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2009 ALAA FALL CONFERENCE

2009 ALAA FALL CONFERENCE. MOBILE ALABAMA. W. Tom Geary Jr. MD Medical Director Bureau of Health Provider Standards Alabama Department of Health w t.geary@adph.state.al.us 334-206-5366. 2009 ALAA FALL CONFERENCE.

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2009 ALAA FALL CONFERENCE

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  1. 2009 ALAA FALL CONFERENCE MOBILE ALABAMA

  2. W. Tom Geary Jr. MD Medical Director Bureau of Health Provider Standards Alabama Department of Health wt.geary@adph.state.al.us 334-206-5366

  3. 2009 ALAA FALL CONFERENCE If you do have questions we ask that you put them in writing-- in Email form-- and send to Diane Mann at the Bureau of Health Provider Standards: diane.mann@adph.state.al.us We will provide a written response after thorough review with the management staff

  4. Assisted Living Survey Process Calculated averages for Calendar Year ‘08 Jan. 1, 2008 to Dec. 31, 2008 • Total of 93 surveys (24 follow-up w/o score) • 48 weeks of survey work= 1.9 surveys/ week Total resulting in a score= 69 surveys • Green: 17= 25% • Yellow: 41= 60% • Red: 11= 15%

  5. Assisted Living Survey Process_______________________________ Survey Result Alf % SCALF % _________________44___________25_______ Green 8 18% 10 40% _______________________________________ Yellow 32 73% 8 32% _______________________________________ Red 4 9% 7 28%

  6. 2009 ALAA FALL CONFERENCE • Statistics for 2009: Jan. 1- July 31 _______________________________________ Survey Result ALF SCALF _______________________________________ Green 14% 0% _______________________________________ Yellow 49% 14% _______________________________________ Red 26% 64% _______________________________________ Initial or follow-up 11% 22% _______________________________________ Total 100% 100%

  7. 2009 ALAA FALL CONFERENCE • Statistics for 2009: Jan. 1- July 31 ______________________________________________ Survey Result ALF 2008 SCALF 2008 _____________________________________________ Green 14% 18% 0% 40% _____________________________________________ Yellow 49% 14% _____________________________________________ Red 26% 64% _____________________________________________ Initial or follow-up 11% 22% _____________________________________________ Total 100% 100%

  8. 2009 ALAA FALL CONFERENCE • Statistics for 2009: Jan. 1- July 31 ______________________________________________ Survey Result ALF 2008 SCALF 2008 _____________________________________________ Green 14% 18% 0% 40% _____________________________________________ Yellow 49% 73% 14% 32% _____________________________________________ Red 26% 64% _____________________________________________ Initial or follow-up 11% 22% _____________________________________________ Total 100% 100%

  9. 2009 ALAA FALL CONFERENCE • Statistics for 2009: Jan. 1- July 31 ______________________________________________ Survey Result ALF 2008 SCALF 2008 _____________________________________________ Green 14% 18% 0% 40% _____________________________________________ Yellow 49% 73% 14% 32% _____________________________________________ Red 26% 9% 64% 28% _____________________________________________ Initial or follow-up 11% 22% _____________________________________________ Total 100% 100%

  10. 2009 ALAA FALL CONFERENCE The most frequently cited problems in assisted living facilities in Alabama are: 1. Staff training not complete 2. Failure to complete all monthly assessments including weights 3. Excessive hot water temperature 4. Fire alarm systems inspected only annually

  11. 2009 ALAA FALL CONFERENCE 5. Failure to complete and revise the plan of care: Formulate interventions Implement interventions Assess effectiveness of interventions

  12. 2009 ALAA FALL CONFERENCE 6. Retention of ineligible residents Failure to screen for eligibility and discharge ineligible residents: Unable to pass medication awareness test- ALF Unable to direct their own care in ALF Excessive PSMS scores-SCALF

  13. 2009 ALAA FALL CONFERENCE 6. Retention of ineligible residents who require care or services beyond that which the facility is licensed to provide: Bed-bound residents Residents can’t be weighed due to debility Bedrails in place for “safety” Sitters needed to provide care Residents having numerous falls despite interventions

  14. 2009 ALAA FALL CONFERENCE 7. Issues focusing on Narcotics: Missing medication No narcotic reconciliation Incorrect counts No nurse available after hours to assess for the need for PRN medications Failure to double lock controlled substances

  15. 2009 ALAA FALL CONFERENCE 1. Staff training issues: At the last ALAA conference in Montgomery we talked about investigative skills- detective work as a tool for the administrator to use to understand what is really going on in the facility; how the staff understands their responsibilities and performs their jobs. The next slide is from that presentation:

  16. ALAA SPRING CONFERENCE If the problem is staff training you should: • First, review the training records and be sure they are complete as required for each employee. • Secondly, interview the employee to see if he/she knows what he/she is supposed to know. • Thirdly, watch the employee perform and see if he/she is doing what he/she is supposed to do.

