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Meet your Coach…

During this game:

• Take plays back to your team to enhance your performance

• Find areas you can improve and tools that can

help your team win big

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Problem:• More quarters to play

• More positions to fill

• Less players who play

• Sprinkle in some 5 star

• On top of all this: biggest regulation overhaul in 30+ years!! So for time’s sake we’ll focus on:

• Abuse

• Infection Control

• Care Plans

• Discharging

https://www.youtube.com/watch?v=D_Vg4uyYwEk

Pre-game training: Look at your team

Consider…

Game time• Break down specific requirements

• Look at areas where we can train our team for success

• Run through warm ups that you can take back to practice with your team

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ROP: Abuse §§§§483.12 483.12 483.12 483.12

§483.12 Freedom from Abuse, Neglect, and Exploitation

• The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.

ROP: Abuse §§§§483.12 483.12 483.12 483.12 Identified facility characteristics 1,2 that could increase the risk for abuse include, but are not limited to:

• Unsympathetic or negative attitudes toward residents;

• Chronic staffing problems;

• Lack of administrative oversight, staff burnout, and stressful working conditions;

• Poor or inadequate preparation or training for care giving responsibilities;

• Deficiencies of the physical environment; and

• Facility policies operate in the interests of the institution rather than the residents.

ROP: Abuse §§§§483.12 483.12 483.12 483.12 Possible indicators of abuse if the source of the injury is not observed

• Injuries that are non-accidental or unexplained;

• Fractures, sprains or dislocations;

• Burns, blisters, or scalds on the hands or torso;

• Bite marks, scratches, skin tears, and lacerations with or without bleeding, including those that are in locations that would unlikely result from an accident;

• Bruises, including those found in unusual locations such as the head, neck, lateral locations on the arms, or posterior torso and trunk, or bruises in shapes (e.g., finger imprints); and

• Facial injuries, including but not limited to, broken or missing teeth, facial fractures, black eye(s), bruising, bleeding or swelling of the mouth or cheeks.

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ROP: Abuse §§§§483.12 483.12 483.12 483.12 • Mental abuse includes abuse that is facilitated or enabled

through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. If a photograph or recording of a resident, or the manner that it is used, demeans or humiliates a resident(s), regardless of whether the resident provided consent and regardless of the resident’s cognitive status, the surveyor must consider non-compliance related to abuse at this tag.

ROP: Abuse §§§§483.12 483.12 483.12 483.12 (Continued)

• This would include, but is not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part such as breasts or buttocks without the resident’s face, labeling resident’s pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position. Depending on what was photographed or recorded, physical and/or sexual abuse may also be identified.

Abuse in Long Term CareSurvey of Nursing Home staff in the US:

• 36% witnessed at least 1 incident of physical abuse of an elderly patient in the previous year;

• 10% committed at least 1 act of physical abuse towards an elderly patient;

• 40% admitted to psychologically abusing patients (2).

“Likely an underestimation as likely 1 in 24 cases of elder abuse is reported”

*“Elder Abuse Fact Sheet.” WHO, June. 2017, http://www.who.int/mediacentre/factsheets/fs357/en/. Accessed 24 July 2017.

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ROP: Abuse §§§§483.12 483.12 483.12 483.12

We have all heard the stories:

• a certified nursing assistant in Hubbard, Iowa, shared a photo online in March (2016) of a nursing home resident with his pants around his ankles, his legs and hand covered in feces…The nurse assistant had used Snapchat to send the photo of the resident, who has dementia, to six colleagues, along with the caption "shit galore," according to government reports.

ROP: Abuse §§§§483.12 483.12 483.12 483.12 Date: May 2013

City: Peoria

State: IL

Type of facility: Nursing home

How it became public: Government inspection report

Social media site: not specified

Description: A housekeeper posted a picture of a vision- and hearing-impaired resident on her social networking webpage, with the caption "This is my friend," along with the resident's first name. The employee apologized and immediately removed the photo. She said she was not aware that a person could not do such a thing without the resident's consent. The home's administrator told ProPublica that the matter was corrected immediately and that annual training is conducted "so that we’ll never have a repeat issue."

