long-term care homes quality inspection program (lqip .../media... · health system accountability...

Long-Term Care Homes Quality Inspection Program (LQIP)

~ Up-date ~

South West LHIN Long-Term Care Homes Network Forum May 30, 2013

Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care

Overview

• Top Ten Non-Compliances • Quality Improvement

Activities • Risk and Priority Assessment

Framework

2 Performance Improvement and Compliance Branch Health System Accountability and Performance Division Ministry of Health and Long-Term Care

Inspection Data


Provincial Inspections July 1, 2010 – April 30, 2013

Inspection Type

# Inspections

(July 1, 2010 – April

30, 2013)

# Inspections

(July 1, 2010 –

April 30, 2013)

Provincial SW LHIN

Complaint Inspection

3109 444

Critical Incident Inspections

1894 365

Follow-up 703 94

Other * 538 46

RQI 112 18

TOTAL 6356

967

* Other inspections include: SAO-Initiated inspections, Post-occupancy, Special Inspection, etc

# Inspections since July 1, 2010

CIS30%

Follow -up11%

Other8%

RQI2%

Complaint49%

Complaint

CIS

Follow -up

Other

RQI


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Provincial Non-Compliances July 1, 2010 – April 30, 2013

Non-compliance # % of non-compliances

Written Notification (with no other action)

5,558 47%

Voluntary Plan of Correction (VPC)

4,896 42%

Compliance Orders (CO) 1,332 11%

Total * 11,786

Referral to the Director (DR) 8

*Total does not include Written Notifications associated with a VPC, CO or DR.


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SW LHIN Non-Compliances July 1, 2010 – April 30, 2013

Non-compliance # % of non-compliances

Written Notification (with no other action)

471 38%

Voluntary Plan of Correction (VPC)

633 50%

Compliance Orders (CO) 148 12%

Total * 1252

Referral to the Director (DR) 1

*Total does not include Written Notifications associated with a VPC, CO or DR.


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Most Common Areas of Non-Compliance

Complaint Inspections


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Main Themes Top 10 Most Frequently Cited Non-Compliances

Complaint Inspections Provincially

July 1, 2010 – April 30, 2013 1. Plan of Care (4 of 10 most frequently cited)

2. Policies (2 of 10 most frequently cited)

3. Residents’ Bill of Rights

4. Nursing and Personal Support Services

5. Administration of Drugs

6. Reporting certain matters to Director

7. Complaints Procedure


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Top 10 Most Frequently Cited Non-Compliances Complaint Inspections Provincially

July 1, 2010 – April 30, 2013

Rank Non-Compliance Description # of unique LTCHs

# of times issued

(% of all complaint

inspections [3324])

1 LTCHA s. 6 (1) Plan of Care ~ sets out the planned care, goals and provides clear direction

166 236 (7.1%)

2 LTCHA s. 6(7) Plan of Care ~ The licensee shall ensure that the care set out in the plan of care is provided to the resident as specified in the plan

172 232 (7.0%)

3 LTCHA s. 3 (1) Residents’ Bill of Rights 131 180 (5.4%)

4 O. Reg. 79/10 s. 8 (1)(a)

Policies ~ in compliance with the LTCHA 127 169 (5.1%)

5 LTCHA s. 6(1)(c) Plan of Care ~ clear directions to staff and others who provide care

98 132 (4.0%)


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Top 10 Most Frequently Cited Non-Compliances Complaint Inspections Provincially July 1, 2010 – April 30, 2013


# of times issued

(% of all complaint

inspections [3324])

6 O. Reg. 79/10 s. 8 (1)(b)

Policies ~ home to comply with own policies 72 96 (2.9%)

7 O. Reg. 79/10 s. 131(2)

Administration of Drugs ~ in accordance with direction of prescriber

67 76 (2.3%)

8 O. Reg. 79/10 s. 33 (1)

Nursing and Personal Support Services ~ requirements for 2 baths per week

62 73 (2.2%)

9 LTCHA s. 6(10)

Plan of Care ~ reassessment and revision

66 72 (2.2%)

10 O. Reg. 79/10 s. 101 (1)

Complaints procedure ~ requirements for dealing with written or verbal complaints

61 71 (2.1%)


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Critical Incident Inspections


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Critical Incident Inspections Provincially

