the new survey process—
TRANSCRIPT
The New Survey Process—Readiness, Resources, Review
Laura Hofmann, LeadingAge WashingtonElena Madrid, Washington Health Care
AssociationOctober 2017
WhWwhahtUnderstand the Purpose & Intent
• Do the Right Things for the Right Reasons• Do you know your residents?• Do you know your staff?• Do you know your partners?
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WhWwhaht483.12 Freedom from Abuse, Neglect, and
Exploitation
Need to know the different requirements for reporting of suspected crimes versus allegations of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property
WhWwhaht483.15 Admission, Transfer, and Discharge
• “Facility-initiated transfer or discharge”: A transfer or discharge which the resident objects to, did not originate through a resident’s verbal or written request, and/or is not in alignment with the resident’s stated goals for care and preferences.
• “Resident-initiated transfer or discharge”: Means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment).
WhWwhaht483.15 Admission, Transfer, and Discharge
Sending copy of transfer/discharge notice to ombudsman:• Applies to facility-initiated discharges• For emergency room transfer, may send notice
to ombudsman when practicable such as in a list of residents on a monthly basis
• Notice of transfer or discharge is not required for resident-initiated discharges
WhWwhahtFacility Assessment
Purpose: to determine what resources are necessary to care for residents competently during day-to-day operations and emergencies• May be used to make decisions about direct
care staff needs as well as capabilities to provide services to the residents in your facility.
http://qioprogram.org/facility-assessment-tool
WhWwhahtWhat does this mean for you?
• Time of transition-within your centers (and for surveyors too)
• A time to reflect, self-assess, and prioritize your efforts
• A marathon, not a sprint
WhWwhahtKey Take Aways-LTCSP
Focus on Key Changes of the LTCSP• Entrance• Tour• Group Meeting• Initial Pool Process• Sample Selection• Ongoing and other Survey Activities• Investigation
WhWwhahtEntrance-Preparation is the Key!
Not limited to:Survey BookResident Roster/Sample MatrixList of Department Heads and ContactsExemptions/ExceptionsProcesses-EHRProceduresFacility Map/Room ListSurety Bond
WhWwhahtNew Survey Process
Specific Unit/Facility Task Assignments:– Dining– Infection Control – Resident Council Meeting– Kitchen Review– Medication Administration/Storage– SNF Beneficiary Protection Notification Review– Sufficient and Competent Nurse Staffing– QAA/QAPI
WhWwhahtResident Interviews
• Emphasis on resident interviews and observations starting on Day 1– Screen every resident in the initial pool– Investigate further or no issue
• Structured Resident interviews– Suggested questions, but not specific script– Cover all areas, including Rights, QOL, QOC– Resident representative/family interviews for non-
interviewable residents– Group interview with Resident Council
WhWwhahtClosed Record Reviews
• Complete during the investigation portion of survey
• Unexpected death, hospitalization, and community discharge last 90 days
• System selected or discharged resident• Using Appendix PP and CE pathways
WhWwhahtCritical Element (CE) Pathways
• Investigations of specific care areas– Mandatory vs. triggered– Systems and outcomes– May be tied to a particular regulatory section
(infection prevention, control) or cut across multiple regulatory sections (dining)
• Level of structure and consistency
WhWwhahtCritical Element (CE) Pathways
• Used to determine compliance– Regulation and guidance– Protocols and checklists for:
• Observations of how care and services are provided• Interviews with residents, families/representatives, and
staff• Record reviews
– Emphasis on critical elements of requirements– Citations tied to related F-tags
WhWwhahtCritical Element (CE) Pathways
Mandatory
• Dining• Infection Control• SNF Beneficiary Protection Notification Review• Kitchen Observation• Medication Administration and Medication
Storage• Resident Council Meeting• Sufficient and Competent Nurse Staffing Review• Environment
WhWwhahtCMS CE Pathways
• Dementia Care• Discharge• Resident Assessment• Neglect• Accidents• Bladder and Bowel Incontinence• Hospitalization• Positioning, Mobility• Tube Feeding• Hydration
WhWwhahtCMS CE Pathways
• Extended Survey• PASARR• Unnecessary Medications• Respiratory Care• Rehab and Restorative• Pressure Ulcer• Physical Restraint• Pain Management
WhWwhahtCMS CE Pathways
• Pain Management• Nutrition• Death• Hospice End of Life• General• Dialysis• Dental
WhWwhahtCMS CE Pathways
• Communication/Sensory• Urinary Catheter or UTI• Behavior Emotional• ADLs• Activities• Personal Funds• Abuse• QAA QAPI• Resident Council
WhWwhahtManaging the Survey Process
• Use Pathways to prepare staff and residents• Make sure staff, residents, and families are
aware of changes you have made based on the new or revised requirements
• Use the regulation to support your discussions with surveyors—keep a copy handy and accessible!
LeadingAge Washington Resources
LeadingAge-Pathway Health • Policies-Procedures and Training tools mailed to
all Communities• Also available on LeadingAge Website under
member only toolsE-Prep App and Facility Assessment tool• Link mailed to all AdministratorsLeadingAge Washington website
WhWwhahtAHCA/WHCA Member Resources
A resource made available by American Health Care Association (AHCA) to all WHCA members is the ahcancalED, RequirED website. This website contains a number of resources including Action Briefs of the new requirements, guidance on “Preparing for the New Survey Process and Requirements of Participation Phase 2” and Emergency Preparedness information, in addition to webinars and other presentations.
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WhWwhahtCMS Resources and Where to Find Them…
• The Integrated Surveyor Training Website (ISTW) can be found here. On this website, click on the heading titled, “I AM A PROVIDER.” This will redirect you to a page that includes the CMS course catalog. In this catalog you will find the Emergency Preparedness Basic Surveyor Training Course under LSC (Life Safety Code). In the catalog you will also find a large number of training resources for your facilities and staff that are used with the surveyors, in addition to the following:
• ASPEN and the Long Term Care Survey Process• LTC Survey Process SME Videos
WhWwhahtCMS Resources and Where to Find Them…
• The CMS Website can be found here and provides valuable resources including links to the LTC Survey Entrance Conference and Provider Matrix and the LTC Survey Pathways, as well as the following:
• Appendix PP 03-08-2017 [Effective through November 27, 2017] [PDF, 3MB]
• Advance Appendix PP including Phase 2 [Effective November 28, 2017] [PDF, 3MB]
• List of Revised FTags [Effective November 28, 2017] [PDF, 152KB]• S&C Memo: Revision to State Operations Manual Appendix PP for Phase 2
(Includes Training Information and Related Issues) [PDF, 121KB]• F-Tag Crosswalk [XLSX, 495KB]• Training for Phase 1 Implementation of New Nursing Home Regulations
[PDF, 108KB]• New Long-term Care Survey Process – Slide Deck and Speaker Notes
[PPTX, 8MB]
WhWwhahtQuestions
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Laura HofmannDirector of Clinical and Nursing Facility Regulatory ServicesLeadingAge WashingtonT: [email protected]
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Elena MadridDirector of Regulatory AffairsWashington Health Care AssociationT: 800-562-6170, ext. 105P: 360-352-3304, ext. 105