Using Federal Regulations to SupportCulture Change in ICFs/MR (DD5)

9:30 AM – 11:30 AMOctober 10, 2007

Joyce L. Halling, QMRP, BA, LPN, LNHAAnn E. Lee, QMRP, MSW, SMQT

Get on TRAC, Inc.Sandy, Utah

The surveyors wrote us out for that last year

What about infection control?

But the “W” tags say we have to do it this way

I can’t get it all done now, how do you expect me to do one more thing?

But we’ve always done it that way

We can’t make the clients do that, the rules say so

The client won’t be safe if we do that

The client’s family said “Nuh-Nuh”, “No way”, “Not in my life time”

The client has a right to refuse treatment/care

The doctor didn’t order that

Have you ever heard . . . ?

How do you view the regulations?

Do they confine you?

Do you use them?

Learning Objectives

Understand the survey process and how it can be utilized to your advantage;

Understand federal certification regulations and how they can be used to create an effective, compliant, culture change environment;

Identify the unique strengths and challenges of your program/clients and how to create the environment that will maximize client potentials;

Steps that will promote the creative nature and potential of your clients and staff; and,

How to effectively deal with surveyor “latitude and attitude!”

Understanding the Survey –Philosophical Underpinnings

Support the person in their own homes and communities

Person-centered planning Person-centered services Focus on the person’s preferences,

goals and aspirations

Understanding the Survey –Philosophical Underpinnings

Support the person to reach aspirations

Outcomes relate to choice, control, relationships, and community inclusion

Focus on satisfaction with life, services, and supports

Understanding the Survey – Types of Regulations

StructuralRequirement must be met in the absolute sense in order to be certified (room size, HVAC)

ProcessRequirement must be complied with but how it is achieved is facility determined (IPP, IDT comprehensive assessment)

OutcomeRequirement reflects the processes experienced by the client and may be negative or positive (active treatment)

Understanding the Survey – ICF/MR Conditions of Participation (CoPs)

Governing Body and Management Client Protections Facility Staffing Active Treatment Client Behavior and Facility Practices Health Care Services Physical Environment Dietetic Services

Understanding the Survey – Four Types of Surveys

Complaint (focused) Full (initial) Extended Fundamental

Full Survey

Initial request for Medicaid certification If a CoP level deficiency was found on

previous annual survey The facility’s Time Limited Agreement

(TLA, Medicaid contract) is < 12 months as a result of deficiencies found on the previous survey

Evidence of “diminished capacity” of the facility is found based on other sources i.e., state licensure survey, complaints

Extended Survey

If surveyors have found or have reason to believe that a Condition level deficiency exists in any of the four fundamental survey CoPs, an extended survey reviews all standards under the fundamental CoPs will be initiated

Focus of theFundamental Survey

Choice and community participation Personal finances and possessions Personal relationships and privacy Client and family participation in the

IDT/IPP Service delivery Client rights and protections Health status

Elements of theFundamental Survey

Eight survey tasks Focuses on 56 tags, primarily outcome

oriented Concentrates on provider compliance with

outcome regulations but provider must meet all structural and process requirements

Requires compliance with 4 Conditions of Participation

CoPs Addressed by a Fundamental Survey

Client Protections Active Treatment Client Behavior and Facility

Practices Health Care Services

Elements of a Fundamental Survey =Client Protections (42 CFR 483.420)

W124 – W130, Inform of rights, Exercise rights, Manage finances, Not subject to abuse or punishment, Unnecessary drugs, Opportunity for personal privacy, Ensure privacy during treatment

W133, Communicate, associate privately W136, Participation in social, religious and

community groups W137, Retain and use personal

possessions

Elements of a Fundamental Survey =Client Protections (cont.)

W143 – W148, Promote participation, Answer communications, Promote visits at reasonable hours, Promote visits within facility areas, Promote leaves of absence, Notify of significant occurrences

W153 - W157, Investigate allegations abuse and neglect, Evidence of investigations, Prevent further abuse, Results reported, Corrective action taken

Elements of a Fundamental Survey =Active Treatment (42 CFR 483.440)

W196, Continuous active treatment W197, Not include independent clients W209, Client/family participation W227, Specific objectives to meet assessed

needs W240, Interventions to support

independence W242, Training in personal skills W247, Choice and self-management

opportunities

Elements of a Fundamental Survey Active Treatment (cont.)

