Transcript The New Survey Process - Nutritious Lifestyles, Inc.

The New Survey Process
Quality Indicator Survey
(QIS)
Presented by:
Janet McKee, MS, RD, LD
President of Nutritious Lifestyles, Inc.
QIS DEVELOPMENT
 University of Colorado, University of
Wisconsin, Maverick Systems, and Alpine
Technology
 Development from 1998-2005
 Field tests by research, CMS staff, CO, IA,
MD, NJ and WI
 Demonstration and evaluation by CA, CT,
KS, LA, OH 2006
QIS DEVELOPMENT
 New survey process started in Florida in
November, 2006
 Florida statewide rollout- 2007
 Northern Florida first with migration to
South
QIS PURPOSE AND
OBJECTIVES
 To guide surveyors through the federal
survey process
 Improve consistency and accuracy of
Quality of Care/Quality of Life problem
identification using a more structured
process
 Comprehensive review of regulatory care
areas using current resources
QIS PURPOSE AND
OBJECTIVES - continued
 Enhanced documentation by organizing
survey findings through automation
 Focus survey resources on facilities with
largest number of quality concerns
 For providers, makes IDR process more
difficult
QIS SURVEY
Two-stage computer-assisted
survey process, which
includes 9 Tasks
Good News
The survey process has
changed, but the F-Tags and
Interpretive Guidelines are the
same.
STAGE I PROCESS
 Preliminary investigation of residents



Randomly selected by QIS Data Collection
Tool (DCT)
Based on a range of care areas covered by the
federal regulations
Resident assessments are based on
observations, interviews, and review of the
clinical records
STAGE I PROCESS – continued
 The computer selects the residents using the
MDS data


Constructs 160 resident outcome and process
indicators called Quality of Care Indicators
(QCIs)
The computer analyzes the on-site collected
data
STAGE I PROCESS - continued
 The QCIs are then compared to national norms
 QCIs that score above the statistical threshold are
computer-selected for a detailed in-depth
investigation in stage II.
 Includes Tasks 1-6
 QIS Manual
http://ahca.myflorida.com/MCHQ/Long_Term_Care/LTC/index.shtml
STAGE II PROCESS
 In-depth investigation of residents with care
areas identified by the computer in Stage I
that exceeded thresholds (national norms)
 Triggered care areas and residents are
systemically investigated using Critical
Element Pathways to determine regulatory
compliance
 Includes Tasks 6-9
STAGE I
TASK 1: OFF-SITE SURVEY
PREPARATION
 Review OSCAR 3 report to determine if
facility has a history of repeat deficiencies.
 Review complaints filed with the agency in
order to facilitate investigation during the
survey.
 Team assignments: census reconciliation,
tour, and facility-level tasks
 NO review of QI/QM reports
TASK 2: ON-SITE ENTRANCE
CONFERENCE
 Team Coordinator announces survey and
introduces team
 Immediately obtains an alphabetical
resident census with room number, unit,
date of birth, and list of residents
admitted within last 30 days that reside in
the facility
TASK 2 ON-SITE ENTRANCE
CONFERENCE - continued
 Provide signs announcing the survey; to be posted
by facility
 Obtain a copy of the facility plan
 Explain private interviews will be conducted with
residents/families
 Team will communicate throughout survey and
request assistance as needed - NO DAILY
MEETINGS
 Conduct complaint investigation during the
survey, if applicable
 List of residents who receive dialysis, on
ventilator, on hospice services
TASK 2 – Concurrent Activities
 Tour
 Begin process of finalizing Stage I sample
 INITIAL KITCHEN/FOOD SERVICE
OBSERVATION WHILE OTHER MEMBERS
ARE GATHERING INFORMATION
 Schedule time to meet and interview Resident
Council President and review meeting minutes
TASK 2 – Concurrent Activities
 DINING OBSERVATION (starts with first
meal that can be observed in full)
 MUST IDENTIFY EMERGENCY WATER
SOURCE/SUPPLY
 MUST PROVIDE SCHEDULE OF MEAL
TIMES AND LOCATION OF ALL
DINING ROOMS
TASK 3: INITIAL TOUR
 Obtain BRIEF overall impression of the
facility and the resident population
 Meet as many staff/residents/families as
possible
 NOT a method of sample selection
 Record egregious resident care situations to
be investigated further in Stage II
 Document concerns with environment
(dining room, cleanliness, smells, etc.)
 Ask staff to identify family members that
visit regularly
TASK 3: INITIAL TOUR continued
 Observe staff/resident interactions (privacy and
dignity)
 Observe staff availability
 Observe activities in progress
 Observe characteristics of resident populations,
i.e. residents with dementia, rehabilitation, and
sub-acute clinically complex residents, residents
with special care needs (feeding tubes, ventilators,
intravenous fluids/medications, tracheostomy
tubes, oxygen therapy)
TASK 4: SAMPLE SELECTION
 Quality Indicator Survey Data Collection Tool
(QIS DCT) provides a systematic automated
resident sampling process.
 QIS DCT generates 3 Stage I samples from the
resident pool