*https://www.propublica.org/article/inappropriate-social-media-posts-by-nursing-home-workers-detailed

ROP: Abuse §§§§483.12 483.12 483.12 483.12 • Lone Tree Health Care Center, also in Iowa, appealed a $68,000 fine imposed

because the facility did not conduct a timely investigation after receiving a tip about photos containing residents being posted on Snapchat in June 2016. Inspectors said the home placed residents in “immediate jeopardy” of harm by not investigating, as well as by not reporting the matter to the state or separating potential abusers from residents.

• Chris Wolf, the home’s administrator, said she thought the fine was excessive. The photos did not contain abuse or nudity, she said, and did not put residents at risk. Three aides were disciplined and staff members at the home received training and were instructed to leave their phones in their cars or at home. Wolf said she was recently informed that CMS was withdrawing the immediate jeopardy designation and cutting the fine in half.

• However, Wolf said, because of the ephemeral nature of photos on Snapchat, neither the home nor authorities saw the posts in question. “As far as I’m concerned, the whole thing is pretty ridiculous. Nobody in an agency capacity has even seen the picture nor can they see the picture, so how can you write a deficiency let alone a fine when there isn’t a picture to substantiate the accusation?”

*http://www.desmoinesregister.com/story/news/health/2017/06/23/

nursing-home-workers-post-nude-vulgar-photos-residents-snapchat/421858001/

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HUDDLE! • We want our team to comprehend abuse

• We want our team to comprehend what role social media plays in abuse

• We want to have as much evidence as possible that we are educating our team

Infection Control: §483.80 • INFECTION CONTROL POLICIES AND PROCEDURES

• The facility must develop and implement written policies and procedures for the provision of infection prevention and control. The facility administration and medical director should ensure that current standards of practice based on recognized guidelines are incorporated in the resident care policies and procedures. These IPCP policies and procedures must include, at a minimum:

• As necessary, and at least annually, review and revision of the IPCP based upon the facility assessment (according to 483.70(e)) which includes any facility and community risk;

• An ongoing system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;

• When and to whom possible incidents of communicable disease or infections should be reported within the facility;

• Which communicable diseases are reportable to local/state public health authorities;

• How to use standard precautions and how and when to use transmission-based precautions (i.e., contact precautions, droplet precautions, airborne isolation precautions). The areas described below are part of standard and transmission-based precautions40 which are further described under their respective sections. For example:

o Hand hygiene (HH) (e.g., hand washing and/or ABHR): consistent

o The selection and use of PPE

o Addressing the provision of facemasks for residents with new respiratory symptoms

o Addressing resident room assignment

o The process to manage a resident on transmission-based precautions when a single/private room is not available;

o Limiting the movement of a resident with a highly infectious disease

o Respiratory Hygiene/Cough Etiquette40

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Infection Control: §483.80 New MVP• “Infection preventionist”: term used for the

person(s) designated by the facility to be responsible for the infection prevention and control program. NOTE: Designation of a specific individual, detailed training, qualifications, and hourly requirements for an infection preventionistare not required until implementation of Phase 3.

Infection Control: §483.80 • Determine if the facility’s infection control

program includes investigation, control, and prevention of foodborne illness.

• Determine if the facility has practices in place to prevent the spread of infection, including proper hand washing techniques.

