The Licensors are in the House.pptx [Read-Only] · 2017-11-02 · 10/27/2017 1 The Licensors are in...
Transcript of The Licensors are in the House.pptx [Read-Only] · 2017-11-02 · 10/27/2017 1 The Licensors are in...
10/27/2017
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The Licensors are in the House
The survey process
Authority
RCW 18.20.110Inspection of assisted living facilities—Approval of changes or new facilities.
The department shall make at least every 18 months with an annual average of 15 months, an inspection and investigation of all assisted living facilities.
However, the department may delay an inspection to 24 months if the assisted living facility (ALF) has had three consecutive inspections with no written notice of violations and has received no written notice of violations resulting from complaint investigation during that same time period.
RCS Licensing Inspection Types
New licensure - often called a Pre-occupancy Inspection (only inspection that is announced)
Full licensing inspection - average every 15 months, up to 18 months.
Follow-up (Post) Inspection - following deficiency citations
Complaint investigations
Monitoring visits
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Full Inspection
Unannounced - can enter off hours, or weekends
Field Manager has authority to require early inspections if problems identified
Average length of full inspection, currently 3-5 days
Number of licensors vary depending on RCS staffing and facility size
Inspection Process
RCS Preparation
Look at history
Complaints since last inspection
Contact Ombuds - Any themes, Quality of Care/Life
Contact HCS Case Manager - QoC/L concerns
RCS Prepares –How Do You Prepare?
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RCS Prepares –How Do You Prepare?
Build Relationships:
Field Manager
Ombuds
Case Managers
Families
Physicians
Hospitals
Health Agencies
Anyone else?
RCS Prepares –How Do You Prepare?
Understand or at least be familiar with the inspection process.
What can you do to educate yourself?
Survey Binder- Keep Up To Date
Resident Roster - Delay in getting this to the licensors will prevent them from moving on.
Resident room list - list of residents and roommates. Note if someone is a non-resident individual, i.e., spouse of a resident. They will not be included in the sample
Staff information - position, title, hire dates, day and month of birth
Staffing schedules - 3 weeks
Disclosure of Services
Liability insurance coverage
Menus
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How Do You Prepare?
Keep an inspection ready binder up to date:
Pet records
Changes in physical environment with construction review approvals
Copies of any waivers the facility may have
List of discharged residents in last 6 months and reason for discharge
How Do You Prepare?
Review facility history since the last full inspection:
What is your compliance history?
Review all Statements of Deficiencies (SODs) – Full and Complaint
Know the deficiencies cited
Identify any patterns of repeat and/or isolated deficiencies, attestation of correction and resident identification
Ongoing monitoring to ensure you have maintained compliance
Do you have any open citations?
Are there any conditions on your license? Are you complying with the conditions?
How Do You Prepare?
What changes have been made since the last full inspection?
Changes in number of licensed beds
Specialty designations
Contracts
Current exemptions
Approved new construction- DOH project reports, go to: http://www.doh.wa.gov/crs
Change of Administrator / Change of owner
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How Do You Prepare?
Through your ongoing audits- How do you identify problems for all departments?
Are problems being addressed?
Who is monitoring to ensure approach to resolving identified problems is working?
Are you confident your facility is moving in the right direction? If not, what needs to happen TODAY to change that.
How Do You Prepare?
Inspection prep is always and ongoing
Your facility dynamics are always changing
Staffing - composition and expertise
Resident acuity and mix, families
Technological advantages and disadvantages
Know the extra things you can do when “in your window”
Entrance
The licensor/team coordinator explain the purpose of the visit
Make introductions to the administrator, designee or staff and provide a business card. Have department name tag visible.
Provide the written list of documents needed
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Entrance
Do staff know what they should do once the team enters?
If licensors are waiting they will use the time to observe the residents and the immediate environment and make introductions to any residents or staff in the area and briefly explain the reason for the visit.