1) MDS sample
2)Admission sample
3)Census sample (subset of resident pool)
 Surveyors may generate a non-random, surveyorinitiated sample (subset of resident pool).
TASK 4: MDS SAMPLE
REVIEW
 Residents whose data trigger the MDSbased Quality Care Indicators (QCIs) will
be reviewed in Stage II.
TASK 4: ADMISSION SAMPLE
REVIEW
 Focus is on quality of care within first six
months for short stays
 Focal points: Nutrition, Rehab, Skin Care
 Record review only
 Mostly closed records reviews
TASK 4: ADMISSION SAMPLE
REVIEW - continued
 WEIGHT LOSS ANALYSES
 SURVEYORS ARE INSTRUCTED TO
USE SAME CHARTING
DOCUMENTATION SOURCE FOR ALL
WEIGHTS, IF POSSIBLE.

FOR EXAMPLE, MARS, TARS, DIETARY,
NURSING NOTES, WEIGHT/HEIGHT
RECORDS. MDS IS LAST RESORT.
 SAMPLE SIZE UP TO 30
TASK 4: CENSUS SAMPLE
REVIEW
 Focus on care of residents currently residing
in the facility and encompasses activities of
daily living, NUTRITION, medications,
ELIMINATION/incontinence, resident
room, oral health, quality of life, SKIN
CARE
 Data collection through observations,
interviews, record reviews
 Sample size - 40 residents currently residing
in the facility
TASK 4: CENSUS SAMPLE
REVIEW - continued
 Collect and record resident specific
information which takes into account
situation, time, and multiple observations
 Set of prescribed questions to review the
initial quality assessment of sample
residents and facility (see CMS forms on
website)
 Includes gathering of sample residents’
specific information by observations,
interviews and record reviews
TASK 4: CENSUS SAMPLE
REVIEW - continued
 This information will be comprehensively
analyzed in Stage II.
 Observations concerning compromised
quality of care of sampled and non-sampled
residents are recorded on surveyor
worksheets for further survey or review in
Stage II.
TASK 4: CENSUS SAMPLE
REVIEW - continued
 Expect first several days to include a lot of
surveyor observations
 Surveys are lasting 5 days in Florida
 Florida trend - More cites, less severity,
more collateral tags
TASK 4: CENSUS SAMPLE
REVIEW - continued
 Surveyors ask questions as written
 Select families from various units
 Conducted with family or representative
that knows the resident and facility’s care
well (3 different families/representatives)
 Concerns identified need to be investigated
immediately, with the family present (see
Attachment A).
TASK 4: CENSUS SAMPLE
REVIEW - continued
Family and Resident Interviews
 Surveyor questions to
Family/Representatives:




Does the facility honor the resident’s desires
and preferences?
Does the resident get assistance with meals?
What is the food like here?
Are you able to participation in making
decisions regarding food choices/preferences?
TASK 4: CENSUS SAMPLE
REVIEW - continued
Family and Resident Interviews
 Surveyor questions to Residents
Is the food appetizing and does it taste good?
 Is food served at the proper temperature?
 Are you offered fluids between meals?
(See Attachments A & B)

