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OHCA Spring Expo – March 6th

ALF/RCF Regulatory Compliance: Survey Readiness

The Springs Living, LLC

Who We Are-

- Locally Owned and operated

- Independent Living, Assisted Living and Memory Care

- 1250 apartments

- 900+ staff

- 10 Communities

- www.thespringsliving.com

Who I am-

Lisa Maynard, Director of People and Process

SNF Administrator, ALF Administrator, Executive Director, HR and Policy

lmaynard@thespringsliving.com

503-435-2323

Basic Orientation• Survey cycle is every 24 months for a revisit

• 6 months after change of ownership and/or new license

• Survey is based upon interviews, observations and record reviews

• Surveyors will review the following items before they visit the community. (preliminary concerns= system concerns)– Complaint history

– Conditions on license

– Ombudsman review

– Protective Services/corrective action/program analysts

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Entering the Community• Surveyors will request entrance conference

– Explain Recent changes

– Review Interview protocols

– Request Entrance Checklist to be completed

– Have someone designated to walk the community to look for hazards

Tools for Success• Create take away on how to make a survey reference

guide (items from Entrance Checklist) which is ready even if you are not in the building. It will get them started.

• Philosophy is to be organized from the beginning.

• Your on stage… they are watching and observing how you are gathering your data.

• First impressions do matter

• Let’s walk through the process and discuss tips for a good survey.

CBC Entrance Conference Checklist Please provide the following information as soon as possible. Facility Name: Facility #: Date & time Facility Type RCF ALF

1. Capacity: Beds Current census:

2. Facility email address – please by exit

3. List of residents by room number

4. Activity calendar (for current month, if available)

5. Menus (for current week)

6. Management-team list giving names and titles

7. List of direct caregivers under the age of 18 years

8. List of all facility employees, giving first and last name, position and hire date

9. Resident council minutes for last 3 months

Memory Care Community Endorsed Facilities Only:

1. Memory Care Community disclosure statement

2. Weekly staffing schedule for the month

3. Memory Care Community activity calendar

Supplies needed

1 Binder 1½ inch ring12 tab binder inserts

To Do:Tabs 1-9 need to be labeled with items from ALF

Tabs 10 -12 need to be labeled for items for MCC

Assisted Living and Memory Care communities will need their own binders. Mixed campus will need two binders.

Checklist is current 5/2013

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Check List Items- ALF & MCC1. Capacity Beds and Current Census

- Marketing

2. Facility Email addresses- please by exit- Business office

3. List of resident by room number- Included on item #3

4. Activity Calendar (for current month, if available)- Activity team should be providing a calendar in your box already

5. Menus (for current week)- Food Service should be providing this to you weekly already

Check List Continued6. Management – team list giving names and titles

- Make this now and have available

7. List of direct caregivers under the age of 18 years- Keep hand written roster (most people do not have very many under 18 caregivers)

8. List of all facility employees, giving fist and last name, position and hire date- Delegate someone to work on this ASAP. Good tool is to use employee phone list and hide the hire date on the spreadsheet.

9. Resident council minutes for last 3 months. - Easy to locate, make copy of each months minutes for the file.

MCC Communities 1. Memory Care Community disclosure statement

- Make sure it’s the most recent copy and it reflects the services and staffing that you are providing.

2. Weekly Staffing schedule for the month

- Make sure this does not include ALF staff if you are a shared building.

- Best practice is to utilize a separate schedule

3. Memory Care Community activity calendar

- Make sure this is reflective of your population, has a variety of activities.

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3 Key CBC Forms • CBC Environment Tour

– Best Practice for monthly walkthrough

• CBC Kitchen/ Food Service Observation– Best Practice for monthly walkthroughs

• CBC Resident Review Form – Create acuity spreadsheet to track Focus Areas

– Review systems with high frequency, ie. 2 person transfers, IDDM with SS.

CBC Environment Tour

CBC Environment Tour

Facility Name: Building: Facility #:

Surveyor: Dates and Times: Cleanliness: floors, walls, roofs, ceilings, windows, and furniture) and all equipment clean and in good repair.

Pests: Measures shall be taken to prevent the entry of rodents, flies, mosquitoes, and other insects.

Facility Grounds: The facility grounds shall be kept orderly and free of litter and refuse.

Accident Hazards: toxic materials properly labeled and stored; minimal resistance for passage of wc and ambulation aids.

Hot Water Temperatures: 110 to 120 degrees F

Waste: Garbage stored in covered refuse containers.

Handrails: Handrails shall be installed at one or both sides of resident use corridors.

Odors: The interior of the facility shall be free from unpleasant odors.

Resident Room Heating/Cooling: comfortable for the resident?

Staff Laundry: soiled linen handling

Resident Laundry Facilities: Shall be clean and accessible to residents.

Survey Posted

Staffing Plan and Administrator or designee posted by shift

Emergency: What are you supposed to do if the fire alarm sounds?