Set lines of communication. You should tell the team who should be the point of contact – Adm, DON, and introduce key staff.
Let your staff know how you want them to communicate with you.
Entrance
Licensors will request a place for the team work. Think strategically where you want inspectors to be planted during the process.
They should try to minimize disruption to your normal day of care provision, however, you will need to accommodate their requests.
Tour
PURPOSE
To provide the licensing team with:
An initial observation of physical environment, quality of life and safety.
Introduction to the residents, facility staff, and family that may be visiting.
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What are licensors observing for?
Everything! What things might they be looking for in your facility?
What might they see?
When do you think they start observing?
Tour
Tour should be conducted with staff member(s), who are knowledgeable about the residents
Observations of quality of life, care and services, environmental and safety issues, required postings
Data collection during the tour consists of observations and informal interviews with residents, families, staff
Tour will include common areas, resident rooms, activity areas, laundry room, storage areas, restrooms
The exterior environment
Tour The tour guide should note any environmental issues noticed during
the tour- correct immediately as you are able/appropriate – i.e., cold - check with RDT
Note residents who express concerns or appear to have unmet or special care and service needs. Follow up with these residents as soon as appropriate
Observe the general appearance of residents: grooming and dress -find staff to assist the resident
Observe staff-to-resident interaction related to quality of life, dignity, privacy, and responsiveness to resident needs including verbal communication, eye contact, and touch
Observe residents’ response to staff. If anything seems unusual, follow up. The the licensors will!
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Communication During the Tour
Licensors will not communicate about an issue too soon unless it is a serious issue that the ALF must deal with immediately.
Licensors should not communicate issues that may lead to failed practice until they have collected enough information to make that decision.
Communication During the Tour
During the tour find ways to point out to licensor positive things and showcase:
Residents- introduce to council president
Offer good care outcomes about the resident – i.e., came from hospital with pressure injury, all healed and no reoccurrence
No family, depressed now highly involved in activity programs
Weight loss success story after you discovered resident loves tacos
Tell them about special programming you offer
Knock on doors and wait for a response to come in
Keep HIPAA in mind when talking about residents in open areas!
Tour- Exterior Environment
Licensors should focus on egress
Tripping hazards in courtyards or walking paths
Smoking areas
Snow or ice build up in driveway or entrance. Is it safe and accessible for visitors and EMS?
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Tour- Completion
RSC staff will meet to discuss findings from tour and pick a resident sample
What should you do during this time?
Resident Sample
PURPOSE
To select a sample of residents in the ALF that best represents the resident population regarding care and service needs.
The sample selection must occur as soon as possible after the tour.
Sample Selection
Selected based on information gathered during pre-inspection prep, entrance, and tour.
Will review Resident Characteristic Roster during sample selection.
The size of resident sample is based on ALF census and consists of residents selected for review.
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Sample Selection
Depends on census, licensors may expand sample as needed based on issues identified and to determine scope of failed practice
3-6 residents=all
7-15 residents=at least 6
16-30 residents=at least 7
31-60 residents=at least 9
61-100 residents=at least 11
101-125 residents=at least 15
126 residents and higher=at least 19
Sample Selection
Licensors will use the roster and information obtained through observations and interviews to ensure residents selected represent a diversified group
Special care needs- diabetic, modified diet, skin issues, falls
Identified as able to interview and not able to interview
Receive nursing services different medication levels
Identified as having special needs (dementia, mental illness, developmental disability)
Identified as receiving services through Specialized Dementia Services
How Would You Pick A Sample?
Sample your residents for review
Who does your audits – same person or multiple people?
How often do you perform audits?
What do you audit?
Who do you audit?
Do your audits include observations, interviews and record review?
Use your Resident Characteristics Roster- Who stands out when you look at it?
Acute care needs or specialized services provided
“Squeaky Wheels”?
