quality indicator survey preparedness: enhancing quality ... · define quality of care and life...

Harmony Healthcare International, Inc.

Copyright © 2012 All Rights Reserved 1

Quality Indicator Survey Preparedness: Enhancing Quality of Care and

Life through Survey Compliance

HARMONY UNIVERSITY The Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:

Beckie Dow, RN, RAC-MT Regional Consultant / Trainer

Housekeeping

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Contact Hours Certificate

A Little About Me

Handouts

Contact Information for Questions

Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 2

Harmony Healthcare International, Inc. 3

Welcome!

Copyright © 2012 All Rights Reserved




Program Objectives

Discuss process and stages of the QIS

Define quality of care and life indicators (QCLIs)

Define care areas

Complaint investigations – a discussion

Extended survey – a discussion

Review QAA regulation (intent and requirements)

Using the QIS Information in Facility QAA Activities

Resources and Q&A



Why Change to QIS?

Improve consistency and accuracy in problem identification

Be more objective and systematic

Enhance documentation through automation

Focus survey resources

Provide tools for CQI



QIS – An Overview

Survey process changes

Regulations are unchanged

Surveyors use customized software on PCs which guides them through a structured investigative process

Survey is a two-staged process

Every 9-15 month timeframe unchanged





What Has Not Changed…

The Social Security Act

The regulations

The interpretive guidance

The enforcement process



Outcomes of QIS (QIS Study)

According to the 2007 Final Report of the Evaluation of the Quality Indicator Survey (QIS) there was:

Overall increase in the number of deficiencies cited

G-level deficiencies increase

Regulatory care areas cited increase



Outcomes of QIS (“Real World”)

40% of facilities have the same number of or fewer surveys deficiencies

Deficiencies in areas previously not fully investigated (i.e., QOL)

There ARE zero deficiency surveys with QIS

Source: LTL Magazine, 3/19/2008





Two Stages

Stage I: Preliminary investigation of regulatory areas to determine resident care areas to determine resident care areas and facility practices for Stage II investigation

Stage II: In-depth investigation to determine whether deficient practice exists, document deficiencies and determine severity and scope



Three Steps in Each Stage

Sampling (computer-generated)

Investigation

Synthesis



Implementation QIS First Tested in….

California

Connecticut

Kansas

Louisiana

Ohio





Implementation Training Model Development

Florida

Connecticut

Kansas

A national training model was developed and refined in these states



Nationwide Implementation Occurring in “Bands”

Band One

Delaware

Maine

Vermont

Georgia

Arizona

Band Two

Colorado

Nebraska

District of Columbia

Indiana

Oregon

Utah

New York




Band Three

New Jersey

Arkansas

Hawaii

South Carolina

Tennessee

Oklahoma

Band Four

Texas

Rhode Island

Wisconsin

Missouri

New Hampshire

Kentucky

Mississippi

North Dakota






Band Five

Wyoming

Alabama

Massachusetts

Illinois

Idaho

Virginia

California

Alaska

Band Six

Pennsylvania

Michigan

South Dakota

Puerto Rico

Virgin Islands

Montana

Nevada

Iowa



Per the April 6, 2011 GAO Report:

According to CMS officials, time needed to train all surveyors within a state could vary from one to three years depending on factors such as the number and availability of surveyors in any given state

The last CMS training period is scheduled to begin between June 2014 and June 2015. Therefore, training of all surveyors nationwide may not be completed until 2018



Per the April 6, 2011 GAO Report:

As of February 2011:

7 state survey agencies have completed training of all surveyors within their states

14 state survey agencies have started training surveyors within their states

32 state survey agencies are scheduled to start training surveyors between 2011 and 2015

Note: “States” includes DC, Puerto Rico and US Virgin Islands





Gradual Roll-out of the QIS States’ QIS Training Status as of 2/2011

Source: GAO Analysis of CMS Data


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An Overview of the QIS Process (Additional Handout)





QIS Tasks

Task 1: Offsite Survey Preparation

Task 2: Onsite Preparatory Activities and Entrance Conference

Task 3: Initial Tour

Task 4: Stage I Survey Tasks

Finalize sample selection

Stage I team meetings

Information gathering

Admission sample review



QIS Tasks

Task 4: Stage I Survey Tasks (Cont.)

