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2019 Provider Training
Oklahoma City – August 27, 2019 7:30 a.m. – 8:15 a.m. Registration 8:15 a.m. – 8:30 a.m. Welcome 8:30 a.m. – 9:30 a.m. The Game is Played Away from the Ball Lee Manzer, Ph.D 9:30 a.m. – 10:00 a.m. OSDH Updates Mike Cook 10:00 a.m. – 10:15 a.m. Break 10:15 a.m. – 10:45 a.m. Quality Measure Project OSDH 10:45 a.m. – 11:30 a.m. Phase III Regulations Theresa Bennett, RN, BSN
11:30 a.m. – 11:45 a.m. Questions and Answers OSDH and Theresa Bennett
11:45 noon – 1:00 p.m. Lunch 1:00 p.m. – 1:45 p.m. Appendix Q Theresa Bennett, RN, BSN
1:45 p.m. – 2:00 p.m. Abuse Regulation Overview OSDH 2:00 p.m. – 3:00 p.m. Abuse, Neglect and Misappropriation: John Carnell
Insights from the Oklahoma Attorney General’s Office
3:00 p.m. – 3:15 p.m. Questions and Answers OSDH and John Carnell 3:15 p.m. – 3:30 p.m. Break 3:30 p.m. – 4:00 p.m. QIO – Dementia Update Melody Malone, PT, CPHQ, MHA 4:00 p.m. – 4:20 p.m. MDS Coding – Dementia and More Diane Henry, RN, LHHA 4:20 p.m. – 4:30 p.m. Closing Remarks and Wrap Up
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SLIDE 1
L. Lee ManzerDepartment of Marketing and International BusinessSpears School of BusinessOklahoma State University
The Game is Played Away From the Ball
(Service)
SLIDE 2
Ponder
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SLIDE 3
Hey, Rose!
SLIDE 4
A German‐born electrical engineer, Charles Steinmetz’s genius and inventions played a major role in making General Electric the industrial power it is today. Once, after he had retired, GE called him to help locate a malfunction in a system of complex machinery.
After testing different components of the machinery, Steinmetz took a piece of chalk and marked an “x” at a specific location on one of the machines. The machine was disassembled, and the GE experts somewhat sheepishly found a defect exactly at Steinmetz’s chalk mark.
But when GE received a bill from Steinmetz for $10,000, company officials questioned the amount and asked for an itemized bill. Steinmetz readily sent the itemized bill that read as follows:
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SLIDE 5
Making one chalk mark: $1
Knowing where to place it: $9,999
SLIDE 6
You are in the Service business.
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SLIDE 7
Values, Beliefs, and Customary Behaviors learned and shared by members of a
particular society
Culture
SLIDE 8
Elevator Culture
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SLIDE 9
Organizational Culture
The pattern of shared values and beliefs that help individuals
understand organizational activities and provide them with
norms for behavior.
SLIDE 10
Flavor of the Month
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SLIDE 11
Service CultureA culture where an appreciation
for good service exists and giving good service to both external and
internal stakeholders is considered a natural way of life and one of the
most (or the most) important norm by everyone in the organization.
A culture where an appreciation for good service exists and giving good service to both external and
internal stakeholders is considered a natural way of life and one of the
most (or the most) important norm by everyone in the organization.
SLIDE 12
The Game isPlayed AwayFrom the Ball
12
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SLIDE 13
Take care of the little things, the big things will take care
of themselves.
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SLIDE 14
Two Problems
• What are the “little” things?
• How do you motivate yourself / employees to do them?
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SLIDE 15
Process vs. Outcome
The stakeholder evaluates both the service outcome andthe service process.
SLIDE 16
If doctors don’t get sued for negligently harming patients, why do they get sued? According to Malcolm Gladwell’s book Blink, the answer comes down to bedside manner. A number of studies have shown that patients do not sue doctors who treat them with respect (however terrible the outcomes may be).
Researchers examined two groups of surgeons – one that had never been sued and one that had been sued at least once. Those who had never been sued spent an average of three more minutes per visit with their patients. They were better listeners and tended to laugh and joke more. There was no difference between the two groups in the amount of quality or medical information imparted.