July 1, 2010 – April 30, 2013

1. Plan of Care (3 of 10 most frequently cited)

2. Prevention of Abuse and Neglect (2 of 10 most frequently cited)

3. Reporting and Complaints (2 of 10 most frequently cited)

4. Policies


6. Nursing and Personal Support Services


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Top 10 Most Frequently Cited Non-Compliances Critical Incident Inspections Provincially

July 1, 2010 – April 30, 2013


# of times issued

(% of all CI inspections

[2016])

1 LTCHA s. 6(7) Plan of Care ~ care set out in the plan of care is provided to the resident as specified in the plan

152 197 (9.8%)

2 LTCHA s. 19(1) Duty to Protect 125 159 (7.9%)

3 LTCHA s. 24(1) Reporting Certain Matters to Director 127 157 (7.8%)

4 LTCHA s. 3 (1) Residents’ Bill of Rights 117 149 (7.4%)


95 123 (6.1%)


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Top 10 Most Frequently Cited Non-Compliances Critical Incident Inspections Provincially July 1, 2010 – December 31, 2012


# of times issued

(% of all CI inspections

[2016])

6 O. Reg. 79/10 s. 36

Transferring and Positioning Techniques 94 105 (5.2%)

7 O. Reg. 79/10 s. 8 (1)(a)

Policies ~ in compliance with the LTCHA 78 87 (4.3%)

8 LTCHA s. 6(1)(c) Plan of Care ~ clear directions to staff and others who provide care

52 65 (3.2%)

9 LTCHA s. 20(1) Policy to Promote Zero Tolerance 56 63 (3.1%)

10 LTCHA s. 23(2) Reporting and Complaints ~ reporting investigation results of mandatory reports to Director

51 57 (2.8%)


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All Inspections


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All Inspections Provincially July 1, 2010 – April 30, 2013

1. Plan of Care (3 of 10 most frequently cited)

2. Policies to be followed (2 of 10 most frequently cited)


4. Reporting certain matters to Director

5. Duty to Protect

6. Transferring and positioning techniques

7. Accommodation Services


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Top 10 Most Frequently Cited Non-Compliances All Inspections Provincially

July 1, 2010 – April 30, 2013


# of times issued

1 LTCHA s.6 (7) Plan of Care ~ The licensee shall ensure that the care set out in the plan of care is provided to the resident as specified in the plan

313 535


266 462

3 LTCHA s. 3 (1) Residents’ Bill of Rights 240 407

4 O. Reg. 79/10 s. 8 (1)(a)

Policies ~ in compliance with the LTCHA 238 356

5 LTCHA s.6 (1)(c) Plan of Care ~ clear directions to staff and others who provide care

165 261


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Top 10 Most Frequently Cited Non-Compliances All Inspections Provincially

July 1, 2010 – April 30, 2013


# of times issued

6 LTCHA s. 24 (1)

Reporting certain matters to Director

186 250

7 LTCHA s. 19 (1)

Duty to protect ~ every licensee of a long-term care home shall protect residents from abuse by anyone and shall ensure that residents are not neglected by the licensee or staff

169 232

8 O. Reg. 79/10 s. 8 (1)(b)

Policies ~ home to comply with own policies 134 190

9 O. Reg. 79/10 s. 36

Transferring and positioning techniques 154 189

10 LTCHA s. 15(2)

Accommodation Services ~ cleanliness and repairs

135 165


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Top 10 Most Frequently Cited Non-Compliances All Inspections SW LHIN only

July 1, 2010 – April 30, 2013


# of times issued

1 O. Reg. 79/10 s. 8 (1)(b)

Policies ~ home to comply with own policies

33 55

2 LTCHA s. 6 (1) (c) Plan of Care ~ clear directions to staff and others who provide care

29 47

3 LTCHA s.6 (7)

Plan of Care ~ The licensee shall ensure that the care set out in the plan of care is provided to the resident as specified in the plan

27 39

4 O. Reg. 79/10 s. 8 (1)(a)

Policies ~ in compliance with the LTCHA 24 33

5 O. Reg. 79/10 s.49 (2)

Falls prevention and management ~ assessment

17 22


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Top 10 Most Frequently Cited Non-Compliances All Inspections SW LHIN only