RESIDENT CHOICES
Resident Food Choices:
Facilitates Cultural Dining, Customer
Satisfaction, and Successful QIS Results







Resident Choice Menu Development
Dessert Cart
Soup Cart
Salad Choice
Bread Basket at Table
Beverage Cart
“Room Service” via carts on floor for Room
Trays
TASK 4: CENSUS SAMPLE
REVIEW - continued
Staff Interviews
 Conducted with licensed staff (RN/LPN)
 Nurse must have frequent and direct contact
with the resident
 Convenient for the staff
 Document what is stated, even if information
contradicts information gathered from
another source (observation or record review)
TASK 4: CENSUS SAMPLE
REVIEW - continued
Staff Interviews
 Question B1: Nutritional supplement,
requires facility documentation of a
recording and monitoring system (check or
%)
 Must show surveyors this documentation.
(See Attachment C)
TASK 4: CENSUS SAMPLE
REVIEW - continued
Clinical Record Review
 Encompasses pressure ulcers, psychotropic
medications, and weight loss
 Conduct record reviews on the unit to
continue observations of activities and staffresident interactions.
TASK 4: SURVEYOR-INITIATED
SAMPLE
 Chosen by a surveyor at his/her discretion,
to be further evaluated during Stage II
 Based on resident-specific information
obtained from complaints, observations,
interviews

Example: dependent diner with a Stage I
pressure ulcer who is not being fed and family
has verbalized complaints
TASK 4: NUTRITION/HYDRATION/
TUBE FEEDING QUALITY OF CARE
INDICATORS USING SAMPLED
RESIDENTS
 Hydration





Sources - Resident and staff interviews and
observations, MDS
Do you have access to fluids?
Do you receive fluids between meals?
Does the resident show signs of dehydration, such
as cracked lips, etc.?
Prevalence of dehydration - output exceeds input
(from MDS)
TASK 4: NUTRITION/HYDRATION/
TUBE FEEDING QUALITY OF CARE
INDICATORS USING SAMPLED
RESIDENTS - continued
 Nutrition –



Sources – MDS, medical records, staff interviews, observations,
chart
Prevalence of weight loss (MDS)
Prevalence of significant weight loss that exceeds the interpretive
guidelines (MDS/Medical records)
• Excludes residents with terminal illness and on planned weight loss
program



Weight loss since admission: 5% unplanned weight loss of 5% or
more within 60 days of admit (MDS/Chart)
No supplements and resident underweight (Observation/chart)
Staff interview: Is the resident receiving a nutritional supplement
defined as a high calorie/high protein product with or between
meals?
TASK 4: NUTRITION/HYDRATION/
TUBE FEEDING QUALITY OF CARE
INDICATORS USING SAMPLED
RESIDENTS - continued
 Tube Feeding



Sources – MDS/Chart
Prevalence of tube feeding (MDS)
Significant weight loss on tube feeding
(MDS/Chart)
TASK 4 : RELEVENT FINDINGS





Document observed problems
Document areas of concern
Document date, time, and source
Document person interviewed and title
IDRs will be difficult
TASK 5: FACILITY-LEVEL
SURVEY AREAS
Survey tasks to be completed:
1. Demand billing
2. Dining observation (see attachment D)
3. Infection control
4. Kitchen/Food Service Observation (see
attachment E)
5. Med Pass
TASK 5: FACILITY-LEVEL
SURVEY AREAS - continued
Nursing services, sufficient staffing*
7. Personal funds*
8. QAA Review
9. Resident Council president interview
10. Abuse prohibition review*
11. Admission, transfer, discharge review*
12. Environmental Observations
6.
*completed only if triggered by complaints or Stage
I interviews, observations or record reviews.
TASK 5: DINING OBSERVATION
 Focuses: enough staff, positive dining
experience, residents’ choice
 Begins with the first full meal that occurs
after the team enters the facility (see
handout)
 If concerns identified, watch a different
meal to see if problem exists during that
meal
TASK 5: DINING OBSERVATION -
continued