No family and non-interviewable
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Resident Group Interview
PURPOSE
The group meeting provides the opportunity for residents to share information and provide the licensing staff another source of data
Resident Group Interview
Getting the word out about the meeting:
The licensors will inform residents of the meeting during the tour.
Don’t schedule the group meeting during the time a popular activity is currently scheduled.
Select interviewable residents to attend. This does not mean they can’t have cognitive impairments. Even residents with cog impairments add value to a meeting.
Although facility staff is not “invited” have someone close by as the licensing team may need to request the assistance of facility staff to escort residents to and from the meetings.
Resident Group Interview
The interview questions will follow standardized questions but the licensors are not required to ask every question on their form. If residents are focused on a particular issue, they will follow their lead.
Licensors will follow up with residents individually who raise concerns that need more clarification.
No staff members or resident family members are routinely present at the group meeting, unless specifically requested and approved by the residents.
General questions that will always be asked are about the treatment of themselves and others, enough to do, missing items, grievances, food.
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Interviews
PURPOSE
To collect information about resident life in the ALF by speaking with residents, licensee/administrator or designee, facility staff and other contacts.
The focus of the interview is on resident quality of life, safety, and provision of care and services.
Resident Interview
The licensor will conduct both formal and informal interviews during the inspection:
Formal interviews are those that involve residents and their families selected in the complete review and the in-depth limited review samples.
Informal interviews are with residents not selected in the sample and the interviews are not structured or planned.
Interviews
Interview family members or resident representatives of non-interviewable residents in the sample
Licensors will obtain an interpreter if the resident sample includes a non-English speaking resident who is alert
Staff members - all disciplines
Interview contacts other than family members to obtain information that is necessary to support a citation
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Observations
PURPOSE
To ensure the care provided is appropriate for the resident’s needs, consistent with the Negotiated Service Agreement, performed by qualified and trained staff, and upholds
resident rights for quality of life, dignity, privacy, and choice.
Observations
RCS registered nursing staff will conduct all care observations that require looking at a resident’s genitals, rectal area and the breast area for females (bikini area)
Any licensor can observe wound care unless on the areas above or unless they are observing to make a clinical judgment about the status of the wound.
They are not to touch or examine a resident or provide hands-on care. Request the licensee or staff to provide the direct care if the resident agrees.
Observation Of Care
Formal observations are specific to a resident and/or care issue. Licensors will observe for the following:
The resident response to the care provided:
Behavior
Level of comfort
The caregiver/staff performing the care
Technique and knowledge
Staff-to-resident interaction
Infection control practices
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Observation Of Care
Does the level of assistance provided match what is identified in the negotiated care plan?
Is physical care provided using safe practices and appropriate handling?
Is inclusion of the resident’s participation in the care task to the maximum of their ability or care planned potential or as identified in the negotiated care plan?
How Do You Observe?
Abuse/Neglect Prevention Review
PURPOSE
To determine if licensee practices are in compliance with the regulations and statutes regarding mandated reporting and prevention of abuse in the assisted living facility
The primary focus of the abuse prevention task is on ensuring the quality of life, dignity, welfare and safety for all residents
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Abuse/Neglect Prevention Review
Conduct interviews with:
Residents to follow up for any possible identification of abuse revealed during the resident group meeting, resident interviews or from observational data. If the resident is unable to be interviewed licensors will contact the resident’s representative.
Staff regarding abuse:
What constitutes physical, mental and emotional abuse?
Steps to take in the event of suspected abuse, neglect, use of restraints, involuntary seclusion and/or financial exploitation
Notification and reporting requirements
Medication Services
Medication services data collection includes review of:
Medication storage: safety, labeling, organizers
Medication delivery system: documentation, assistance/ administration, alterations, appropriate for resident needs
Medication prescriptions received timely
Respect of resident rights: right to refuse, individual choice and preference
Disposal of medications
Conduct interviews with contacts including outside the ALF regarding medication services if further data needed to verify non-compliance
Medication Services
Observe medication storage area during tour and at other times during the inspection for the following:
Medications are secure for residents not capable of self-storage;
Medication is properly labeled;
Medications for a specific resident are stored together and are kept separate from other resident medications and/or food or toxic chemicals;
Storage area is locked, accessible only to designated, responsible staff; and
Medications are stored according to medication label recommendations, (example: KEEP REFRIGERATED).