Huddle!• Assess your current program

• Educate your staff on correct products to fight infections

• Educate your staff on standard precautions

• Consider preventative lists

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• Reach out to experts

• Ask for unbiased

but trained eyes

• Assess regularly

• Reach out to experts

• Look for other

ways to educate

• Partner with vendors who can keep you updated on the latest and greatest

QUATS –

Quaternary Ammonium Compounds

HYDROGEN PEROXIDE

DISINFECTING CLEANER (Newer)

BLEACH

General Care Areas General Care Areas General Care Areas

Generally not effective for TB* May be effective against TB*** May be effective against TB***

Excellent Cleaner Excellent Cleaner No cleaning ability. Must pre-clean

surfaces before disinfecting

Pleasant fragrance Mild fragrance Strong Chlorine odor

May be used on a food contact surface with potable water rinse May be used on a food contact

surface with potable water rinse

May be used on a food contact

surface

Stable when diluted Stable when diluted Unstable. Solutions must be made

up before each use

Low cost/gal when diluted Sold RTU – Moderate cost High cost/gal when diluted

1/2oz-2oz per gal** RTU 8-12oz per gal**

Will not kill C diff Will not kill C diff Recommended by CDC to kill C diff.

Must be EPA registered.

Century Q 256

(quat)

Ful-Trole 64

(quat)

Microcide TB

Clorox Healthcare

Hydrogen Peroxide

Cleaner (spray)

Clorox Bleach

Germicidal Wipes

Clorox Germicidal

Bleach

Hepatitis A Yes-10 min Yes-10 min Yes – 10 min Yes-30 sec Yes-1 min Yes-5 min

Hepatitis B Yes-10 min Yes-10 min Yes-5 min Yes-30 sec Yes-1 min Yes-5 min

Hepatitis C Yes-10 min Yes-10 min Yes-5 min Yes-30 sec Yes-1 min Yes-5 min

HIV/AIDS Yes-10 min Yes-2 min Yes-1 min Yes-30 sec Yes-30 sec Yes-2 min

Seasonal Influenza Yes-10 min Yes-10 min Yes-3 min Yes-30 sec Yes-1 min Yes-5 min

Streptococcus

pneumoniae

Yes-10 min Yes-10 min Yes – 3 min Yes-30 sec Yes-30 sec Yes-5 min

CA-MRSA Yes-10 min Yes-10 min Yes-3 min Yes-1 min Yes-30 sec Yes-5 min

MRSA Yes-10 min Yes-10 min Yes-3 min Yes-1 min Yes-30 sec Yes-5 min

VRE Yes-10 min Yes-10 min Yes-3 min Yes-30 sec Yes-30 sec Yes-5 min

Acinetobacter Yes-10 min NO NO Yes – 30 sec Yes-30 sec Yes-5 min

Norovirus NO NO Yes-30 sec Yes-3 min Yes-1 min Yes-2 min

Tuberculosis TB NO NO Yes-5 min Yes-4 min Yes-3 min Yes-5 min

Clostridium Difficile – C

diff spores

NO NO NO NO Yes-3 min Yes-10 min

Staphylococcus aureus Yes-10 min Yes-10 min Yes-3 min 1 min Yes-30 sec Yes-5 min

• Reach out to experts

• Look for other

ways to educate

• Partner with vendors who can keep you updated on the latest and greatest

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• PREVENTION !

• PREVENTION

High Touch AreasDisinfect these places frequently. This includes:

• light switches

• door knobs

• knobs or handles on medical equipment

• remote controls

• toilet seats and flushers

• grab bars

• public computer keyboards

• telephones

• arms of chairs

• blood pressure cuffs

• bed rails

• call buttons

Think of areas that you touch or grab frequently throughout the day and then think of how many others have done the same thing. Those are your high-touch areas.

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§483.21(b) Comprehensive Care Plans • §483.21(b)(1) The facility must develop and

implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the

comprehensive assessment.

INTENT §483.21(b) • Each resident will have a person-centered

comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident’s medical, physical, mental and psychosocial needs.

GUIDANCE §483.21(b) • Person-centered care includes making an effort

to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident’s life before coming to reside in the nursing home.

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§§§§483.21(b) Comprehensive Care Plans 483.21(b) Comprehensive Care Plans 483.21(b) Comprehensive Care Plans 483.21(b) Comprehensive Care Plans • (ii) Prepared by an interdisciplinary team, that includes but is not

limited to-

• (A) The attending physician.

• (B) A registered nurse with responsibility for the resident.

• (C) A nurse aide with responsibility for the resident.

