Quality Indicator Survey

S 4by Cindy Luxem, CEO/President, Kansas Health Care

Association, Topeka, KS and LuMarie Polivka-West, Vice President,

Chief of Clinical Services, Florida Health Care Association

2007 American Health Care Association Annual Convention

Background A revised survey processA revised survey process Contract awarded in 2005 with University Contract awarded in 2005 with University

of Colorado to conduct demonstration of Colorado to conduct demonstration Independent evaluation of demonstration Independent evaluation of demonstration

(Abt Associates) (Abt Associates) Florida is participating in demonstration to Florida is participating in demonstration to

evaluate training model with the evaluate training model with the statewide roll out of the QISstatewide roll out of the QIS

2 Stages of the Quality Indicator Survey Stage I: Preliminarily investigate all

regulatory areas and determine care areas for in-depth Stage II review

Stage II: Determine if deficient practice, and document deficiencies including F tags, scope and severity

Stage I Entrance Entrance Conference held during which

necessary information is requested from facility (see Entrance Conference Facility Worksheet), i.e. alphabetical roster (this has been identified as a problem by AHCA)

Abbreviated Tour (concurrent to entrance conference) to provide orientation; goals are different than traditional survey tour (no selection of resident sampling)

Within One Hour Key personnel and locations Name of resident council president Meal time schedule and dining room

location All admission sample closed records

List provided to facility after entrance conference

Within Four Hours Ventilator/Dialysis/Hospice Worksheet Dialysis contract and related policies;

overview of how care is coordinated For facility dialysis: List of residents,

room, and ESRD caregiver and who provides the service (internal or external provisions)

Day and times for dialysis treatment Flu/Pneumococcal P&P

Within 4 Hours cont. Rooms with less than required square footage

that have a variance Lists of rooms: >4 residents (variance) Rooms below grade; no window to outside or

access to a corridor QA&A committee info: Contact persons,

members, frequency of meetings PASSAR information Any experimental research in the facility Complaint/Abuse/Grievance info; contact person

and P&P

Within 24 Hours… Medicare residents that have requested

demand billing since lasty survey (9-15 mo)

Medicare/Caid application (671) Resident Census and Condition (672) Copy of the OSCAR 3 Query: Is full time DON coverage

provided?

Stage I Sampling MDS sample – drawn offsite and includes

all residents with an MDS assessment within the past 6 months of the survey

Census sample - random sample of current residents (n=40)

Admission sample - random sample of new admissions (n=30)

Stage I Resident Level Investigation Resident Interviews Resident Observations Staff Interviews Medical Record Reviews Family Interviews

Stage I Facility Level Investigation Resident Council Interviews Observations of Dining and Kitchen Infection Control Practices Demand Bill Procedures Quality Assessment and Assurance

Program

Stage I Synthesis Onsite data are combined with MDS data toOnsite data are combined with MDS data to

create resident-centered outcome andcreate resident-centered outcome and

process indicators, called Quality of Careprocess indicators, called Quality of Care

Indicators (QCIs)Indicators (QCIs)• QCIs and Facility-level Tasks • MDS (includes the 24 QI) • Census • Admission • Facility

Admission Sample Review Prognosis DX LOS Discharge info (if applicable) Within 60 days of admit: Any PT, OT,

ST? Pressure ulcer, weight loss, Terminal

prognosis

Census Sample Comatose Bed mobility Transfer ICD 9 codes that focus on nutrition Stability Pressure Ulcers Psycho tropics Weight Loss

Family Interview “Want to understand why it is like to

live in this nursing home” Determine through screening the

level of resident knowledge Prior Hx Preferences; Are they honored? Choices Activities Dignity Interactions

Family Interviews Staffing - Is it sufficient? ADL Oral Health Abuse Personal property Environment Rights Costs/Funds Admission Notice of changes Care plan participation

Resident Interview

Openers: How long have you been here, are you from around here, what is the food like?