  17. 2009 ALAA FALL CONFERENCE Today I am talking about the actual training- getting it done and having the records that document what was done. • Look at the documentation for training for each employee - and yourself! • Get everyone trained • Get the documentation in the employee file in a well organized manner

  18. 2009 ALAA FALL CONFERENCE • The surveyors are going to look at the personnel records. • They are going to ask to see records for the employee physical examinations and Tb screening. • They are going to ask for Basic CPR training records. • They are going to review the training records and documentation of attendance.

  19. 2009 ALAA FALL CONFERENCE • There are 7 basic topics for both types of facilities: 1. State law and rules on ALFs (or SCALFs) 2. Identifying and reporting abuse, neglect and exploitation 3. Basic first aid 4. Advance directives 5. Protecting resident confidentiality 6. Safety and nutritional needs of the elderly 7.Resident fire and environmental safety

  20. 2009 ALAA FALL CONFERENCE • In Regular Assisted Living there are two additional topics: 8. Special needs of the elderly, mentally ill, and mentally retarded 9. Identifying signs and symptoms of dementia If documentation is lacking for completion of all 9 training sessions- a deficiency will be cited. The surveyor will observe the staff and ask what their training sessions covered and how many training sessions they had to complete to work in the facility?

  21. 2009 ALAA FALL CONFERENCE • In the SCALF there are 12 more topics: Sessions 8-19 of The DETA Care series If documentation of training and attendance for any employee is missing- the facility will be cited. The DETA Brain series is designed for professionals- Administrators, Nurses (RN, LPN)Therapists, Doctors, etc….to give them more in-depth knowledge to help staff and families and other professionals understand dementia

  22. 2009 ALAA FALL CONFERENCE The second most common citation is: 2. Failure to complete all monthly assessments including weights The monthly assessments are a part of the overall CARE PLAN. This starts before or at the time of admission and relies on the physician’s examination, diagnoses and recommendations. It also requires the facility to state what they will do for that particular resident.

  23. 2009 ALAA FALL CONFERENCE The planning for each resident’s care starts before or at the time of admission and continues until discharge. It must be kept current It must be reviewed and updated:1. annually (at least) by the attending physician2. after each hospitalization3. if there is a significant change in the resident’s condition4. at any other appropriate time

  24. 2009 ALAA FALL CONFERENCE • How can anyone possibly know if the resident has had a significant change if there is no clearly defined process to look for changes?

  25. 2009 ALAA FALL CONFERENCE • Whenever necessary and at least every month the staff must look at every resident and see if he/she is declining. • The point of this process is to discover physical, emotional, and mental problems that we can reverse- if we intervene early.

  26. 2009 ALAA FALL CONFERENCE • We expect that the primary caregivers, the Assisted Living Staff- the people who see the residents daily and help with ADLS- will function in place of a loving family member: pay attention and notice if the resident is “going down hill”. • And report what they hear and observe so that action is taken.

  27. 2009 ALAA FALL CONFERENCE The rules formalize what we know from the published literature and the experience of the bureau about the major warning signs of decline in the elderly: • They stop eating. • They lose strength, balance, and coordination. • They decline mentally and become confused. • They wander and resist care.

  28. 2009 ALAA FALL CONFERENCE • There are a host of reasons for an elderly resident to eat less and less, lose strength and coordination, and decline mentally. • Medication effects are a very common reason for problems and complications among the elderly. A drug that was great at age 50 may not be so good at age 80.

  29. 2009 ALAA FALL CONFERENCE Monthly assessments in the ALF require: 1. Documentation of WEIGHT 2. Documentation of MEDICATION AWARENESS(This must be tested at every “Med-Pass” to detect day-to-day changes in mentation) 3. Documentation of any SIGNIFICANT CHANGE No one can discover a trend- a change over time- unless you accumulate the data over time and analyze the information. Then you can- and must- act on the result.

  30. 2009 ALAA FALL CONFERENCE 3. Definition of SIGNIFICANT CHANGE ALF: significant weight loss over time-1,3,6 months two or more falls in 30 days or less behaviorthat is unmanageable, combative, or potentially harmful adverse drug reactionorover sedation elopement of a cognitively impaired resident- someone inappropriate for regular ALF care

  31. 2009 ALAA FALL CONFERENCE Monthly Assessment in the SCALF requires a review of: 1. Monthly Weights 2. Falls 3.Incidents 4. Elopements 5. Behavioral symptoms 6. Significant changes 7. Medication

  32. 2009 ALAA FALL CONFERENCE 6. Definition of Significant Change SCALF: • two or more falls within a 30 day period • significant weight loss over time-1,3,6 months • behaviorthat is unmanageable, combative, or potentially harmful any sign or symptom of adverse drug reaction or over sedation elopement any accident with injury

  33. 2009 ALAA FALL CONFERENCE 3. Definition of SIGNIFICANT CHANGE ALF: significant weight loss over time-1,3,6 months two or more falls in 30 days or less behaviorthat is unmanageable, combative, or potentially harmful adverse drug reactionorover sedation elopement of a cognitively impaired resident- someone inappropriate for regular ALF care

  34. 2009 ALAA FALL CONFERENCE The rules require the following: • “Any significant change requires immediate implementation and documentation of interventions or reassessment of existing interventions.”