Census sample review

Staff interviews

Medical record review

Resident interviews

Resident observations

Family interviews



QIS Tasks

Task 5: Non-Staged Survey Tasks Resident council president interview

Dining observation

Kitchen/food service observation

Infection control/immunization policies and practices

Demand billing review

Quality assessment and assurance (QA&A) Review

Medication Administration Observation

Unnecessary Drug Review **





QIS Tasks

Task 6: Transition From Stage I to

Stage II

Review surveyor-initiated residents and/or care areas

Import all data into the primary laptop

Team meetings

Review the Relevant Findings Report

Review the QCLI Results Report



QIS Tasks

Task 7: Stage II Survey Tasks

Information Gathering

Critical Element Pathways

Facility-Level Triggered Investigations Environmental Observation

Resident Funds

Admission, Transfer, and Discharge Review

Sufficient Staff

Abuse Prohibition



QIS Tasks

Task 8: Analysis and Decision-Making:

Integration of Information

Decision-making regarding scope and severity (To cite or not to cite???)

Task 9: Exit Conference





Entrance Conference

Worksheet provided from CMS as to what facility needs to provide immediately and very soon after the survey begins

No 802!



Initial Tour

Surveyors introduce themselves to residents, staff and families

Examine environment and general well-being of the residents

Kitchen is included in initial tour



Survey Team’s Communication with Facility Staff

During Stage 1, the team will not have completed full investigations and cannot yet discuss findings

Subsequently, staff will have opportunities to clarify issues brought to their attention but “surveyors are not to release information about ongoing concerns until their investigation is completed”





Initial Resident Samples

Census sample

40 randomly selected current resident

Admission sample

30 randomly selected recent admissions

MDS sample

All residents with an MDS within the last six months



Why Three Samples?

Ensures different “types” of residents are looked at (long-term via census sample and short-term via admission sample)

MDS sample includes all residents (except those who have not yet had an MDS)



What If Someone or Something Really Stands Out to a Surveyor?

Surveyors can “surveyor-initiate” anyone else into the sample at any time





Stage I Data Collection “Pre-decisional”

Staff interview*

Observation*

Resident interview*

Family interview*

Record review**

Facility-level tasks *admission sample **census and admission

samples



Stage I Data Collection Staff Interview

Interview will be conducted with the licensed staff on the unit (i.e., charge nurses)

Questions will be asked about all 40 residents in the Census Sample

Use the charts! Have a plan to ensure that the work on the unit continues during the interview process!


Stage I Data Collection Staff Interview

Catheter use

Nutrition

Skin care/pressure ulcers

Side rails

Contractures

Falls and fractures





Stage I Data Collection Resident Interview & Observation

Interview done with all interviewable residents from the Census Sample

MDS determines if resident is interviewable

Surveyor has opportunity to chat with resident and decide if they are or are not interviewable



Is a Resident Interviewable?

CPS BIMS Interviewable?

0,1 13-15 Resident

2 N/A N/A

3 8-12 Resident

4-6 0-7 Family

Source: Nursing Home Quality (4/2011) QIS Update to Leading Age Colorado



“Do staff treat you with respect and dignity?”

Activities—needed equipment and availability on evenings, weekends

“Is this a comfortable building in which to live?”

“Have you ever been treated roughly/rudely by staff?”





“Have you had any missing personal items?”

“Does the food taste good and look appetizing?”

“Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time?”

“Can you get your money when you need it, including on the weekends?”



