proposal for

Proposal for

The Developmental Disabilities Administration

Nursing Assessment Demonstration Project

February 2011

The Developmental Disabilities Administration (DDA)


Table of Contents

INTRODUCTION...........................................................................................................................3

PROJECT OVERSIGHT................................................................................................................4

SELECTION CRITERIA FOR AGENCY PARTICIPATION..........................................................5

APPLICATION TO PARTICIPATE IN THE DDA DEMONSTRATION PROJECT.......................7

RESPONSIBILITIES FOR SELECTED PROVIDERS..................................................................9

RESPONSIBILITIES FOR THE AGENCY RN CM/DN/NURSING SUPERVISOR.....................10

SITUATIONS THAT WOULD EXCLUDE A PERSON FROM PARTICIPATION.......................11

NADP PARTICIPANT REVIEW PERIOD DETERMINATION....................................................12

SITUATIONS THAT MAY WARRANT REASSESSMENT.........................................................13

DATA COLLECTION REQUIREMENTS....................................................................................16

CRITERIA FOR AGENCY REMOVAL FROM THE PROJECT..................................................18

Quality Assurance Process.........................................................................................................19

of 21

The Developmental Disabilities Administration (DDA)


Introduction

The purpose of this Nursing Assessment Demonstration Project (NADP)

with DDA approved licensed providers is to assess the ability to safely

allow an exception to the current regulation (COMAR 10.27.11) to increase

the time from the maximum of 45 days between on-site nursing

assessments as required by regulation to either 60 or 90 days. The

determination to increase the length of time between on-site nursing

assessments will be based upon a standardized process by which people

receiving delegated nursing services can be assessed and identified as

eligible for the extended review period. The anticipated length of this

project is one year from the date of implementation. Based upon data

review the Principle Work group may extend the pilot if further study is

needed to develop recommendations for regulatory changes.

of 21

Project Oversight

The DDA Nursing Assessment Demonstration Project will be monitored by members of

the principle project workgroup. Members of this workgroup represent the MD Board of

Nursing (MBON), the DDA Regional Nurses (Health Services Liaisons), OHCQ Nurses,

Maryland Association of Community Services (MACS), the DDA Provider Community,

the Office of the Secretary of the Department of Health and Mental Hygiene (DHMH),

and the DDA Senior Management.

The role of this workgroup will include but is not limited to:

1. Review of DDA licensed provider applications;

2. Selection of agencies that will participate in the project;

3. Collection and synthesis of data submitted by participating agencies and project

monitors;

4. Compose quarterly written reports of project status;

5. Compose a final written report at the end of the NADP with recommendations to

the MBON based upon the findings of the demonstration project.

of 21

Selection Criteria for Agency Participation

DDA licensed providers that wish to participate in the DDA NADP must, at a minimum

meet the following criteria:

1. Be free from sanction(s), or pending sanction(s) from DDA or any other state

licensing entity;

2. Maintain the continuous services of a RN Case Manager /Delegating Nurse (RN

CM/DN);

3. Have current written policies and procedures governing nursing services

inclusive of criteria for nursing reassessment and CN/DN notification when there

are changes in CMT staff;

4. Have ability to submit data electronically in required format;

5. Be current in their submission of QA Plan; and,

6. Be current in their license renewal application.

The selection of agencies that will be included in the DDA Nursing Assessment

Demonstration Project will be made by the members of the principle project workgroup.

Members of this workgroup represent the MD Board of Nursing, the DDA Regional

Nurses, OHCQ Nurses, Maryland Association of Community Services (MACS), the DDA

of 21

Provider Community, the Office of the Secretary of the Department of Health and

Mental Hygiene (DHMH), and the DDA Senior Management.

If the number of applicants exceeds the number of agencies that will be accepted per

region, the principle project work group will make their selection based upon the

following:

Geographic area covered by the agency;

The ratio that represents the proposed number of people that will be participants

in the project / the number of total number of people for whom the agency

provides services;

Date of application.

If during the first 90 days of the implementation of the pilot, there are agencies that end

their participation, the principle project work group will select from the applicants that

were not originally selected based upon the following criteria:

Date of application

An agency that most closely represents the agency originally selected for the

sample that is no longer participating.

of 21

Application to Participate in the DDA Demonstration Project

A minimum of 14 and a maximum of 16 providers will be selected to participate in this

demonstration project. Up to five (5) providers will be selected from the DDA Central

and Southern regions and up to 3 providers in the DDA Eastern and Western Regions.