What would you do if there was an altercation between residents?

Repairs: How is broken equipment reported to maintenance staff?

What is the system for ensuring the facility common areas are maintained in good repair and clean?

- Designate one person to walk the campus monthly with this form

- Alternate team members for the walk through. A fresh set of eyes is very helpful.

- Become aware of items which they will look at.

- Designate a person who has completed walkthroughs to make a campus walk while you are meeting with them during the entrance meeting.

CBC Kitchen/Food Service Observation

CBC Kitchen / Food Service Observation

Facility Name: Building: Facility Number:

Surveyor Name: Observation Dates/Times:

Instructions: All questions relate to the requirement to prevent the contamination of food and the spread of

food-borne illness. Food shall be prepared and served in accordance with the Oregon Health Services Food

Sanitation Rules. C240

Food Storage: Are the refrigerator, freezer shelves and floors clean and free of spillage? Foods free of slime & mold? Are refrigerated foods covered, labeled, dated, and shelved to allow air circulation? Are foods stored correctly (e.g. cooked foods over raw meat in refrigerator, egg and egg rich foods refrigerated)? Is dry storage maintained in a manner to prevent rodent and pest infestation? Is the food in the freezer frozen and the refrigerator 41 degrees F or below? (allow 2-3 degrees variance) Do not check during meal preparation.

Food Preparation: Are cracked eggs being used only in foods that are thoroughly cooked, such as baked goods or casseroles? Are frozen raw meats and poultry thawed in the refrigerator on the lowest shelves, or in cold, running water? ___ How is food cooled?

Food Service: Are hot foods maintained at 140 degrees F or above and cold foods maintained at 41 degrees F or below when served from tray line? Are the food trays covered until served? Is food protected from contamination during transportation and distribution? Are food in critical temperature zone, 41 to 140 degrees F, for no longer than 2-4 hours?

Sanitation and Equipment: Are employees washing hands before and after handling food, using clean utensils when necessary and following infection control practices? Are dishes, utensils and equipment sanitized before going to the clean storage area? Garbage storage is enclosed and separate from food storage.

Adequate staple food supply? Dry, staple foods - 1 week supply Perishable foods - 2 day supply

Special diets: ___ What special diets do you provide?

- Same process as the Environment Tour

- Review with different staff members, don’t keep interviewing the morning staff.

- Pick different meal times and weekday and weekend for the tour.

- Early Monday is a great time to see where the concerns might be.

- Look for trends and patterns from one observation to another.

- Make action plans for any areas of concern and review that it has been followed up on.

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CBC Resident Review Form

Confidential #:

CBC Resident Review Form

Facility Facility # Review date Surveyor

Resident name:

Rm #:

Birth date:

Move-in date:

Diagnoses:

Change of Condition, Monitoring, Health Services

___ Staff reported on and documented changes in condition ___ Short term change of condition = Intervention determined and communicated to all staff, all shifts, weekly progress notes ___ Significant change of condition = Evaluation, referral to RN, RN assessment documented, update service plan ___ Monitoring = consistent with needs, changes and interventions reported to all staff in writing ___ If needed, further medical action taken timely ___ Delegation ___ Intermittent Direct Nursing Services provided as needed ___ Coordination with on-site and off site services provided by other health care providers

Focus areas

___ ER/Hospital visits/Urgent care ___ Tube feeding/Meal assistance ___ Self medication ___ Siderails/Restraints ___ Heavy care ADLs ___ Pain management ___ 2 person transfer ___ Behaviors ___ Fall risk/History ___ Behavior PRNs/Phych meds ___ Recent decline ___ Routine coumadin ___ Hospice/HH/Dialysis ___ Catheter/Ostomy ___ IDDM/SS/CBGs ___ Incontimence ___ Skin issues ___ Elopement/Dementia ___ Weight changes ___ Other

- Great tool for chart audit- Defines the focus area for you- Helps create a acuity matrix for

you and your staff to make sure you have the correct interventions in place.

- Helps guide you toward the sample resident charts that will be pulled.

- Creates a global perspective of systems with high resident focus. For example, two person transfers but only staff one person.

Sample Selection for Chart Review• Interviews are based on those who oversee care, MA

or RSC

• Review Acuity report to gather data for sample set

• 10% of resident census will be pulled, minimum of 2 charts

• Chart’s will be selected based on the following – Heavy care needs, high acuity

– Behavioral symptoms

– Home health or hospice services

– Cognitively impaired and cognitively intact

Weekly Focus Areas • Resident/apartments across the top

101 102 103 104 105 106 107 108 109 110 111 112

ER /Hospital visits/ Urgent Care

Self Medication

Heavy Care ADLs

2 person transfer

Fall Risk/History

Recent decline

Hospice/HH/Dialysis

IDDM/SS/CBCs

Skin Issues

Weight Changes

Tube Feeding/Meal assist

Siderails/Residents

Pain Management

Behaviors

Behaviors PRNs/Phych Meds

Routine coumading

Catheter/Ostomy

Incontinence

Elopement/Dementia

Other

Focus Areas down the side

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Weekly Focus Areas • Designate staff member to complete weekly as acuity

can change frequently. Helps triage the follow up items for the day.

