C270 – Changes of ConditionCompliance Guidelines

Safety, Oversight and Quality Unit

December 2019

Objectives

•SOQ, with valuable input from OHCA, Leading Age, several provider agencies and nursing consultants, developed Compliance Guidelines for one of our most frequently-cited rules – Changes of Condition and Monitoring (411-054-0040).

•This presentation will highlight important information in the Compliance Guidelines document.

Disclaimer

You need to read the Compliance Guidelines for yourself!

This presentation is just going to cover important parts of the document.

Purpose, Intent, Introduction

• Page 1 summarizes the following:

• Purpose: HB 3359 required the Department to develop, maintain and periodically update compliance guidelines for the most frequently-cited deficiencies.

• Intent: This explains the intent of rule 411-054-0040 – to ensure facilities respond to resident changes of condition in a way which promotes the health and safety of the resident.

• Introduction: This explains the intent in more detail – it introduces the requirements of monitoring and implementing interventions if necessary.

Special Note

• Page 1 also includes a special note to RNs, LPNs and administrators.

• Nurses are expected to know the nursing standards and work within their scope of practice.

• Administrators are expected to have systems in place which support the nurses in meeting these standards and scope of practice.

• Reference documents relating to nursing standards and scope of practice are noted.

Compliance Guidelines

• Pages 1 – 6 offer explanations of the requirements for responding to short term changes of condition (pages 1 –3) and significant changes of condition (pages 3 – 6).

• Each section begins with examples of that type of change of condition. These are also found in 411-054-0005 Definitions.

• Each section then provides an explanation of the process for identification and documenting a change of condition.

• Examples of methods of documenting are included.

Compliance Guidelines (continued)

• Each section concludes with an explanation of what is required in terms of monitoring a change of condition.

• Again, examples of methods for monitoring are included.

• Let’s look at some important details……

Determining Action/Intervention

• Survey sees a variety of facility staff placing residents on “Alert charting” and writing a “Temporary Service Plan” following a resident’s change of condition.

• The first 4 bullets under 1a. on page 2 offer important information for the facility to consider:

• Bullet 1: make sure you document for staff what to monitor and how often.

• Bullet 2: Actions/interventions should be made by a nurse or “trained and experienced staff.”

Trained & Experienced Staff

• A footnote was added on page 10 explaining “trained and experienced staff.”

• The requirement is referenced in 411-054-0034 Resident Move-In and Evaluation but is not defined.

• The workgroup wanted to ensure staff who are not nurses are not performing nursing functions. Therefore, the workgroup clarified that staff may determine actions/interventions for a change of condition based on training in:• Basic First Aid;

• Basic protocols for common changes of condition; or

• Resident-specific protocols.

Involving the Nurse

• Bullet 3: 411-054-0045 Resident Health Services references requirements for involving the facility RN when there is a resident change of condition.

• Bullet 4: This offers examples of where determined actions/interventions can be documented. These are common documents survey reviews to determine compliance with this rule.

Monitoring

• Section 1b. on page 3 explains the requirements for monitoring a short term change of condition.

• Bullet 1 states probably the most important part of the rule about monitoring:

• “Monitor each resident consistent with his/her evaluated needs and service plan” - 411-054-0040 (2)(a).

• This means existing service-planned interventions need to evaluated (“monitored”) as well as any new interventions that are developed in response to a change of condition.

Monitoring

• Bullet 1: Also includes a standard definition of “monitoring.”

• Bullet 2: Explains requirements for documenting on the progress of the change of condition.

• “Weekly progress” is defined – very important.

• Monitoring improvement may require documentation of the initial status of the condition.

• Includes examples of where progress can be documented.

• Bullet 3: Explains discontinuing monitoring.

Significant Change of Condition

• The first 6 bullets under 2a. on page 4 offer important information for the facility to consider:

• Bullet 1: The facility needs to document a significant change of condition occurred.

• Bullet 2: The COC was evaluated by “trained and experienced staff.”

• Bullet 3: This clarifies wording in the rule: the rule states the COC is to be referred to the “facility nurse” but the workgroup has interpreted this to mean the facility RN, since the RN is required to conduct an assessment of the significant COC.

Significant Change of Condition

• Bullet 4: The workgroup defined “timely” as it relates to the RN assessment of the significant COC. Basically, the assessment must be initiated within 48 hours and with enough information gathered to ensure essential care needs are addressed.

• Bullet 5: The requirements for the RN assessment are reviewed.

• Bullet 6: Nursing standards and scope of practice are discussed in relation to the RN’s role in updating the resident’s service plan.

