SVH Program Census Current SVH Program Structure offering three
levels of care: 150 State Veterans Home Facilities 140 Nursing Home
Care programs (25, 163 beds) 55 Domiciliary Care programs (6,039
beds) 2 Adult Day Health Care programs (85 participant slots)
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Number of SVHs 2008 - 2015 4
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Surveys Types 2010 -2014 5
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Totals 6 Function20142013 Number of nursing home care
surveys146142 Number of nursing home care deficiencies464385 Avg.
number of deficiencies per survey3.182.71 Number of domiciliary
surveyed5755 Number of domiciliary deficiencies5355 Avg. number of
deficiencies per survey1.081.00 Number of adult day health care
surveys23 Number of adult day health care deficiencies00
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Immediate Jeopardy Numbers 7
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Reasons for IJ: 51.120 Quality of Care -Accidents #108 (8):
Coffee burn; widespread falls concerns (2); eating vs NPO; unsafe
smoking practices(2), high water temperatures in bathroom sinks,
high instances of physical aggression. 51.120 Quality of Care
-Reporting Sentinel Events #96 (1) Necrotic tissue in a wound with
no assessment and care plan. 51.190 Resident Behavior-Abuse #65 (2)
Resident in fear of care by CAN; New resident with elopement risk
but was not accessed in 7 days with 2 departures. 51.120 Quality of
Care -Incontinence #103 (1) Improper care of residents who have
Foley Catheters. 51.120 Quality of Care -Unnecessary Medication
#112 (1) Deep vein thrombosis (DVT), which is being treated with a
blood thinner (Coumadin). 51.120 Quality of Care -Mental and
Psychosocial Functioning #106 (1) Physical and verbal aggression,
20 total incidents. 51.200 Physical Environment-Life Safety #147
(1) Fire pumps (2) operational for only one (1) hour. DOM Safety-
(1) Dish machine wash temperature utilized to clean dishes below
manufactures required safety temperature. 8
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Top NH standards Line # Regulation Number Standard Frequency %
14751.200 a. Facility meets applicable provisions of the 2009 Life
Safety Code of National Fire Protection Association. 19241%
10851.120 i. 1-2 Ensure environment remains free of accident
hazards as is possible and residents receive adequate supervision
and assistance devices to prevent accidents. 409% 9451.110 e. 3
Services provided or arranged by facility must meet professional
standards of quality and by qualified persons in accordance with
the care plan. 337% 9351.110 e. 2 Comprehensive care plan is:
developed within 7 calendar days after assessments, prepared by an
interdisciplinary team and periodically reviewed and revised after
each assessment. 276% 14851.200 b. 1-4 An emergency electrical
power system is provided in accordance with NFPA; on-site emergency
standby generator of sufficient size to serve connected load. 245%
9251.110 e. Comprehensive care plan is: individualized that
includes measurable objectives and timetables to meet residents
physician, mental and psychosocial needs that are identified in the
comprehensive assessment. 122.5% 102 51.120 d. 1- 2. Pressure
sores: Based on comprehensive assessment, resident enters facility
without sore does not develop one unless clinical condition is
unavoidable and having one receives necessary tx and services to
promote healing. 112% 6651.90 c. Facility management must ensure
all alleged violations are reported immediately to
administrator/officials per state law; have evidence violations are
thoroughly investigated; results reported back to administrator
with appropriate corrective action if verified. 112% 9
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Top DOM standards Line # Guideline Number Standard Frequency %
1672. Safety C. There is evidence reported that reported life
safety deficiencies have been or are being corrected. 3260% 1682.
Safety D. Facility has available an emergency source of electrical
power to provide essential service when normal electricity supply
is interrupted. 815% 181 4. Medical E. Primary Care medical
services are provided for domiciliary patients as needed. 24%
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38 CFR Part 53 Payments to States for Programs to Promote the
Hiring and Retention of Nurses at State Veterans Homes. Goal is to
reduce nursing shortages at a SVH for an employee incentive
program. Must have documented credible evidence of a nursing
shortage. Request for 1 year of funds up to a total of 3 years.
