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
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
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
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