Composition and Theory: A Plan of Correction Masterpiece! June 24, :00am-12:30pm

Transcription

1 Writing A POC Masterpiece Presented by: Lisa Thomson, NHA, Vice President Michelle Stober, RN, BSN, Director The Nurse Leader in a Regulated World Objectives The presenters will provide an overview of the SNF enforcement options for citations issued on a Statement of deficiency or 2567 The presenters will outline and review the mandatory components of an acceptable plan of correction and provide specific examples for completion The presenters will summarize the process for monitoring a plan of correction with sample tools 1

2 Words to Ponder I come to the office each morning and stay for long hours doing what has to be done to the best of my ability. And when you ve done the best you can, you can t do any better. So when I go to sleep I turn everything over to the Lord and forget it Harry S. Truman If the President can put things to rest, why can t we????? Because the president does not go through survey! The Nursing Home Survey 5 Understanding Agencies- CMS CMS (Centers for Medicare and Medicaid) Provide regulation for federal dollars used for Medicare and Medicaid Have a set of regulations called federal tags (Ftags) for any facility receiving Medicare dollars Regulations ensure that people receive the proper care and services which Medicare and Medicaid funds pay for 2

3 Survey Types Certification Revisit or Verification Traditional Survey Focus Survey Follow-up Survey Quality Indicator Survey Complaint Survey Why the Nursing Home Survey? Nursing homes participating in the Medicare and Medicaid programs are required by federal law to undergo an annual survey (9-15 month window) The purpose of the survey is to assess whether the quality of care and services, as intended by the law is being provided in the nursing home according to federal regulations. What is the SOM? State Operations Manual (SOM) Basic requirements of operations for Medicare Certified health care entities Change is on-going How health care entities are to be evaluated and certified Guidance/Guidance/Manuals/downloads/som1 07ap_pp_guidelines_ltcf.pdf 3

4 Use of the SOM Ensure latest copy or use website If on web- in find box type regulation. (i.e., F441) and it will take you to F441 regulation Read it and use it as an educational tool and resource. It represents minimum standard of practice It serves as a Guidance to surveyors Utilizing SOM Interpretive Guidelines Policy Development Use to create polices (i.e., F225) Audit development Utilize the surveyor protocols Quality Management Topic Stay ahead of the game Who searches for upcoming changes Use for evidenced based clinical information Where can I find the SOM? Directory of the State Operations Manual Appendices stoc.pdf Appendix p Defines the components, timing, and details of SNF surveys Appendix pp Defines the regulation, intent, and interpretive guidelines for surveyors delines_ltcf.pdf 4

5 Components of an Interpretive Guideline (in SOM) F Tag Number (180 Federal Tags) Related Statute (relates to the Federal Register) Intent Definitions (on some) Overview (on complex ones e.g. F314) Interpretive Guidelines Procedures (on some) Resources Probes Deficiency/Citation When an inspection team finds that a nursing home doesn't meet a specific standard, it issues a deficiency citation. CMS may impose penalties, or enforcement actions, for serious deficiencies or for deficiencies that the nursing home fails to correct for a long period of time. e.g., Medicare may assess a fine, deny payment to the nursing home, assign a temporary manager, or install a state monitor. 14 Compliance Determination of compliance begins with resident review. The survey team looks at the resident assessment, care plan and orders to determine whether the facility recognized and addressed the concerns and resident care needs being investigated. Surveyors will observe whether staff consistently implement the care plan over time and across various shifts. 5

6 Expectation= Substantial Compliance Nursing Homes are expected to remain in substantial compliance with Medicare and Medicaid program requirements as well as state law. Emphasis is placed on continued, rather than cyclical compliance. Policies and procedures must be able to promptly remedy deficient practices and to ensure that correction is sustainable. Key Point: Take the initiative and responsibility to continuously monitor performance. 16 Example: Deficient Practice The medication administration record revealed the resident had received the medication 24 out of the past 30 days. She had not been medicated prior to wound treatment on the day the surveyor observed the treatment. The surveyor interviewed the RN on duty, employee # 2 who stated she I did not think she needed it because she has dementia and acting out is normal for her. Scope and Severity Scope and Severity is a system of rating the seriousness of deficiencies Each deficiency, the surveyor determines the level of harm to the resident or resident(s) involved and the scope of the problem within the nursing home. 18 6

