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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
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.
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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.
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You can see just by the words used
that the focus is on residents, each
resident, results of care, and how
services are delivered.
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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.
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Assessment is the basis for
individualized plan of care!!!
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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
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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.
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Notice the emphasis on “actual and
potential” negative outcomes; and
also the requirement again for the
facility’s to help residents reach
“highest Practicable”
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As you can see, the need to maintain
a statewide average of 12 month
intervals can be complex and
involve many sceduling meetings
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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
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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
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Goal of this offsite meeting is to
analyze various sources of
information in order to:
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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.
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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.
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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.
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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.
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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.
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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.
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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
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This is one of the 7 Investigative
Protocols used by surveyors and
involves staff interviews, record
reviews, and resident care concerns
as indicated.
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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.
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This occurs before Task 6.This is an
expantension of Information
Gathering component of the survey
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
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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
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.
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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.
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When a facility failed to meet
Standards there are several possible
remedies that the state may apply?
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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.