Unpleasant odors

Food on hands, face

Facial hair removed

Glasses clean

Fingernails clean

Oral health problems

Clothes fit properly

Shoes appropriate

Contractures

Participation in activities

s/sx dehydration

s/sx pain

Odor in PT room

Evidence of pests

Safety concerns

Staff appearance and behavior with PT



Stage I Data Collection Family Interview

Three family members of non-interview-able residents will be interviewed (from the Census Sample)

Interview to be conducted with a person that “knows the resident well and visits the facility often enough to provide information about service provided”




Stage I Data Collection Family Interview

“Do staff treat ____ with respect and dignity?”

“Is there enough staff available in this facility to make sure that residents get the care and assistance they need without having to wait a long time?”

“Have you ever noticed any staff member being rough with, talking in a demeaning way or yelling at ____ or any other resident?”



Stage I Data Collection Census Sample Record Review

Review includes:

End stage disease

Pressure ulcers

Unnecessary medications

Weight loss



.

Stage I Data Collection Admission Sample Record Review

Review includes:

Discharge

Rehospitalization

Pressure ulcers

Weight loss

Admission Sample report now includes only closed records (i.e., no current residents)





Facility-level Tasks (non-staged)

Resident Council President/Representative Interview

Dining Observation

Kitchen/Food Service Observation

Infection Control

Liability Notices and Beneficiary Appeal Rights Review

Quality Assessment and Assurance Review

Medication Administration Observation

Medication Storage



Facility-level Tasks (non-staged) Resident Council President or Representative Interview

No more large group meeting

Asks questions regarding

Resident rights

How grievances are handled by the facility

Facilitation of resident council meetings

Facility rules



Facility-level Tasks (non-staged) Dining Observation

Evaluates dining service for:

Respect of resident preferences

Promotion of maximum level of independence

Positioning, equipment, etc.

QOL, environment and sanitation of dining experience

Sufficient staff to provide needed assistance

Palatable food and available substitutes





Facility-level Tasks (non-staged) Kitchen/Food Service Observation

Evaluate:

Food storage (including temperatures)

Infection control practices

Food handing practices (i.e., thawing of food)

Food prep and services

Dishwashing practices

Equipment sanitation

Refuse/pest control



Facility-level Tasks (non-staged) Infection Control

Includes:

Infection control observations (i.e., hand washing, sharps disposal, PPE use, etc.)

Review of infection control program

Review of influenza and pneumococcal immunization programs

Isolation/precautions



Facility-level Tasks (non-staged) Liability Notices and Beneficiary Appeal Rights Review

Examine denial notices

Priority to examine demand billing for private pay resident

Surveyor will:

Review records and P&Ps

Interview staff (SW, billing staff, etc.)

Interview family or resident





Facility-level Tasks (non-staged) Quality Assessment and Assurance (QAA) Review

Goal is to determine if there is a committee that meets the requirements and examine if it is “functioning”

Surveyor will

Look for proof of when committee meets, who is involved, etc.

Ask QAA coordinator questions

Also will ask facility staff regarding QAA



Facility-level Tasks (non-staged) Medication Administration Observation

Observe 10 residents (randomly selected)

Observe at least 50 medications

Must observe meds administered by different routes

Different shifts and staff are to be observed



Facility-level Tasks (non-staged) Medication Storage

Are meds stored safely, at correct temperatures, etc?

Labeling, including expiration dates, checked

Narcotic storage and records reviewed

Narcotic disposal records reviewed





Unnecessary Medication Review

Not a “Mandatory Task” but acts like one

Residents selected are those who are currently residing in the facility and have the most care areas identified for Stage II review

Compliance with Medication Regime Review (MRR) requirement also reviewed



Unnecessary Medication Review

Medication regime evaluated to ensure:

Adequate indication for use and monitoring

Appropriate duration and dose

Gradual dose reductions (unless medically contraindicated)

Medication dose reduced or discontinued in presence of adverse drug reactions or side effects



Complaint Investigation

QIS is used for investigation of complaints during a QIS standard survey

Surveyor-selected by survey team coordinator

QIS is not used for investigation of complaint via abbreviated survey





How Do Surveyors Move from Stage I into Stage II?