If more than one dining room, observe all
dining rooms plus residents dining in-room
If there are problems identified, the
surveyor can initiate the full dining
observation at any point
Focus on residents who require the most
assistance. (See Attachment D)
TASK 5: DINING OBSERVATION
- continued


Dining observations will also occur during Stage
II for sampled residents with nutrition-related
concerns, such as weight loss, decline in eating
ability, or dehydration, using the nutrition critical
pathway
Names of residents observed not receiving needed
services, positioning, or adequate assistance will
be recorded on the dining room worksheet to
further investigate in Stage II.
TASK 5: DINING OBSERVATION continued


Family and residents with dining concerns
should be documented for private followup. Interviews will be conducted.
If surveyor identifies concerns (e.g. resident
complaints or high prevalence of
unintended weight loss), surveyor may
request sample tray (same process as
current procedure)
TASK 5: DINING OBSERVATION -
continued


Test tray will be sent to unit the furthest
distance away
Test tray is to be done when the last resident
is served. If concerns are identified, such as
F371 or F364 - unpalatable food or at
improper temperatures or unsanitary
conditions, the surveyor is to initiate the
appropriate tag and document concerns in
the computer to address further in Stage II
TASK 5: DINING OBSERVATION -
continued


Multiple meal observations through
survey
Work sheet entered in computer during
Stage II
TASK 5: DINING OBSERVATION -
continued
Examples of Questions on Dining
Observation Tool:
 Are staff members assisting with dining at
scheduled times, providing timely and
appropriate assistance?
 Are staff members talking with residents?
 Are staff members allowing residents
adequate time to eat?
 Are meal substitutes offered when meals are
refused?
TASK 5: DINING OBSERVATION -
continued






Are residents positioned to maximize eating abilities?
Are dining rooms free of offensive odors?
Does staff utilize hygienic practice?
Does the facility offer sufficient liquids with meals?
Does the facility serve meals in an attractive manner?
Are residents’ desires taken into account when using
clothing protectors?
 Are adaptive devices utilized to promote independence?
(See Attachment D)
TASK 5: KITCHEN/FOOD
SERVICE OBSERVATION
●
●
●
Brief visit during initial tour
● Observe general sanitation practices,
cleanliness of the kitchen, and any practices
that might indicate potential for food-borne
illness
Complete rest of worksheet during repeated
focused visits to the kitchen.
Unannounced
● Make observations, conduct staff interviews.
(See Attachment E).
TASK 5: KITCHEN/FOOD
SERVICE OBSERVATION continued
Focus Areas of Kitchen Observation
 Is food stored at appropriate temperatures?
 Is food stored under sanitary conditions?
 Were dishes cleaned and stored properly?
 Does the facility prohibit staff with open wounds,
signs and symptoms of infection or indications of
illness from handling food?
 Was food served in a sanitary manner that
preserves nutritional value?
TASK 5: KITCHEN/FOOD
SERVICE OBSERVATION continued
Focus Areas of Kitchen Observation
 Is food placed on the steam table two or
more hours prior to service?
 Are hot foods (above 1400F) cooled to 700F
to 410F within 4 hours?
 Is food and equipment clean and in working
order?
PRESIDENT OF RESIDENT
COUNCIL IS INTERVIEWED
 May be questioned about food satisfaction,
cold food complaints, poor quality,
sanitation, service, honoring preferences,
etc.
STAGE II
TASK 6: TRANSITION FROM
STAGE I TO STAGE II
 Team of surveyors meet
 Surveyors verify items completed in Stage I
 Computer verification and printing of
reports and findings
 Calculated Quality of Care results,
identifying residents and core areas for
inclusion in Stage II
TASK 7: CRITICAL ELEMENT
PATHWAYS

