2014 State Veterans Homes VA Survey Deficiency Overview

Valarie DelankoJoAnne Parker

Office of GEC Operations (10NC4)

2

Discussion Topics

• Top Deficiencies cited: January 2014 thru May 2014 for Nursing Home Care and Domiciliary.

• Recognition survey updates

3

SVH Program Census

Current SVH Program Structure offering three levels of care:

– 149 State Veterans Home Facilities• 140 Nursing Home Care programs (24,163

beds)• 54 Domiciliary Care programs (5,865 beds)

• 2 Adult Day Health Care programs (85 participant slots)

4

Surveys Types 2010 -2014 (May)

2010 2011 2012 2013 20140

20

40

60

80

100

120

140

160

87

134 135 140

96

4 11 12 10 46 3 3 1 1

Total Survey Types

Annual Recognition For Cause

5

Totals

Function Jan – May 2014

2013

Number of nursing home care surveys

71 97

Number of surveys with deficiencies 47 (66%) 68 (70%)

Number of nursing home care deficiencies

220 385

Avg. number of deficiencies per survey 3.10 3.96

Number of domiciliary surveyed 30 54

Number of surveys with deficiencies 10 (33%) 23 (42%)

Number of domiciliary deficiencies 28 56

Avg. number of deficiencies per survey .93 1.03

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IJs -2011 to present

Total Cited 2014 11

• Accidents #108 (4): Coffee burn; widespread falls; eating vs NPO; safe smoking practices

• Necrotic tissue; Dish machine temperatures; Foley catheter

• Staff/resident incident; elopement risk; drug/drug interaction

2011 2012 2013 20140

2

4

6

8

10

12

810

4

11IJ

7

Top NH standards Line

#Regulation

NumberStandard Frequency %

147 51.200 a.Facility meets applicable provisions of the 2009 Life Safety Code of National Fire Protection Association.

94 43%

14851.200 b. 1-4

An emergency electrical power system is provided in accordance with NFPA; on-site emergency standby generator of sufficient size to serve connected load.

16 7%

10851.120 i. 1-2

Ensure environment remains free of accident hazards as is possible and residents receive adequate supervision and assistance devices to prevent accidents.

19 9%

93 51.110 e. 2Comprehensive care plan is: developed within 7 calendar days after assessments, prepared by an interdisciplinary team and periodically reviewed and revised after each assessment.

13 6%

94 51.110 e. 3Services provided or arranged by facility must meet professional standards of quality and by qualified persons in accordance with the care plan.

13 6%

92 51.110 e.

Comprehensive care plan is: individualized that includes measurable objectives and timetables to meet residents physician, mental and psychosocial needs that are identified in the comprehensive assessment.

6 3%

10251.120 d. 1-2.

Pressure sores: Based on comprehensive assessment, resident enters facility without sore does not develop one unless clinical condition is unavoidable and having one receives necessary tx and services to promote healing.

4 2%

66 51.90 c.

Facility management must ensure all alleged violations are reported immediately to administrator/officials per state law; have evidence violations are thoroughly investigated; results reported back to administrator with appropriate corrective action if verified.

4 2%

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Top DOM standards

Line #

Guideline Number

Standard Frequency %

167 2. Safety C.There is evidence reported that reported life safety deficiencies have been or are being corrected. 19 68%

168 2. Safety D.Facility has available an emergency source of electrical power to provide essential service when normal electricity supply is interrupted.

3 11%

1804. Medical D.

A patient treatment plan is established and maintained for each domiciliary patient. 1 4%

1814. Medical E.

Primary Care medical services are provided for domiciliary patients as needed.

1 4%

21610. Pharmacy D.

Patient on self-medication are instructed by qualified personnel on proper use of drugs. 1 4%

1915. Nursing D.

Nursing Service participates in the establishment and maintenance of a treatment plan for each domiciliary patient.

1 4%

2048 Dietetics E.

Dietetic Service personnel practice safe and sanitary food handling techniques.

1 4%

21810. Pharmacy F.

There is an established system for monitoring the outcome of drug therapy or treatment.

1 4%

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Top NH standards

Line #Regulation

NumberStandard

147 51.200 a.Facility meets applicable provisions of the 2009 Life Safety Code of National Fire Protection Association.

Examples:

• Automatic fire alarm control panel (FACP) reports a supervisory visual notification trouble signal on the panel, but no action taken.

• Fail to maintain the automatic sprinkler systems, complete and document required inspection, testing, and maintenance services in accordance with established code inspection frequency.

• No documented weekly no-flow churn test for the fire pump .• No documentation of biannual smoke detector sensitivity testing for the smoke

detectors.• Fail to maintain smoke barrier doors that would close and resist the passage of smoke

and provide rated doors for hazardous areas - edge gaps on doors exceeding the permissible 1/8” inch clearance, doors fire ratings are insufficient for a hazardous area.

• Exits shall terminate directly at a public way or at an exterior exit discharge that is safe.• Fail to provide a Digital Alarm Communicator Transmitter (DACT) system in an area

where the alarm is likely to be heard by staff.

