Nursing Staff Competencies...has met competency evaluation requirements unless the individual: • Is a full-time employee in a training and competency evaluation program approved

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Consulting | Talent | Training | Resources

Nursing Staff CompetenciesMeeting & Exceeding Expectations for F726

Montana Hospital Association

Fall Convention and Trade Show

September 20, 2018

Louann Lawson, BA, RN, RAC‐CT, CIMT


© Pathway Health 2018

Objectives

Upon completion of this presentation, participants should be able to:

1. Describe the essential elements of a nursing competency

2. Learn the steps necessary to create a learning tool to show competency

3. Identify core clinical competencies

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Provider Knowledge & Skills

• Knowledge of local culture• Respect shown to consumers• Beliefs about what consumers value• History / reputation in community• Availability of continuum of care• Education, competency, skills of staff• Evaluation of facility training program for staff and

volunteers• Human resources• Convenience• Insurance contracts – who can you take• Community Involvement9/4/2018

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© Pathway Health 20189/4/2018

Clinical Competency is a MUST!



Nursing Services F Tags

F725 – Sufficient Nursing Staff

F726 – Competent Nursing Staff

F727 – RN 8hrs, 7 days/week, Full Time DON

F728 – Facility Hiring & Use of Nurse Aides

F729 – Nurse Aide Registry Verification, Retraining

F730 – Nurse Aide Performance Review – 12 hours/year In-service

F731 – Waiver – Licensed Nurses 24 Hours/Day and RN Coverage

F732 – Posted Nursing Staffing Information

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

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Training Requirements for Phase 2 (11/28/2017)

Regulatory Area Training Requirements

Resident Rights Add: Aging & Disability Resource Center & Medicaid Fraud Control Unit Contact Information (email too)

Admission, Transfer, Discharge

Transfer & DC Documentation

Person Centered Care Planning

Baseline Care Plan (48 hour care plan)

Nursing Services Nursing Staffing Plan & Competencies/Skills

Behavioral Health Services

Dementia Care

Pharmacy Services Medical Chart Review & Psych Meds

Dental Services Loss or Damaged Dentures Policy

Referrals and Transportation

Provision of Services

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Regulatory Area Training Requirements

Food and Nutrition Services Dietary Staffing Plan

Ethnic, Cultural, & Religious Preferences

Administration Facility Wide Resource Assessment

Quality Assurance & Performance Improvement

Provide initial QAPI plan to survey team

Infection Control Incorporate Infection Control into FWRA

Antibiotic Stewardship Program

Physical Environment Smoking Policies




F940 - General

F941 - Communication

F942 - Resident Rights

F493 - Abuse, Neglect, and Exploitation

F494 - QAPI

F495 - Infection Control

F496 - Compliance and Ethics

F949 - Behavioral Health Trauma Informed Care


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Facility Training Program

To ensure any training needs are met for:

• New Staff

• Existing Staff

• Individuals providing services under a contractual arrangement

• Volunteers

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Facility Training Program

• Consistent with their expected job roles

• What policies are required

• Review job descriptions

• Do they meet professional standards of practice

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Nursing

Take into account the responsibility that certain types of staff have such as RNs and LPNs overseeing the medical management of residents with regard to:

• Medications

• Fall Prevention

• Pressure injuries

• Readmission to the hospital

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F726 – Competent Nursing Staff

“Facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related

services to assure resident safety

And

Attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident as determined by:

1. Resident Assessments

2. Individual Plans of Care

3. Considering number, acuity, and diagnoses of population in accordance with the facility assessment


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Operationalizing F726

Facilities will need to determine nursing services competencies - and how do they do that?

1. Ensure that the individual has had appropriate educational preparation

2. Verify certification, registration or licensure from the State Registry or Professional Board

3. Ensure new staff meet a level of competency by verifying skills

4. Ongoing education based on facility assessment, staff need, new regulations, etc.

5. Return verification of competency

• Post tests

• Return demonstration

• Skills check lists

• Etc.

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F726: Overview of 483.35

“§ 483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.

§ 483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs.”


