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NEW LONG TERM CARE SURVEY PROCESS PHASE 2 REQUIREMENTS OF PARTICIPATION

AUGUST 23, 2017

Disclaimer:

The information contained in this presentation is representative of the current information provided by CMS as of August 16, 2017:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/New-Long-term-Care-Survey-Process%E2%80%93Slide-Deck-and-Speaker-Notes.pptx

CMS has not released an update to Appendix P as of August 16, 2017.

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BACKGROUND

Two different survey processes to review facility compliance with the Requirements of Participation (RoPs): 1. Traditional Nursing Home Survey (Traditional) – original paper-based

2. Quality Indicator Survey (QIS) – customized software

CMS set out to build on the best of both the Traditional and QIS processes to establish a single nationwide survey process.

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GOALS OF THE NEW PROCESS

Same survey for entire country

Incorporates strengths from Traditional & OIS

New innovative approaches

Effective and efficient

Resident-centered

Balance between structure and surveyor autonomy 4

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New Survey Process Traditional Survey Process

Automation

Using an automated process, surveyors will use a tablet or laptop throughout the process to record findings their findings in the new software

Data collected by the surveyors are recorded on paper

The computer is used ONLY to prepare the deficiencies on the CMS-2567 form

Sample Size

Determined by the facility census Max sample size is 35 residents 70% - MDS pre-selected 30% - surveyor-selected

Determined by facility census Total is pre-selected based on

QM/QI percentiles May be adjusted based on issues

identified on tour Maximum sample size is 30

residents Includes complaints

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Offsite

Each team member independently reviews the Casper 3 report and other facility history information

Review offsite selected residents and their indicators and the facility rates.

Review Casper 3 and 4 reports Survey team uses QM/QIs report

offsite to identify preliminary sample of residents areas of concern

Information Needed Upon

Entrance

Completed matrix for new admissions over the last 30 days

Facility census number Alphabetical list of residents List of residents who smoke and

designated smoking times

Roster Sample Matrix Form (CMS-802)

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Initial Entry to Facility

No formal tour process Surveyors complete a full

observation, interview all interviewable residents, and complete a limited record review for initial pool residents: Offsite selected residents New admissions Vulnerable residents Identified Concern that

doesn’t fall into one of the above subgroups

8 hours on average for interviews, observations, and screening.

Gather information about pre-selected residents and new concerns

Determine whether pre-selected residents are still appropriate

1 – 3 hours on average

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Survey Structure

Resident sample size is about 20% of facility census

Interview, observation and limited record review care areas are provided for the initial pool process; surveyors can ask the questions as they would like

Surveyors meet to discuss and select sample, may have more concerns than can be added to the sample; may need to prioritize concerns

Investigations are then completed during the remainder of the survey for each sample resident using CE pathways

Facility tasks and closed record reviews are completed during the survey

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

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Group Interviews

Resident Council Meeting with active members

Includes Resident Council minutes review to identify concerns

Meet with Resident Group/Council

Includes Resident Council minutes review to identify concerns

NEW LTC SURVEY PROCESS OVERVIEW

Three parts to the new Survey Process:

1. Initial pool process

2. Sample Selection

3. Investigation

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Initial Pool Process Select Sample Investigations

Sample size based on census: 70% offsite selected 30% selected onsite by

team: Vulnerable New Admission Complaint FRI (Facility Reported

Incidents- federal only) Identified concern

Survey team selects sample

All concerns for sample residents requiring further investigation Closed records Facility tasks

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OFFSITE PREPARATION

Team Coordinator (TC) completes offsite preparation: Repeat deficiencies Results of last Standard

survey Complaints Facility Reported

Incidences (FRIs) - federal only

Variances/waivers

Necessary documents

are printed

Unit and mandatory facility task assignments: Dining Infection Control Skilled Nursing Facility (SNF)

Beneficiary Protection Notification Review

Resident Council Meeting Kitchen Medication administration and

storage Sufficient and competent nurse

staffing QAA/QAPI

FACILITY ENTRANCE Team Coordinator (TC) conducts an Entrance Conference Updated Entrance Conference Worksheet

