2012 state veterans homes va survey deficiency overview
DESCRIPTION
2012 State Veterans Homes VA Survey Deficiency Overview. JoAnne Parker Kelly Mingle Office of GEC Operations (10NC4). Discussion Topics. All Deficiencies cited in 2012 Top 10 Deficiencies Discussion Bonus – Recognition updates. Background Information. - PowerPoint PPT PresentationTRANSCRIPT
2012 State Veterans Homes VA Survey Deficiency Overview
JoAnne ParkerKelly Mingle
Office of GEC Operations (10NC4)
Discussion Topics
• All Deficiencies cited in 2012• Top 10 Deficiencies Discussion• Bonus – Recognition updates
Background Information
• Current SVH Program Structure offering three levels of care:– 143 State Veterans Home Facilities
• 134 Nursing Home Care programs (24,526 beds)
• 53 domiciliary care programs (5,801 beds)
• 2 adult day health care programs (85 participant slots)
FY12 Types of Surveys
Survey Type Surveys % of Total
Annual 135 90.00%
For Cause 3 2.00%
Recognition 12 8.00%
Total 150 100%
Comparison – Surveys Types (FY10-12)
Totals for FY12
Total Number of Nursing Homes Surveyed
150
Total Number of Surveys with Deficiencies
65
Total Nursing Home Deficiencies285
Average Number of Deficiencies Cited per Survey
1.90
IJs for FY12CFR
# Tag # Times Reason51.11
0 87 1 Failure to complete assessment for smoking residents/
51.120 108 8
Accidents: Failure to develop smoking policy and supervise residents smoking/Resident smoking with oxygen and without
supervision/Failure to implement, monitor, and supervise fall interventions
51.110 92 1 Failure to follow care plans/supervise residents that smoke
1C 161 1 Failure to ensure three (3) residents from self harm/ Failure to document attempted suicide
51.200 147 1 Failure to provide adequate fire safety systems
51.210 1 1 Failure to use resources effectively to maintain the highest practical,
physical, mental, and psychological well being of each resident.51.21
0 18 1 Failure to ensure nurse aides able to demonstrate competency to care for residents’ needs
51.210 28 1 Failure to correct quality deficiencies within established time period
51.90 65 1 Failure to provide appropriate supervision to the residents while in the shower room
51.200 149 1 Lack of functional water thermometer on ARJO tubs
51.110 93 1 Failure to ensure safe smoking practices
51.110 94 1 Failure to ensure safe smoking practices
51.210 27 2 Failure to implement, monitor and supervise residents that
smoke/Failure to develop and implement appropriate plans of action
IJs for FY12CFR
# Tag # Times Reason51.11
0 87 1 Failure to complete assessment for smoking residents/
51.120 108 8
Accidents: Failure to develop smoking policy and supervise residents smoking/Resident smoking with oxygen and without
supervision/Failure to implement, monitor, and supervise fall interventions
51.110 92 1 Failure to follow care plans/supervise residents that smoke
1C 161 1 Failure to ensure three (3) residents from self harm/ Failure to document attempted suicide
51.200 147 1 Failure to provide adequate fire safety systems
51.210 1 1 Failure to use resources effectively to maintain the highest practical,
physical, mental, and psychological well being of each resident.51.21
0 18 1 Failure to ensure nurse aides able to demonstrate competency to care for residents’ needs
51.210 28 1 Failure to correct quality deficiencies within established time period
51.90 65 1 Failure to provide appropriate supervision to the residents while in the shower room
51.200 149 1 Lack of functional water thermometer on ARJO tubs
51.110 93 1 Failure to ensure safe smoking practices
51.110 94 1 Failure to ensure safe smoking practices
51.210 27 2 Failure to implement, monitor and supervise residents that
smoke/Failure to develop and implement appropriate plans of action
10 Ten Deficiencies FY12
StandardNumber of
Deficiencies - FY 12 Percentage
Physical Environment 97 34.64%
Resident Assessment 61 21.79%
Quality of Care 54 19.29%
Quality of Life 29 10.36%