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Competencies

• Evaluating the ability to perform a task based on clinical skills, knowledge, education, and experience

• Ongoing (Assess, monitor, maintain, and improve skills)

• To prevent negative outcomes

• To provide excellent care and treatment

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Competency Example r/t Types of Care

Dementia Care Unit

Competencies Required:

• Dementia Care

• Behavior Training

• Medication Management

• Activities for Dementia Care

• ADLs

• Chronic disease management

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Proficiency of Nurse Aides

Facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for resident needs as identified through resident assessments and described in the plan of care.


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Example: Peri-Care Return Demonstration

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Competency Definition

“A measurable pattern of knowledge, skills, abilities, behaviors and other characteristics that an individual needs to perform work roles or occupational functions successfully”

All nursing staff must also meet the specific competency requirements as part of license and certification requirements defined under state law or regulation.

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Competencies listed in SOM

• Preventing and reporting abuse, neglect, and exploitation

• Dementia management

• Infection Control

• Competencies related to an approved nurse aide training and evaluation program

• Medication management

• Change in condition

• Resident rights

• Person-centered care

• Communication

• Basic nursing skills

• Basic restorative services

• Skin and wound care

• Pain management

• Cultural competency

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Example: Change in Condition

Be able to identify and address a change in condition

Demonstrate effective actions to address a change in condition

Nurse aide – document and inform supervisor

Licensed nurse – data collection and assessment/evaluation, inform practitioner or physician

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Available Tools

Detecting and communicating a change in condition

AHRQ – Agency for Health Care Research and Quality

https://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/ltcmodule1.html

INTERACT

www.pathway-interact.com

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SNF VBP: SNFRM 10/1/18

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Cultural Competency

A set of behaviors and attitudes held by clinicians that allows them to communicate effectively with individuals of various cultural backgrounds and to help provide care that is appropriate to the culture and the individual

1. Cultural responsiveness

2. Cultural awareness

3. Cultural sensitivity

National Center for Cultural Competencyhttps://nccc.georgetown.edu/index.html

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Examples of Evaluating Competency

• Lecture with return demonstration for physical activities

• A pre-test and post-test for documentation issues

• Demonstrated ability to use tools, devices, or equipment that were the subject of the training an used to care for residents

• Reviewing adverse events that occurred as an indication of gaps in competency

• Demonstrated ability to perform activities per scope of practice as in license or certification (skills fair)

• Annual Review


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Competency Based Training Program

a. Evaluates current staff training program to ensure competencies

b. Identifies gaps in education that may contribute to poor outcomes

c. Outlines what education is needed based on resident population

d. Delineates what specific training is needed based on facility assessment

e. Details the tracking system used to ensure competency program is assessing, planning, implementing, and evaluating effectiveness of training

f. Ensures the competency training is not limited to online computer based but also test for critical thinking skills as well as the ability to manage care in complex environments with multiple interruptions


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F727 – Registered Nurse

• Facility must use the services of a registered nurse for at least 8 hours per day, 7 days per week unless there is a waiver in place

• Facility must designate a registered nurse to serve as the Director of Nursing on a full time basis unless there is a waiver in place (35 or more hours)

• Director of Nursing may serve as the “charge nurse” only when the facility has an average daily occupancy of 60 or fewer residents


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F728 – Hiring & Use of Nurse Aides

Facility must not use any individual working in a facility as a nurse aide for more than 4 months, on a full time basis unless that individual:

• is competent to provide nursing and related services

• has completed a training and competency evaluation program or a competency evaluation program approved by the State as meeting the requirements

• has been deemed or determined competent


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Temporary Employees

Facility must not use on a temporary, per diem, leased, or any basis other than a permanent employee any individual who does not meet the requirements

***Agency or any other staff use does give us a “pass” on the requirements


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Minimum Competency

Facility must not use any individual who has worked less than 4 months as a nurse aide in a facility unless the individual:

• Is a full time employee in a state-approved training and competency evaluation program

• Has demonstrated competence through satisfactory participation in a state-approved nurse aide training and competency evaluation program or competency evaluation program or

• Has been deemed or determined competenthttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf9/4/2018

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F729 – Registry Verification

Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless the individual:

• Is a full-time employee in a training and competency evaluation program approved by the state or

• Can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the state and has not yet been included in the registry (facility must follow up to ensure that the individual actually becomes registered)


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Multi-State Registry Verification

“Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry that the facility believes will include information on the individual”


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Required Retraining

If there has been a continuous period of 24 months since the individual has provided nursing or related services for monetary compensation, the individual must complete a new:

(NATCEP) Nurse Aide Training and Competency Evaluation Program

Or

(CEP) Competency Evaluation Program

***Prove one 8 consecutive hour day of nurse aide work in 24 months to keep currenthttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf9/4/2018

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F730 –Regular In-

Service Education

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• Facility must complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews

• Each nurse aide must have no less than 12 hours of in-service education based on their individual performance review

• Calculate the date due by the employment date rather than the calendar year




In-Service Education Probes

• What is the process for reviewing the performance of your nurse aides?