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SLIDE 17
The“Little Things”
of Service
SLIDE 18
Quality Service VariablesReliability – Consistency of your performance and dependability
Responsive – Your willingness or readiness to provide service
Competence – The possession of the required skills and knowledge, by the employee, to provide the service
Access – Organization approachability and ease of contact
Courtesy – Politeness, respect, friendliness of contact personnel
Communication – Keeping stakeholders informed in language they understand, listening
Credibility – Trustworthiness, believability, honesty, stakeholder’s best interest at heart
Security – Freedom from danger, risk, or doubt
Understanding/Knowing – Efforts to know stakeholder’s needs
Tangibles – Physical evidence of service; buildings, appearance of personnel; tools used to provide service; other employees in facility
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SLIDE 19
My father worked in a small business in a small town selling hardware
and building supplies. He certainly never thought of himself as an
entrepreneur, although that is what he was. When he talked about
business, he never discussed money. He talked about customers – keeping
them loyal to his company, assuring that there was a noticeable return on
investment for the customer in every transaction and listening to what the
customers said so the company could respond.
My father once told us about a farmer who had quit coming to the store
after many years of being a good customer. My dad drove out to the
man’s farm to see why he was no longer buying from the store. The
farmer said simply the he had asked one of the employees to extend his
credit, and the employee had said no. No explanation, no recognition of
his patronage.
“Why didn’t you come to me?” Dad asked.
“Shouldn’t have to,” the farmer said, simply. - Sara M. Freedman, Dean
Spears School of Business 2006-2009
SLIDE 20
“Responsiveness”
Your willingness or readiness to provide service
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SLIDE 21
Some day the door may be for the dog
SLIDE 22
A lion once met a tiger as he drew beside the pool.Said the tiger, “Tell me why you’re roaring like a fool.”
Advertising
A rabbit heard them talking and he ran home like a streak.Thought he’d try the lion’s plan, though his roar was just a squeak.
“That’s not foolish,” said the lion, with a twinkle in his eye;“They call me King of Beasts, because I advertise.”
A fox came to investigate – had dinner in the woods.So when you advertise, my friends, . . .
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SLIDE 23
Be Sure You Got the Goods
SLIDE 24
Contact us for programs to be offered on‐site at your organization
Web: www.cepd.okstate.edu
Twitter: @OSUCEPD
Facebook: OSUCEPD
Phone: 405‐744‐5208
THANK YOU!
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Michael CookDirector, Long Term Care ServiceOklahoma State Department of Health
Long Term Care UpdateJune 25, 2018
13 Teams – Team Supervisor & 4 Surveyors• 65 Positions ‐ 63 Filled & 2 Vacancies • 45 Trained – Passed the SMQT• 20 Training
Staffing
Workload (CMS Mission & Priority Document)• Tier 1 (Recertifications & IJ Complaints)• Tier 2 (NIJH, NIJM, NIJL Complaints)• Tier 3 (Initials) 3 to 6 months• Tier 4• Other (Revisits) 60 to 90 days
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SB 142 – no long‐term care resident shall be prescribed or administered an antipsychotic drug that was not already prescribed to the resident prior to admission to the facility unless certain conditions have been satisfied
Bills
SB 201 – Personal degradation" means a willful act by a caretaker intended to shame, degrade, humiliate or otherwise harm the personal dignity of a vulnerable adult
SB 280 – An Act relating to long‐term care which relates to nursing facility incentive reimbursement rate plan
SB 888 – Persons who are fifty‐five (55) years of age or older, or their legal guardians or lay caregivers, shall receive options counseling for long‐term care prior to admission to a long‐term care facility
Section 1864 of the Social Security Act (the Act) establishes the framework within which SAs,
under agreements between the State and the Secretary, carry out the Medicare certification
process. Sections 1902(a)(9) and (33) of the Act stipulate that the same agency is authorized to
set and enforce standards for Medicaid. (The SA may partially redelegate the functions to local
agencies.)
42 CFR 488 requires the SA to perform surveys to support its certifications. 42 CFR Part 431,
Subpart M, sets forth the functions the SA performs for the SMA. SAs perform initial surveys and
periodic resurveys of all providers and certain kinds of suppliers. These surveys are conducted to
ascertain whether a provider/supplier meets applicable requirements for participation in the
Medicare and/or Medicaid programs, and to evaluate performance and effectiveness in rendering
a safe and acceptable quality of care.
Although the regional office (RO) is ultimately responsible for deciding whether a
provider/supplier may participate in the Medicare program, certification is an SA function. After
the SA completes an inspection for the Medicare program, it submits evidence and a certification
recommendation for a final RO determination. When the SA certifies for Medicaid purposes, it is
reporting its own adjudicative determination.