Agencies interested in participating in the DDA Demonstration Project must:

1. Submit an application which includes agency demographic information for

consideration for participation to the DDA Assistant Director for Programs;

2. Provide the name(s) of the Nursing Supervisor or RN CM/DN that will participate

in the project. In addition, the agency will provide contact phone numbers and

email addresses for all named RNs;

3. Submit to MBON, OHCQ, and the four DDA regional Health Services Liaisons a

preliminary list of all people receiving services who will be participating in the

demonstration project. The preliminary list that is submitted with the application

includes:

a. Person’s fist initial and last name;

b. Person’s address;

c. Name of the delegating RN CM/DN; and

d. Type of services provided by the agency.

of 21

4. Prior to the implementation of the project a final participant list must be

submitted. The following information should be included for each person:

a. Person’s first initial and last name;

b. Person’s address;

c. Name of RN CM/DN;

d. Date of initial nursing assessment by current RN CM/DN;

e. Date of most recent 45 day nursing assessment by current RN CM/DN;

f. Date of HRST completion and resulting score;

g. Identify 60 or 90 day proposed assessment period;

h. Indicate the number of the following HRST medication categories:

i. Psychotropic medications;

ii. Anti-depressant medications;

iii. Anticonvulsant medications;

iv. GI medications;

v. Bowel medications;

vi. Other medications (e.g. medicated shampoo’s, creams, eye

medications, sun lotion, etc.);

i. Indicate the total number of medications the person is prescribed.

of 21

Responsibilities for Selected Providers

Providers which are selected to participate in the NADP must sign an agreement to

adhere to all of the guidelines and conditions stipulated by the project description. This

agreement includes:

1. Agency management acceptance of the nurse’s professional judgment regarding

the frequency of nursing assessments;

2. Maintaining the continuous services of RN CM/DN (s);

3. Notification to the DDA Regional Nurses, OHCQ, and MBON demonstration

project liaison the loss of the RN CM/DN (s) or nurse supervising RN within 5

days;

7. Per COMAR 10.27.11 have current written policies and procedures governing

nursing services inclusive of criteria for nursing reassessment and CM/DN

notification when there are changes in CMT staff;

8. Submit required data reports at agreed upon intervals to the DDA Regional

Nurse via the excel spread sheet provided by DDA.

of 21

DDA licensed providers which are selected to participate in the project must complete

the following prior to increasing the 45 day nursing assessment requirement to 60 or 90

days for any person receiving services (participant):

1. Each identified participant will have an Initial Nursing Assessment (INA)

completed by the current RN CM/DN;

2. The RN CM/DN must complete and document one nursing review

(per COMAR 10.27.11) and a Health Risk Screening Tool (HRST) within 45 days

for each participant in the NADP prior to inclusion in the project.

Responsibilities for the Agency RN CM/DN/Nursing Supervisor

Agencies which are selected to participate in the NADP agree to require the nursing

supervisor and project participant’s RN CM/DN to:

1. Be present at all OHCQ exit visits if there are regulatory deficiencies

related to healthcare of individuals in the project ;

2. Report to OHCQ, DDA Regional Nurse and MBON project liaison the

failure or resistance of the agency to follow the RN CM/DNs professional

judgment regarding the frequency of nursing assessments;

3. Be able to articulate the basis for his/her determination for the exception to

the required 45 day site visit to be extended to a 60 or 90 day visit. The

rationale must be based on the nursing assessment and the HRST not

just the HRST score.

of 21

Situations that Would Exclude a Person from Participation

There are elements of a profile for a person receiving delegated nursing of medication

administration which would likely exclude a person from participation in the

demonstration project. These exclusions include but are not limited to:

1. A drug profile which includes any high risk medication or frequent use of

PRN medications (e.g., oral hypoglycemic agents, insulin, oral and

subcutaneous anticoagulants, Schedule II medications, chemotherapeutic

agents, methotrexate, nebulizer use, oxygen use, etc);

2. Unstable/high risk medical conditions (e.g., wound care, poorly controlled

seizure disorder, need for suctioning, need for catheterization, need for

wound dressing, end-stage conditions, Alzheimer’s/dementia,

enema/suppository use, choking/aspiration risk, G/J tube, history of recurrent

GI bleeds/aspiration,/dehydration/impaction/obstruction);

3. Frequent infections (e.g. pneumonia, UTI, cellulitis, MRSA, VRE, etc)

4. Frequent emergent medical evaluations (e.g. emergency appointments,

ER use, nurse evaluation);

5. Frequent hospitalizations;

6. Unstable psychosocial conditions (e.g., SIB, danger to others, complex

psycho-active therapeutic regime, etc.);

7. Unstable/high risk functional conditions (e.g., frequent falls, nutritional

instability, need for positioning/transferring/lifting, etc.);

of 21

8. Recipient of additional fiscal compensation or request for service change

related to health and safety.