• How are these reviews documented and does the documentation reflect at least 12 hours of in-service training per year based upon the aide’s individual performance review?

• What is your evidence that you can produce that demonstrates the in-service education provided addresses

o Areas of weakness identified on the performance review

o Special resident needs

o Needs of residents with cognitive impairments 9/4/2018



§ 483.40 Behavioral Health Services

§ 483.40(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population


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Change of Condition -All Staff

All staff will need to be aware of the facility protocol for identification and communication of a resident with an early, acute change of condition in order for the nurse to evaluate and provide approaches to prevent resident decline or hospitalization whenever possible



Example: Building Nurse Competencies

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Clinical Competence

Assess clinical competencies

Basic Skills (head-to-to assessment skills)

Disease state competencies

Technology competencies

Right Individual in the Right Role

Engage vendors

Lab

Radiology

Tele-health

Diagnostic

Pharmacy

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A Few Questions……

• Are we confident in our preadmission process?

• Is our admission assessment and management process solid?

• Do our nurses have excellent head-to-toe assessment skills?

• Do our nurses understand disease processes?

• Do our nurses understand pharmacology related to disease processes and management?

• What is our process for comprehensive discharge care planning upon admission?

• What systems do we have in place to ensure good assessment, communication and follow through for early identification of changes in condition?



Clinical Capacity

Assess clinical capacity

Safely manage acute conditions

Disease state programs

Episodic Management

Rapid turnaround for admissions

All hours

Engage Medical Director and Physicians

Specialists

Extenders



Clinical Capabilities

ASSESS CURRENT STATUS

DETERMINE TARGETED

POPULATION

DEVELOP CAPABILITIES LIST

UTILIZE BEST PRACTICE STANDARD

TOOLS FOR COMMUNICATION

MEDICAL DIRECTOR, PHYSICIANS, AND

EXTENDERS – INPUT AND AGREEMENT

INTERNAL AND EXTERNAL

COMMUNICATION

MONITOR VIA QAPI

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Competencies

Admission Medical Record Review

a. H & P

b. Diagnosis List

c. Physician Orders

d. Lab or Diagnostic Testing

e. Consultation Reports

f. Medication and Treatment List

g. Therapy Notes

h. Wound Care Notes

i. Dietary Reports

j. Discharge Summary

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Competencies

k. Pain management needs

l. S/S or identified infection

m. B&B information (LBM, voiding status, etc.)

n. Vitals (normal? Unstable?)

o. Weight and weight history

p. Special procedures (IV’s, TPN, resp. care, etc.)

q. Abnormal (or pending)labs

r. Mood and Behavior concerns

s. Fall risk

t. Device use

u. Psychotropic drug use

v. **Medication Reconciliation



Competencies

Admission Assessment (Baseline):

• Vitals, weight, height

• Allergies

• Diagnoses

• Body Audit

• Skin Condition

• Neurological Evaluation

• Cardiovascular

• Respiratory

• Musculoskeletal

• Gastrointestinal/Genitourinary

• Oral/Dental

• Communication, Vision, Hearing

• Sleep Patterns

• Pain

• Fall Risk, Devices

• Mood/Behavior

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HOW can we create user friendly tools? Determine the Need. Identify HOW to meet the Need!

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Orientation Licensed Nurse Skills Checklist



Orientation Licensed Nurse Skills Checklist - continued

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Competencies -Building Tools

Step 1: Provide Education!CHF (Example)

Description

Classification

Right Versus Left Sided Heart Failure

Presentation

Nursing Interventions

Significant Lab Values

Symptom Management

Dietary Interventions

Respiratory Interventions

Medication Management

Practitioner Communication

Excellent Reference!American Heart AssociationClasses of Heart Failure:http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.WlTV8a6nFyw



Competencies - Test Competence (Example)

Develop your own test based upon education! Here is just an

example



Competencies – Return Demonstration

Example: Lung sounds: (Simulation devices are wonderful if possible!)