Certification – Medicare/Medicaid
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RecertificationComplaintsRevisitsInitialsLife Safety CodeState Monitoring SurveysFederal Comparative SurveysFederal Monitoring Surveys
Investigations ‐ Types
Surveyor (provide initial findings)Team SupervisorCoordinator (G or Higher)Manager of SurveyIDR/IIDR (Panel of Peers)Director of Long Term Care ServiceCMS Regional Office (G or Higher)Hearing (35% Reduction, Federal ALJ)CMS Central Office ($250,000)
CMS‐2567 Official Statement of Findings
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Thank You
PBJ – Payroll Based Journal• RN Hours 8 consecutive hours a day 7 days a week
• Weekend Hours
FRIs – Facility Reported Incidents
Abuse, Neglect, Misappropriation
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Final Phase of Regulation Implementation• Phase III Requirements• November 28, 2019
Appendix Q – Immediate Jeopardy Determination
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FFY 2014 FFY 2015 FFY 2016 FFY 2017 FFY 2018
NFs 316 311 307 308 309
ICF/IID 88 88 85 87 89
Providers
Surveys
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NFs OTC AH IJ Total NFs OTC AH IJ Total
FFY 2014 3569 138 77 3784 FFY 2014 94.3% 3.6% 2.0% 100.0%
FFY 2015 3314 104 103 3521 FFY 2015 94.1% 3.0% 2.9% 100.0%
FFY 2016 2652 85 47 2784 FFY 2016 95.3% 3.1% 1.7% 100.0%
FFY 2017 2593 133 77 2803 FFY 2017 92.5% 4.7% 2.7% 100.0%
FFY 2018 2419 94 37 2550 FFY 2018 94.9% 3.7% 1.5% 100.0%
Michael CookDirector, Long Term Care ServiceOklahoma State Department of [email protected]
THANK YOU!
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Quality Measures and Composite Scores
Beverly ClarkManager of Training
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Using Data To: View the Past and Predict the Future• MDS• CASPER• LTCSP• QAPI
Using Data To: View the Past and Predict the Future• MDS• CASPER• LTCSP• QAPI
CASPER Access
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Quality Measures and Composite Score
• CMS tracks 13 Quality Measures• Composite Score target 6.0• Data is tracked at the Facility, State, Region
and National level• Reports are available through CASPER
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Quality Measure Intended Purpose
Four intended purposes:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html
• To give data to the nursing home to help them in their quality improvement efforts.
• Provide information to facilitate discussions with the nursing home staff regarding the quality of care; and
• Provide information about the care at nursing homes where residents already live;
• Provide information about the quality of care at nursing homes in order to help residents/families to choose a nursing home;
Quality Measure and Composite Score Report
• Surveyors have been providing reports at the time of the recertification survey
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Quality Measure and Composite Score Report
• Surveyors also provide a booklet with resources to support Quality Improvement
Surveyor’s Perspective
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Support Resources
• Oklahoma CMP Fund Program• OFMQ• TMF Health Quality Institute• QIES/MDS Help Desk• Others
Quality MeasuresWhy are they important to you?
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Working together, We can improve Quality
Care
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Oklahoma Long Term Care Provider Training:
Implementation Phase 3and Proposed Changes To
Promote Efficiency, And Transparency
Theresa Bennett, RN, BSN
Technical Advisor
Dallas Division of Survey & Certification
214-767-4406
Abuse: F607
CFR 483.12(b)(4) Establish coordination with the QAPI Program at 483.75The facility must develop written policies and procedures that define how coordination with the QAPI program will be operationalized as identified under the QAPI program.Note: As related to Abuse, all substantiated cases of physical and/or sexual abuse are high risk problems that require corrective actions be tracked by the QAA Committee. Deprivation of Care by an individual (neglect) is by definition abuse.
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F607 continued
• Facility Policies must identify which cases of abuse, neglect, misappropriation of resident property, and exploitation should be considered as a high risk quality concern that would be referred to the QAA Committee.
• Substantiated or actual cases of physical or sexual abuse for example by facility staff or other residents, are always considered to be high risk problems for which corrective action is required and must be tracked by the QAA Committee.
483.21 Comprehensive Resident Centered Care Plans: F659
The services provided in the facility based on a care plan must be provided by qualified staff. To be considered qualified or competent they must be able to provide care that is culturally-competent and trauma –informed.