• List of residents who smoke and smoking times, which will be used on the first day

• The number and location of medical storage rooms and carts, which will be used later in the survey

• Updated instructions for the list of residents for the beneficiary notices revie

Updated facility matrix Brief visit to the kitchen Surveyors go to assigned areas

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INITIAL POOL PROCESS

Surveyor request names of new admissions

Identify initial pool—about eight residents

Offsite selected

Vulnerable

New admissions

Complaints or FRIs (Facility Reported Incidences- federal only)

Identified concern

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RESIDENT INTERVIEWS

Screen every resident

Suggested questions—but not a specific surveyor script

Must cover all care areas

Includes Rights, QOL, QOC

Investigate further or no issue

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OBSERVATIONS

Cover all care areas and probes

Conduct rounds

Complete formal observations

Investigate further or no issue Facility Task vs. Critical Elements (CE) Pathways Facility Task Pathways

Critical Elements Pathways

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RESIDENT REPRESENTATIVE/FAMILY INTERVIEWS

Non-interviewable residents

Familiar with the resident’s care

Complete at least three during initial pool process or early enough to follow up on concerns

Sampled residents if possible

Investigate further or no issue

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LIMITED RECORD REVIEW Conduct limited record review after interviews and observations are

completed prior to sample selection.

All initial pool residents: advance directives and confirm specific information

If interview not conducted: review certain care areas in record

Confirm insulin, anticoagulant, and antipsychotic with a diagnosis of Alzheimer’s or dementia, and PASARR (Pre-Admission Screening and Resident Review)

New admissions – broad range of high-risk medications

Extenuating circumstances, interview staff

Investigate further or no issue 19

DINING

Observation of first full meal

Cover all dining rooms and room trays

Observe enough to adequately identify concerns

If feasible, observe initial pool residents with weight loss

If concerns identified, observe another meal

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TEAM MEETINGS

Brief meeting at the end of each day will be conducted by the survey team to discuss:

Workload

Coverage

Concern

Synchronize/share data (if needed)

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SAMPLE SELECTION

Prioritize using sampling considerations:

Replace discharged residents selected offsite with those selected onsite

Can replace residents selected offsite with rationale

Harm, SQC if suspected, IJ if identified

Abuse Concern

Transmission based precautions

All MDS indicator areas if not already included 22

UNNECESSARY MEDICATION REVIEW – SAMPLE SELECTION

System selects five residents for full medication review

Insulin

Anticoagulant

Antipsychotic with Alzheimer’s or dementia diagnosis

Based on observation, interview, record review, and MDS

Broad range of high-risk medications and adverse consequences all psychotropic medications, insulin, anticoagulants, opioids, diuretics and

antibiotics, as well as some adverse consequences, including falls, weight loss, and sedation 23

INVESTIGATION

General guidelines

Conduct investigations for all concerns that warrant further investigation for sampled residents

Continuous observations, if required

Interview representative, if appropriate, when concerns are identified

Majority of time spent observing and interviewing with relevant review of record to complete investigation

Use Appendix PP and Appendix P - critical elements (CE) pathways 24

ONGOING AND OTHER SURVEY ACTIVITIES

Closed Record Reviews

Completed during the investigation portion of survey

System selected

Unexpected death, hospitalization, and community discharge within the last 90 days

Discharged Resident

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Facility Task Investigations

Completed any time during investigation

Uses facility task pathways

CE compliance decision

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Dining – Subsequent Meal (if needed)

Second meal observation if concerns noted during first full meal observation

Use Appendix PP and CE Pathway for Dining

Dining task is completed outside any resident specific investigation into nutrition and/or weight loss

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Infection Control

All surveyors will observe for infection control throughout the survey process

Review of influenza and pneumococcal vaccinations will be coordinated by assigned surveyor

Infection prevention and control, and antibiotic stewardship program will be reviewed by assigned surveyor

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SNF Beneficiary Protection Notification Review

A new pathway has been developed for to make the process more user friendly.

