Survey and Regulatory Update

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• Survey and Regulatory Update
• October 6, 2008
• Jill Snow, Sr. VP, Clinical Services
• SavaSeniorCare
• Lyn Bentley, Dir. Regulatory Services
• American Health Care Association

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Topics Covered Today

• Survey Trends
• CMS 2008 Nursing Home Action Plan
• Five Star
• Special Focus Facilities
• Enforcement
• Surveyor Guidance Revisions
• Interpretive Guidelines
• F325, F371
• F323 Rewind!

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Survey StatisticsTop 10 Health Survey TagsJune
2007 OSCAR Data

• F371- Sanitary Conditions
• F309 Highest Practicable
• Well Being
• F281 Professional
• Standards
• F323 Accidents
• F324 - Supervision

• F253 Housekeeping
• Maintenance
• F279 Care Plans
• F315 Incontinence
• F441 Infection Control
• F314 Pressure Ulcers

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Survey StatisticsTop 10 Health Survey TagsJune
2008 OSCAR Data

• F253 Housekeeping and maintenance
• F314 Pressure ulcers
• F329 Unnecessary medications
• F315 Catheterization
• F441 Infection control

• F323 Accidents/ hazards
• F371 Sanitary Conditions
• F309 Highest Practicable Well-Being
• F281 Professional standards
• F279 Comprehensive Care Plan

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Survey StatisticsLife Safety Survey TagsJune
2007 OSCAR Data

• K18 Construction of Doors
• K29 Hazardous areas separate by Construction
• K62 Sprinkler System Maintenance
• K147 Emergency Plan
• K38 Exits Accessible

• K25 Smoke Partition Construction
• K56 Sprinkler System of Approved Type
• K50 Fire Drills
• K144 Generators
• K67 Ventilating Equipment

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Survey StatisticsLife Safety Survey TagsJune
2008 OSCAR Data

• K25 Smoke Partition Construction
• K50 Fire Drills
• K56 Sprinkler System of Approved Type
• K144 Generators
• K76 Medical Gas Systems

• K18 Construction of Doors
• K29 Hazardous areas separate by Construction
• K62 Sprinkler System Maintenance
• K147 Emergency Plan
• K38 Exits Accessible

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CMS 2008 Nursing Home Action Plan

• Consumer Awareness and Assistance
• Survey, Standards, and Enforcement Processes
• Quality Improvement
• Quality Through Partnerships
• Value-Based Purchasing

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Consumer Awareness and Assistance

• Improve staffing data on CMS Web site
• use payroll database extract?
• Develop staffing quality measure (phase 2)
• Develop immunization measures for public
  reporting

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Survey, Standards, and Enforcement Processes

• Background Check Pilot Preventing Abuse and
  Neglect
• issue final national evaluation study summer 2008
• Improving fire safety
• better protection
• better information
• better monitoring
• better enforcement

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Survey, Standards, and Enforcement Processes

• Interpretive guidance to surveyors
• Refinement of state performance standards
• Frequency Quality of Surveys Enforcement and
  Remedy Value
• Establish escrow accounts for civil monetary
  penalties

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Survey, Standards, and Enforcement Processes

• Monitor civil monetary penalty amounts
• Update nurse aide training curriculum
• final report with policy options summer 2008

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Quality Improvement

• Development and validation of MDS 3.0
• Data Assessment and Verification Contract (DAVE)
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• STRIVE time study
• publish final rule for SNF PPS

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Quality Improvement

• Expand Collaborative Focus Facility (CFF) Project
• Culture change

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Quality Approaches Through Partnerships

• Communicating with other stakeholders
• Advancing Excellence in Americas Nursing Homes
  Campaign
• Emergency preparedness

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Quality Approaches Through Partnerships

• Long-term care task force
• internal to CMS
• Long-term care rebalancing

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Value-Based Purchasing

• Design nursing home value-based purchasing
  demonstration
• Post-acute care instrument development and
  demonstration

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Five Star Quality Program

• CMS is presenting this program as an improvement
  to Nursing Home Compare
• Rating system will include three components
• Survey Results
• Staffing
• Quality Measures

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Five Star, cont.Quality Measures

• Subset of current NH Compare
• ADL change
• Mobility change
• Long-stay prevalence measures
• Pressure ulcers
• Physical restraints
• UTIs
• Long-term catheters
• Pain

• Short-stay prevalence measures
• Delirium
• Pain
• Pressure ulcers

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Five Star, cont.

• Topic Expert Panel includes primarily
  researchers, one provider representative
• Abt is meeting with the panel for their ideas
  about development of Five Star
• Abt is developing the weighting formula will
  be complete in Oct. 2008
• First phase of Five Star will be live on CMS
  Web site in Dec. 2008

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Five Star, cont.

• Second phase of Five Star may include posting
  additional information
• Patient/family satisfaction scores
• Add new quality measures
• Include specific characteristics of nursing homes
  (e.g., specialty units languages spoken private
  rooms)
• Staffing data collected from payroll sources

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Special Focus Facilities

• Feb. 2008 CMS posted list of Special Focus
  Facilities to its Web site
• List is updated about once a month
• Categories
• Newly added
• Have not improved
• Have shown improvement
• Recently graduated
• No longer certified

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SFFs, cont.

• If facility has been purchased, old name is shown
  in parentheses
• Names of graduated and terminated facilities will
  remain on the CMS Web site for six months
• Link to SFF list from Nursing Home Compare should
  be removed when a facility graduates

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SFFs, cont.

