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INDIANA EXPERIENCE WITH QIS

INDIANA EXPERIENCE WITH QIS. Brenda Buroker RN Survey Manager – QIS State Lead Indiana State Department of Health. ISDH Progress in Training Staff. 17 of 21 Teams Trained Goal has remained to have all teams trained by the end of 2012

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INDIANA EXPERIENCE WITH QIS

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  1. INDIANA EXPERIENCE WITH QIS Brenda Buroker RN Survey Manager – QIS State Lead Indiana State Department of Health

  2. ISDH Progress in Training Staff • 17 of 21 Teams Trained • Goal has remained to have all teams trained by the end of 2012 • Training of staff in QIS will be turned over to the Training Department at ISDH in 2013

  3. NOT WITHOUT PAIN • LOSS OF SURVEYORS • Loss of flexibility of job • Loss of everything familiar • Physically challenging carrying a laptop around all day • CRUCIAL TO HAVE 4 SURVEYORS ON A TEAM • Vacations/Illness/Turnover • Workload

  4. NEW SURVEY AREAS

  5. GOAL OF NEW SURVEY PROCESS • A SURVEY PROCESS TO MAKE SURVEYS MORE • Efficient • Accurate • Consistent

  6. EFFICIENCY • A more structured approach to the survey we have been conducting • Number of days to complete a survey • Focus on problem areas

  7. ACCURACY • New tags written • Following the Critical Element Pathways • Identify Substandard Quality of Care sooner in the process

  8. CONSISTENCY • Continual state, regional and national comparison • Desk Audit Review • Ask the same questions the same way at every survey

  9. The RESIDENTS • Interview Rates • Interview Refusals • Dining Observation

  10. IMPORTANT FAMILY INTERVIEWS • Interviews with 3 resident families per survey. • Threshold is low

  11. Facility Response • REMARKS WE HAVE RECEIVED: • Process worked as described by survey team • Well organized process • Interfered minimally with daily routine • Love QIS, but tags are odd and different areas are investigated than previous survey process • Smooth process • Communication is less, but is as much as possible with QIS

  12. ABUSE • RESIDENT INTERVIEW • Have you ever been treated roughly by staff? • Has staff yelled or been rude to you? • Do you ever feel afraid because the way you or some other resident is treated? • RESIDENT OBSERVATION • Are staff treating the resident in a manner that may indicate abuse?

  13. ABUSE • FAMILY INTERVIEW • Have you ever noticed any staff member being rough with, talking in a demeaning way or yelled at your family member or any other resident?

  14. CHOICES • RESIDENT INTERVIEW • Do you choose when to get up in the morning? • Do you choose when to go bed at night? • Do you choose how many times a week you take a bath or shower? • Do you choose whether you take a shower, tub, or bed bath? • Can you have visitors any time during the day or night?

  15. CHOICES • FAMILY INTERVIEW • Does [resident’s name] get up in the morning according to his/her previous routine? • Does [resident’s name] go to bed according to his/her previous routine? • Does [resident’s name] receive the same number of baths or showers in a week based on past preferences? • Can you visit anytime during the day or nighttime?

  16. DIGNITY • RESIDENT OBSERVATION • Dressed in hospital gown during the day or name visible • Cover for drainage bags • Wait for permission to enter room following knock on door • Explaining care the staff is going to provide • Including resident in conversation during care • Labels such as “feeder” or “honey” • Posting personal care instructions for all to see • Mimicking or making fun of resident • Displaying disapproving behavior: sighing or rolling eyes

  17. GOING FORWARD • Monitor time spent on surveys • Tags cited • Resident Interview Percentages • Following protocols

  18. INDIANA EXPERIENCE WITH QIS From an Industry Perspective….What We’ve Learned and How to Prepare Rebecca Bartle, RN, MSN, HFA Regulatory Affairs Director Hoosier Owners and Providers for the Elderly

  19. "Those who cannot learn from history are doomed to repeat it." -George Santayana

  20. Syzygy • Culture Change • MDS 3.0 • QIS • The nearly straight-line configuration of three celestial bodies (as the sun, moon, and earth during a solar or lunar eclipse) • Latin conjunction (from Greek origin) “yoked together”

