1
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•
•
•
•
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Top 5 deficiencies, FFY 2007-2010
Recent citations under top 5
Colorado survey trends
National, regional survey trends
Trends in IDRs
Trends in IJs and SQCs
• QIS Process
2
FFY 2009
FFY 2010
Tag
323
281
309
279
371
Regulation
Accidents, Supervis
Standards of Practice
Quality of Care
Care Plans
Kitchen Sanitation
Tag
323
281
371
309
279
FFY 2007
FFY 2008
Tag
323
309
279
371
281
Regulation
Accidents, Supervis
Quality of Care
Care Plans
Kitchen Sanitation
Standards of Practice
Regulation
Accidents, Supervis
Standards of Practice
Kitchen Sanitation
Quality of Care
Care Plans
Tag
323
309
371
279
329
Regulation
Accidents, Supervis
Quality of Care
Kitchen Sanitation
Care Plans
Unnecessary Drugs
Federal Recertification Data
Source: Aspen Reports
3
Recent Citations Under F323
Accidents, Supervision
•Falls
• Unsafe smoking
•Resident-to-resident abuse in cognitively
impaired
Source: Aspen Reports
4
Recent Citations Under F281
Professional Standards
•Medication administration errors
•Nursing practice with medication pass
•Lack of signing off on MARs
•Not verifying orders
•Not transcribing orders
•Poor practice with medication pass
Source: Aspen Reports
5
Recent Citations Under F309
Quality of Care
•Pain
•Blood sugar
•Failure to implement care plans generally
•Diabetic care with insulin administration
•Lack of ulcer care/treatments
Source: Aspen Reports
6
Recent Citations Under F279
Comprehensive Care Plans
•No individualistic care plans
•Not including all problem areas/interventions
•Not comprehensive
Source: Aspen Reports
7
Recent Citations Under F371
Kitchen Sanitation
•Hand hygiene!
•Food temperatures
•Kitchen sanitation
•Improper handling of food delivery
•Sanitation in the dining room during service
•Sanitation assisting residents
Source: Aspen Reports
8
Number of Deficiencies
3000
2500
2000
2017
1919
2146
2223
2202 2481
1500
1000
500
0
FFY 2005 FFY 2006 FFY 2007 FFY 2008 FFY 2009 FFY 2010
Federal Recertification Data
Source: Aspen Reports
9
30
Number of Deficiencies
25
20
15
10
5
5.1
0
3.3
5.1
4.2
1.9
1
0.47
FFY 2004 FFY 2005 FFY 2006 FFFY FFY 2008 FFY 2009 FFY 2010
2007
Federal Recertification Data
Source: Aspen Reports
10
Number of Deficiencies
14
12
10
8
Nation
Region
6
Colorado
4
2
0
FFY FFY FFY FFY FFY FFY FFY FFY
2003 2004 2005 2006 2007 2008 2009 2010
Federal Recertification Data
Source: Casper Reports
11
14
12
12
10
8
6
7
5.9
4
2
0
Nation
Region
Colorado
Federal Recertification Data
Source: Casper Reports
12
Number of Complaint Surveys
350
325
326
307
300
256
253
234
241
FFY
2008
FFY
2009
FFY
2010
250
200
150
100
50
0
FFY FFY2005 FFY
2004
2006
FFY
2007
Source: Aspen Reports
13
Year
FFY 2004
FFY 2005
FFY 2006
FFY 2007
FFY 2008
FFY 2009
FFY 2010
# Complaint
Surveys
325
326
307
256
253
234
241
# Deficiency
Free Surveys
216
193
173
89
100
106
93
Average #
Citations
1.9
0.9
1
2
1.6
1.6
2.1
Source: Aspen Reports
14
•Smoking with oxygen (2) F323 K
•Hot beverage temperatures not within safe
parameters (2) F323 K
•Gaps between mattress and rails/bars (3) K
•Hypoglycemic episodes (1) J
Source: Aspen Reports
15
•Smoking with oxygen (1) F 323
•Hypoglycemia episodes (1)F309
•Resident-to-resident abuse (1) F323
Source: Aspen Reports
16
886 Tags Overall
16%
Sustained
Deleted
5%
84%
Sustained as
is
13%
Reduced
82%
Moved
Source: Aspen Reports
17
QIS Data for 1st Half FFY 2011
•26 QIS surveys completed
•6.8 average number of days on site
•17.4 average number of citations per survey
•3.8% of QIS surveys result in IJ citation
•3.6 % of QIS deficiencies are cited at G or above
Source: Aspen Reports
18
Impact of QIS Project for 1st Half FFY 2011
•Difficulty meeting workload
•Longer to complete surveys
•Increased surveyor turnover
•Negative ergonomic implications
•Longer training period
•Dependence on technology
Source: Aspen Reports
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20