The American Health Care Association

1. The American Health Care Association Melissa Temkin, Director of Membership and Regulatory Relations mtemkin@ahca.org, 202-898-2822 CD Network

2. AHCA/NCAL Annual Meeting • October 4-7, 2009 • McCormick Place, Chicago, IL • 13 tracks, including Care Practice, Quality, Survey, etc. • Sessions can be listed in ADA’s activity log for CEUs • For more information, go to www.ahcancal.org CD Network

3. The Quality Indicator Survey(QIS) and Nutritionis sponsored by the CD Network and Provide Nutrition CD Network

4. The Consultant Dietitian Network(CD Network) • Who We Are • Registered, licensed dietitians who provide nutrition consulting and food service management services across the United States. • We provide services to all aspects of the healthcare industry with a special emphasis on Long-Term Care. CD Network

5. The Quality Indicator Survey(QIS) and Nutrition Presented by: Pam Brummit, MA, RD, LD Brenda Richardson, MA, RD, LD, CD CD Network

6. QIS DEVELOPMENT • University of Colorado, University of Wisconsin, Maverick Systems, and Alpine Technology • Development from 1998-2005 • Field tests by research, CMS staff, CO, IA, MD, NJ and WI • Demonstration and evaluation by CA, CT, KS, LA, OH 2006 CD Network

7. PURPOSE AND OBJECTIVES of the QIS • To guide surveyors through the federal survey process • Improve consistency and accuracy of Quality of Care/Quality of Life problem identification using a more structured process • Comprehensive review of regulatory care areas using current resources CD Network

8. QIS PURPOSE AND OBJECTIVES - cont • Enhanced documentation by organizing survey findings through automation • Focus survey resources on facilities with largest number of quality concerns • For providers, makes IDR process more difficult CD Network

9. PRELIMINARY RESULTS • Review of initial testing has shown increased consistency and improved documentation of survey findings • Result, QIS will be implemented on a larger scale. CD Network

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11. The Good NewsThe survey process has changed, but the F-Tags and Interpretive Guidelines are the same. CD Network

12. QIS SURVEYTwo-stage computer-assisted survey process, which includes 9 Tasks CD Network

13. STAGE I PROCESS • Preliminary investigation of residents • Randomly selected by QIS Data Collection Tool (DCT) • Based on a range of care areas covered by the federal regulations • Resident assessments are based on observations, interviews, review of the clinical records and an analysis of MDS data. CD Network

14. STAGE I PROCESS - continued • Constructs 160 resident outcome and process indicators called Quality of Care Indicators (QCIs) • The QCIs are then compared to national norms • QCIs that score above the statistical threshold are computer-selected for a detailed in-depth investigation in stage II. • Includes Tasks 1-6 CD Network

15. STAGE II PROCESS • In-depth investigation of residents with care areas identified by the computer in Stage I that exceeded thresholds (national norms) • Triggered care areas and residents are systemically investigated using Critical Element Pathways to determine regulatory compliance • Includes Tasks 6-9 CD Network

16. STAGE I CD Network

17. TASK 1: OFF-SITE SURVEY PREPARATION • MDS data is loaded into primary PC to create resident pool from which further Stage I random samples are selected. • MDS data are also used to calculate the QCIs for Stage II. • Review of past deficiencies, Ombudsman information and complaints in order to facilitate investigation during the survey. CD Network

18. TASK 2:ON-SITE ENTRANCE CONFERENCE • Team Coordinator announces survey and introduces team • Obtains an alphabetical resident census and list of residents admitted within last 30 days that reside in the facility • List of residents who receive dialysis, on ventilator, on hospice services • Staffing schedules for Licensed and Registered Nursing staff • Begin process of finalizing Stage I sample CD Network

19. TASK 2 – Concurrent Activities • INITIAL KITCHEN/FOOD SERVICE OBSERVATION WHILE OTHER MEMBERS ARE GATHERING INFORMATION • Dining observation (starts with first meal that can be observed in full) • Must identify emergency water source/supply • Must provide schedule of meal times and location of all dining rooms CD Network

20. TASK 3: INITIAL TOUR • Obtain BRIEF overall impression of the facility and the resident population • Meet as many staff/residents/families as possible • Record egregious resident care situations to be investigated further in Stage II • Document concerns with environment (dining room, cleanliness, smells, etc.) • Ask staff to identify family members that visit regularly CD Network