Data collected in Stage I is combined with MDS data

Outcome data is turned into 110 Quality of Care and Life Indicators (QCLIs):

78 Census

27 MDS

5 Admission

QCLIs are compared to predetermined thresholds

If threshold is exceeded, the Care Area (CA) is triggered



Quality of Care and Life Indicators (QCLIs)

Resident-centered and process indicators

Calculations include numerator, denominator and exclusions

When a QCLI exceeds its predetermined threshold, a care area is triggered for review in stage II

QCLI Dictionary


Quality of Care and Life Indicators (QCLIs)


26%

16%

16%

5%

5%

6%

13%

13%

Resident Observation

Resident Interview

Family Interviews

Staff Interviews

Admission Chart

Census Chart

MDS QIs

New MDS Indicators





Care Areas

CMS defines a Care Area as “critical component of nursing home care”

If the threshold of a QCLI is exceeded, the care area will be triggered

Care areas selected by the computer for review in Stage II of the QIS



Stage II Sample

Three residents from each triggered care area

All surveyor-initiated residents

Dialysis, hospice and ventilator residents

Begin with one of each

If problems found, expand to three and then further expand if needed for scope and severity

All residents triggered for abuse



How are Care Areas Investigated?

Guidance to Surveyors from State Operations Manual (Appendix PP)

General Critical Element Pathway (CEP)

Specific Critical Element Pathway (CEP)

Triggered Facility-level Task





General Critical Element Pathway

Is the comprehensive assessment complete?

Is the care plan based on the assessment?

Do the care and services meet professional standards of care?

Is the care plan consistently implemented?

Are revisions made to the plan of care as needed?



Specific Critical Element Pathway

Let’s review two of them:

Critical Elements for Pain Recognition and Management

Critical Elements for Hospice, End of Life and/or Palliative Care


Stage 2 Critical Elements for Pain Recognition and Management

CEP instructs surveyor to:

Observe resident, including receiving care

Interview the resident, family, or responsible party

Interview direct care staff

Review record




Stage 2 Critical Elements for Hospice, End of Life and/or Palliative Care

CEP instructs surveyor to:

Observe resident as well as resident and staff interactions

Interview the resident, family, or responsible party

Interview direct care staff and professional staff

If appropriate, review practices related to communications with hospice



Triggered Facility Level Tasks

Abuse prohibition

Admission/transfer/discharge

Environment

Sufficient nursing staff

Personal funds



Triggered Facility Level Tasks Abuse Prohibition

Will include:

Policy and procedure review

Investigation of facility handing of allegations

Interview of “several resident and families” to determine their awareness of how to report

Interview of direct care staff re: reporting, etc.

Interview of frontline supervisors re: monitoring of staff, preventing burnout, etc.





Triggered Facility Level Tasks Admission/Transfer/Discharge

Investigates residents rights, bed hold practices, facility-initiated resident transfer

May include:

Resident/family interview

Record review

Closed record review



Triggered Facility Level Tasks Environment

Includes:

Observation of:

Resident rooms

Common areas

Required postings

Water temperatures

Resident care equipment



Triggered Facility Level Tasks Sufficient Nursing Staff

Interview/review regarding:

Sufficient licensed staff

Regulatory minimums met?

Supervision provided as needed?

CNA assignments

Families/residents to be interviewed regarding timeliness of assistance, etc.