• In 9th Scope of Work for Quality Improvement
  Organizations, they must provide technical
  assistance to SFF each year of next 3 years of
  contract
• State survey agency identifies potential SFFs and
  QIO contacts one
• If facility, refuses, QIO contacts next SFF
  identified

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Enforcement

• Concerns raised by providers in Regions IV and V
  related to Immediate Jeopardy citations
• AHCA contracted with PointRight to research
  citations in Regions IV and V
• Information given to CMS
• Status

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Surveyor Guidance Revisions Update

• F371 - Safe Food Handling- Mid 2008
• F325 - Nutritional Parameters - Mid 2008
• F309 Guidance for Pain Management 2008 or
  early 2009
• F441 - Infection Control Fall 2009
• F223 through F226 Abuse sometime in the
  future
• F309 Guidance for End-of-Life sometime in the
  future

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Key Policy Interpretations by CMS in 2008

• Surveying facilities receiving food prepared by
  off-site kitchens
• State Selection of Special Focus Facilities for
  technical assistance by QIOs
• Use of Interpretive Guidelines

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Structure of Interpretive Guidelines

• Regulatory Text and F-Tag
• Intent
• Definitions
• Overview
• Endnotes (references)
• Investigative Protocol
• Decision Making compliance vs. non-compliance
• Additional requirements (other F-Tags to
  consider)
• Deficiency categorization (F-Tag, scope
  severity)

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1/18/08 SC LetterUse of Interpretive Guidelines

• What they are not
• A requirement
• A standard of practice
• Lack of use is not deficient practice
• A deficiency demonstrates how the facility fails
  to comply with the regulatory requirement not how
  it fails to comply with interpretation of the
  requirements.

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1/18/08 SC LetterUse of Interpretive Guidelines

• What they are
• Authoritative (reliable) interpretation of
  regulatory language
• Serve as guidelines
• Specify survey protocols such as investigative,
  definitions of regulatory terms, and interview
  probes
• Facilitates surveyors consistent regulatory
  interpretation, and
• Determination of seriousness and scope of
  deficiencies.

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1/18/08 SC LetterUse of Interpretive Guidelines

• What they are (contd)
• Accepted standards of practice
• May reflect best and/or evidence-based practice
• Educational tools for surveyors
• Can be used to evaluate facility specific systems.

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Common Themes of the Interpretive Guidelines

• Systemic approach
• Process oriented approach to resident care and
  facility operation
• Evidence-based practices for clinical management
  areas
• Resident approach
• Care plans interdisciplinary and individualized
• Quality Assessment and Assurance component
• Staff knowledge vs. leadership knowledge

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F325 Nutrition

• Intent
• Provide nutritional care and services to each
  resident, consistent with the residents
  comprehensive assessment
• Recognize, evaluate and address the needs of
  every resident and
• Provide therapeutic diet that takes into account
  the residents clinical condition and preferences.

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F325 Nutrition

• Merged F325 and F326
• Assessment
• Analysis
• Interdisciplinary
• Care Plan emphasis
• Monitoring
• No Level I

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F371 Sanitary Conditions

• Intent
• Food for resident consumption obtained from
  approved sources
• Proper sanitation practices and food handling
  practices to prevent the outbreak of food borne
  illness and
• Begins when food is received from the vendor and
  continues throughout the facilitys food handling
  processes.

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F371 Sanitary Conditions

• Merged F370 and F371
• Emphasis is on process to maintain sanitary
  conditions as much as the sanitary conditions
  itself looking for systemic approach
• Knowledge
• Staff that handle food (kitchen, nursing, FA,
  etc.)
• Identify and prevent food hazards
• 3 Categories of contaminants

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F323 Rewind

• Combination of F323 and F324
• Intent
• Resident environment remains as free of accident
  hazards as possible
• Residents received adequate supervision and
  assistive devices to prevent accidents.

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F323 Rewind

• Examples of citations
• Smoking
• Elopement
• Resident to Resident Altercation
• Environmental hazards
• Falls
• WHY SUCH AN INCREASE?

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Interpretive Guidance F323

• Identify, Evaluate, Implement, Monitor
• What systemic measures are in place to identify
  and evaluate risk for residents?
• Fall management programs
• Safety programs
• Preventive maintenance programs
• Behavior management programs

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F323 Interpretive Guidance

• Once identified, was the risk consistently
  addressed?
• Example Facility cited under F323 for a
  defective resident lift device family had
  brought in the lift from home.
• Problem Facility could not demonstrate a
  comprehensive preventive maintenance program that
  included having resident equipment inspected
  prior to use.

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F323 Interpretive Guidance

• Supervision
• Adequate supervision is enhanced when the
  facility
• Accurately assesses a resident and/or the
  resident environment
• Determines that the supervision of the resident
  was necessary and provides supervision based on
  the individual residents assessed needs and
  risks identified in the environment
• Examples Smoking, Resident to Resident

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F323 Interpretive Guidance

• Environment
• Physical Environment
• Hazards in the environment
• Access to hazardous areas
• Water temperatures
• Devices and Equipment
• Preventive maintenance
• Maintenance alert
• Safety Committees Essential

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Common Themes of the Interpretive Guidelines

• Systemic approach
• Process oriented approach to resident care and
  facility operation
• Evidenced based practices for clinical management
  areas
• Resident approach
• Care plans interdisciplinary and individualized
• Quality Assessment and Assurance component
• Staff knowledge vs. leadership knowledge

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Questions