7 Scope and Severity Surveyor assigns a scope and severity value, A L, to the deficiency. "A" is the least serious and "L" is the most serious rating. 19 Scope and Severity Grid Scope of the Deficiency Severity of the Deficiency Isolated Pattern Widespread Immediate jeopardy to resident health or safety Actual harm that is not immediate jeopardy No actual harm with potential for more than minimal harm that is not immediate jeopardy No actual harm with potential for minimal harm J K L G H I D E F A B C Purple Shaded boxes within the grid denote deficiency ratings which constitute Substandard Quality of Care if the requirement which is not met is one that falls under the following federal regulations: 42 CFR Resident behavior and facility practices 42 CFR Quality of life 42 CFR Quality of care 20 After the Survey.. 7

8 Post Survey Exit Distribute team specific tasks to analyze problems and processes. Dish with The Deficiency Interdisciplinary Response Team "The DIRT will meet daily from 8:00-8:30 AM until POC is submitted. Commit to calendar for follow up meetings. What went wrong. Be sure to get a copy of the roster. Who was affected? Who is potentially affected? Group chat: Who will you target? After the Survey The CMS 2567 Form that the deficiencies are written on Statement of Deficiencies (SOD) Your Plan of Correction (POC) Admissible in court for evidence Surveyors will quote staff and YOU! Don t you agree? Be careful Plan of Correction Basics Timing of Submission: 10 days after receipt of SOD (2567) Location on SOD - Align POC with each deficiency/citation 8

9 What Should be in POC Disclaimer- F000 This Plan of Correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. (Example only) What Should be in a POC All deficiencies cited in the CMS-2567 must be individually addressed in your Plan of Correction. POC is a public document and must not include resident or facility staff names Use only the resident and staff identifiers used by the surveyor in CMS What Should be on a POC Completion Dates A single date of completion (month, date, year) must be entered in the right hand column of the CMS-2567 for each deficiency. The overall completion date for all the items within that cited deficiency should be the one that appears in the right-hand column opposite the tag number. The earliest allowable correction date is one day after the survey completion date shown at the top of the report. 27 9

10 What should be in POC Specific enough to satisfy Realistic plans: This is what will be expected to be demonstrated upon revisit. Take sufficient credit for what has and will be done. What Should not Appear in POC Do not include items that do not pertain to the deficiency. (e.g. If cited for falls (F323) do not include bowel and bladder systems if not cited for F315.) Guarantees Criticism of surveyors or findings Unrealistic measures The POC and the IDT The IDT team must complete an in-depth rootcause analysis to ascertain why the problems exist and why they occurred Include in your Plan of Correction specific interventions necessary to achieve resolution and sustain compliance 30 10

11 Root Cause and the POC Does day-to-day operations and communication strategies reflect individualized resident needs Assess facility performance and systems of care by asking: How do our nursing assistants know how, what, when, and to whom to report changes in condition to? How does the charge nurse monitor for the implementation of the care plan, and changes in condition? Ask Why The Deficiency? Get to the ROOT Cause of Pain Management Deficient Practice People Weak Staff Education Plan Staff Development job eliminated: No ownership Poor Communication Resident Observations not passed on Lack of Permanent assignments No C.N.A. Kardex Physician response time Staff misunderstand behavioral responses and pain Operations/Environment Systems for identification of those at risk Med pass oversight/med management Staff not aligned with RAI process Care Plan Meetings lack adequate notices for families Care Plans not current No Monthly Staff Meetings to keep informed No structured QA&A Meeting Pain Management Deficient Practice Methods: Policies & Procedures Pain Assessments Incomplete Pain Assessments not checked with the MDS/CP 24 hour report lacks sufficient information P&P not available on Nursing Units P/P not known to key staff Behavior Management Program does not look at PAIN Equipment and Supplies EDK not updated Minimal Non Pharmacological Interventions Pharmacy delivery times are inconsistent Activities not involved in Pain Management Lack of bedside music, alternatives Writing the Plan of Correction 33 11

12 Do you have the right tools?? 34 Where to Begin...Writing POC Considerations: Legal document can be used in court Public document- Consumers review Stating that an employee was disciplined which implies guilt 35 Where to Begin... Writing POC Writing the POC Recap of the deficiency. Statement of the problem. Example: F241 It is the policy and procedure of XYZ care center to provide treatments to residents with dignity and respect