July 1, 2010 – April 30, 2013


# of times issued

6 LTCHA s. 8 (3)

Nursing and Personal Support services ~ 24/7 RN

15 21

7 LTCHA s. 24 (1) 2

Reporting certain matters to Director ~ abuse 20 20

8 O. Reg. 79/10 s. 91

Hazardous substances ~ labelled and inaccessible

15 20

9 LTCHA s. 19 (1)

Duty to protect ~ every licensee of a long-term care home shall protect residents from abuse by anyone and shall ensure that residents are not neglected by the licensee or staff

16 19

10 O. Reg. 79/10 s. 33 (1)

Bathing ~ minimum 2x/week and choice 13 18


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Resident Quality Inspections / RQIs


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Main Themes Top 10 Most Frequently Cited Non-Compliance

RQI’s Provincially July 1, 2010 – April 30, 2013

1. Policies in compliance with LTCHA

2. Plan of Care


4. Satisfaction Surveys

5. Accommodation Services

6. Safe Storage of Drugs

7. Dining and Snack Service

8. Information for Residents

9. Safe and Secure Home

10. Infection Prevention and Control Program


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Top 10 Most Frequently Cited Non-Compliances RQIs Provincially

July 1, 2010 – April 30, 2013


# of times issued

(% of all RQIs [127])

1 O. Reg. 79/10 s. 8 (1)(a)

Policies ~ in compliance with the LTCHA 67 67 (53%)


62 62 (49%)

3 LTCHA s. 3 (1) Residents’ Bill of Rights

58 58 (46%)

4 LTCHA s. 85(3)

Satisfaction Survey ~ seeking advice of RC & FC in developing & carrying out Survey and acting on results

53 53 (42%)


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Top 10 Most Frequently Cited Non-Compliances RQIs Provincially

July 1, 2010 – April 30, 2013


# of times issued

(% of all RQIs [127])

5 LTCHA s. 15(2) Accommodation Services ~ specific duties re: cleanliness and repair

52 52 (41%)

6 O. Reg. 79/10 s. 129(1)

Safe Storage of Drugs 51 51 (40%)

7 O. Reg. 79/10 s. 73(1)

Dining and Snack Service ~ minimum requirements re program elements

50 50 (39%)

8 LTCHA s. 78(2)

Information for Residents ~ minimum requirements for contents of resident information package

49 49 (39%)

9 O. Reg. 79/10 s. 17 (1)

Safe and Secure Home ~ resident-staff communication system

36 36 (28%)

10 O. Reg. 79/10 s. 229(4)

Infection Prevention & Control Program ~ staff participation in implementation

35 35 (28%)


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Quality Improvement Activities at LQIP


Centralized Intake, Assessment and Triage Team April 1 – 30, 2013

Information Received Provincial LSAO Seeking information 66 11 Complaint 235 44 CIS Notification 1333 314 LTCH Complaint/response 69 17 Bed Refusal 350 46 Discharge 0 0 Other 16 5 TOTAL 2069 437

CIATT cont’d

• Volume management / contract positions • CIS system - challenges • 51.5% of complaints received assigned for

inspection • 9% of CIs received assigned for inspection • 21.5% of complaints related to abuse/neglect • 42% of CIs related to abuse/neglect

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RQI ~ Process Improvement & Integrity

RQI Support Team has been formed to support CQI activities, and ensure the integrity and consistency of the inspection process.

Team will conduct RQI Process and Support Assessment of the Resident Quality Inspection (RQI) process: designated RQI Support Team members are referred to as ‘Reviewers’ for

auditing purposes embedded with the RQI team of inspectors during an RQI to assess

inspectors’ compliance with the RQI process activities a means to reinforce the inspection methodology in real time

immediate feedback with educational / supportive approach promote process integrity make recommendations for improving the RQI quality management

system. The Reviewers are RQI certified inspectors and / or certified RQI Master

Trainers.


London SAO Performance Indicators....