Determine is it a particular shift (etc.) that is problematic




Triggered Facility Level Tasks Personal Funds

Includes:

Personal funds manager interview

Record review

Surety bond review



Levels of Scope and Severity



Determining Scope and Severity

The computer does it automatically

The surveyors determine severity for each resident as a deficient practice is found

Scope is determined at the end of the survey as the team integrates data





Exit Conference

Varies by state procedures

Should be no different than with the traditional survey

Like the traditional survey, they likely will not disclose scope and severity but rather “preliminary findings” from survey



Extended Survey

Occurs with SQC level deficiencies in:

42 CFR 483.13, Resident Behavior and Facility Practices;

42 CFR 483.15, Quality of Life; and/or

42 CFR 483.25, Quality of Care.



Extended Survey – The Purpose

To gather further information (unless already gathered during the standard survey) concerning the facility’s nursing and medical services and administration

Surveyors investigate 41 F-tags (through Guidance to Surveyors):

6 Nursing Services

7 Physician Services

6 Staff Qualifications

22 Administration





Extended Survey – The Timing

At the discretion of the State Survey Agency, the QIS extended survey can be conducted either:

Prior to exit of the standard survey

Subsequent to standard survey but no longer than two weeks after completion of the standard survey



The Plan of Correction (POC)

If deficiencies are found during QIS, facility will be issued a CMS-2567 (SOD) just as in traditional survey

Your SOD and POC will public documents

In-depth analysis by the team of each deficiency leads to a POC that is meaningful and lasting



The Plan of Correction (POC) Required Elements

Corrective action for those found to be affected by the deficient practice

How others potentially effected will be identified

Systemic changes to ensure the practice does not recur

Monitoring of corrective action

Date of compliance

Title of person responsible for compliance





The QIS Post-Survey Revisit (Follow-up)

Purpose: reevaluate the specific care and services that were cited as noncompliant and determine if the facility is and can remain compliant

Facility must provide resident roster

Information from standard survey will be used by surveyor




Areas reinvestigated using CE pathways (no Stage I activities)

Surveyors will review SOD/POC off-site

State, S/S of deficiencies and nature of deficiencies determine procedures for revisit

QAA will be reevaluated as will areas found to be out of compliance on survey




Will evaluate at least three residents for each F-tag that facility was out of compliance with

If not incompliance on revisit, procedures for enforcement action are initiated just as in standard survey





Federal Oversight of a Quality Indicator Survey (FOQIS)

Purpose of FOQIS is to:

Evaluate the performance of a State Agency (SA) survey team during a certification survey

To observe the SA team in determining compliance with Federal Certification requirements

To determine the competence of the SA team in conducting the survey process




Identify any low outliers for:

Triggering rate for care areas and facility tasks

Negative response rate by data source

Facility task citation rate

Care area/task citation rate when triggered at the state or district-level




Federal Surveyors are told to “review the state’s survey schedule and select a survey for the FOQIS” based on outliers

Rather than trying to observe and evaluate all SA Stage I and Stage II investigations, FOQIS uses a targeted, data-driven approach to guide on-site investigations






Unless logistically not possible, the federal surveyor should enter with the team

First activity formally evaluated is the Initial Team Meeting

Selection of tasks during the FOQIS is based on the state’s survey history

Federal surveyors will make parallel observations and attend interviews




Each surveyor will be observed while conducting a resident interview and observation

During Stage II, one care area or task for each surveyor will be observed, depending on which areas had a low citation rate when triggered




When the state team is required to initiate a Stage II investigation due to a harm or IJ concern, a Stage II parallel investigation of the initiated care area and resident should be conducted by the federal surveyor

Guidance is provided as to what to prioritize for parallel observation in Stage II if it is not possible to observe all tasks





Differences Between the QIS and the Traditional Survey: Automation

Traditional

Survey team collects data and records the findings on paper

The computer is only used to prepare the deficiencies recorded on the CMS-2567

QIS

Each survey team member uses a tablet PC throughout the survey process to record findings that are synthesized and organized by the QIS software



Differences Between the QIS and the Traditional Survey: Offsite

Traditional

Review OSCAR 3 and 4 report

Survey team uses QM/QI report and review of complaint investigations offsite to identify preliminary sample of residents (about 20% of facility census) and areas of concern

