State of Michigan

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State of Michigan

• Department of Community Health
• Bureau of Health Systems
• Division of Operations
• Roxanne Perry
• February 28, 2008

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Welcome
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Clinical Process Guidelines

• Green Bill

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Clinical Process Guidelines

• Clarification Work Group
• Clinical Advisory Panel

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Purpose of CPGs

• To provide a uniform definition of the issue
• To establish clinical/research evidence as the
  basis for management
• To provide a format for analysis
• To provide a standard of practice
• To provide a template for action, documentation
  and monitoring

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Format of CPGs
Care Process Step Expectations Rationale
Recognition/ Assessment
Diagnosis/ Cause Identification
Treatment/ Management
Monitoring
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Example CPG-Evaluation of Falls/Falls Risk

• Memorandum to LTC facilities from Clinical
  Advisory Panel
• The Basic Care Process defined
• Process Guideline
• Documentation Checklist
• MDS/Fall RAP Key guidelines Assessment and
  Problem Definition, Care Plan
• Tables and illustrations
• Checklist for Assessment
• References

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Clinical Process Guidelines

• Topics
• Guideline for Use of Bed Rails in Long Term
  Care Facilities (April 2001)
• Evaluation of Falls/Fall Risk (October 2001)
• Pain Management (March 2002)
• End of Life Care (March 2002)
• Medication Management and Reduction of Adverse
  Drug Reactions (October 2002)
• Prevention and Management of Pressure Ulcers
  (February 2003)

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Clinical Process Guidelines

• Topics
• Behavior Management and Antipsychotic
  Medication Prescribing (October 2003)
• Acute Change of Condition (June 2004)
• Maintaining Hydration/Electrolyte Imbalance
  (September 2005)
• Altered Nutritional Status (September 2005)
• Depression (November 2006)
• Heart Failure (December 2007)

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New Applications for Use

• May be provided as a recommendation in
  enforcement letter.
• May be used as developmental structure by
  Clinical Advisor
• May be included in Directed Plan of
  Correction/Directed In-service
• May be used as a framework for establishing
  compliance (and past non-compliance)

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Past Non-Compliance
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Criteria for Past Non-Compliance

• To cite past non-compliance, all three(3)
  criteria must be met
• 1. The facility must not have been in
  compliance
• with a regulatory requirement at the time
  the situation occurred, i.e. the facility must
  have had a violation and
• 2. The situation of non-compliance must have
  occurred after the exit date of the last survey,
  and before the current survey (standard,
  complaint, revisit) and

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Criteria for Past Non-Compliancecontd

• 3. There must be specific evidence that the
  facility corrected the non-compliance (at the
  time of the incident) and is in substantial
  compliance at the current survey.

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Facility Past Non-Compliance Form

• Date of Report Administrator Name
• Facility name
• Address
• Phone
• Resident Name Date of Birth
• Room
• Diagnosis
• Date of event
• Was the resident injured?
• If yes Describe injury

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Facility Past Non-Compliance Formcontd

• Description of deficient practice (Why and how
  did it happen?)
• Plan of Correction
• In-depth analysis of how the deficiency occurred.
• How facility identified resident affected and
  residents having potential to be affected by the
  same deficient practice.
• Corrective action taken for resident affected.
• Measures or systemic changes made to ensure that
  deficient practice will not occur and affect
  others.
• How facility monitors its corrective actions to
  ensure deficient practice is corrected and will
  not recur.
• Date of completion of plan of correction. Attach
  documents for evidence of compliance.
• Name (printed) and Signature of person
  completing form

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Documentation of Past Non-Compliance

• 1. Past non-compliance that is not Immediate
  Jeopardy and for which a quality assurance
  program has corrected the non-compliance, should
  not be cited. Note The facility needs to bring
  this to the attention of the surveyor. The
  facility must provide the evidence to the
  surveyor who will contact his/her manager to
  review the information and make a determination
  if the evidence meets the criteria for past
  non-compliance.
• 2. Past non-compliance identified as immediate
  jeopardy is entered on CMS 2567 under the
  specific deficiency tag, scope and severity with
  supporting documentation.
• 3. The CMS 2567 should include the appropriate
  F-tag, date of deficiency, the date of past
  non-compliance, the evidence of past
  non-compliance and implementation of a plan of
  correction so that the civil money penalty can be
  determined.

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Documentation of Past Non-Compliancecontd

• NOTE The generic F698 has been
  discontinuedEnforcement Action on Immediate
  Jeopardy Past Non-Compliance
• 1. Civil money penalty is required for
  immediate
• jeopardy. Usually a per instance
  CMP is
• imposed.
• NOTE Past non-compliance does not apply to State
  Nursing Home Rules and the Public Health Code. A
  State of Michigan-tag (M-tag) may be cited.

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Documentation of Past Non-Compliancecontd

• IDR
• 1. Will be allowed for past non-compliance
  cites.
• i.e. To contest whether a deficiency
  occurred.
• 2. Can IDR whether a past non-compliance
  citation is a
• deficiency.
• 3. Cannot IDR whether a deficiency (cite) is
  past non-compliance.

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Putting it all together

• Use the Clinical Process Guidelines as a problem
  solving tool and to assure ongoing compliance.
• Identify the use of the CPGs when offering
  evidence of past non-compliance.
• Maintain a clear file of QA efforts in a manner
  that can be provided to surveyors.
• Continually monitor and document the monitoring
  of all QA efforts.

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Revisits

• Revisits may be conducted at any time for any
  level of non-compliance.
• Revisits are required for
• 1) Non-compliance at F (substandard quality of
  care)
• 2) Harm level citations
• 3) Immediate Jeopardy

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Evidence in Lieu of Revisit

• In some cases, acceptable level of compliance may
  be submitted in lieu of a revisit.
• Evidence of compliance in lieu of a revisit is
  not acceptable after a second revisit has been
  conducted.

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Evidence in Lieu of Revisit

• Examples of acceptable evidence are
• 1) Invoice or receipt verifying repairs,
  purchases, etc.
• 2) Sign-in sheets for in-service training
  verifying attendance
• 3) Contact with resident council

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Resources

• Bureau of Health Systems
• http//www.michigan.gov/bhs
• State Operations Manual (CMS)
• Appendix P
• http//cms.hhs.gov/manuals/Downloads/som107ap_p_lt
  cf.pdf
• Appendix PP
• http//cms.hhs.gov/manuals/Downloads/som107ap_pp_g
  uidelines_ltcf.pdf

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Resourcescontd

• Clinical Process Guidelines
• Deborah Ayers, DCH QI Nurse Consultant
• 517-241-2656
• dayers_at_michigan.gov