Nursing Assessment Demonstration Project (NADP)

Participant Review Period Determination

People selected to participate in the NADP must meet the basic requirements for nurse

delegation per COMAR 10.27.11. Based on the Initial Nursing Assessment, the current

45 day review, and the HRST completed within the past 45 days, the RN CM/DN will

use the following criteria for evaluating the individual and for determining the time

between nursing assessments:

1. If the HRST score is consistent with a Level 1 or Level 2 determination and if the

nursing assessments support that the person would be safe with less frequent

nursing supervision, the frequency of the nursing assessments may be extended to

every 90 days. The decision to extend the frequency of the nursing assessments to

90 days is not mandated by the HRST score but is the decision of the RN CM/DN

based on prudent nursing judgment.

2. If the HRST score is consistent with a Level 3 determination and if the nursing

assessments support that the person would be safe with less frequent nursing

supervision, the frequency of the nursing assessments may be extended to every 60

days. The decision to extend the frequency of the nursing assessments to 60 days

is not mandated by the HRST score but is the decision of the RN CM/DN based on

prudent nursing judgment

3. If the HRST score is consistent with a Level 4 or Level 5 or Level 6, the

frequency of the nursing assessments must be minimally every 45 days.

of 21

4. Per COMAR 10.27.11, if the condition of the individual is not “chronic, stable,

routine, predictable and uncomplicated,” the RN CM/DN must perform nursing

assessments minimally every 2 weeks.

5. Approval of the IP team and the person/legal guardian for participation in the

demonstration project.

Project participants receiving less frequent nursing supervision must be reevaluated at

the time of each nursing assessment. The RN CM/DN will assess if the person

continues to meet the criteria for less frequent nursing supervision. The determination

will be based on the nursing assessment and, if indicated, a new level determination

utilizing the HRST. A new HRST screening may be indicated by a change in condition

or minimally annually at the time of the IP. This determination must be documented in

the nursing assessment.

Situations That May Warrant Reassessment

There are many situations that may arise prior to a next planned nursing assessment

which would indicate that the need for reassessment. Each participating agency in the

NADP must have written policies and procedures, as required by current regulation.

These policies and procedures must include the criteria that guides how and when the

RN CM/DN will be contacted and if and when reassessment is necessary. The

following factors should be considered for reassessment:

of 21

1. A change in the person’s health, to include but not limited to:

a. Increase use in inhalants/pain meds, etc.;

b. Increase in falls/injury/swelling;

c. Changes/breaks in skin integrity (rash, bruises, blisters, sores

discolorations, swelling, etc);

d. Neurological changes ;

e. Changes in breast self –examination, menstrual cycle;

f. Hospitalizations/emergency room/or urgent care visits;

g. Change in medications or medication dosages;

h. Change in diagnosis;

i. Unexpected weight gain or loss greater than 5 pounds in 4 weeks;

j. Emergency medical conditions requiring 911; or

k. Any other event/incident identified in the person’s Nursing Care Plan

(NCP) by the RN CM/DN for that person.

2. A change in the person’s functional condition, to include but not limited to:

a. Change in ability to perform ADLs;

b. Change in sleep patterns;

c. Change in mobility;

d. Changes in bowel and bladder habits; or

of 21

e. Change in eating patterns/appetite or swallowing/choking issues;

f. Any other event/incident identified in the person’s Nursing Care Plan

(NCP) by the RN CM/DN for that person;

3. A change in the person’s psychosocial condition, to include but not limited to:

a. Change in behaviors/mood/impulse control/self- isolation;

b. New or an increase in self injury; or

c. Any other event/incident identified in the person’s Nursing Care Plan

(NCP) by the RN CM/DN for that person.

4. Other issues, including but limited to:

a. Internally reported, internally investigated and externally reported

medication errors (such as documentation errors, missed doses of

medication, medication errors requiring HCP intervention, etc);

b. Missed health appointment;,

c. Police visits/ 911 calls/emergency responder for that individual;

d. Change in the RN CM/DN assigned to the person;

e. Notification by OHCQ or DDA regional staff of any health related

regulatory deficiency for any participant of the demonstration project;

f. frequent changes in direct support staff working for a project participant;

or

of 21

g. Notification of a complaint filed with DDA headquarters, the DDA

Regional office or OHCQ regarding healthcare for any person who is a

participant in the NADP.