  21. Everything is in align with the Resident’s wishes However, we must “ask”……… because the answer is not always what “we” think it is……………

  22. What We’ve Learned…….

  23. Overview of Citations(January 2011- June 2012) • 199 surveys • 1643 total deficiencies • 102 unique F tags cited • Median number of deficiencies= 7 • Average number of deficiencies= 8 • Highest number of deficiencies= 35 • Most frequent scope and severity= “D” (61%)

  24. A= 67 B= 79 C= 106 D= 1001 E= 270 F= 76 G= 39 J= 1 K=2 L=2 Citations by Scope and Severity

  25. Top Ten Tags Cited • 441- Infection Control (89) (45%) • 323- Accidents/Supervision (80) (38%) • 309- Quality of Care (76) (37%) • 279- Comprehensive Care plans (74) (37%) • 282- Qualified Persons (71) (36%) • 329-Unnecessary Drugs (66) (33%) • 371-Dietary Sanitation (57) (29%) • 253-Housekeeping and Maintenance (56) (28%) • 314-Pressure Sores (44) (22%) • 315-Urinary Incontinence (35) (18%)

  26. #1-F441- Infection Control • Handwashing • Gloves (wearing/changing) • Incontinent Care • PPE/Transmission Based Precautions (C-Diff) • Medication Pass (eye drops) • Handling of Linens • Tracking and Trending of facility acquired and non-facility acquired infections • Blood glucose monitoring equipment (clean/disinfect)

  27. #2-F323- Accidents/Supervision • Siderails/assessment/entrapment risk • Utilize lift according to manufacturer’s instructions • Proper transfers as per plan of care • Residents toileted; left unattended • Meds unattended/cart unlocked • Fall risk identified/interventions implemented/root cause identified • Alarms per plan of care; not in place • Improper storage of chemicals • Elopement risk/supervision • Unsafe water temperatures

  28. #3-F309-Quality of Care • Coordination of dialysis services (monitoring weight, access site) • Abnormal lab results (reporting and treatment) • Timely specimen collection • Evaluation and treatment of resident pain • Assessment of bruising, skin tears (non-pressure related skin conditions) • Failure to notify physician of change in condition (deterioration) • Failure to follow through with ordered consultations • Inadequate bowel monitoring

  29. Behaviors/Psychoactive Medication Use Refusals of Care or Treatment Restraint Use Nutrition Skin conditions (pressure and non-pressure related conditions) Discharge planning Suicidal Ideations Dehydration Catheter use Activities Advance Directives #4-F279- Comprehensive Care Plans

  30. #5-F282- Qualified Persons • Labs and medications not initiated, as ordered • Diet not served as ordered; mechanically altered • Dressing not in place, as ordered • Treatment not provided, as ordered • Blood glucose monitoring/insulin coverage not administered as ordered • Fall interventions not in place, as ordered • Failure to monitor and document consumption of supplements • Failure to clarify medication orders to ensure complete medication orders in place….

  31. Cont. F282 • Positioning devices • Geri-sleeves • Adherence with fluid restrictions • Splint/orthotic application, as ordered • Obtaining blood pressures, as ordered

  32. #6-F329- Unnecessary Drugs • Antipsychotics without medical justification and/or lacking monitoring for side effects • Hypnotics without adequate justification • Anticoagulant medication and laboratory monitoring • Adequate indications for PRN anti-anxiety medication administration • Lack of attempted non-pharmacological interventions • Lack of review for Gradual Dose Reduction

  33. #7-F371- Dietary Sanitation • Labeling and dating food in refrigerators • Beard restraints/hair coverings • Soap dispensers • Sanitizing chemicals/testing strips • Ice machine/cleanliness • Handwashing • Handling food/containers on trays improperly • Pans clean and in good repair • Cross contamination • Dishes stored with lime build up • Refrigeration temps

  34. #8-F253- Housekeeping/Maintenance • Marred and paint chipped walls • Dusty ceiling vents/blinds • Missing floor tile • Broken or missing cove base • Bedside tables in poor condition • Soiled shower chairs • Spillage on feeding pumps • Marred and scratched furniture • Urine odors, strong musty odor, objectionable odor…………. • Malodorous scent