101 102 103 104 105 106 107 108 109 110 111 112

ER /Hospital visits/ Urgent Care x

Self Medication x x

Heavy Care ADLs x x x

2 person transfer x x x x

Fall Risk/History x x x x x x

Recent decline

Hospice/HH/Dialysis x

IDDM/SS/CBCs x x

Skin Issues x x

Weight Changes x x X

Tube Feeding/Meal assist x x

Siderails/Residents x x X

Pain Management x x x

Behaviors x

Behaviors PRNs/Phych Meds x x X X X X X X X X X X

Routine coumadin x

Catheter/Ostomy x

Incontinence x x

Elopement/Dementia

Other

Sample Focus Area Matrix • With 12 Residents more than likely will pull 2 charts

• Chart 102 concern with 2 person transfer and IDDM with Pain

• Chart 105 concern recent hospital stay with fall.

101 102 103 104 105 106 107 108 109 110 111 112

ER /Hospital visits/ Urgent Care x

Self Medication x x

Heavy Care ADLs x x x

2 person transfer x x x x

Fall Risk/History x x x x x x

Recent decline

Hospice/HH/Dialysis x

IDDM/SS/CBCs x x

Skin Issues x x

Weight Changes x x X

Tube Feeding/Meal assist x x

Siderails/Residents x x X

Pain Management x x x

Behaviors x

Behaviors PRNs/Phych Meds x x X X X X X X X X X X

Routine coumadin x

Catheter/Ostomy x

Incontinence x x

Elopement/Dementia

Other

Focus Area Matrix- System • Systems Review

• Concern areas- IDDM/SS/CBCs, ER Hospital visits

101 102 103 104 105 106 107 108 109 110 111 112

ER /Hospital visits/ Urgent Care x

Self Medication x x

Heavy Care ADLs x x x

2 person transfer x x x x

Fall Risk/History x x x x x x

Recent decline

Hospice/HH/Dialysis x

IDDM/SS/CBCs x x

Skin Issues x x

Weight Changes x x X

Tube Feeding/Meal assist x x

Siderails/Residents x x X

Pain Management x x x

Behaviors x

Behaviors PRNs/Phych Meds x x X X X X X X X X X X

Routine coumadin x

Catheter/Ostomy x

Incontinence x x

Elopement/Dementia

Other

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Focus Area Matrix• 12 Residents

• 2 resident charts will be pulled for Record Review

101 102 103 104 105 106 107 108 109 110 111 112

ER /Hospital visits/ Urgent Care x

Self Medication x x

Heavy Care ADLs x x x

2 person transfer x x x x

Fall Risk/History x x x x x x

Recent decline

Hospice/HH/Dialysis x

IDDM/SS/CBCs x x

Skin Issues x x

Weight Changes x x X

Tube Feeding/Meal assist x x

Siderails/Residents x x X

Pain Management x x x

Behaviors x

Behaviors PRNs/Phych Meds x x X X X X X X X X X X

Routine coumadin x

Catheter/Ostomy x

Incontinence x x

Elopement/Dementia

Other

Top 10 Citations – 40 total Surveys10/1/13 to 12/10/13

1. Service Plan General Acuity Matrix

2. Change of Condition Acuity Matrix

3. Systems: Treatment Orders Systems

4. Resident Health Systems Systems

5. Systems: Med Administration Systems

6. Resident Services Meals, Food Sant. CBC Observation Form

7. Abuse Reporting and Investigation Acuity Matrix/System

8. Res. Move-In and Evaluation System

9. Reasonable Precautions Acuity

10. Res. Health Services: On & Off Site Acuity

Citations come from

Acuity Issue

50%

Observations

10%

System Issues 40%

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Survey Tips• Operate every day as if you are in survey window

• Use the CBC Forms on a routine bases- it cues you through what they are looking for.

• Use your Focus Area Matrix / Spread Sheet to review your acuity and systems – Determine high level residents and complete chart

review/record review

– Determine system that have high use and review systems to ensure compliance and consistency.

Lessons Learned • If you don’t know the answer tell them that you will

“look into it” and get back with them.

• NEVER, NEVER add documentation when it didn’t happen. People get stressed out and will do things they think will keep them out of trouble.

• Practice asking your staff the questions surveyors will ask, they will be better prepared.

• Fix items that are immediate safety issues.– Water temps, trip hazards

• Don’t argue and be respectful, their job is hard too.

• Don’t forget to celebrate when it’s over, your team will appreciate it