  35. 2009 ALAA FALL CONFERENCE • Some have asked: “Exactly what do you expect us to do if we find a significant change?”. What specifically constitutes acceptable:1. immediate implementation and documentation of an intervention or2. adequate reassessment of an existing intervention?

  36. 2009 ALAA FALL CONFERENCE We expect every facility to: • follow a simple step-by-step approach to problem solving that is applicable to every problem-including the many that are not covered in the rules. • And to document in the record what they do.

  37. 2009 ALAA FALL CONFERENCE • You know as well as I do that no one can correct a problem without investigating the issues and discovering the cause. • I am a male and, as such, have the genetic disposition to try to fix or repair or assemble things at home before reading the instructions and studying the problem. • That never works!

  38. 2009 ALAA FALL CONFERENCE Step 1: Assessment- What does this mean?Gathering information about the problem Who does this?Everyone!Everyone has a role in this- the care assistant, the nurse, the doctor- everyone looks for something that can be changed to improve the situation.

  39. 2009 ALAA FALL CONFERENCE 1. Assessment- For example: An elderly lady is not eating well and has lost weight this month. Start by Talking to the resident, the care assistants and her family. Is the food good? Is it what she likes? Could the menu be adjusted to different foods or serving size?

  40. 2009 ALAA FALL CONFERENCE 1. Assessment- An elderly lady is not eating well and has lost weight this month. Start by Talking to the resident, the care assistants and her family. Could the menu be adjusted to different foods or serving size?Watch the resident eat. Is she chewing and swallowing well? Could the resident use special equipment to facilitate eating?

  41. 2009 ALAA FALL CONFERENCE 1. Assessment- An elderly lady is not eating well and has lost weight this month. Start by Talkingto the resident, the care assistants and her family. Could the menu be adjusted to different foods or serving size?Watchthe resident eat. Is she chewing and swallowing well? Could the resident use special equipment to facilitate eating?Review the medications- could something be affecting her appetite and eating?

  42. 2009 ALAA FALL CONFERENCE 1. Assessment- An elderly lady is not eating well and has lost weight this month. Start by Talking to the resident, the care assistants and her family. Could the menu be adjusted to different foods or serving size?Watchthe resident eat. Is she chewing and swallowing well? Could the resident use special equipment to facilitate eating?Reviewthe medications- could something be affecting her eating? Call the doctor and arrange an Examination. Does the resident need an X-ray or other tests to see why she is eating less and less?

  43. 2009 ALAA FALL CONFERENCE Step 2: Planan intervention- based on your assessment. From our example on the last slide: The X-ray was negative for any pathology or obstruction, the medications were reviewed and thought not to be the problem. • PLAN: The resident and family and staff decided to try 6 small meals per day with a supplement at each meal.

  44. 2009 ALAA FALL CONFERENCE Step 3: Implementthe plan Get orders from the doctor for the change in diet and the supplement. Get a supply of the supplement ordered and into the facility. Inform the kitchen personnel of the change in meal time and amount. Inform the resident, family, and care attendants of the new diet and schedule.

  45. 2009 ALAA FALL CONFERENCE Step 4: Monitorthe plan for effectiveness Ask the resident, family, and care assistants if she is now able to eat more food. Watch and see if she is drinking the supplements.Weigh her again and perhaps every week.Observe how her clothes seem to fit.

  46. 2009 ALAA FALL CONFERENCE Step 5: Revisethe plan if it is not working If, in our example, the resident continues to lose weight and hates the taste of the supplement, talk to the family and doctor and get a different type or flavor or add ice cream and flavoring to the supplement. More extensive investigation (ASSESSMENT) may be part of the revision process. This becomes a feedback loop for continuous refinement of the PLAN.

  47. 2009 ALAA FALL CONFERENCE To review the process:_____________________________________ • Assessment • Plan • Implement • Monitor • Revise -> reassess,New plan, implement, monitor, revise

  48. 2009 ALAA FALL CONFERENCE Each of these steps must be documented in the record. Documentation does not have to be extensive or voluminous. It may be a brief note of the discussions, phone calls, orders received, etc… Review of the process becomes straightforward- both to a surveyor and the staff. If the first plan fails, revise it. This means the level of intervention must be ratcheted up.

  49. Falls Case Study • Let’s look at a case study that exemplifies what the Bureau is looking for when we survey a facility. • Example Resident: 79 year old man admitted to a Regular ALF from home on June 10, 2007. He had heart bypass surgery 6 years ago; his wife died several weeks ago and he can’t live alone. He doesn’t want to be a burden to his family.

  50. 2009 ALAA FALL CONFERENCE Falls Case Study We will assume for this example that a thorough search for hazards in the room or personal clothing and equipment revealed none. In addition a review of medications was negative for those increasing the risk for falls. A review of physical mobility or mental deficits in need of correction, etc… revealed no problems.

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