21. TASK 3: INITIAL TOUR – cont. • Observations: • staff/resident interactions (privacy and dignity) • staff availability • activities in progress • characteristics of resident populations, i.e. residents with dementia, rehabilitation, and sub-acute clinically complex residents, residents with special care needs (feeding tubes, ventilators, intravenous fluids/medications, tracheostomy tubes, oxygen therapy) • If meal service begins during tour, will begin dining service observation. CD Network

22. TASK 4: SAMPLE SELECTION • Quality Indicator Survey Data Collection Tool (QIS DCT) provides a systematic automated resident sampling process. • QIS DCT generates 3 Stage I samples from the resident pool • 1) MDS sample • 2)Admission sample • 3)Census sample (subset of resident pool) • Surveyors may generate a non-random, surveyor-initiated sample (subset of resident pool). • Once samples are generated, data is downloaded to surveyor’s individual PCs CD Network

23. TASK 4: MDS SAMPLE • Drawn from resident pool generated off-site. • Includes all residents who have had an MDS assessment any time during the past six months • Excludes residents with only a discharge or re-entry MDS and residents with only an admission MDS CD Network

24. TASK 4: ADMISSION SAMPLE REVIEW • The sample is randomly generated offsite by QIS DCT from the resident pool. • Up to 30 residents with an admission MDS submitted within six months (180 days) prior to the extraction date and admitted to the facility more than 30 days prior to the extraction date. CD Network

25. TASK 4: ADMISSION SAMPLE REVIEW • Focus is on quality of care within first six months for short stay and long stay residents at critical points (i.e. hospitalization, weight loss, rehabilitation) • Focal points: Nutrition, Rehab, Skin Care • Completed by records review only • Includes closed record reviews CD Network

26. TASK 4: ADMISSION SAMPLE REVIEW - continued Weight loss • Weights obtained from an appropriate source for time period being reviewed • Must use the same charting or documentation source for all of the weights, if possible. • Excludes residents with explicit terminal diagnosis and residents with LOS < 15 days CD Network

27. TASK 4: ADMISSION SAMPLE REVIEW - continued • Weight information may be collected from the following sources: • Medication and/or Treatment Administration Records • Dietary notes • Nursing notes • Weight and height records • The charting or documentation source that includes the weights recorded when the resident was actually weighed (e.g., Certified Nurse Aide flow sheets, weight books, etc.) • MDS is only used as the source of last resort) CD Network

28. TASK 4: CENSUS SAMPLE REVIEW • The Census Sample is selected randomly by the QIS DCT from the Resident Pool. • Offsite, 40 residents randomly drawn as the Stage I Census Sample. • Reconciled onsite to ensure that the sample only includes residents who are currently residing in the facility. • When discharged residents are replaced during the reconciliation process, newly admitted residents are added to the sample as replacements CD Network

29. TASK 4: CENSUS SAMPLE REVIEW • Focus on care of long term residents currently residing in the facility and encompasses activities of daily living, nutrition, medications, elimination/incontinence, resident room, oral health, quality of life, skin care • Data collection through observations, interviews and record reviews CD Network

30. TASK 4: CENSUS SAMPLE REVIEW - continued • This information will be comprehensively analyzed in Stage II. • Observations concerning compromised quality of care of sampled and non-sampled residents are recorded on surveyor worksheets for further review in Stage II. CD Network

31. TASK 4: CENSUS SAMPLE REVIEW - continued Resident Observations • Collect and record resident-specific information which takes into account situation and time of day • Multiple observations may be made Resident Interviews • Interview those residents assessed as interviewable by the QIS DCT • Questions asked as they are written CD Network

32. Interview Questions What is the food like here? Are you able to participate in making decisions regarding food choices/ preferences? Is this acceptable to you? Resident Observations None related TASK 4: CENSUS SAMPLE REVIEW - continued CD Network

33. Interview Questions Does the food taste good and look appetizing? Is food served at the proper temperature? Do you receive the fluids you want between meals? Resident Observations Physical signs of dehydration (dry, cracked lips and/or dry mouth, exhibits signs of thirst) TASK 4: CENSUS SAMPLE REVIEW - continued CD Network

34. Interview Questions Do you have mouth/facial pain with no relief? Do you have any chewing or eating problems (could be due to: no teeth, missing teeth, oral lesions, broken or loose teeth)? Do you have tooth problems, gum problems, mouth sores, or denture problems? Resident Observations Mouth contains debris, or teeth/dentures not brushed, or mouth odor, or dentures not in place Teeth broken/loose, or inflamed/bleeding gums, or problems with dentures TASK 4: CENSUS SAMPLE REVIEW - continued CD Network

