2014 State Veterans Homes VA Survey Deficiency Overview

1. 2014 State Veterans Homes VA Survey Deficiency Overview Valarie Delanko JoAnne Parker Office of GEC Operations (10NC4)

2. Discussion Topics • Top Deficiencies cited: January 2014 thru May 2014 for Nursing Home Care and Domiciliary. • Recognition survey updates

3. SVH Program Census Current SVH Program Structure offering three levels of care: • 149 State Veterans Home Facilities • 140 Nursing Home Care programs (24,163 beds) • 54 Domiciliary Care programs (5,865 beds) • 2 Adult Day Health Care programs (85 participant slots)

4. Surveys Types 2010 -2014 (May)

5. Totals

6. IJs -2011 to present

7. Top NH standards

8. Top DOM standards

9. NH Top NH standards Examples: Automatic fire alarm control panel (FACP) reports a supervisory visual notification trouble signal on the panel, but no action taken. Fail to maintain the automatic sprinkler systems, complete and document required inspection, testing, and maintenance services in accordance with established code inspection frequency. No documented weekly no-flow churn test for the fire pump . No documentation of biannual smoke detector sensitivity testing for the smoke detectors. Fail to maintain smoke barrier doors that would close and resist the passage of smoke and provide rated doors for hazardous areas - edge gaps on doors exceeding the permissible 1/8” inch clearance, doors fire ratings are insufficient for a hazardous area. Exits shall terminate directly at a public way or at an exterior exit discharge that is safe. Fail to provide a Digital Alarm Communicator Transmitter (DACT) system in an area where the alarm is likely to be heard by staff.

10. NH Top NH standards Examples: Fail to perform the weekly inspection and document monthly load tests of the Emergency Power Supply System (EPSS). Generator did not have a remote manual emergency stop station installed outside of the generator compartment as required by code. Generators load bank test not completed.

11. NH Top NH standards Examples: Fail to provide adequate supervision and/or safety devices. Fail to provide adequate supervision/monitoring of the proper feeding techniques specified by Speech Therapy to prevent aspiration. Fail to ensure that adequate supervision provided while attempting to self-transfer and left unattended in the bathroom.

12. NH Top NH standards Examples: Fail to review and revise the resident care plan to prevent accidents i.e., adjust for dysphasia. Failed to revise care plans, i.e., resident’s inappropriate behaviors that caused the burn with interventions to prevent re occurrence, as needing close monitoring to prevent altercations with other residents.

13. NH Top NH standards Examples: Interventions on resident care plan were not being followed, i.e. failed to provide toileting assistance as care planned, failed to ensure the fall alarm equipment functioned properly, failed to utilize hipsters as care planned and failed to provide appropriate monitoring for safety after administration of an as needed medication during an acute episode of anxiety. Fail to ensure assessments met professional standards of quality and were provided in accordance with each resident’s written plans of care; i.e. shunt not assessed returned from dialysis, no monthly labs, pressure ulcer tx not provided as ordered. nurse failed to document the nature of the burns, failed to complete an incident report to include measures to prevent further occurrence of such accidents, and failed to report to the physician for examination of the injury and possible treatment orders.

14. DOM Top DOM standards Examples: Does not have quarterly automatic (wet & dry) sprinkler system's inspection and test reports. Fail to properly maintain the automatic fire sprinkler system fire pump, complete or document weekly inspection services, and recalibrate or replace system pressure gauges. Fire pump pressure gauges overdue for a 5 year calibration or replacement inspection. No weekly fire pump inspection services. No-flow churn test were not being performed. No documented fire drills for each shift in each quarter. Fail to establish an inspection, testing and maintenance program for the battery-powered illumination devices installed within the facility - no monthly 30 second or annual 90 minute program for the inspection. Lack of annual inspection, testing and maintenance services for the portable fire extinguishers.

15. DOM Top DOM standards Examples: Fail to perform the weekly inspection and document monthly load tests of the Emergency Power Supply System (EPSS). Generator did not have a remote manual emergency stop station installed outside of the generator compartment as required by code. Generators load bank test not completed.

16. Recognition 1-1-14 to 7-28-14

17. Contacts • Valarie Delanko, RDN, LDN, CPHQ National Program Manager SVH Quality & Survey Oversight • Jo Anne Parker, MHA National Program Manager SVH Survey Process