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483.21(b)(iii)Cultural Competency Includes
Regulation states culture includes language, cultural preferences, and other cultural concerns such as customs, beliefs, and values. Culture may consist of racial healing, wellness, and the delivery of health services that are focused on reducing health disparities.
Trauma Informed Care (Quality of Care) F699The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
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Governing Body(GB) - F837
The GB is a part of Administration 483.70.
The governing body is responsible and accountable for the QAPI program. This accountability is stipulated at QAPI §483.75(f) Governance and Leadership.
483.75(f) Governance and Leadership
GB has full legal authority and responsibility for operation of the facility to include ensuring that: An ongoing QAPI program is defined, implemented and maintained, and addresses identified priorities.The QAPI program identifies and prioritizes problems and opportunities based on performance indicator data, and that corrective actions address gaps in systems. Clear expectations are set around safety, quality, rights, choice, and respect.
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QAPI/QAA Program/ Data Collection and Monitoring: F866
The Infection Preventionist (IP) is responsible for the QAPI program as related to Infection Control for the facility. • This includes the Antibiotic Stewardship program
and incidents such as HAI’s on a regular basis, but at least quarterly.
• The IP must report on facility processes, outcome surveillance, and outbreaks (ongoing since last meeting), occupational health of communicable diseases such as Influenza, and use of antibiotics along with drug resistant data.
QAPI Phase 3 Related to Implementation F867• 483.75 a(1,3-4), b, f; 483.73 c (1-4); 483.75 d (1-2 i-iii) e (1-3);483.75 g (2 iii)
Quality Assessment Performance Improvement (QAPI) - Includes program systems analysis, and actions to address systems issues, and reports demonstrating systemic identification, investigation, analysis, and prevention of adverse events. Also reports demonstrating the development, implementation, and evaluation of performance improvement activities.
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Suggested Care Areas: High Risk, High Volume, Problem-Prone For QAPI Oversight
• Tracheostomy Care• Pressure Injury Prevention• Administration of high risk medications such as Coumadin, Insulin,
and Opioids• Transcription of orders• Medication Administration• Laboratory Testing• Call light response times
Quality Assessment and Assurance - F868
The Infection Preventionist is a required member (total of 5)of the QAA committee, along with the DON, Medical Director, and either the administrator/owner/ board member, or person in other leadership role.
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Infection Preventionist F882
Qualifications and Role – Can be one or more individuals who will be responsible for the Infection Prevention Control Program (IPCP).• Must have primary training in nursing, medical technology,
microbiology, epidemiology, or other related field; be qualified by education, experience, training, or certification; be employed by facility at least part-time, and completed specialized training in infection prevention and control.
• Will be a permanent member of the QAA committee.The regulation lists responsibilities of the IP that must be included in the IPCP.
Compliance and Ethics F895 – CFR 483.85 (a-e)
This is a program of the facility operating organization. • It is designed, implemented, and enforced so that the
organization is effective in preventing and detecting criminal, civil, and administrative violations and in promoting quality of care.
• Establishes written compliance ethics standards, policies, and procedures that are capable of reducing the prospect of criminal, civil, or administrative violations.
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Compliance and Ethics continuedSpecific individuals within the high level personnel of the operating organization are assigned to oversee the compliance and ethics program such as the CEO, members of the board of directors, or directors of major divisions.
There must be consistent enforcement of violations.
Special consideration for organization with five or more facilities.
Special consideration for operating organization with five or more facilities: annual mandatory training on the compliance & ethics program; designated compliance officer; designated compliance liaisons; and an annual review.
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Resident Call System F919, 483.90 (g)(1)
The facility must adequately equip to allow for residents to call for staff assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area for each resident’s bedside.
General Training Requirements F940
The facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under contractual arrangement; and volunteers consistent with their expected roles. They must determine the amount and types of training necessary based on the Facility Assessment.
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Training Topics Must Include but are not limited to:• Communication• Resident’s Rights and facility responsibilities• Abuse, Neglect and Exploitation to include: activities that
constitute abuse, neglect, exploitation, and misappropriation; procedures for reporting incidents; dementia management and abuse prevention
• Infection Control• Compliance and Ethics with an effective way to communicate
each facility’s program and an effective way to communicate the program’s standards, policies, and procedures.