35. TASK 4: CENSUS SAMPLE REVIEW - continued Family Interviews • Surveyors ask questions as written • Select families from various units • Conducted with three family members or resident representatives that know the resident well and visit often enough to provide information about the facility’s services • Concerns identified during the interviews may need to be investigated immediately, with the family present CD Network

36. TASK 4: CENSUS SAMPLE REVIEW - continued Family Interview Questions • Does the facility honor the resident’s preferences on what he/she eats or drinks? • Does the facility honor the resident’s desires and preferences? • Does the resident receive the assistance with meals that she/he needs? • Does the resident have any chewing or eating problems, or mouth pain? • Does the resident have any tooth problems, gum problems, mouth sores or denture problems? CD Network

37. TASK 4: CENSUS SAMPLE REVIEW - continued Staff Interviews • Conducted with licensed staff (RN/LPN) • Nurse must have frequent and direct contact with the resident • Document what is stated, even if information contradicts information gathered from another source (observation or record review) CD Network

38. TASK 4: CENSUS SAMPLE REVIEW - continued Staff Interview Questions • Question: Is this resident receiving a nutritional supplement, defined as a prescribed high protein, high calorie, nutritional supplement between or with meals? • If yes, there must be documentation in the medical record and staff must show documentation to surveyor. CD Network

39. TASK 4: CENSUS SAMPLE REVIEW - continued Staff Interviews • Documentation may include a checkbox or checklist that the supplement was given, provide a percentage of supplement consumed or list the amount consumed. • The following sources may provide supporting documentation: • Medication Administration Record • Treatment Record • Snack/Supplement List • Meal documentation with supplements listed separately • Other source as indicated by facility staff CD Network

40. TASK 4: CENSUS SAMPLE REVIEW - continued Clinical Record Review • Encompasses pressure ulcers, psychotropic medications, and weight loss • Surveyors are instructed to attempt to conduct record reviews on the unit to continue observations of activities and staff-resident interactions. • Weights documented the same as the Admission Sample CD Network

41. TASK 4: SURVEYOR-INITIATED SAMPLE • Chosen by a surveyor at his/her discretion, to be further evaluated during Stage II • Based on resident-specific information obtained from complaints, observations, interviews • Example: Dependent diner with a Stage I pressure ulcer who is not being fed and family has verbalized complaints CD Network

42. TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS - continued • Nutrition • Sources – MDS, medical records, staff interviews, observations, chart • Prevalence of weight loss (MDS) • Prevalence of significant weight loss that exceeds the interpretive guidelines (MDS/Medical records) • Excludes residents with terminal illness and on planned weight loss program CD Network

43. TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS - continued • Nutrition (continued) • Weight loss since admission: unplanned weight loss of 5% or more any time within 60 days of admit (MDS/Chart) • No supplements and resident underweight (Observation/chart) • Staff interview: Is the resident receiving a nutritional supplement defined as a high calorie/high protein product with or between meals? CD Network

44. TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS • Hydration • Sources - Resident and staff interviews and observations, MDS • Do you have access to fluids? • Do you receive fluids between meals? • Does the resident show signs of dehydration, such as cracked lips, etc.? • Prevalence of dehydration - output exceeds input (from MDS) CD Network

45. TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS - continued • Tube Feeding • Sources – MDS/Chart • Prevalence of tube feeding (MDS) • Significant weight loss on tube feeding (MDS/Chart) CD Network

46. TASK 4 : RELEVENT FINDINGS • Document: • Observed problems • Areas of concern • Date, time, and source • Person interviewed and title • IDRs WILL BE DIFFICULT CD Network

47. The CD Network and Provide Nutrition would like to introduceBrenda Richardson, MA, RD, LD, CD CD Network

48. TASK 5: FACILITY-LEVEL SURVEY AREAS Survey tasks to be completed: • Demand billing • Dining observation • Infection control • Kitchen/Food Service Observation • Med Pass CD Network

49. TASK 5: FACILITY-LEVEL SURVEY AREAS - continued • QAA Review • Resident Council president interview • Abuse prohibition review* • Admission, transfer, discharge review* • Environmental Observations* • Nursing services, sufficient staffing* • Personal funds* * completed only if triggered by complaints or Stage I interviews, observations or record reviews. CD Network

50. TASK 5: DINING OBSERVATION • Begins with the first full meal that occurs after the team enters the facility • General observations • Adequate staff to assist residents • Positive dining experience • Not limited to observation of specific residents • If concerns identified, may watch a different meal to see if problem exists during that meal • If more than one dining room, observe all dining rooms plus residents dining in-room CD Network