Gathering equipment

Confirming identity

Hand Hygiene

Auscultation

• Location

• Description of normal breath sounds

• Description of abnormal breath sounds

o Crackles/Rales

o Rhonchi

o Wheezes

o Pleural Friction Rub

https://www.youtube.com/watch?v=kv3B81mWc1E

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Competencies

Have we developed tools for a good cardiac assessment?• Diagnosis• History• Smoking (current, history of, ppd, etc.)• Significant diagnostics• Vitals (baseline—parameters, etc.)• Heart sounds• Pain (chest pain including descriptions)• Respiratory Assessment (Patterns, Dyspnea, lung sounds, oxygen use, etc.)• Cough/Sputum• Cognition (confusion, recent decline, etc.)• Skin (color, cyanosis, edema, diaphoresis, capillary refill, etc.)• Nausea/vomiting• Weight gain, nutrition concerns• Activity (abilities, limitations, exercise, etc.)• Sleep patterns (SOB at night, with lying flat, pain, etc.)



Competencies

Care Plan Process• Risk Factors• Diagnosis• Contributing Factors• Goals

o Person-centered/individualizedo Based upon comprehensive assessment

• Interventionso Assess/monitor (lung/heart sounds, cough, fatigue, edema, SOB, vitals, Oxygen

sats, etc.)o Oxygeno Weight Monitoring/managemento Assistance with ADL’so Paino Therapyo Diagnostics (Lab, x-ray, EKG monitoring, etc.)o Teaching/counselling (smoking cessation, diet, stress, medication management,

exercise, etc.)



Competencies

Documentation

Documentation

Documentation!

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Identification of Core Clinical Competencies

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Core Competencies for ALL Staff

• Abuse, neglect, exploitation, and misappropriation of resident property (abuse prevention)

• Resident Rights

• Dementia care and management

• Infection control

• Change of Condition identification and notification


• Areas defined by the Facility Assessment

• Emergency preparedness

• Department specific requirements and competencies

• Professional standards of practice requirements and competencies as applicable

• And other areas as defined by state/federal regulations

**Will need to ensure adequate competencies to meet your unique resident population (facility assessment)



Core Competencies for Nursing Services

Competency in skills and techniques necessary to care for residents’ needs includes but is not limited to competencies in areas such as (minimum competency requirements):

• Resident Rights;

• Person centered care;

• Communication;

• Basic nursing skills;

• Basic restorative services;

• Skin and wound care;

• Medication management;

• Pain management;

• Infection control;

• Identification of changes in condition;


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Strategies to put it ALL together!

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Steps for Developing the Process

1.Prepare a “Needs Assessment” of our Clinical Team!

a.Communication System for Changes of Condition

b.Assessment Skills of the Nurses

c.Knowledge of Disease States

d.Pharmacology knowledge for nurses

e.Comprehensive, person-centered care planning

f. Communication

g.Documentation

h.Facility wide resource assessment




2.Engage Key Players:

a.Medical Director

b.Practitioners

c.Acute Care Partners

d.Pharmacy Consultant

e.Lab/Radiology

f. Home Care, Assisted Living, Hospice entities

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3. Develop Your System

a. Policies and Procedures

b. EHR/Forms Management

c. Assessment Process

d. Care Plan Process (Including Discharge Care Planning)

e. Communication Process

f. Staff Education

g. Practitioner Education

h. Resident/Family Education

i. Evaluation and Follow-up



Action Plan

AREA OF CONCERN

RECOMMENDATIONS GOAL DATE RESPONSIBLE PERSON

Lung Assessment not completed with resident s/s “productive cough”(Pneumonia dx)

1. Nurse re-educated in assessment process with return demonstration of lung assessment.

2. Nurse re-education in documentation requirements.

3. Follow up review of assessment and documentation each shift

3/1/18

3/1/18

Beginning 4/15/18

DON or Nurse Manager





QAPI Action Plan

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Questions?





Disclaimer

“This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health.”

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Documents

Nursing Staff Competencies...has met competency evaluation requirements unless the individual: • Is a full-time employee in a training and competency evaluation program approved