W249, Sufficient frequency and number of interventions

W255 - W257, Program monitoring and change

W262 - W263, Specially constituted committee to monitor management of inappropriate behavior

W120, Outside resources meet needs W186, Sufficient direct care staff W436, Maintain and teach use of assistive

devices W448 - W449, Evacuation drills

Elements of a Fundamental Survey =Client Behavior and Facility Practices (42 CFR 483.450)

W285, Safeguard rights while managing inappropriate behavior

W286 - W288, Behavior management never used for disciplinary purposes, Convenience of staff, or Active treatment substitute,

W291, Time out room uses W293, Protection while in time out W301 - W302, Check and release while in

restraint W313, Drugs to control inappropriate behavior,

benefits outweigh side effects W314, Drug regimen review

Elements of a Fundamental Survey =Health Care Services (42 CFR 483.460)

W322, Annual physical exam as well as routine preventative care

W331, Nursing services in accordance with client needs

W338, Medical care plan (if needed) results in necessary medical intervention

W356, Dental care W369, Medications administered without

error W371, Self administration of medications

taught if appropriate

Active Treatment Circle as Required by the Fundamental Survey

Comprehensive Functional Assessment

Interdisciplinary Team (IDT)

Individual Program Plan (IPP)

Program Implementation

Program Change

Program Monitoring

Program Documentation

Ever Wondered How or Why

Survey Sample

Number of Clients

Number of Clients in Sample

Number of Interviews

Client/Family

4 - 8 50% 50% of sample

9 - 16 4 4

17 - 50 8 5

Survey Sample (cont.)

Number of Clients

Number of Clients in Sample

Number of Interviews

Client/Family

51 – 100 10 5

101 - 500 10% 50% of sample (15

max)

Over 500 50 15

Sample Selection

150 Bed facility, sample size 10%, 15 clients 15 residents have mild mental

retardation, 10% = 1 resident 26 residents have moderate mental

retardation, 17% = 3 residents 47 have severe mental retardation,

31%, 5 residents 62 have profound mental retardation,

42%, 6 residents

Sample Variables

Sample is not statistically valid All living areas represented All day/school programs represented Surveyors can add clients as they deem

appropriate Clients with obvious maladaptive behaviors Unaddressed developmental needs Unaddressed medical needs Client with complaints

What does it mean?

CMS regulations are not prescriptive on how you do it, just do it!

Surveyors should focus on just the fundamental requirements as long as you can meet the intent of the regulation

Surveyors should focus on the clear language of the regulation, not on best practice or opinion

What does it mean?

Facility rationale must be supported by a comprehensive assessment

Share the ‘blame’ - No one person determines client or facility services, the IDT does

You can make an educated guess about who will be sample residents

The only constant about change is the continuing need to change!

Culture Change

Do you feel like the sign on thepsychiatric hospital that says:

“Please do not disturb any further”

Core Concepts – Culture Change

Start at ‘normal’ Give quality supports, both client

and staff Purposeful activity Build on preferences Foundation of staff investment Match client needs to staff strengths Involved leadership

Active Treatment Circle

Comprehensive Functional Assessment

Interdisciplinary Team (IDT)

Individual Program Plan (IPP)

Program Implementation

Program Change

Program Monitoring

Program Documentation

Culture Change asActive Treatment

Facility Comprehensive Change Assessment

Interdisciplinary Change Team

Change Implementation Plan

Implement Change Program

Change to Changes

Change Monitoring

Change Documentation

Experience Sharing and Problem

Solving

Culture Change Steps

Facility Comprehensive Change Assessment

Interdisciplinary Change Team Change Implementation Plan Implement Change Program Change to Changes Change Monitoring Change Documentation

Thanks for everything!

TrainingReviewAssessment, and

Consulting

Get on TRAC, Inc.

Joyce = djhalling@msn.comAnn E. = annengerlee@hotmail.com