• (D) A member of food and nutrition services staff.

• (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan.

• (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.

Huddle!• We have to promote communication within our

team

• We have to promote ‘person-centered’ care plans

Set up your Defense!• Activity

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§§§§483.21(c)(1) Discharge Planning Process 483.21(c)(1) Discharge Planning Process 483.21(c)(1) Discharge Planning Process 483.21(c)(1) Discharge Planning Process

• The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.

INTENT §§§§483.21(c)(1) 483.21(c)(1) 483.21(c)(1) 483.21(c)(1)

• This requirement intends to ensure that the facility has a discharge planning process in place which addresses each resident’s discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan.

Huddle!• Educate your patient

• Educate your patient multiple ways

• Share programs available once they return home

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Set up your Defense!• Videos that go over topics all patients need to

understand: nutrition, hydration, medication adherence

• Look at checklists to ensure planning a safe discharge

• Options for dining… ever heard of Sister Homestyle Entrees??

Game time!

Nutrition as you Head

Home

Game time!• CMS has a great list

• Make it your own

• http://www.caregiving.org/pdf/resources/CMS_Discharge_Planning.pdf

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Game time!• Become knowledgeable on

what is available

• Transfer that knowledge to your patients

Game time!• Become knowledgeable on

what is available

• Transfer that knowledge to your patients

§§§§483.40 Behavioral health services 483.40 Behavioral health services 483.40 Behavioral health services 483.40 Behavioral health services • Each resident must receive and the facility must

provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

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GUIDANCE GUIDANCE GUIDANCE GUIDANCE §§§§483.40 483.40 483.40 483.40 • Providing behavioral health care and services is an

integral part of the person-centered environment. This involves an interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident’s distress or loss of abilities.

GGGGUIDANCE UIDANCE UIDANCE UIDANCE §§§§483.40 483.40 483.40 483.40 The facility must provide necessary behavioral health care and services which include:

• Ensuring that the necessary care and services are person-centered and reflect the resident’s goals for care, while maximizing the resident’s dignity, autonomy, privacy, socialization, independence, choice, and safety;

• Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being.

• Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident’s customary routines, interests, preferences, etc. and enhance the resident’s well-being;

• Providing an environment and atmosphere that is conducive to mental and psychosocial well-being;

• Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated. For concerns about the use of pharmacological interventions, see Pharmacy Services requirements at §483.45.

Huddle!• Empower your team to work together to offer

interventions; Dining team can also be your activities department!

• Interventions that are dual role: dining and activities…have we mentioned nutrition is crucial for healthy living??

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Game time!How to Pull Off a Cooking Demo• Determine what you will demonstrate

• Identify equipment needed• Do you need a trash can, dish towels, sanitizer,

gloves, tablecloth, knife & cutting board, mixing bowl, ingredient bowls, can opener, spatula, etc?

• Practice:• Organize ingredients & talking points

• Time yourself

• Prepare questions to engage the audience

• Present:• Pre-measure and/or cook ingredients

• Leave a few whole/raw ingredients to demo

• Offer samples

• New Menu Items

• Unfamiliar Foods

• Panini or Wrap

• Quesadilla

• Healthy Cooking Ideas

• Feature Garden or Farmer’s Market Items

• Signature Dish

• Around the World

• Favorite Ethnic Dishes

• Resident Featured Recipe

Demonstration Ideas

Game time!Activity Based Dining• Omelet Bars

• Waffle Bars

• Pasta Bars

• Guacamole

• Desserts

• Make Your Own Pizza

• Sundae Bars

• Folding Napkins

Game time!Soda Jerk

• Ice cream

• Soda

• Cups and straws

• Paper caps and aprons

• A bunch of jerks to scoop ice cream and pour soda.

What a great way to have fun with everyone in your community at a budget price.

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Game time!What else?