Residents Behavior and Facility Practices 10 3.57%
Administration 9 3.21%
Infection Control 8 2.86%
Dietary Services 5 1.79%
Resident Rights 5 1.79%
Nursing Services 2 0.71%
Total 280 100%
Deficiencies by Type FY 12
Deficiencies by Type FY 11
Deficiencies by Type FY 10
DOM Totals FY12
Total Number of Domiciliary Surveyed 59
Total Number of Surveys with Deficiencies Cited 23
Total Domiciliary Deficiencies Cited 27
Average Number of Deficiencies Cited per Survey 0.46
Top DOM standards FY12Tag Regulation
Number Standard Frequency % of All Tags
4E 181.4 ePrimary care medical services are provided for domiciliary patients as needed
2 7.41%
11A 219.11 aMedical records are completely legible and accurately documented, readily accessible, and systematically organized to facilitate retrieving and compiling information
2 7.41%
4F 182.4 f Each patient has a complete medical re-evaluation annual and as needed 1 3.70%
5C 190.5 c Nursing services rendered are documented in the patient's medical record 1 3.70%
5D 191.5 dNursing service participates in the establishment and maintenance of a treatment plan for each domiciliary patient
1 3.70%
7A 196.7A qualified social worker is on staff or the facility has a written agreement with a qualified social worker or recognized social agency for consultation on a regularly scheduled basis
1 3.70%
7B-C 197.7 b-cA written psychosocial assessment is maintained in each patient's medical record
1 3.70%
7C 198.7 cResults of social services rendered are documented in the patient's medical record
1 3.70%
7D 199.7 d The facility has an organized procedure for discharge and transfers 1 3.70%
9D 210.9 d Each patient's activity plan is a part of the overall treatment plan 1 3.70%
10A 213.10 a A registered pharmacist is responsible for pharmacy services 1 3.70%
13A 226.13 a Patients are treated with respect and dignity 1 3.70%
13E 230.13 ePatients are oriented to the policies and procedures concerning the rights and responsibilities of the domiciliary patient
1 3.70%
DOM Comparison FY10 - 13
A Closer Look
• Based on frequency of issue:– Physical Environment– Assessments– Quality of Life– Quality of Care
• Based on level of improvement:– Dietary
Physical Environment
Tag Regulation Number Standard FY11 FY12 % change
147 51.200a Life Safety from Fire
97 80 -17.5%
148 51.200 b1-4 Emergency Power
10 7 -30.0%
Assessments
Tag Regulation Number Standard FY11 FY12 % change
87 51.110b1 Resident Assessment: Comprehensive Assessments of residents needs
2 3 +50.0%
92 51.110d1 Resident Assessment: Comprehensive Care Plan
8 12 +50.0%
93 51.110d2 Resident Assessment: Comprehensive Care Plan
16 12 -25.0%
94 51.110d3 Resident Assessment: Periodic Review
12 15 +25.0%
Quality of Care
Tag Regulation Number Standard FY11 FY12 % change
96 51.120a1-3 Quality of Care: Reporting of Sentinel Events
6 3 -50.0%
102 51.120d Quality of Care: Pressure Sores
10 3 -70.0%
108 51.120i1-2 Quality of Care: Accidents 25 24 -4.0%
Quality of Life
Tag Regulation Number Standard FY11 FY12 % change
67 51.100a/b Quality of Life: Dignity
10 11 +10.0%
72 51.100g1 Quality of Life: Patient Activities
10 7 -30.0%
Dietary
Tag Regulation Number Standard FY11 FY12 % change
123 51.140d Food 18 1 -94.4%
127 51.140h Sanitary Conditions
11 3 -72.7%
Recognition UpdateNew State Veterans Homes06/29/2012 Tyler, TX 100-Bed NHC
07/12/2012 Tucson, AZ 120-Bed NHC
Pell City, AL 174-Bed NHC, 80-Bed DOM
Black Mountain, NC 100-Bed NHC
Changes to Existing State Veterans Homes03/09/2012 Marshalltown, IA 180-Bed Replacement03/22/2012 Bangor, ME New Therapy Unit and Transitional Wing
08/12/2012 Milford, DE 30-Bed Addition08/02/2012 Charlotte Hall, MD Converted 8 DOM beds to NHC10/25/2012 Spring City, PA 120-Bed NHC Replacement08/23/2012 Minneapolis, MN 100-Bed NHC Replacement
35-Participant ADHC
02/01/2013 Scranton, PA Converted 12 DOM beds to NHC
Take Away
• SVHs hard working to secure Veterans Safety
• Relationship between SVHs and VA is important
• Moving Forward