Training Topics continued• Required in-service training for nurse aides – no less
than 12 hours per year to include: • Dementia management• Resident Abuse Prevention• Address individual weaknesses based performance
reviews and the facility assessment• Required training for feeding assistants• Care of the cognitively impaired• Behavioral Health which includes trauma informed care &• Culturally competent care
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Proposed Rule Changes For LTC, July 18, 2019
•Comments due September 16, 2019
•42CFR 410, 482, 483, 485, and 488
Revision to Requirements Phase One and Phase Two
• 483.10 Resident Rights – Require facilities to provide resident on admission physician’s name and contact info, with any change to this info, or upon resident’s request.
• Revise grievance policy requirements to include removing prescriptive requirements for written grievance decisions, removing official duties for grievance official, and reducing time to maintain evidence of grievances to 18 months.
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Changes continued for Phase 1 and 2 Regulations
• 483.15 Admission/Discharge/Transfer – Requiring facilities to send discharge notices to the Ombudsman for facility-initiated involuntary transfers and discharges.
• 483.25 Quality of Care – modify requirement to focus on “appropriate” use of bed rail and eliminate reference to “instillation of rails”.
• 483.35 Nursing Services – reduce retaining of daily staffing data to 15 months.
Proposed Changes Continued Phase 1 & 2• 483.40 Behavioral Health – remove requirements that
are duplicative.• 483.45 Pharmacy Services – Remove language
requiring that PRN prescriptions for antipsychotics cannot be renewed unless the attending physician evaluates the resident and allows the physician to extend the prescription with documentation of rationale.
• 483.60 Food and Nutrition – revise qualifications for director of food and nutrition to 2 years of experience or completed minimum course in food safety, and frequent consultation with dietitian
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Changes Phase 1 & 2 Continued• 483.70 Administration – Reduce the facility assessment review to
every two years.• 483.90 Physical Environment – Propose older existing LTC facilities to
continue to use FSES 2001. This would allow older facilities who may not meet FSES 2012 to remain in compliance without incurring substantial expenses. Also propose that only newly constructed and newly certified that have never been a nursing home be required to have no more than two residents per room and equip each room with a bathroom, sink, and commode. This would remove unintended disincentives to purchase facilities or make upgrades to existing facilities.
Technical corrections
• Revise IDR and IIDR processes by ensuring that administrative actions are processed timely, and providers understand the outcomes of results.
• Propose to eliminate requirement that facilities actively waive their right to a hearing in writing and create a waiver process that operates by default when CMS has not received a timely request. The 35% penalty reduction would remain.
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Phase 3 - We propose to delay the implementation of the following requirements for one year from
the effective date.
First: 483.75 Quality Assurance and Performance Improvement (QAPI) We are removing prescriptive requirements to allow facilities greater flexibility to tailor their program to the specific needs of their specific facility.
Phase 3 ContinuedSecond: 483.80 Infection Control Propose to remove the requirement that the Infection Preventionist work at the facility “part-time”orhave frequent contact with the IPCP staff at the facility. Instead, we will require that the facility must ensure the IP has sufficient time at the facility to meet the objectives of its IPCP. CMS is specifically asking for comment solicitations on this proposal.
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Phase 3 Continued
Third: 483.85 Compliance and Ethics Program:CMS proposes to remove many requirements that are not stated in the statute. Revisions proposed include removing requirements for the compliance officer and compliance liaisons. Also revising the requirement for reviewing the program from annually to biennially.
Thank you!Questions?
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Oklahoma Long Term Care Provider Training: Immediate
Jeopardy (IJ) Update 2019
Theresa Bennett, RN, BSN
Technical Advisor
Dallas Division of Survey & Certification
214-767-4406
Introduction to Appendix Q
What is Appendix Q?
When is it used?
How is it used?
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Key Changes to Appendix Q• Aligns with regulatory definitions of IJ;• Removes “Culpability” and “Potential”;• Replaces “Immediacy” with “Need for Immediate
Action”;• Defines key terms such as likelihood and serious
harm;• Establishes three components that surveyors must
identify to determine IJ; and • Incorporates Psychosocial harm and Reasonable
Person Concepts for all providers and suppliers
What is the Basis of IJ?
Federal Regulations (SNF, NF & SNF/NF)Immediate Jeopardy means a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident.
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Key Definition: Recipient at Risk
This is an individual who, as a result of noncompliance, and in consideration of the recipient’s physical, mental, psychosocial, or health needs, and/or vulnerabilities, is likely to experience a serious adverse outcome.