Identified areas have a set of Critical
Element (CE) Pathways
 Guide the investigation.
 Assist in completing a consistent,
organized, systematic review of triggered
areas
 Computer-assisted to identify all care
areas
TASK 7: CRITICAL ELEMENT
PATHWAYS - continued
 Help surveyors determine compliance.
 Incorporate each step of the resident care
process reflected in the regulations:
 Assessment
 Care Planning
 Implementation of Care
 Care Plan Revision
 Provision of care and service to meet the
needs of resident (outcomes)
TASK 7: CRITICAL ELEMENT
PATHWAYS - continued
Critical Element Pathways:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Activities
ADLs and/or ROM
Behavioral/Emotional Status
Bowel & Bladder/Catheters
Communication/Sensory Problems
Dental Status/Services
DIALYSIS
General
HOSPICE/PALLIATIVE CARE
TASK 7: CRITICAL ELEMENT
PATHWAYS - continued
10. Hospitalization or Death
11. NUTRITION, HYDRATION, TUBE
FEEDING STATUS
12. Pain Management
13. Psychoactive Medications
14. Physical Restraints
15. PRESSURE ULCERS
16. Rehab/Community Discharging
17. Ventilators
TASK 7: CRITICAL ELEMENT
PATHWAYS - continued
 Stage II Survey of residents


Residents whose in-depth review of quality of
care indicators exceeds thresholds in Stage I
process and residents selected by surveyors.
Minimum of three residents for each triggered
care area.
 For example, nutrition, hydration and tube
feeding are three care areas with one CE
pathway. Therefore, a minimum of three
residents will be selected for each triggered
care area.
CRITICAL ELEMENT PATHWAY:
NUTRITION, HYDRATION, TUBE
FEEDING STATUS
 In-depth, detailed review of residents that
have triggered care areas.
 Observations
 Medical record reviews
 Resident/Representative Interviews.
TASK 7: NUTRITION/HYDRATION/
TUBE FEEDING STATUS - QUESTIONS,
DIRECTIVES AND OBJECTIVES
Samples of Questions:
 Were fluids provided at meals?
 Was the resident encouraged to drink?
 If the resident has dysphagia, what measures were
taken to ensure adequate fluid intakes?
 Did the initial assessment include a baseline BMI,
height, weight, and weight history?
 Were calorie, protein, and fluid needs assessed?
(See Attachment F)
TASK 7: NUTRITION/HYDRATION/
TUBE FEEDING STATUS – QUESTIONS
- continued
 Does the resident have sunken eyes,
nausea/vomiting, edema, muscle wasting?
 Observation of staff providing appropriate
assistance for residents dependent upon staff
for care.
 Are supplements given to minimize
interference with meal intakes?
 Does the resident consume supplements and to
what extent? (from medical records)
TASK 7: NUTRITION/HYDRATION/
TUBE FEEDING STATUS – QUESTIONS
– continued
 Is family involved in the plan of care re:
nutrition? (Family interview)
 Are the resident’s preferences honored
regarding choices, portion sizes,
nourishments, fluid restrictions?
TASK 7: NUTRITION/HYDRATION/
TUBE FEEDING STATUS – QUESTIONS
– continued
 Did the facility identify labs suggestive of
dehydration?
 Were preventive plans of care in place to
promote a specific amount of fluid to
prevent hydration?
 Were methods in place to record food
intakes and report deviations?
TASK 7: CRITICAL ELEMENT
PATHWAYS - continued
Potential Critical Element Pathway
citations for Nutrition, Hydration,
and Tube Feeding Status:
F272, F279, F280, F281, F282,
F321, F325, F327, F328
(See Attachment F)
TASK 7: GENERAL CRITICAL
ELEMENT PATHWAYS
 General CE Pathways:
– For core issues not already addressed
– Accidents (Falls)
– Fecal impaction
– Other skin conditions (burns, skin tears)
– Non-UTI infections
– DM, COPD, CHF, Wound Care (excluding
pressure ulcers)
– Includes probes
TASK 8: ANALYSIS, DECISIONMAKING AND INTEGRATION OF
INFORMATION
 Analysis of information
 Integration of facility-level information
 Integration of Critical Elements
 Analysis/assignment of scope and
severity, and team decision-making
TASK 9: EXIT CONFERENCE
 Surveyors will use a potential citation
report to guide the exit
 Will provide list of residents if facility
requests
 Report finalization
 Revisit if needed
THE END
THANK YOU
Janet S. McKee
President of Nutritious Lifestyles, Inc.
918 Lucerne Terrace
Orlando, Fl 32806
407-894-1444
[email protected]