If a DDA provider agency is accepted into the demonstration project and loses the RN

CM/DN(s) or nurse supervising RN, the agency must report to the DDA Regional Nurse

within 5 days. If a new DDA RN CM/DN is hired within 30 days, the RN CM/DN must

complete an Initial Nursing Assessment and a subsequent 45 day nursing assessment

for each participant they delegate for in the demonstration project before considering an

exception to the nursing assessment regulation.

Data Collection Requirements

Agencies which are selected to participate in the NADP are required to maintain the

spreadsheet which identifies each participant in the demonstration project, his/her

address, and the current term for his/her nursing assessment ( 60 day or 90 day). The

participating DDA provider agency will be required to submit required data reports at a

minimum, quarterly, to the DDA Regional Nurse via the excel spread sheet provided by

DDA. Data must be submitted no more than 15 business days following the end of the

quarter. All data that is submitted must also be maintained at the DD agency for review

by the project monitors upon request.

of 21

The following data elements will be collected during the NADP on the data sheets

provided:

Nursing Assessments

a. # people who had nursing review period reduced;

b. # of people who had nursing review period increased ;

c. # of people who had no change in assessment period;

d. List of each person requiring interim re-assessments (# of re-assessments);

e. The reason for each re-assessment, if completed.

Health and Safety

a. Medications Errors;

i. Total # medications missed

ii. Total # doses missed

iii. Total # days medications missed

iv. Were the meds identified on the HRST?

v. Other meds not identified on HRST?

b. Number of falls (by person);

c. Number of hospital visits/admissions (by person with explanation) ;

d. Number of unplanned medical care appointments (by person with explanation).

Health Services Policies of 21

a. Number of changes in RN CM/DN;

b. Number of changes in CMTs working with participant;

c. Number of changes (e.g., medication, health status, etc.) communicated to RN

CM/DN;

d. Number of changes (medication, health status, etc.) not communicated to RN

CM/DN with explanations ;

e. Number of incidents reported per Policy on Reportable Incidents (PORI)(per

person with explanation) ;

f. Number of incidents not reported per PORI (per person with explanation);

g. Amount of time spent by RN CM/DN on remediation;

h. Type of remediation (e.g., skills, med admin, policies/procedures);

i. Topic of remediation.

Criteria for Agency Removal from the Project

The MBON, the DDA and the principle NADP workgroup may terminate an agency’s

participation in the demonstration project based on the criteria listed below. If an agency

is removed from the demonstration project, all people identified as project participants

will revert to a maximum of 45 days between nursing assessments as required by

COMAR 10.27.11.

1. Failure to obtain the services of another RN CM/DN within 30 days when the RN CM/DN or supervising nurse leaves the agency;

of 21

2. Non-compliance with the provisions of the agreement between DDA and the provider agency or the RN CM/DN (s)/supervising nurse.

If an agency is removed from the demonstration project, documentation of this action

will be sent to the agency, the DDA regional office, the MBON and OHCQ.

Quality Assurance Process

The DDA NADP principle project workgroup will meet, at a minimum each quarter

during the course of the demonstration project. During these meetings, the workgroup

will review data collected since the last meeting, determine any changes which may be

indicated by the data review process, and submit those recommendations to the

Maryland Board of Nursing MBON) and the DDA Senior Management Team.

The on-site DDA NADP project monitors will include staff from OHCQ, the DDA

Regional Office Nurses and Quality Assurance staff. Their responsibilities include but

are not limited to:

1. Monitoring provider agencies in the demonstration project by visits at least

quarterly;

2. Reporting to the principle project workgroup, DDA, OHCQ, and MBON any

participating DDA agency’s:

a. non-compliance with submission of quarterly data reports;

b. discrepancies in data submitted versus monitoring visits to the DDA site;

c. the lack of a RN CM/DN nurse for one month or longer;

d. any other findings that may impact the quality of services and/or health of

the people who are participants in the demonstration project.

of 21

The MBON will receive reports from their NADP workgroup representative on:

1. A quarterly basis from the principle project workgroup;

2. Recommendations from the principle project workgroup for agencies that

should be removed from the NADP.

Upon request, members of the MBON may elect to meet with the Project Monitors to

discuss findings reported in written reports.

of 21

proposal for

Documents