Key Components of IJ•Noncompliance with one or more Federal health, safety, and /or quality regulations;
•That has caused or makes likely to cause serious harm, injury, impairment, or death; and
• Immediate action is necessary to prevent the occurrence or reoccurrence of serious harm, injury, impairment, or death to one or more recipients
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Key Definition: Removal Plan
A removal plan encompasses steps that include actions the entity has taken or will take immediately to address the
noncompliance that resulted in or made serious injury, serious harm, serious
impairment, or death likely.
IJ TEMPLATE COMPLETED BY SURVEY TEAM
• If all three components of IJ are identified on the template, consultation will be done with the State Office prior to informing the facility.
•The provider will be given a copy of the template or templates by the survey team, and
•A plan of removal will be requested.
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WHEN IS IJ REMOVED?
A PLAN OF REMOVAL IS ACCEPTABLE AND APPROVED;
THE PLAN IS FULLY IMPLEMENTED;
NO RECIPIENT IS CURRENTLYEXPERIENCING SEROUS HARM, INJURY, IMPAIRMENT; AND/OR
SERIOUS HARM, INJURY, IMPAIRMENT OR DEATH IS NOT LIKELY.
TERMINATION FOR IMMEDIATE JEOPARDY
Termination can occur as soon as 2 days, and no later than 23 days
Compliance is not necessary to avoid termination; only removal of IJ.
An onsite revisit will be necessary to avoid IJ termination if not removed prior to exit.
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What you need to know when IJ is not removed prior to exit
• If IJ is not removed prior to the exit, a notice is sent by the Survey Agency within 2 calendar days with the IJ findings, a request for a plan of removal to include an allegation of removal, and notice of imposition for remedies as authorized by CMS RO;
• The State Agency will notify the RO that IJ was called and not removed within two business days of the survey exit by email or fax; and
• The RO will review the IJ findings from the State, and issue a notice of termination in 23 days if IJ is not removed.
Additional Information For You
Appendix Core QSubpart Long Term Care (LTC)IJ Template
QUESTIONS!
Date/Time IJ Template provided to entity:
IJ Component Yes/No
Noncompliance: Has the entity failed to meet one or more federal health, safety, and/or quality regulations?If yes, in the blank space, briefly summarize the issues that lead to the determination that the entity is in noncompliance with the identified requirement. This includes the action(s), error(s), or lack of action, and the extent of the noncompliance (for example, number of cases). Use one IJ template for each tag being considered at IJ level.
Yes No
(circle one)
Serious injury, serious harm, serious impairment or death:Is there evidence that a serious adverse outcome occurred, or a serious adverse outcome is likely as a result of the identified noncompliance?If Yes, in the blank space, briefly summarize the serious adverse outcome, or likely serious adverse outcome to the recipient.
Yes No
(circle one)
Need for Immediate Action:Does the entity need to immediately develop a Plan of Removal related to the noncompliance that has caused or is likely to cause serious injury, serious harm, serious impairment, or death?If yes, in the blank space, briefly explain why.
Yes No
(circle one)
Immediate Jeopardy Template
Preliminary fact analysis which demonstrates whether key component exists.
Disclaimer: The findings on this IJ Template are preliminary and do not represent an official finding against a Medicare provider or supplier. Form CMS-2567 is the only form that contains official survey findings.
AND
AND
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Freedom fromAbuse, Neglect and Exploitation
Beverly Clark, MSManager of Training
483.12 Freedom from Abuse, Neglect, and Exploitation
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2018Deficiencies were written
for 7 of the 10 tags
# of Citations % Providers Cited
F607 – Develop Policies/Procedures 30 citations (9.7 %)
F609 – Reporting Alleged Violations 28 citations (9.1 %)
F610 – Invest/Prevent/Correct 21 citations (6.8 %)
Alleged Violations
F600 – Free from Abuse and Neglect 11 citations (6.0 %)
F604 – Free from Physical Restraint 5 citations (1.6 %)
F602 – Free from Misappropriation/ 1 citation (0.3 %)
Exploitation
F608 – Reporting Reasonable 1 citation (0.3 %)
Suspicion of a Crime
Antipsychotic Medication and Dementia: More Hugs…Less Drugs
Melody Malone, PT, CPHQ, MHAQuality Improvement ConsultantTMF Health Quality Institute
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TMF CMS QIOWe are your CMS QIO. We are here for you. The Centers for Medicare & Medicaid Services has charged the
Quality Innovation Network Quality Improvement Organizations (QIN‐QIO) with implementing strategies facilitating quality improvement throughout the health care system.
The TMF QIN‐QIO partners with providers and stakeholders throughout Texas, Arkansas, Missouri, Oklahoma and Puerto Rico to meet objectives in support of the National Quality Strategy aims.
