Risk ManagementPreparation - Prevention - Response

Janice Sumner, RNVP of Clinical Operations

HMRVSI, Inc.July 30, 2015

Risk

• The possibility that something bad or unpleasant (such as injury or loss will happen)

• Someone or something may cause something bad or unpleasant to happen

• A person that someone judges to be a bad choice for many things

Preparation

• Quality assurance program

• Current information

• Education

Prevention

• The act or practice of stopping something bad from happening

Response

• Something done as a result to something that has happened

• An incident that constitutes a reply or reaction

MDS Focused Survey Targeted Survey

• Specialized onsite surveys to access adequacy of a resident’s assessment as related to information reported to CMS

• Can not be combined with a normal recertification survey

• Can be conducted immediately after or before a compliant survey

Three areas to be evaluated

• Compliance with regulatory requirements

• Timeliness

• Compare MDS with the medical record

MDS Survey Request

• Policies and Procedures for MDS and Quality Measures

• Staffing schedule: MDS and Quality Assurance

• Resident Information

Top 5 Deficiencies

• Follow up from injury

• Pressure Ulcers

• Restraints

• Diagnosis for indwelling catheter

• Late loss ADLs

MDS Survey Results

• Increased compliance with timeliness of assessments

• Decreased compliance with supporting documentation

Electronic StaffingPBJ

• Must transmit timely and efficiently• Requires electronically submission– Includes agency and contract staff– Based on payroll/verification– Must be auditable– Uniform format

• Staffing data must include hours worked by each staff every day

Dates to Remember

• Fiscal quarter 1 October 1 – December 31

• Fiscal quarter 2 January 1 – March 31

• Fiscal quarter 3 April 4 – June 30

• Fiscal quarter 4 July 1 – September 30

Additional Dates

• Mandated July 1, 2016

• Voluntary registration August 15, 2015

Registration

• QIES System– Quality Improvement &Evaluation System

Job Descriptions

• Administrator

• Nursing Services

• Restorative Services

• Dietary Services

• Social services

• Activity Services

Additional Job Descriptions

• Physician Services

• Nursing Services

• Dietary Services

• Therapeutic Services

• Dental Services

• Mental Health Services

• Clinical Laboratory Services

• Diagnostic X-ray Services

• Housekeeping Services

• Additional Services

Food for Thought

• Create policy and procedure

• Communication with providers

• Process for information

– Timeliness

– Format of information

– Compliance to accuracy

Final Rule

• Biggest change to nursing home rules in 24 years

• Published July 13, 2015

• Open for comments 9-14-15

Goal of Final Rule

• To achieve improvement in quality of health care and resident safety through federal programs while reducing the procedural burden on providers

Significant Requirements

• Implementation of a Comprehensive Quality Assurance and Performance Program

• Required facility compliance and ethics program

Additional Changes

• Resident’s Rights

• Pharmacy Services

• Behavioral Health

• Diagnostic Services

• Dental Services

• Food & Nutritional Services

• Specialized Rehab Services

• Physical Environment

QAPI Requirements

• Facility will be required to present a comprehensive QAPI to state agency surveyors during the first annual survey after the effective date of the regulation

• Facility must develop, implement, and maintain effective comprehensive data driven QAPI program with a focus on indicators of the outcomes of care and quality of life

Elements of a QAPI

• Program activities

• Leadership

• QAA committee

• Disclosure of information

• Sanctions

Compliance and Ethics

Components

• Posted information related to reporting

• Policies for disciplinary standards

Facility Assessment and Staffing

How Will the Facility Maintain the Assessment?

• List of resident current census and facility capacity

• Care provided by resident population

• Ethic Cultural Religious

• Facility Resources

• Facility based and community based assessment

Reporting Requirements for Suspicious Crimes

• Suspicion of bodily harm must be reported in 2 hours

• Suspicion of a crime without bodily harm must be reported in 24 hours

• Suspicion of a crime must be reported to state and law enforcement

Transition of Care

• Dr Order for Transfer• Demographic • Responsible Party• Advanced Directives• Reason for Transfer• Past Medical History

• Active Diagnosis• Pertinent Lab Reports• Functional Status• Psychosocial Issues• Social Supports• Behavioral Issues

Transitional Care

• Medications

• Allergies

• Immunizations

• Smoking Status

• Vital signs

• Unique device identifiers

• Comprehensive care plan

Transition Care Form

• Recapitulation of stay

• Final summary

• Reconciliation of all medications

• Post discharge care plan

Comprehensive Care Plan

• Initial care plan within 48 hours of admission

• Goals based upon admission orders

• PASARR recommendations if applicable

ICPOInfection Control & Prevention Officer

• Must have specialized training in infection prevention and control

• Will be responsible for identifying, reporting and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors

Physician Services

• Must have a Physician, NP, or Clinical Nurse Specialist to evaluate resident before a nonemergency transfer to hospital

• Physician must delegate task of writing dietary orders to a RD or other clinically qualified nutritional professional

• Physician must delegate the task of writing therapy orders to a qualified therapist

September 14, 2015

• http://www.regulations.gov