Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 During the 35 year period of 19501985, oversight of care in nursing homes consisted primarily of “paper compliance”; essentially ensuring that facilities had the “capabilities” to provide necessary care to residents. As a result of complaint investigations, and reports from consumers and family members, in 1986 the IOM issued a comprehensive report, the culmination of decades of work, detailing the existing problems in NH and recommending reform/changes in the process. Slide 6 The 1987 reform law is usually referred to OBRA ’87 and marked the turning point for providers, consumers, and regulators. The survey process for oversight of resident cares focused on outcome to/for the resident and was designed to ensure that the resident was assisted to maintain or improve his/her highest practicable level of well-being. I will refer many times today to the concept of highest practicable level and will provide examples of how those simple 5 words impacts on the process. Slide 7 You can see just by the words used that the focus is on residents, each resident, results of care, and how services are delivered. Slide 8 I devoted on entire slide to QoC because it so succinctly described the requirements of the facility and therefore, the expectation of each resident. As you can see, the facility must have a plan of care for each resident. Later I will describe the requirements of care plan development which will start with an individualized assessment of EACH resident. Slide 9 Slide 10 Assessment is the basis for individualized plan of care!!! Slide 11 The state Medicaid Agency, Department of Human Services provides funding also to conduct NH surveys. Minnesota’s state average is 143 hours, this includes pre-survey, on site survey time, travel time, and documentation. Slide 12 The Medicare program is the federal medical insurance program for those persons over the age of 65 and the disabled. Medicaid is the federal program that provides medical assistance for certain individuals and families with low incomes. 7 MN NH are “licensed only”, ie MN Veterans homes. Slide 13 Slide 14 Slide 15 Slide 16 Slide 17 Notice the emphasis on “actual and potential” negative outcomes; and also the requirement again for the facility’s to help residents reach “highest Practicable” Slide 18 Slide 19 Slide 20 As you can see, the need to maintain a statewide average of 12 month intervals can be complex and involve many sceduling meetings Slide 21 Slide 22 Slide 23 The resident is our primary concern. All information gathered during the survey process is kept confidential. Respect for resident privacy includes during times of care-giving observations, resident record review, and interviews with res or family members. During information- sharing meetings with team members, all discussions are considered and kept confidential/private. Slide 24 Slide 25 Slide 26 CMS has provided these additional tools to surveyors in order to ensure that investigation for compliance with the above quality of Care and Resident Rights requirements is systematic and consistent for all Medicare beneficiaries regardless of where (which state) they reside. The Investigative Protocols are consistent with the regulations and are an extension of the Interpretive Guidelines. Slide 27 Goal of this offsite meeting is to analyze various sources of information in order to: Slide 28 Includes OSCAR reports 3 and 4 which summarize the citations issued in previous 3 years and info about facility as it compares to others in the state and region. We notify the regional Ombudsman’s Office of our schedule, and call the ombudsman about our entrance date, invite them to the exit conference, and ask them if they have any information they are able to share. Slide 29 Slide 30 Slide 31 Now we are at the facility. Team enters the facility and asks to meet with the administrator. During the Entrance Conference, the Team Leader explains the survey process, answers any questions, obtains facility information such as nursing schedules, mealtimes, location of key personnel, etc. Slide 32 It is desirable for team members to have a facility staff person who is familiar with the residents accompany them. The initial tour is not delayed if facility staff are not available. The tour is to begin as soon as possible after entering the facility. Team members hang bright yellow signs in the facility announcing that the survey team is on the premises and available to speak to anyone. Slide 33 Slide 34 Slide 35 Slide 36 Slide 37 Pre-selected residents for the sample are retained for the sample unless they are discharged or the survey team has another reason to substitute, such as a need to select an interviewable resident. Case Mix stratified means at least one resident with light or heavy cares and at least one resident who is either interviewable or noninterviewable. Family members will generally be interviewed for the non-interviewable res. Slide 38 General observations of facilityassessment of the environment affecting the resident’s life, health and safety. Kitchen and food service observations-assessment of the facility’s food storage, preparation and service. Slide 39 Slide 40 Slide 41 Slide 42 Slide 43 Slide 44 Slide 45 Slide 46 Slide 47 Slide 48 Slide 49 The Group interview is generally with “resident Council members”, but other residents who are assessed to be able to make their own decisions may be invited to attend. All 3 types of interviews include specific questions; again in order to promote consistency with interviews also. Slide 50 Surveyors observe as many different staff members and as many different routes of medication administration as possible in order to get a broad picture of Medication Administration Slide 51 Slide 52 This is one of the 7 Investigative Protocols used by surveyors and involves staff interviews, record reviews, and resident care concerns as indicated. Slide 53 The team maintains an open and ongoing dialog with the facility during the survey process to give the facility an opportunity to provide additional information. Slide 54 Slide 55 This occurs before Task 6.This is an expantension of Information Gathering component of the survey process. Facility representatives who participate will vary depending upon the issue(s) requiring clarification, IE a potential deficiency of the dietary department would be more clearly answered by the dietitian versus the activities director. Slide 56 Slide 57 Slide 58 Facility chooses which members of the staff to invite. The ombudsman may be present. All exits are tape recorded as a matter of MDH policy, even if no deficiencies. All residents addressed in the deficiencies are identified by means of an identifier such as a number or letter. Residents are not identified by name in deficiencies. Slide 59 Slide 60 Slide 61 Slide 62 Slide 63 Slide 64 As a result of OBRA, regulations established an approach for determining the relative seriousness of each instance of noncompliance with standards. Scope is isolated when one or a very limited number of residents are affected or one or a limited number of staff are involved, and/or the situation has occurred only occasionally or in a limited number of locations. Scope is a pattern when more than a very few limited number of residents are affected, and/or more than a limited number of staff are involved, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the facility. Scope is widespread when the problems causing the deficiencies are pervasive in the facility and/or represent systemic failure that affected or has the potential to affect a large portion of the facility’s residents. Widespread refers to the entire facility population, not a subset of residents or one unit of a facility. Widespread scope may be identified if a systemic failure in a facility, such as failure to maintain food at a safe temperature, would be likely to affect a large number of residents and is pervasive. Slide 65 Slide 66 Slide 67 Slide 68 When a facility failed to meet Standards there are several possible remedies that the state may apply? Slide 69 Slide 70 What does CMS have in mind for Regulation revision or survey guidance? CMS has a multi-year contract with the American Institutes for Research to review and revise the survey guidance for surveyors at selected Tags. The areas included are those above.