STATE VETERANS HOME Survey Process Updates

Nancy Quest Office of Geriatrics and Extended Care Patient Care Services Department of Veterans Affairs

STATE VETERANS HOME

VHA Handbook 1145.01 ~ May 17, 2010

 Survey Procedures for State Veterans Homes (SVH) Providing Nursing Home & Adult Day Health Care – Provides guidance to the field for overseeing and processing annual, recognition, and “for-cause” surveys of SVH providing nursing home and adult day health care 2

STATE VETERANS HOME

Geriatrics & Extended Care (GEC) – VACO  Provide oversight for clinical & survey program  Manage SVH recognition survey process  Manage the annual survey process  Authorizes and manage “for cause” surveys  Manage the national contract supported surveys (i.e., Ascellon Corp contract) 3

STATE VETERANS HOME

Veterans Integrated Service Network (VISN) Director  Administers the SVH program within the VISN  Appoints a SVH VISN Liaison  Submits Issue Briefs 4

STATE VETERANS HOME

SVH VISN Liaison  Manages the SVH program with the VISN  Notifies GEC VACO of sentinel / reportable events at SVH  Serves as the point of contact VACO, VAMC, SVH 5

STATE VETERANS HOME

    VA Medical Center of Jurisdiction Director Field level official responsible for oversight of the SVH program Appoints SVH VA Medical Center Representative & Fiscal Surveyor Approves/disapproves survey reports and corrective action plans Certifies compliance with VA standards 6

STATE VETERANS HOME

     SVH VA Medical Center Representative Manages the SVH program at field level Coordinates communication between SVH, VA Medical Center Director, SVH VISN Liaison and GEC VACO Serves as team co-lead during surveys Oversees the survey process Monitors and communicates reportable events 7

STATE VETERANS HOME

   VA Medical Center Fiscal Representative Communicates, collaborates and participates with the VA Medical Center Representative in all surveys Reviews fiscal standards during surveys Submits findings to VA Medical Center Representative 8

STATE VETERANS HOME

VA Survey Process

 Surveys are conducted to determine compliance with VA standards  Annual and For Cause surveys are unannounced  Recognition survey is pre-arranged  VA standards and VA ratings remain unchanged  Survey teams are comprised of VA and contracted surveyors 9

STATE VETERANS HOME

Vision of the Survey Process

      Consistency of survey approaches Clear protocol - pre, during and post survey Smaller numbers of experienced surveyors Clear and objective statements of findings Consistency in dealing with findings Timely reporting to State Veterans Homes 10

STATE VETERANS HOME

New Survey Process  New contract-supported survey process since November 2009  Approximately 70+ annual surveys  Approximately 5 recognition surveys  Fewer than 10 ‘for cause’ surveys  One formal appeal 11

STATE VETERANS HOME

Year to Date Most Commonly Cited Deficiencies 12

STATE VETERANS HOME

       Most Commonly Cited Deficiencies Clinical records were incomplete or inaccurate Physician orders were not followed Lack of fall prevention measures Thickened liquids were not provided as prescribed or prepared incorrectly Weekly fire pump tests not conducted Facility in disrepair ~ holes, nicks & torn wall board, chipped paint, scuffed doors, missing & detached baseboards, rust in the shower room Lack of direct supervision for cognitively impaired residents who smoked 13

STATE VETERANS HOME

Acceptable Corrective Action Plan  Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;  Address how the facility will identify other residents having the potential to be affected by the same deficient practice; 14

STATE VETERANS HOME

   Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed.

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STATE VETERANS HOME

THANK YOU!!

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