Virginia Survey Process

Medical Director’s role

Judy Wilhide Brandt, RN, BA, RAC-MT, C-NEjudy@judywilhide.com909-800-9124www.judywilhide.com

Basics

• Annual survey: Q 9 – 15 months• Complaints: PRN• Process outlined in SOM Appendix P & PP• Very well defined, published survey tasks• Structured investigation prescribed by

state/federal guidelines– Very subjective decision making/citation

assignment

Traditional Survey Process Tasks

• Sample Selection- Offsite Survey Preparation: Used to select initial areas of concern & initial residents for sample

• ≈60% of residents chosen in Phase 1 & ≈40% in Phase 2

– Quality Measure (QM) Reports• If weight loss, dehydration, and/or pressure ulcers

trigger as a concern, half the phase 1 sample has to have these issues.

– Previous survey/complaint history– Waiver/variance info– Ombudsman info– PASSR info

Example of resident sample sizeCensus Phase 1 Phase 2 Compre-

hensive Review

Focused Review

Closed Record

Res/Family

Interviews

WHP

60 9 6 4 9 2 4/2 5120 14 10 5 16 3 5/2 7

200+ 18 12 5 22 3 7/3 9

Point:

• Areas of concern should never be a total surprise– Discourage “survey prep” mentality just prior to

survey window– Encourage IDT to review QMs monthly

• Target areas that trigger at 70% to review:–MDS coding–Care concerns–Proper chart documentation to explain whether

QM represents an issue or not with appropriate follow up

Quality Measures used in Survey Process

Comparative Analysis/Benchmarks

• Compares your facility to:– Other certified facilities in

your state– Other certified facilities

nationally• This comparison is used in

traditional surveys

• Allows you to benchmark your progress and compare yourself to others

You Shall Rise and Show Respect to the Aged

State ComparisonNational Comparison/Percentile Ranking

Resident Level Report

You Shall Rise and Show Respect to the Aged

Initial Tour

• Initial opportunity to observe residents, staff and physical environment including kitchen

• Identify residents or potential concerns for investigation

• Facility should have staff member who can discuss the resident accompany all surveyors

• Very common for most of the worst citations to begin development on the initial tour

1004/19/23

Residents: new admissions have no or infrequent visitors. psychosocial, interactive, and/or behavioral

needs. bedfast and totally dependent on care. dialysis or hospice Psychotropics Room variances MI/DD Communication issues: Non-oral, languages

Special Considerations for Sample:

Information Gathering• 5A General Observations of the Facility

• 5B Kitchen/Food Service Observations

• 5C Resident Review– Observation, Interview, Record review

• 5D Quality of Life Assessment

• 5E Medication Pass and Pharmacy Services

• 5F Quality Assessment and Assurance Review

• 5G Abuse Prohibition Review

Major Areas Reviewed:

Official Top 10 Virginia list 2013• F-309 Quality of Care• F-514 Clinical records - order • F-280 Care plan 7-days/team/periodic review • F-329 Unnecessary drugs • F-323 Accident prevention - environment • F-502 Laboratory Services • F-278 Accuracy of assessment • F-431 Drugs labels/expired drugs • F=441 Infection Control Program • F-279 Care plan, comprehensive

Most frequent high level citations Virginia 2013

• F-329: Antipsychotics mostly: Need actual behaviors, actual reasons, MD ordering and general statements not sufficient. “dementia with behaviors” certainly not sufficient

• F-502: Screwed up labs: Not ordered, not done, not responded to, not done as ordered, not reported, etc.

• Diabetic Management: Screwed up with bad outcomes

• Injuries: Falls, elopement, physical plant hazards• F441: infection control: Mostly watching med passes,

dressing changes, incontinence care, not washing hands by CNAs

• PHYSICIAN SERVICES• F385 Residents’ Care Supervised by Physician• F386 Physician Responsibilities During Visits• F387 Frequency/Timeliness of Physician

Visits• F388 Visits by Physician/Phys Assistant/Etc• F389 Emergency Physician Services 24

Hr/Day• F390 Phys Delegation of Tasks in SNFs/NFs

• The Medical Director – can help ensure that appropriate systems exist to facilitate

good medical care, – establish and apply good monitoring systems and effective

documentation and follow up of findings– help improve physician compliance with regulations,

including required visits. • During and after the survey process, the medical

director can – clarify for the surveyors clinical questions or information

about the care of specific residents,– request surveyor clarification of citations on clinical care, – attend the exit conference to demonstrate physician

interest and help in understanding the nature and scope of the facility's deficiencies,

– help the facility draft corrective actions.

Care coordination

• A medical director should establish a framework for physician participation, and physicians should believe that they are accountable for their actions and their care.– Ensure primary attending and backup physician coverage; – Ensure that physician/NPP are available to help residents

attain and maintain their highest practicable level of functioning, consistent with regulatory requirements;

– Develop a process to review basic MD/NPP credentials (e.g., licensure and pertinent background);

– Address and resolve concerns and issues between the physicians, health care practitioners and facility staff

– Resolve issues related to continuity of care and transfer of medical information between the facility and other care settings.

Common NF Issues in poor survey outcomes• Lack of clinical education by clinical

management– Lack of on-going educational development of

CNAs, LPNs, RNs, therapists

• Perceived or real inadequate staffing• Lack of a robust activities department• Lack of leadership experience/knowledge by

administrator/nursing management• Budgetary decisions that do not support

quality of care/life

How you can help• Lead the team• Do comprehensive assessments, document legibly

your conclusions and plan, every time– Tips:

• Diagnose, describe and stage pressure ulcers (yourself)• Diagnose, describe other types of wounds• Avoid simply listing diagnoses without current status and plan• Follow up on resident injuries: Demand careful review by IDT of

falls, fractures, etc.• Follow up on infections, changes of condition: Did staff properly

recognize and report? Do they know what they are doing clinically?

• Prescribe psychotropics when needed and document justification.– Don’t prescribe when not indicated

• Demand quality of care– Sanitation, hygiene, nutritious, delicious meals

• Do you ever eat the food? How about the pureed food?– Restorative nursing– Skin – Dental– Foot care

• Demand continuity of care– Shift to shift– Across transitions: Hospital, home health

• Pain control

• During high risk times:– Newly admitted: Does the staff know how to assess a new

resident? Skin, pain, preferences, functional status (falls)

How you can help

• Demand appropriate staffing for acuity• Actively engage in QA efforts• Realize that a little pain for the IDT during a

survey may result in lasting improvements – Don’t buckle to pressure in survey to ‘write

something to make it better’– Admit your shortcomings, demand the IDT admit

theirs: make it better (QAPI)– Stay the course– Tell the truth

How you can help

Plan of correction:• Be actively involved in survey• Attend exit conference• Assist in implementing realistic POC for lasting

change– Root cause analysis

• Develop/educate staff– CNA, LPN, RN– Dietary– OT, ST, PT

Questions/discussion