YEAR: 2011 2012 2013 2014

# Deficiencies

:

97 80 187 94

NH

10

Top NH standards

Line #Regulation

NumberStandard

148 51.200 b. 1-4An emergency electrical power system is provided in accordance with NFPA; on-site emergency standby generator of sufficient size to serve connected load.

Examples:• Fail to perform the weekly inspection and document monthly

load tests of the Emergency Power Supply System (EPSS). • Generator did not have a remote manual emergency stop

station installed outside of the generator compartment as required by code.

• Generators load bank test not completed.

YEAR: 2011 2012 2013 2014

# Deficiencies

:

10 7 15 16

NH

11

Top NH standards

Line #Regulation

NumberStandard

108 51.120 i. 1-2

Ensure environment remains free of accident hazards as is possible and residents receive adequate supervision and assistance devices to prevent accidents.

Examples:• Fail to provide adequate supervision and/or safety devices.• Fail to provide adequate supervision/monitoring of the proper

feeding techniques specified by Speech Therapy to prevent aspiration.

• Fail to ensure that adequate supervision provided while attempting to self-transfer and left unattended in the bathroom.

YEAR: 2011 2012 2013 2014

# Deficiencies

:

25 24 23 19

NH

12

Top NH standards

Line #Regulation

NumberStandard

93 51.110 e. 2

Comprehensive care plan is: developed within 7 calendar days after assessments, prepared by an interdisciplinary team and periodically reviewed and revised after each assessment.

Examples:• Fail to review and revise the resident care plan to prevent

accidents i.e., adjust for dysphasia.• Failed to revise care plans, i.e., resident’s inappropriate

behaviors that caused the burn with interventions to prevent re occurrence, as needing close monitoring to prevent altercations with other residents.

YEAR: 2011 2012 2013 2014

# Deficiencies

:

16 12 16 13

NH

13

Top NH standards

Line #Regulation

NumberStandard

94 51.110 e. 3Services provided or arranged by facility must meet professional standards of quality and by qualified persons in accordance with the care plan.

Examples:• Interventions on resident care plan were not being followed, i.e. failed to provide

toileting assistance as care planned, failed to ensure the fall alarm equipment functioned properly, failed to utilize hipsters as care planned and failed to provide appropriate monitoring for safety after administration of an as needed medication during an acute episode of anxiety.

• Fail to ensure assessments met professional standards of quality and were provided in accordance with each resident’s written plans of care; i.e. shunt not assessed returned from dialysis, no monthly labs, pressure ulcer tx not provided as ordered. nurse failed to document the nature of the burns, failed to complete an incident report to include measures to prevent further occurrence of such accidents, and failed to report to the physician for examination of the injury and possible treatment orders.

YEAR: 2011 2012 2013 2014

# Deficiencies

:

12 15 13 13

NH

14

Top DOM standards

Line #Regulation

NumberStandard

167 2. Safety C.There is evidence reported that reported life safety deficiencies have been or are being corrected.

Examples:

• Does not have quarterly automatic (wet & dry) sprinkler system's inspection and test reports.

• Fail to properly maintain the automatic fire sprinkler system fire pump, complete or document weekly inspection services, and recalibrate or replace system pressure gauges. Fire pump pressure gauges overdue for a 5 year calibration or replacement inspection.

• No weekly fire pump inspection services. No-flow churn test were not being performed.

• No documented fire drills for each shift in each quarter.• Fail to establish an inspection, testing and maintenance program for the battery-

powered illumination devices installed within the facility - no monthly 30 second or annual 90 minute program for the inspection.

• Lack of annual inspection, testing and maintenance services for the portable fire extinguishers.

YEAR: 2011 2012 2013 2014

# Deficiencies

:

2 0 34 19

DOM

15

Top DOM standards

Line #Regulation

NumberStandard

168 2. Safety D.Facility has available an emergency source of electrical power to provide essential service when normal electricity supply is interrupted.

Examples:• Fail to perform the weekly inspection and document monthly

load tests of the Emergency Power Supply System (EPSS). • Generator did not have a remote manual emergency stop

station installed outside of the generator compartment as required by code.

• Generators load bank test not completed.

YEAR: 2011 2012 2013 2014

# Deficiencies

:

1 0 4 3

DOM

16

Recognition 1-1-14 to 7-28-14

New State Veterans Homes

Effective Per

Diem Date

Date Letter Signed

SVH Beds

11/06/13 01/07014 Payson, UT 108-BED NHC

10/17/13 01/06/14 Kinston, NC 100-Bed NHC

10/24/13 02/24/13 Ivins, UT 108-Bed NHC

       

Changes to Existing State Veterans Homes

08/15/13 06/13/14 Bennington, VT 171-Bed NHC (6-Bed Reduction)

       

Recognition Packages in VA Concurrence

    Redding, CA 90-Bed DOM

    West Los Angeles, CA 84-Bed DOM Addition

    Marshalltown, IA 509-Bed NHC (64-Bed Reduction)       

       

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Contacts

• Valarie Delanko, RDN, LDN, CPHQ National Program Manager SVH Quality &

Survey Oversight

• Jo Anne Parker, MHA National Program Manager SVH Survey

Process