QIS

Review the OSCAR 3 Report and current (uninvestigated) complaints

Download the MDS data to tablet PCs

DCT selects a random sample of residents for Stage I



Differences Between the QIS and the Traditional Survey: Entrance Information

Traditional

Review of Roster Sample Matrix Form (CMS 802)

QIS

Obtain alphabetical resident census with room numbers and units

List of new admissions over last 30 days





Differences Between the QIS and the Traditional Survey: Tour

Traditional

Gather information about pre-selected residents and new concerns

Determine whether pre-selected residents are still appropriate

QIS

No sample selection

Initial overview of facility



Differences Between the QIS and the Traditional Survey: Sample Selection

Traditional

Sample size determined by facility census

Residents selected based on QM/QI percentiles and issues identified offsite and on tour

QIS

The ASE-Q provides a randomly selected sample of residents for the following:

Admission sample is a review of up to 30 current or discharged resident records

Census sample includes up to 40 current residents for observation, interview, and record review



Differences Between the QIS and the Traditional Survey: Survey Structure

Traditional Resident sample is about 20% of facility census for resident observations, interviews, and record reviews

Phase I: Focused and comprehensive reviews based on QM/QI report and issues identified from offsite information and facility tour

Phase II: Focused record reviews

Facility and environmental tasks completed during the

survey.

QIS Stage I: Preliminary investigation of regulatory areas in the admission and census samples and mandatory facility-level tasks started

Stage II: Completion of in-depth investigation of triggered care areas and/or facility-level tasks

based on Stage I findings





Differences Between the QIS and the Traditional Survey: Group Interview

Traditional

Meet with Resident Group/Council

Includes Resident Council minutes review to identify concerns

QIS

Interview with Resident Council President or Representative

Source: CMS Quality Indicator Survey/ASE-Q Brochure (4/11)



Using the QIS Information in Facility QAA Activities



Quality Assessment and Assurance





F520 - Quality Assessment and Assurance

A facility must maintain a quality assessment and assurance committee consisting of

The Director of Nursing Services;

A physician designated by the facility; and

At least three other members of the facility’s staff



F521 - Quality Assessment and Assurance

The quality assessment and assurance committee

Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and

Develops and implements appropriate plans of action to correct identified quality deficiencies



Intent of QAA Regulation

“….to ensure the facility has an established quality assurance committee in the facility which identifies and addresses quality issues, and implements corrective action plans as necessary”





Quality Assurance Should:

Identify triggers that warn of an evolving problem

Identify patterns

Identify potential for reoccurrence

Identify when changes are needed to interventions

Ensure staff accountability



So What QIS Tools Can Be Used as Part of Facility QAA?



Tips to Using QIS Tools as QAA

Ensure control over the documents – they should be part of QAA and not end up in the charts!

Decide how you will choose your sample

Use the tools continually over time – not once in a while for a review





Tips to Using Interviews as QAA

View the tools as a valuable means to gather information

Look into any negative answer

Ensure unbiased questioning when using the interviews

Ask the questions exactly as written

Ensure comments are documented and investigated



Use Facility Level Tasks as Aids in Evaluating Facility Practices

For example, consider:

Using the Dining Observation tool to routinely evaluate processes, as a key when formulating policies and while providing staff education

Allowing the Resident Council President/Representative Interview tool to guide facility staff regarding what to discuss with residents (i.e., resident right information)



Use the Critical Element Pathways

For instance:

Use the Pressure Ulcer Critical Element Pathway to investigate a nosocomial pressure ulcer

Use the Pain Management Critical Element Pathway to investigate pain management for a resident who is at end-of-life

Use the Physical Restraint Critical Element Pathway while reviewing documentation for anyone with a restraint or a potential restraint