RQIs Complaints Report Delivery

#’s per year Completed within 30 business days of

intake date

Faxed within 60 days of completion of

inspection

2011 = 10 2012 = 15

2013 first quarter = 10

Meeting target 100% of the time

Meeting target 95% of the time

*Note: review target

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LQIP Risk and Priority Assessment Framework Inspections, Coaching and Enforcement


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The Need for Continuous Quality Improvement and Transformation

The LTCHA was implemented in 2010 Homes are reporting as required with a 31% increase in total Critical

incidents being reported since 2009. Specific types of incidents are higher:

– Improper care or treatment (56%) – Abuse/neglect (39%)

Required: – Efficient targeting of Ministry inspection resources – Support to homes to improve performance/coaching – Enforcement when supports do not work and care does not

improve


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Compliance Transformation – the next wave

LTCHA Implementation

The Basics As @ July 1, 2010 LTCHA & Reg.79 Implementation Education (internal &

external) Introduction of new

inspection system

July 1, 2010

On- going Activities: Continual Education & Professional Development, System & Program Monitoring & Analysis within CQI and Risk Management, Decision Support, Communication

LQIP Implementation Setting the CQI

foundation

Fully implement inspection system

Align all inspections to RQI methodology

Design CQI and Risk Management frameworks

Determine data elements for reporting

2010 – 2012

CQI / RM Implementation

Decision Support in Action

Fully implement CQI and Risk Management frameworks

Analyze data & performance metrics to fully leverage decision support capacity

Maximize inspection resources and efforts shift to proactive inspection approach (increased #s of RQIs), focus on LTCHs w/ compliance issues

Implement Coaching Teams model

Inspection Excellence

Achieving the Gold Standard

Further enhance

CQI activities seek accreditation

status for LQIP Become go-to

inspection program setting industry performance benchmarks & gold standard for inspections

2013 Beyond 2013


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Purpose of the LQIP Risk and Priority Assessment Framework

1) For day-to-day operation of LQIP, it provides: data to assist SAOs in scheduling inspections, esp. Resident Quality

Inspections (RQI) & the allocation of staff resources Provides longitudinal record of home’s performance / level of risk on key

data elements/ performance criteria 2) Continuous Performance Improvement – use as an ‘Early Warning System’:

to identify trends within LTC Homes to assist in the evaluation of strategies to assist homes that are

struggling; mentorship programs, education, enforcement strategies, etc. 3) Information can provide decision support to ministry in roll out of new

programs to LTC homes: e.g. when implementing a pilot program, can identify and utilize

consistently high performing homes


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Proposed Risk Levels/Coaching Interventions Risk Level Select possible ministry actions

[Note: additional actions are available]

Level 1 Compliant/substantially compliant

Routine inspections, as required

Level 2 Non-compliant = risk issues identified, not corrected within required time frames, appear to be issues related to licensee’s ability to correct concerns

Voluntary action to acquire external coaching supports

meetings with SAO and licensee

Level 3 Non-compliant = moderate to high risk issues identified, high risk orders re-issued, ongoing inability to rectify the concerns

Coaching/management support required

Can issue a Mandatory Management Order – need to validate that the licensee is unwilling or unable to resolve issues themselves

Level 4 Continued non-compliance with Orders in high risk areas; on-going evidence of serious risk

Licence Revocation


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Current Risk Assessment of LTC Homes [as @ Fall 2012]

No. of Homes in each Level

Level 1 510

Level 2 88

Level 3 4

Level 4 1


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Data elements

Compliance / inspection: # of inspections # of findings of non-compliance or violations resulting in any sanction

(WN, VPC, DR, CO, WAO) # of findings of non-compliance or violation resulting in orders # complaints with findings of non-compliance or violations # CIS with findings of non- compliance or violations

RAI-MDS: Incidence of worsening pressure ulcers Incidence of worsening pain Incidence of worsening resident behaviour


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Data elements (cont’d)

LSAA Report: Identifies any home that triggers the LSAA Compliance Indicator which is: An order that has been issued in a high risk area on two successive

occasions. Risk indicators:

Injury that results in transfer or admission to hospital Medication Incidents Missing resident Environmental hazards Infection Control Pressure ulcers Alleged/actual abuse/assault Presence of daily physical restraints Weight loss management Continence care and bowel management Falls


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Data elements (cont’d)

Qualitative data:

High leadership turn-over (ex. DOC, Administrator)

Financial Challenges (i.e. information from creditors, banks, risk of receivership)

Reports from governmental bodies / agencies (e.g. Office of the Fire Marshal, Min. of Labour)

other


Thank you!

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Questions…..

Jasper

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