• Garnish ideas

• Dessert art

• Themed Meals

• “Sampling Surveyors”

5 star TOO??Measures for Long-Stay residents (residents in the facility for greater than 100 days)

that are derived from MDS assessments:

• Percentage of residents whose ability to move independently worsened

• Percentage of high risk residents with pressure ulcers (sores)

• Percentage of residents who have/had a catheter inserted and left in their bladder

• Percentage of residents who were physically restrained

• Percentage of residents with a urinary tract infection

• Percentage of residents who self-report moderate to severe pain

• Percentage of residents experiencing one or more falls with major injury

• Percentage of residents who received an antipsychotic medication

5 star TOO??Measures for Long-Stay residents (residents in the facility for greater than 100 days)

that are derived from MDS assessments:

• Percentage of residents whose ability to move independently worsened

• Percentage of high risk residents with pressure ulcers (sores)

• Percentage of residents who have/had a catheter inserted and left in their bladder

• Percentage of residents who were physically restrained

• Percentage of residents with a urinary tract infection

• Percentage of residents who self-report moderate to severe pain

• Percentage of residents experiencing one or more falls with major injury

• Percentage of residents who received an antipsychotic medication

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Huddle!QUALITY MEASURE: Percentage of high risk residents

with pressure ulcers (sores)

Dining Services Manager partner with Dietitian and Nursing to look and think about the following:

– Have you tried fortified foods or homemade supplements?

– Are residents on supplements?

– Are residents taking supplements?

– When are residents given supplements? During meals? Before meals?

• If resident has supplement right before meal won’t eat

• If resident has with meal… won’t eat

– How do you use supplements properly?

– Have any supplements changed? Juice 206 by Hormel

– If not taking supplements find out why? Do they like juice or milk?

• Baby boomers want options: Coffee, Cappuccino, different juice flavors, ice cream cups

Game Time!• Food FIRST!!

• Refer to Supplement Intake Guide

• Refer to supplements guide

Huddle!QUALITY MEASURE: Percentage of residents

with a UTI

Dining Services Manager partner with Dietitian and Nursing to look

and think about the following:• Focus on hydration

• As many as 75% of residents have average fluid intakes below 1,500cc per day, while a minimum recommendation is between 1,500 and 2,000cc of fluid intake per day.

• Provide foods high in water content

• Consider reasons for dehydrations:

– Decreased thirst perception

– Inability to obtain fluids

– Intentionally decrease intake to prevent episodes

of incontinence

– Dysphagia

– Communication barriers

Lettuce (Iceberg)– 96% Strawberries – 90%

Banana – 74% Cream of Wheat – 87%

Cantaloupe – 90% Canned Pears – 86%

Cauliflower– 92% Cottage Cheese – 79%

Watermelon – 91% Spinach – 92%

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Game Time!• Refer to Actions for Prevention

• Consider new products:

– Ocean Sprays’ Cranberry + Health

Actions for Prevention

Keep a list of residents at high risk of dehydration in the

nurses’ station and other strategic locations to remind

others to monitor residents’ fluid intake.

Consider placing a symbol, such as a drop of water, near the

beds of those residents at risk of dehydration as a sign for

staff members to encourage fluid intake.

At meal times, place a different colored napkin at the place

setting where residents’ are at risk.

Schedule fluid administration at least three times a day

between meals. Older people tolerate frequent

administration of fluid in smaller quantities better than

infrequent larger quantities.

To maintain hydration, note the residents’ preferences for

type and temperature of fluids, and individualize the

hydration plan to encourage compliance.

Huddle!QUALITY MEASURE: Percentage of residents experiencing one or more falls

with major injury

Dining Services Manager partner with

Dietitian and Nursing to look and think about the following:• How much is resident drinking? Are they

hydrated?

• Look at lab work: Was hemoglobin low? Did that cause weakness?

• Are they anemic?

• Factors such as postprandial hypotension

• Look at intakes

• Look at weights, has there been weight loss going in?

Game Time!• Refer to Actions for Prevention

• Promote food

• Consider supplements

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Rally Cry• Know your team

• Educate your team

• Don’t give up

Thank you!Erika Kramer

Ekramer@martinbros.com