Cognitive determination

If cognitively appropriate the questions entail quality of life and care

Resident Interview Cont. Abuse: Do you ever feel afraid… Personal property Skin condition Potential restraints: device in place

that may potentially restrict movement or access to one’s body

Pain*; observations also done Food

Resident Interviews Staffing Oral Health Positioning Privacy Exercise of rights Funds Room

Staff Interviews Catheter use; reason; diagnosis Neurogenic bladder must be verified

in medical record Nutrition; supplements and reasons

for Skin Care Protocols

Facility Survey Tasks Demand Billing Dining

Frequency of meals Assistance Meal service and proper handling Dignity and independence Adequate time Positioning (maximized eating

ability)

Facility Survey Tasks cont. Atmosphere Substitutes Furnishing/space Food quality and sufficient liquids;

adequate assist as needed

Infection Control Observations for hand washing

(Competency tool) Glove use Staff with lesions? Soiled laundry process Isolation Functioning infection control program Staff adherence to P&P

Kitchen/Food Service Tour Storage Food Infection control guidelines Storage temperatures and process Food prep and service; includes

snacks, leftover storage, etc. Sanitization Equipment

Stage II Sampling Computer identifies sample such that all

triggered care areas are included with as few residents as possible

The more care areas triggered, the larger the sample

All sentinel events and complaints

Stage II Resident Level Investigation Each surveyor evaluates care process in

relation to Stage I findings Both resident-level and facility-wide

investigations Use of Critical Elements Pathways to

structure investigative process Rate severity for each resident where

deficient practice is found

Stage II Facility Level Investigations If triggered in Stage I:

Abuse Prohibition Environment Nursing service Sufficient staff Resident funds Admission, transfer, and discharge

Stage II Synthesis Combine Stage II findings across residents

into single computer by F tag Integrate survey team findings into single

statement Use documentation recorded in Stage I

and Stage II Identify deficiencies and determine

severity and scope Upload directly to 2567

Surveyor Initiative

At any time in the process,At any time in the process,

surveyors can initiate the additionsurveyors can initiate the addition

of: of: Residents Residents Care areas Care areas F tagsF tags

Medication Observation Medication administration observation is

assigned to specific surveyors during offsite preparation

Medication administration observation is conducted throughout the survey

Documentation is completed during Stage II

Medication 10 resident sample Preparation Administration: correct dose, order,

and given per ; appropriate technique and order

Storage Staff need a working knowledge of

medications Beyond the med cart = survey

success

CMS: QIS Process Strengths Larger Sample SizesLarger Sample Sizes

To identify patterns of poor care, it requires a To identify patterns of poor care, it requires a sample of adequate size to infer about facility sample of adequate size to infer about facility population. population.

Different samples (e.g., admission and census) Different samples (e.g., admission and census) emphasize different types of residents.emphasize different types of residents.

Comprehensive Past studies demonstrated that some

surveyors targeted only selected deficiencies while missing the big picture

Staged approach requires surveyors to examine all regulations

Structured Approach Systematic observations and questions are

comparable across sites and replicable Providers could use the tool to reliably

assess and improve quality on an ongoing basis

Quality Assurance Assessment QA & A: How do staff know their role

in QA? How are they kept in the loop?

How are problems identified and addressed?

How does the facility review practices to identify concerns; Committee function

Do action plans relate to the analysis of data?

Enhanced Documentation Information collected throughout the

process is collated by computer for development of 2567

Trail of findings available to follow on-site decision-making

Should be more defensible because of rates and structured findings

Citations On average modest increase in number

from previous annual survey under QIS Greater variation in citations across

surveys (higher standard deviation and interquartile range)

Zero deficiencies still occur Citations have been well documented and

infrequently overturned

Types of Deficiencies Cited at Higher Rate in QIS Quality of Life

Dignity Activity program meets individual needs

Resident Assessment Comprehensive assessments Develop comprehensive care plans

Quality of Care Facility is free of accident hazards Provide necessary care for highest practicable well being Drug regimen is free from unnecessary drugs Proper treatment to prevent/heal pressure sores

Resident Behavior and Facility Practices Persons guilty of abuse not employed Right to be free from physical restraints not required for

treatment Staff treatment of residents

Concluding Remarks Varied QIS outcomes but according to

providers, slightly higher level of deficiencies.

Resurvey protocol supposed to be similar to current survey process with a focus on deficiencies from first survey.

Complaint surveys CMS has contracted for nationwide training

of surveyors in all states over the next four years.