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Medication Services
For residents on nurse delegation licensors will interview staff regarding nurse delegation practices for the resident.
For residents doing self-med program licensors will observe resident room for medication issues such as medications on floor or inappropriately stored, such that residents may gain access to another resident’s medications.
Observe whether staff confirmed the resident’s identity prior to giving medications.
Identify medications not being given in a timely manner, such as antibiotics and pain medications.
Review how emergency medication issues are handled. If a resident is out of medication, what does the facility do to obtain in a timely manner?
Environmental Observation
The Licensor will:
Conduct observations regarding the appearance of the ALF beginning with the entrance and tour process and throughout the inspection.
Conduct observations in the common areas and resident rooms.
Check water temperature in half of resident rooms of the residents who were selected in the resident sample. They will expand the sample if there are concerns.
Environmental Observation
If smoking is permitted for residents, is there shelter, is it fire safe, what is the supervision, are residents assessed for safety?
The team will share observations with each other to continue to look for any patterns of areas of concern that were identified.
They will notify the Field Manager and contact CRU to report to State Fire Marshall if a fire safety issue is identified.
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Food Services
The Licensor will:
Use the tour as the first opportunity to observe the food service environment and general food service practices including proper food handling skills and handwashing.
Observe food safety to include: personal hygiene, employee health, temperature control, and potential cross-contamination during food preparation and service.
Food Services
Residents will be asked during dining observations, resident interview and group interview about:
Preferences;
Alternate choices;
How they express their comments on food services;
Prescribed diets;
Prescribed nutrient supplements and concentrates;
A variety of daily food choices;
Temperature of food; and
Assistance with eating, if needed.
Food Services
During Dining Observation, licensors will:
Observe for timeliness of meal service;
Observe for sufficient time and staff provided to meet resident needs. Observe meal for attractively-served meals that are nourishing and palatable;
Observe sample residents if needing eating assistance as per resident needs;
Observe residents receiving meals in their room, noting why they are in their rooms, and if they are assisted per care needs.
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Resident Record Review
Conduct a complete resident record review for residents in the sample
Resident assessment;
Monitoring of resident’s well-being;
Negotiated service agreement; and
Medication record and other information
Determine if information obtained from record review will require further interviews and observations
Expand record review only if necessary to make a compliance decision
Facility Record Review
When licensors review facility records:
Incident/accident documentation
Policies and procedures (rarely)
Financial records (rarely) as they are related to specific complaints/concerns
Outside Record Review
When licensors review other records:
Review of outside records, such as hospital records, police records, agency records, and other records not associated with the ALF will rarely be done, and is only done when necessary to determine failed practice
Licensors should initiate the review of outside records as soon as possible. The inspection is not complete until the last date of data collection.
You need to know the last date of data collection!
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Staff Sample Record Review
Selection criteria for facility staff sample:
If the administrator has changed since the last inspection, licensors will review that record to ensure qualification and training requirements are met.
Review of staff list for hire dates and titles:
Select 3 employees who have been hired since the last inspection and review training and qualifications.
Review 1 or 2 employees who have worked over 2 years to ensure a system is in place to conduct background re-checks and continuing education requirements.
Disaster Plans are generally reviewed as part of this task.
Exit Preparation
The licensor will:
Communicate with the administrator to ensure no “surprises” at the exit conference.
Review information for deficiencies and identify any negative resident outcomes or the potential for a negative outcome.
The team should meet with the administrator to discuss any final findings related to the inspection just prior to the exit conference.