The DPOC Model: Great for Problem Solving

Assessment of Causative Factors

Steps/Interventions Undertaken

Triggers/Parameters to Signal of an Evolving Problem

How the Facility Will Measure the Success of its Efforts


Root Cause Analysis

Step 1 – Gather initial information

Step 2 – Fill in the gaps

Step 3 – Analysis

Step 4 – Action plan development

Step 5 – Evaluation of results

Source: Oregon Patient Safety Commission


Root Cause Analysis Step 1 – Gather Initial Information

Immediate data gathering; get the facts first

Focus on what happened, not “who did it”

Keep an open-minded attitude





Root Cause Analysis Step 2 – Fill in the Gaps

Discuss the incidence as a team

Identify gaps and reconcile differences of views

Gather more information

Investigate the scene of the incident and any involved equipment



Root Cause Analysis Step 3 - Analysis

Ask why until you can’t ask it anymore!

Review contributing factors

Document

Conduct the “Common Sense Test” on the conclusions or the investigation



Root Cause Analysis Step 4 – Action Plan Development

Develop an immediate plan as well as (if needed) a long or short term plan

Use the S.M.A.R.T.S. system for action plans

Document the plan

Implement the plan

Consider the application of the plan to others





A “SMARTS” Action Plan

Specific

Measurable

Attainable

Realistic

Timely

Supported




Root Cause Analysis Step 5 – Evaluation of Results

Track the implementation

Measure how each plan is doing

Celebrate success

Plan for maintaining the changes




RCA – A Case Study




Root Cause Analysis

Root Cause Analysis Materials for Long Term Care Facilities

http://oregonpatientsafety.org/healthcare-professionals/nursing-homes/root-cause-analysis-materials-for-long-term-care-facilities/283/



A Process to Consider for Revising Policies and Protocols

Brain storm with the team regarding the steps

Determine the specific and succinct steps

Document each on a post-it, index card, etc.

Layout steps

Team dialogue and move/replace/add steps until process is agreed upon



Process Improvement Considerations

Evaluate policies/procedures/protocols

Are they evidence-based?

Are they followed? If not, why?

Watch care practices

Is the care plan available, understood and followed by staff?

How is the care plan kept up-to-date?

When changes are made, how is the team notified of them?




























How is resident noncompliance addressed by the team?

Education

Alternatives

Documentation

Reapproach




Is staff knowledge an issue?

Was formal education provided regarding the identified concern?

How was attendance and retention of material documented?

Are your policies and protocols the basis for education?




What are documentation practices? Is documentation according to policy?

Does the care plan, care card and chart all coincide?

Are there multiple places to write the same thing?

Are variations in the medical record explained (i.e., two disciplines see a “different resident”)?

Is risk evaluation and care plan to address risks seen?

Does documentation reflect that scope of practice limitations have been adhered to?






Consider trends that may impact resident outcomes:

New staff on a given unit

Supervisor changes

Issues with residents that may cluster on one caregiver’s assignment

Issues with residents that may coincide with changes in facility routines (i.e., meal time changes, activities programming changes)



So…Here’s to Success!!!

A few final tips:

MBWA

MDS accuracy

Empower residents and staff

Focus on satisfaction

Use the tools in an ongoing fashion (not once in a while)

Focus on any and all negative responses



References

Priority Order of QIS National Implementation (S&C Letter) http://www.cms.gov/surveycertificationgeninfo/downloads/SCLetter09_50.pdf

S & C Letter with Brochure describing the QIS http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter08-21.pdf

QIS Forms and Worksheets https://www.qtso.com/qisdownload.html


http://www.cms.gov/surveycertificationgeninfo/downloads/SCLetter09_50.pdf

http://www.cms.gov/surveycertificationgeninfo/downloads/SCLetter09_50.pdf

http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter08-21.pdf




https://www.qtso.com/qisdownload.html




References

QCLI Dictionary

https://www.qtso.com/download/qcli/July_2012_Dictionary_for_Posting.pdf


Questions/Answers

Harmony Healthcare International

1 (800) 530 – 4413

[email protected]



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