Partnering with the QIO program enables you to make difference in your own community while contributing to national health quality goals that benefit all Americans. It’s an opportunity to share your organization’s experience and proven solutions with a broader community.
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ObjectivesAt the end of this presentation the learner will be able to:
List three alternatives to antipsychotic drug use
Describe the quality improvement process
Develop a plan to improve dementia care
Develop a plan to address facility practices regarding inappropriate use of antipsychotic drugs
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Is dementia a mental illness?NO.
Dementia is a cognitive decline.
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What does dementia… …look like?
…sound like?
…feel like?
Cause? What emotions?
› In the resident?
› In the staff?
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What is it like to have dementia?
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Getty Images
What is it like to have dementia?
Getty Images
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What is a behavior?
Communication of
an Unmet Need
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Unmet needs look like: Resisting care
Biting
Hitting
Pacing/wandering
Screaming
Yelling
Making noise
Lashing out
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10
15
20
25
Antipsychotic Medications(Long‐Stay)
Recruited Facility Average All of Oklahoma National Average
Casper QM 11/1/18‐
5/31/19 16.7%
Anticholinergics Side EffectsMore pronounced in the elderly:
Mnemonic: Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter.
Drowsiness or sedation
Blurred vision
Dizziness
Urinary retention
Confusion or delirium
Hallucinations
Dry mouth
Constipation
Reduced sweating and elevated body temperature
Falls and risk for fracture
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Resources Medications to Avoid in the Elderly, according to Beers Criteria and STOPP Criteria
Antipsychotic Medication Reference
TMFQIN.org: Reducing Antipsychotic Medication Use (login required)
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How do you fill the void…...of medication reduction?
Address the unmet need
Use non‐pharmacological approaches
Address pain
Identify and address other medical issues:
› Anxiety
› Depression
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Where do we start?Resident‐focused:
The person is more important than the system
The system should serve the needs of those within it
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Person‐Centered Care We’ve got to know the people we serve
We need to know their story
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Know your residents What did they do in their lives?
What made their lives meaningful?
What was important to them?
What might be potential problems?
What do they like to see, smell,touch, taste and hear?
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What do you know about your residents?
Likes/dislikes
› When they like to shower, wake, go to bed, eat
› Where they like to sit
How much assistance they need
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Assess what the unmet need is telling you:
Pain
Loss of function
Inability to do what they want to do
Fatigue
Confusion
Boredom
Fear
Discomfort
Hunger
Need to go to the bathroom
Sleep deprivation
Lack of control in their daily care, etc.
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Facility PracticesWhat are things we do as staff, owners and operators that could be contributing to residents’ unhappiness?
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Facility Practices Change of routine
› Resident vs. facility
› Meals, bathing, etc.
Noise
› Alarms
› Change of shift
› Staff chatting
› TVs and radios competing for air time
Change of layout
› Resident’s room
› Unit/neighborhood
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Facility Practices Sleep patterns
Lights at night
› How we approach residents
› Body language
› Turning and repositioning
• Turning for Ulcer ReductioN (TURN) Study
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Care Process for a Resident with Dementia Interdisciplinary team
Focus on needs of the resident and other residents
Systematic care process
A. Recognition and assessment
B. Cause identification and diagnosis
C. Development of care plan
D. Individualized interventions and treatment
E. Monitoring and follow‐up
F. Quality assessment and assurance
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ResourceCMS’ Critical Element Pathways
Dementia Care
Behavioral and Emotional Status
Abuse
Pain Recognition and Management
Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review
TMFQIN.org: CMS Documents and Links (login required)
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Staff Skills and Qualifications Medical, nursing, mental, and psychosocial needs
Effectively interact with residents
› Approach
› Body space
Identify indications of distress
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Resources CMS’ Hand in Hand: A Training Series for Nursing Homes Toolkit
Update of Quality Concerns in Dementia Care –Why Doctors Should Rarely Prescribe Antipsychotics in Texas Nursing Homes Webinar
MUSIC & MEMORY®
TMFQIN.org: Resources for Reducing Antipsychotic Medication Use (login required)
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So, where do we go from here?
Use the quality improvement process.
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The most fundamental reason a problem has occurred:
When performance does not meet expectations.
112
The root cause is…
Getty Images
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What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in an improvement?
Model for Improvement
Act Plan
Study Do
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The PDSA Cycle for Learning and Improvement
Act
• What changesare to be made?