  35. #9-F314- Pressure Sores • Lack of skin assessment • Dressing not changed, as ordered • Failure to obtain treatment (wound worsened) • Lack of position changes • Cushions/devices not in use • Treatment not done in accordance with physician’s orders

  36. #10-F315- Urinary Incontinence • Lack of proper perineal/incontinence care • Decline in bladder function- lacking assessment, training, etc. • Lack of order for use and care of an indwelling catheter • UTIs and catheter utilization • Drainage bag/tubing maintenance (below bladder level) • Obtaining timely UAs, as ordered • Lack of medical justification for catheter use

  37. Widespread Deficiencies… • F371- Dietary Sanitation (approximately 50%; 30+ deficiencies) • F441- Infection Control (approximately 15%; 10+ deficiencies) • F520 - Quality Assessment and Assurance (approximately 10%; 7+ deficiencies)

  38. Actual Harm Deficiencies….. • F309- Quality of Care (approximately 22%) • F323- Accidents/Supervision (approximately 19%) • F314- Pressure Sores (approximately 11%)

  39. Immediate Jeopardy Deficiencies • F314 (J)- Pressure Sores • F309 (K)- Quality of Care • F323 (K)- Accidents/Supervision • F323 (L)- Accidents/Supervision • F490 (L)- Administration

  40. Deficiencies by Category…..

  41. 151-Exercise of Rights 153-Adjudged Incompetent 155-Refusal of Treatment 156-Notice of Rights & Services 157-Notfication of Changes 159-Management of Personal Funds 160-Conveyance upon Death 161-Assurance of Financial Security 164-Privacy and Confidentiality* 165-Grievances 166-Resolve Grievances* 167-Examination of Survey Results 168-Receiving Information 170-Mail 172-Access and Visitation Rights 174-Telephone 176-Self-Administration of Drugs 203-Notice Before Transfer 205-Notice of Bed hold Policy & Readmission Resident Rights

  42. Resident Behavior & Facility Practices • 221-Physical Restraints* • 223-Abuse* • 224-Mistreatment, Neglect or Misappropriation of Resident Property* • 225-Not Employ Individuals Guilty of Abuse, Neglect • 226-Development and Implementation of Procedures

  43. 241-Dignity* 242-Self-Determination and Participation* 244-Facility Listen/Act on Grievances 246-Accommodation of Needs* 247-Notice of Room/Roommate Change 248-Activities* 249-Activities Director Qualifications 250-Social Services* 252-Environment* 253-Housekeeping and Maintenance* 254-Clean Bed and Bath Linens* Quality of Life

  44. Resident Assessment • 272-Resident Assessment* • 273-Comprehensive Assessment within 14 Days • 278-Accuracy/Coordination • 279-Comprehensive Careplans* • 280-Timing and Participation • 281-Standards of Professional Practice • 282-Qualified Persons* • 285-PASRR/Coordination • 286-Assessments 15 months in Active Record

  45. 309-Quality of Care* 311-Treatment to Maintain or Improve Abilities 312-Receives Necessary Services to Maintain Abilities 313-Vision and Hearing 314-Pressure Sores* 315-Urinary Incontinence* 317-Range of Motion-No reduction 318-Range of Motion-Maintenance/Improve* 322-Naso-gastric Tubes 323-Naso-gastric Tubes-Treatment and Services* 325-Nutrition/Parameters* 327-Hydration* 328-Special Needs 329-Unnecessary Drugs* 332-Free of Medication Error Rate of 5% or Greater* 333-Free of Significant Med Errors 334-Influenza & Pneumococcal Immunizations Quality of Care

  46. Nursing Services • 353-Sufficient Staff* • 354- Nursing Waivers • 356-Nursing Staffing Information

  47. Dietary Services • 362-Dietary Sufficient Staff • 363-Menus and Nutritional Adequacy • 364-Food Appearance/Palatability* • 365-Food Prepared for Individual Needs • 366-Substitutes Offered* • 367-Therapeutic Diets* • 368-Frequency of Meals • 371-Sanitation, Store, Prepare, Distribute and Serve Food*

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