Monitoring a Significant COC

• Section 2b. on page 5 explains the requirements for monitoring a significant change of condition.

• Open bullet 4: Some significant changes of condition may represent a change related to a medical condition where monitoring of that condition may necessitate data collection.

• Open bullet 7: (page 6) gives an example of documentation of monitoring. Remember that non-nurses may document objective information – data and observations. Only nurses may analyze the documentation of data and observation; and the RN may need to conduct an assessment before determining if the resident’s condition is improving.

Monitoring a Significant COC

• Open bullet 8: (page 6) Explains discontinuing monitoring. With a significant change of condition, the condition may either:

• Resolve; or

• Represent a new baseline or permanent change to the resident’s level of functioning.

• For a new baseline or permanent change in functioning, the service plan should be updated to reflect this new status.

The Rest of the Rule: P & Ps

• Pages 6 and 7 offer explanations of the requirements for facility policies and procedures that relate to monitoring and reporting of changes of condition, and staff training related to changes of condition.

• 1: The facility must actually have written policies to ensure a resident monitoring and reporting system.

Policies and Procedures

• 2: Staff training – this is important. Besides the training staff are required to receive per 411-054-0070, this part of the rule also requires staff to be trained on each individual resident’s specific change of condition.

• This is accomplished by providing clear, resident-specific information and instructions in the service plan, or an ISP, TSP or whatever as to the resident’s baseline status and what staff need to do in response to a potential change of condition.

• Remember, when you ask non-licensed staff to provide supports or interventions, or to document on the status of a condition, it is the facility’s responsibility to ensure those staff have received adequate instruction on how to do so.

Policies and Procedures

• 3 and 4: This is a reference to 411-054-0045 Resident Health Services.

• The facility must specify the role of the nurse in the monitoring system.

• The facility’s policies and procedures must support the nurses’ adherence to their nursing standards and scope of practice.

Examples

• Pages 7 and 8 provide examples of a short term change of condition (1) and a significant change of condition (2).

• Bullet 2: (page 7) The group included a reference to using root cause analysis in this example of a resident who has falls.

• Also note that in this example, when a resident has had a fall and sustained an injury, the facility should initiate monitoring of the resident’s mobility/balance/movement (related to the fall) and monitoring of the injury. This is a common deficiency survey sees.

Examples

• Bullet 6: very important. In this example, the facility should review all service-planned fall interventions to verify they were being followed by staff at the time of the fall. This is how the facility rules out neglect!

• Bullet 7: Note that different changes of condition may require different durations of monitoring until considered resolved.

Examples

• Bullet 8: If the facility implements any newinterventions, it should monitor those interventions to determine whether they are effective and being followed.

• Bullet 9: (page 8) Examples of monitoring and explanations of how they comply with the rule are provided.

Survey Process

•Pages 8 and 9 provide an explanation of the survey team’s typical process for reviewing resident changes of condition.

Related Tags

•Pages 9 and 10 provide a list of tags (rule numbers are included) that could also be reviewed in connection with a resident change of condition.

• A very brief explanation of the part of the rule that applies to the change of condition is provided.

Note

•Page 10 includes a disclaimer which reminds the reader that this Compliance Guideline document is not intended to replace, override, modify or otherwise amend regulatory text.

•Rather, the Compliance Guidelines hope to provide guidance for facilities and surveyors in evaluating whether a facility is in compliance with the OARs.

Resources / Links

• The last item on page 10 provides a list of resources that are referenced in this document.

• There is a hyperlink set up for each resource that will take the user to that document.

• All documents can be downloaded, saved and printed.

• These resources are also noted elsewhere in the document.

What’s Next

• HB 3359 requires the Department to maintain and periodically update these Compliance Guidelines.

• A copy of the Compliance Guidelines is posted on the CBC Provider Webpage; they will be updated as needed.

• This companion PowerPoint will be posted on the CBC Provider Webpage.

• The Department will be completing and posting an online training to accompany these Compliance Guidelines.

What’s Next

• HB 3359 also requires the Department to develop Compliance Guidelines for other frequently-cited tags.

• The Department will be developing Compliance Guidelines for Staff Training, Medication and Service Planning.

• The Department plans to provide a Webinar review of each of these Compliance Guidelines along with an online training.

Compliance GuidelinesReference Tool

Guide To The GuidelinesWebinar

Online TrainingTraining Tool

Thanks for your participation in this webinar!

Questions can be directed to:

Warren Bird, Policy Analyst 3WARREN.D.BIRD@STATE.OR.US