Applications must be submitted between July September to Director,
Geriatrics and Extended Care Operations. Funds request cannot
exceed 2% of the total per diem paid to the SVH in the federal
fiscal year. Cannot be used for: benefits, salary, health
insurance, retirement plan or construction, expansion, or
remodeling. 11
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Falls Collaborative Preventing Falls and Fall Related Injuries
for Veterans: a collaboration between SVHs and the National Center
for Patient Safety (NCPS). February 2014 shared the opportunity
with NASVH to work with NCPS. Many expressed interest in a
breakthrough series project. Began in April 2014 introducing
national practice innovations and strategies for implementation and
adoption. Between June 2014 and January 2015, pre-work was
completed by SVHs; monthly webinars by NCPS, educational
presentations from SMEs; networking calls and project team
information was shared. NSPC provided consultation and coaching to
individual SVHs. At closure, each SVH submitted a final summary of
improvements and results. 12
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Falls Collaborative Results 6 increased falls education with
all staff 6 added post fall huddles 3 incorporated hip protectors 3
used multidisciplinary consulting and fall related referrals 2
developed methods to classify falls 2 added intentional rounding 2
provided feedback to staff 2 added an environmental assessment of
the residents room and ordered concave mattresses 13
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Falls Collaborative Ten State Veteran Homes that participated
in the collaborative: Ohio Veterans Home - Georgetown (VISN 10)
Ohio Veterans Home Sandusky (VISN 10) Mississippi Veterans Home -
Collins (VISN 16) Mississippi Veterans Home - Kosciusko (VISN 16)
Mississippi Veterans Home - Jackson (VISN 16) Clyde W. Cosper Texas
State Veterans Home - Bonham (VISN 17) Alfredo Gonzales Texas State
Veterans Home - McAllen (VISN 17) Ussery-Roan Texas State Veterans
Hospital - Amarillo (VISN 18) Lamun-Lusk-Sanchez Texas State
Veterans Home- Big Spring (VISN 18) Ogden Veterans Home - Ogden
(VISN 19) 14
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Recognition Update: 9/2014 2/2015 Recognition Packages in VA
Concurrence Redding, CA 90-Bed DOM 60-Bed NH West Los Angeles,
CA84-Bed DOM Addition Marshalltown, IA509-Bed NHC (66-Bed
Reduction) Fresno, CA 180-Bed DOM West Lafayette, IN 337-Bed NH
(128-Bed Reduction) 80-Bed DOM (35-Bed Reduction) Upcoming
Recognitions Lebanon, OR154-Bed NH Hilo, HI24-Participant ADHC
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Satisfaction Surveys Responded to your request Developed a
satisfaction survey utilizing Survey Monkey: 10 questions for VA
Team 10 questions for Ascellon Team OMB approved survey on January
7, 2015 Launched with February 2015 surveys Survey Links: Link to
give feedback on VA Team:
https://www.surveymonkey.com/s/SVH-VA_Team
https://www.surveymonkey.com/s/SVH-VA_Team Link to give feedback on
Ascellon: https://www.surveymonkey.com/s/SVH-Ascellon
https://www.surveymonkey.com/s/SVH-Ascellon Aggregate reports will
be given starting with the Summer meeting and quarterly reports
will be sent to the NASVH President 16
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Standard Operating Procedures Cancelling of State Veterans Home
(SVH) On-Site Surveys Weather - the State or Ascellon has travel
restrictions regarding weather related conditions that prohibit
surveyor travel to include, snow, hurricane, flood, tornado
Infectious disease outbreak - an infectious disease outbreak
confirmed anytime one or more of these events occur: The SVH closes
certain sections of a facility, restricts visitation, reports to
state health department or begins preventative treatment on other
residents and/or staff. 17
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Contacts Valarie Delanko, RDN, LDN, CPHQ National Program
Manager SVH Quality & Survey Oversight 814-860-2201 Jo Anne
Parker, MHA National Program Manager SVH Survey Process
202-623-8328 18