Schedule the exit conference with the administrator and invite the Ombuds and interested residents to attend.
Tips For A Good Inspection Experience
Respect for the value of each other’s position
Understanding of the process and the regulations
Be prepared to have an inspection at any time
Communication, Communication, Communication!
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Exit Conference
The exit conference occurs at the end of the full/complaint inspection
However sometimes they will say they have not completed “data collection”
Important to know if this is the final exit or will there be an additional follow up/call to the on-site exit
An exit can occur over the phone. Most often a telephone exit will be seen in a complaint inspection vs a full inspection
Exit Conference
Deficiencies identified by RCS staff at the exit must be regulatory based. Because the licensors have communicated with the administrator throughout the inspection, the identified deficient practices should not be a surprise.
If, after the exit, licensors make changes or additions to the information presented at the exit, a licensor will contact the administrator with information about the changes prior to sending the Statement of Deficiencies. Again no surprises.
Exit Conference
Inform the administrator of the process following the exit and what to expect, including further data collection, Statement of Deficiencies (SOD) report, Attestation of Correction, and the Informal Dispute Resolution (IDR) process.
If you submit information after the exit the administrator will be contacted by telephone if there are any additions or significant changes to the deficiencies discussed at the exit.
Take good notes.
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At This Point You Should Clearly Know
Which residents are included in the deficient practice.
The regulations being cited or at least a specific explanation of the failed practice.
If they have identified harm to any residents and if potential enforcement action will be recommended.
If there is a condition placed on the license during the inspection process – Do you have a written copy? Are you clear about what the condition requires of you?
Is the inspection completed or will there be further data collection after the team leaves the facility?
If there is further data collection to be done off site- when can you expect to hear the results of that and when will the inspection be officially completed?
At This Point You Should Clearly Know
If there were complaints completed during the full inspection- do you know if any citations were a result of the complaints? Did you get a better description of the nature of the complaint?
If you cannot answer these questions you should ask for clarification. Don’t be afraid to ask!
If you have questions about the process, (possible) enforcement action recommendations, team dynamics not resolved with the team leader, contact the field manager.
After the Exit- What You Should Do?
Gather any additional information you have that you wish to have considered and send to the Field Manager or Team Leader.
Begin working on correction-
Correction should start when the facility becomes aware of the problem, don’t wait completely until you get the SOD.
The licensors/complaint investigator should give you enough information at exit in order to start taking immediate action and evaluate the facility’s systems.
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What If My SOD Is Late?
If you don’t receive your SOD by when you think you should have it contact the Field Manager. They SHOULD notify you if they will not meet the 10wd time frame.
Sometimes they started their 10 working day clock differently from when you started counting (based on last day of data gathering)
If they say it will be late they should give you an idea of when you will receive it.
Things that can delay a SOD getting to you timely…
Staffing, scheduling, enforcement
Post-Survey Timeline
SOD/Attestation to department within 10 calendar days
IDR- Written intent within 10 days to the department
Appeal- Written intent within 28 days to office of appeals
POC/Attestation- Correction within 45 calendar days from when they leave your facility
Longer period may be allowed if reasonable- usually this is for construction projects that take much longer to complete or is seasonal work
Reading Your SOD
Don’t become defensive when reading the SOD- be open to improving your systems and operations
Look for things that may be inaccurate but be open to where there are problems
Are they making linkages that are not really there- i.e. A Tb test was late putting all the residents at risk for Tb.
If there are inaccuracies, mis-quotes, missing information, wrong resident identifiers, poor choice of wording- think about each item-
By fixing the concerns would it-
still be a deficiency?
change from harm to no harm?
just sound better and be a better end product
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Reading Your SOD--Hmmmm
I got cited for this and my competitor did not--- Not Fair
When I read this each citation sounds the same – I am being double cited
It has always been this way and this year I am being cited for it
I submitted my POC dates but I am not ready- can I change them
Questions?