A list of residents D/C’d from all Medicare Part A services

Both in-facility and home

Random selection by surveyor

Facility completes newly developed worksheet 29


Kitchen Observation

Full Kitchen Observation will be conducted in addition to the brief kitchen observation upon entrance

Appendix PP and Facility Task Pathway will be used to completed kitchen investigation

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Medication Administration

If opportunity presents itself, observation of medication administration for a sampled resident whose medication regimen is being reviewed.

Reconciliation of any controlled medications observed during medication administration

Observation of 25 medication opportunities

Observation of different routes, units, and shifts

Medication Storage

Observation of half of medication storage rooms and half of medication carts

If issues, will expand and review more medication rooms and medication carts. 31


Resident Council Meeting

Should occur early in the survey

Questions asked of residents are different from Traditional and QIS

Areas related:

Functioning of the council

A few resident specific areas (i.e. abuse)

Sufficient staffing 32


Sufficient and Competent Nurse Staffing Review

Mandatory task to be investigated on every survey to verify sufficient numbers and competency of staff per the RoPs

Consideration to staffing concerns being linked to QOL and QOC concerns

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Increased efficiency

Will investigate just the relevant concerns that cause the task to trigger

Eliminates duplicative LSC areas

Disaster and Emergency Preparedness

Oxygen Storage

Generator

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Potential Citations

Survey team will meet to review individual compliance decisions made by assigned surveyor to determine compliance and S/S for all potential deficiencies.

Exit conference will be conducted with facility staff.

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OPERATIONAL CONSIDERATIONS

F-Tag renumbering, designation and definition

Current survey process has 176 possible F-Tags; effective 11/28/2017 there are 179 possible F-Tags with more to come with implementation of Phase 3 In the Resident Right category there are currently 27 possible tags but in

November there will be 35 possible tags under the Resident Rights Category

Some F-tags that were under Quality of Care have been moved to other categories but the old F-309 has been broken down into specific tags for pain, dialysis, hospice, etc. 36


These types of splits will create more opportunities for multiple citations; HOWEVER They provide opportunity for more focused and acceptable

plans of action that could be classified as “past non-compliance”

They provide opportunity for more successful IDRs because the reasons for citations will have more commonality and not be as broad as current survey process

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OPERATIONAL CONSIDERATIONS -- SQC Substandard QOC

49 possible F-tags a across 8 different regulatory groupings when cited at F, H, I, J, K, or L

Classification is based on specific tag and not the regulatory grouping

All 10 tags in the regulatory grouping of Freedom from Abuse may be classified as SQC

4 of the 7 possible F-tags under Pharmacy Services may be cited as SQC

F757 (Drug Regimen is Free From Unnecessary Drugs);

F758 (Free From Unnecessary Psychotropic Meds/PRN Use);

F759 (Free of Medication Error Rates of 5% or More); and

F760 (Residents Are Free of Significant Med Errors).

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Facility Task vs. Critical Elements (CE) Pathways Facility Task Pathways – focuses on

processes and required tasks, i.e. kitchen observation, resident / staff interview; medication administration, dining observations, etc.

Critical Elements Pathways -- focuses on care and services, i.e. hydration, nutrition, end of life, dialysis, catheters, etc.

39 https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/QIS-Survey-Forms.html


Appendix P

Unsure when this will be published

Watch for additional S&C letters

S&C: 17-41 NH -- Survey Team Composition and Investigation of Complaints

S&C: 18-38 LSC -- Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies

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Survey Readiness

Educate staff and residents in new survey process

Develop and keep current a “survey ready” book

Be proactive – use the Facility Task Tools and Critical Element Pathways as part of your QAPI process

Create systems to ensure MDS accuracy and optimize flexibility im MDS schedule and completion of assessments

Create systems that validate the medical record is “telling the story”

Be prepared to share your action plans when appropriate so that a deficiency may be classified as “past –non-compliance

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QUESTIONS? APRIL PAYNE, LNHA VICE PRESIDENT OF QUALITY IMPROVEMENT DIRECTOR OF THE VIRGINIA CENTER FOR ASSISTED LIVING [email protected] | O: 804.212.1698 | M: 804.212.9917

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