohibition Review
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Major Areas Reviewed:
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Official Top 10 Virginia list 2013• F-309 Quality of Care• F-514 Clinical records - order • F-280 Care plan 7-days/team/periodic review • F-329 Unnecessary drugs • F-323 Accident prevention - environment • F-502 Laboratory Services • F-278 Accuracy of assessment • F-431 Drugs labels/expired drugs • F=441 Infection Control Program • F-279 Care plan, comprehensive
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Most frequent high level citations Virginia 2013
• F-329: Antipsychotics mostly: Need actual behaviors, actual reasons, MD ordering and general statements not sufficient. “dementia with behaviors” certainly not sufficient
• F-502: Screwed up labs: Not ordered, not done, not responded to, not done as ordered, not reported, etc.
• Diabetic Management: Screwed up with bad outcomes
• Injuries: Falls, elopement, physical plant hazards• F441: infection control: Mostly watching med passes,
dressing changes, incontinence care, not washing hands by CNAs
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• PHYSICIAN SERVICES• F385 Residents’ Care Supervised by Physician• F386 Physician Responsibilities During Visits• F387 Frequency/Timeliness of Physician
Visits• F388 Visits by Physician/Phys Assistant/Etc• F389 Emergency Physician Services 24
Hr/Day• F390 Phys Delegation of Tasks in SNFs/NFs
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• The Medical Director – can help ensure that appropriate systems exist to facilitate
good medical care, – establish and apply good monitoring systems and effective
documentation and follow up of findings– help improve physician compliance with regulations,
including required visits. • During and after the survey process, the medical
director can – clarify for the surveyors clinical questions or information
about the care of specific residents,– request surveyor clarification of citations on clinical care, – attend the exit conference to demonstrate physician
interest and help in understanding the nature and scope of the facility's deficiencies,
– help the facility draft corrective actions.
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Care coordination
• A medical director should establish a framework for physician participation, and physicians should believe that they are accountable for their actions and their care.– Ensure primary attending and backup physician coverage; – Ensure that physician/NPP are available to help residents
attain and maintain their highest practicable level of functioning, consistent with regulatory requirements;
– Develop a process to review basic MD/NPP credentials (e.g., licensure and pertinent background);
– Address and resolve concerns and issues between the physicians, health care practitioners and facility staff
– Resolve issues related to continuity of care and transfer of medical information between the facility and other care settings.
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Common NF Issues in poor survey outcomes• Lack of clinical education by clinical
management– Lack of on-going educational development of
CNAs, LPNs, RNs, therapists
• Perceived or real inadequate staffing• Lack of a robust activities department• Lack of leadership experience/knowledge by
administrator/nursing management• Budgetary decisions that do not support
quality of care/life
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How you can help• Lead the team• Do comprehensive assessments, document legibly
your conclusions and plan, every time– Tips:
• Diagnose, describe and stage pressure ulcers (yourself)• Diagnose, describe other types of wounds• Avoid simply listing diagnoses without current status and plan• Follow up on resident injuries: Demand careful review by IDT of
falls, fractures, etc.• Follow up on infections, changes of condition: Did staff properly
recognize and report? Do they know what they are doing clinically?
• Prescribe psychotropics when needed and document justification.– Don’t prescribe when not indicated
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• Demand quality of care– Sanitation, hygiene, nutritious, delicious meals
• Do you ever eat the food? How about the pureed food?– Restorative nursing– Skin – Dental– Foot care
• Demand continuity of care– Shift to shift– Across transitions: Hospital, home health
• Pain control
• During high risk times:– Newly admitted: Does the staff know how to assess a new
resident? Skin, pain, preferences, functional status (falls)
How you can help
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• Demand appropriate staffing for acuity• Actively engage in QA efforts• Realize that a little pain for the IDT during a
survey may result in lasting improvements – Don’t buckle to pressure in survey to ‘write
something to make it better’– Admit your shortcomings, demand the IDT admit
theirs: make it better (QAPI)– Stay the course– Tell the truth
How you can help
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Plan of correction:• Be actively involved in survey• Attend exit conference• Assist in implementing realistic POC for lasting
change– Root cause analysis
• Develop/educate staff– CNA, LPN, RN– Dietary– OT, ST, PT
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Questions/discussion