Risk ManagementPreparation -  Prevention - Response
Janice Sumner, RN
VP of Clinical Operations
HMRVSI, Inc.
July 30, 2015
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Risk
•The possibility that something bad orunpleasant (such as injury or loss will happen)
•Someone or something may cause somethingbad or unpleasant to happen
•A person that someone judges to be a badchoice for many things
Preparation
•Quality assurance program
•Current information
•Education
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Prevention
•The act or practice of stopping something badfrom happening
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Response
•Something done as a result to something thathas happened
•An incident that constitutes a reply or reaction
MDS Focused SurveyTargeted Survey
•Specialized onsite surveys to access adequacyof a resident’s assessment as related toinformation reported to CMS
•Can not be combined with a normalrecertification survey
•Can be conducted immediately after or beforea compliant survey
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Three areas to be evaluated
•Compliance with regulatory requirements
•Timeliness
•Compare MDS with the medical record
MDS Survey Request
•Policies and Procedures for MDS and QualityMeasures
•Staffing schedule: MDS and Quality Assurance
•Resident Information
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Top 5 Deficiencies
•Follow up from injury
•Pressure Ulcers
•Restraints
•Diagnosis for indwelling catheter
•Late loss ADLs
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MDS Survey Results
•Increased compliance with timeliness ofassessments
•Decreased compliance with supportingdocumentation
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Electronic StaffingPBJ
•Must transmit timely and efficiently
•Requires electronically submission
–Includes agency and contract staff
–Based on payroll/verification
–Must be auditable
–Uniform format
•Staffing data must include hours worked byeach staff every day
Dates to Remember
•Fiscal quarter 1October 1 – December 31
•Fiscal quarter 2January 1 – March 31
•Fiscal quarter 3April 4 – June 30
•Fiscal quarter 4July 1 – September 30
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Additional Dates
•Mandated  July 1, 2016
•Voluntary registration August 15, 2015
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Registration
•QIES System
–Quality Improvement &Evaluation System
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Job Descriptions
•Administrator
•Nursing Services
•Restorative Services
•Dietary Services
•Social services
•Activity Services
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Additional Job Descriptions
•Physician Services
•Nursing Services
•Dietary Services
•Therapeutic Services
•Dental Services
•Mental Health Services
•Clinical LaboratoryServices
•Diagnostic X-rayServices
•Housekeeping Services
•Additional Services
Food for Thought
•Create policy and procedure
•Communication with providers
•Process for information
–Timeliness
–Format of information
–Compliance to accuracy
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Final Rule
•Biggest change to nursing home rules in 24years
•Published July 13, 2015
•Open for comments 9-14-15
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Goal of Final Rule
•To achieve improvement in quality of healthcare and resident safety through federalprograms while reducing the proceduralburden on providers
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Significant Requirements
•Implementation of a Comprehensive QualityAssurance and Performance Program
•Required facility compliance and ethicsprogram
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Additional Changes
•Resident’s Rights
•Pharmacy Services
•Behavioral Health
•Diagnostic Services
•Dental Services
•Food & NutritionalServices
•Specialized RehabServices
•Physical Environment
QAPI Requirements
•Facility will be required to present acomprehensive QAPI to state agencysurveyors during the first annual survey afterthe effective date of the regulation
•Facility must develop, implement, andmaintain effective comprehensive data drivenQAPI program with a focus on indicators ofthe outcomes of care and quality of life
Elements of a QAPI
•Program activities
•Leadership
•QAA committee
•Disclosure of information
•Sanctions
Compliance and Ethics
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Components
•Posted information related to reporting
•Policies for disciplinary standards
Facility Assessment and Staffing
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How Will the Facility Maintain theAssessment?
•List of resident current census and facilitycapacity
•Care provided by resident population
•EthicCulturalReligious
•Facility Resources
•Facility based and community basedassessment
Reporting Requirements for SuspiciousCrimes
•Suspicion of bodily harm must be reported in2 hours
•Suspicion of a crime without bodily harm mustbe reported in 24 hours
•Suspicion of a crime must be reported to stateand law enforcement
Transition of Care
•Dr Order for Transfer
•Demographic
•Responsible Party
•Advanced Directives
•Reason for Transfer
•Past Medical History
•Active Diagnosis
•Pertinent Lab Reports
•Functional Status
•Psychosocial Issues
•Social Supports
•Behavioral Issues
Transitional Care
•Medications
•Allergies
•Immunizations
•Smoking Status
•Vital signs
•Unique deviceidentifiers
•Comprehensive careplan
Transition Care Form
•Recapitulation of stay
•Final summary
•Reconciliation of all medications
•Post discharge care plan
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Comprehensive Care Plan
•Initial care plan within 48 hours of admission
•Goals based upon admission orders
•PASARR recommendations if applicable
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ICPOInfection Control & Prevention Officer
•Must have specialized training in infectionprevention and control
•Will be responsible for identifying, reportingand controlling infections and communicablediseases for all residents, staff, volunteers, andvisitors
Physician Services
•Must have a Physician, NP, or Clinical NurseSpecialist to evaluate resident before anonemergency transfer to hospital
•Physician must delegate task of writing dietaryorders to a RD or other clinically qualifiednutritional professional
•Physician must delegate the task of writingtherapy orders to a qualified therapist
September 14, 2015