13 Criteria for Writing the POC Criterion One: Corrective action for residents cited List what you did for that resident to correct Example: Resident #15 had a new pain assessment performed. MD reviewed current medication orders. Care plan and nurse aide care sheet reviewed and revised by interdisciplinary team. Writing the Plan of Correction Criterion 2: How the facility will identify other residents affected by deficient practice Document how you will find other residents that may be at risk. Audit, question staff, review results, etc.. Example: All residents who were scored on MDS as having pain were reviewed for appropriate pain management program. All Residents are monitored daily for s/sx of pain which is reported via stop and watch form, shift report and communicated to supervisor and MD. Writing the Plan of Correction Criterion 3: What systemic changes will be put into place to ensure the deficiency will not reoccur Education, onboarding or orientation Staffing changes Changes in reporting procedures Implementation of discussion at meetings Policy & procedure changes Use of consultants QA Initiatives 13

14 After the Survey Plan of Correction Criterion Four: How the effectiveness of corrective action will be monitored and by whom Audits- when will they be performed and for how long? Audit review and outcome Corrective measures QA Committee oversight of monitoring The POC and the IDT Review each cited resident s record with the IDT. Document that the team reviewed record Everyone has to understand and be onboard with citations and plan of correction 41 POC Post Survey Action Plan What needs to be done: Cited resident record review. Complete New assessments as needed Audit other residents Review and revise policies and procedures Educate staff Audit and observe QA reporting Who is going to do it- and WHEN. Check off when complete 14

15 POC- Ensuring Compliance Ensuring Compliance Accountability Checklist Weekly assignments IDT review of progress daily until 100% compliant Audit schedule & review of outcomes weekly (or more) until resurvey Continuous improvement for noted deficiencies Plan of Correction and Resurvey All cited deficiencies will be reviewed Any new deficiencies can be cited Keep auditing areas that were not cited to ensure continuous compliance Exit will take place to report substantial compliance POC Management Assignments The NHA & DON will oversee the coordination and writing of the POC with members of the DIRT. The facility NHA will receive a weekly report regarding the assigned areas of responsibility 15

16 Quality Assurance Program Review plan of correction and audits Any changes from submitted plan of correction must be made at QA meeting Use audits from QIS survey for ongoing compliance reviews 46 Writing a Plan of Correction Your turn!!!- Get into groups of 4-5 and write a plan of correction for this citation. Use the 5 criterion as described. What are your Policies? Examine the policies and procedures related to the key processes for areas of deficiency Consider doing a Regulation of the month education that includes policy reviews Are staff members familiar with them? Do staff members need in-services on them? Do they need to rewritten or updated? Are they evidenced based or standards of practice? 16

17 The Reality of P/P Where is the P&P kept? (In the DON office is not sufficient) Pull policies: Do they match what staff are doing? Round during Wound Tx; Observe potentially affected residents and resident response. Verify the MAR. Inspect what you expect People: Staff Readiness Do you have adequate staff to ensure facilitating the key processes of care for pain? Do job descriptions for licensed and nonlicensed staff members list their role and responsibilities for the quality of life of residents in their care? Is the staff evaluation process tied to performance related to the specifics of their specific job description? Are management positions filled with qualified and effective employees? QA Committee and the POC The quality-assurance committee has the authority to discontinue these types of checks and monitoring systems once they are confident that the deficiency is resolved. Audit/monitor both three months and six months after discontinuing the original monitoring systems 51 17

18 Review your QA Program Audits scheduled on a to monitor facility practices? Does the facility QA&A should evidence of root cause analysis and problem solving? Is the Medical Director part of the solution? Do staff members participate in audit? Are audit results evaluated and acted upon? How is feedback provided to staff members and senior leadership regarding audit results? A POC Masterpiece is Created with Vision Wise Administrators Acknowledge why it is called a Nursing Home As you correct deficiencies explore the what if s If you could enhance the current nursing model what would it look like? Can you work within your PPD to be more effective? Fix what is happening right now Build an educational plan that includes the DON and the Administrator: Stay on Top of what is happening The Administrator & Don Are King & Queen Of Everything And everything is constantly evolving A POC provides opportunity to be efficient not deficient Strive to give Direction, take Direction, and move in the Right Direction 18

19 Create POCs That Capture A Vision The standards and practices of the facility are evident through the facilitation of Process Improvement The Plan of Correction should build on what exists A POC is a Masterpiece that reflects a commitment to the residents we serve Take the Time To remember why you do what you do! 56 Questions? 57 19

20 Contact us at 58 Note: Disclaimer This material is for informational purposes only. It is not intended to give specific legal or risk management advice, nor are any suggested checklists or actions plans intended to include or address all possible risk management exposures or solutions. You are encouraged to retain your own expert consultants and legal advisors in order to develop a risk management plan specific to your own activities