• AdApt?, AdOpt?or Abandon?
• Next cycle?
Plan
• Objective• Questions and
predictions (why)• Plan to carry out
the cycle (who,what, where, when)
Study
• Complete theanalysis of the data• Compare data to
predictions• Summarize what
was learned
Do
• Carry out the plan• Document problems
and unexpectedobservations
• Begin analysisof the data
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Overall Goal: Person‐Centered Care
Non‐Pharm Interventions
Dementia Care Training Strategies
Assessment AccuracyMD, NursingSW, AD, Psy
Environmental Strategies
Resident and Resident Rep. Involvement
Develop Improvement Strategies for Each Component of the Root Cause 115
Goal – Improved Outcomes
Change Concepts, Theories, Ideas
Concept B
Concept CConcept D
Concept A
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Person‐Centered Care When you think you have tried every intervention, ask yourself, “What’s one more thing I can try?”
Never give up.
Never stop.
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What’s your mindset?
Embrace the challenge!
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Questions?
Getty Images
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Join the TMF QIN‐QIO Websitehttps://www.TMFQIN.org Provides targeted technical assistance and will engage providers and stakeholders in improvement initiatives through numerous Learning and Action Networks (LANs)
The networks serve as information hubs to monitor data, engage relevant organizations, facilitate learning and sharing of best practices, reduce disparities and elevate the voice of the patient
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LANsJoin any of the following TMFQIN.org networks and you can sign up to receive email notifications to stay current on announcements, emerging content, events and discussions in the online forums.
Antibiotic Stewardship
Behavioral Health
Cardiovascular Health and Million Hearts
Health for Life – Everyone with Diabetes Counts
Immunizations
Medication Safety
Nursing Home Quality Improvement
Patient and Family
Quality Improvement Initiative
Quality Payment Program
Readmissions
Value‐Based Improvement and Outcomes
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All Are Welcome To join, create a free account at www.TMFQIN.org. Visit the Networks tab for more information
As you complete registration, follow the prompts to choose the network(s) you would like to join
› Select Nursing Home Quality Improvement
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Contact
Melody Malone, PT, CPHQ, MHA
Quality Improvement Consultant
TMF Health Quality Institute
214‐632‐2238
https://TMFQIN.org
This material was prepared by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW‐QINQIO‐C2‐19‐37
08/19/2019
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MDS Coding:
Dementia and More
Diane Henry, RN, LHHAState RAI Coordinator
Objectives
After completing this session, you will be able to:• Discuss MDS items related to the
Antipsychotic Quality Measure
• Understand requirements for Gradual Dose Reduction (GDR)
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3 Key Functions of the MDS
• Generates an updated, accurate picture of the resident’s current health status.
• Assists in care planning and preventing decline of the residents status and helping to improve the resident’s status where possible.
• Generates quality measures to identify the resident’s outcome in specific areas.
MDS Section I and N:Diagnosis & Medications
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Section I MDS Items related to Antipsychotic Quality Measure
N0410 Item related to Antipsychotic Quality Measure
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Four Key Coding Tips• Does the resident have a diagnosis of:
– Schizophrenia (MDS Item I6000)– Tourette’s Syndrome (Item I5350)– Huntington’s Disease (MDS Item I5250)
• Code medications according to classification, and not how it is being used
• Code medications in all classifications
• Only code the medication if given in the look-back period
N0410 & N450Antipsychotic Medications
• Antipsychotic Medications = potential adverse outcomes– Determine lowest possible dose to achieve
the desired therapeutic effects– N0450: During the first year, a gradual dose
reduction (GDR) is required, as long as not contraindicated
– N0450 is NOT used in the calculation of the antipsychotic quality measure
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Ask These Questions…..
• Are psychotropic medications only being used when appropriate?
• Have less restrictive interventions been attempted prior to administering psychotropic medications?
• What is the resident trying to communicate through behaviors?– Have we ruled out underlying causes? Pain?
Boredom? Incontinence?
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“The most important [message] is that we need to change the way we look at people with dementia. We need to see the whole person, what their strengths are, and not just their disability.”
--Dr. Allen Power, M.D.
The Oklahoma State Department of Health (OSDH) does not promote
or endorse specific tools, products or organizations that may be
mentioned in this presentation.
08/19/2019
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Questions
Diane Henry, RN, LHHAState RAI Coordinator
QIES Help Desk405-271-5278
[email protected]@health.ok.gov
