NH Quality Flashcards
what is the trend of numbers of NHs in the US?
declining
how many NHs take medicare and medicaid?
most NHs
what kinds of care needs to people admitted to NHs typically have?
- assistance with ADLs
- cognitive impairment
- pressure ulcers
- feeding tube
when did NHs become regulated and by whom?
- 1965
- medicare/medicaid
what were some of the proposed changes of the IOM report on quality of care in nursing homes (1986)?
- RN comprehensive/ongoing assessment
- criteria to improve quality including increased QOL
- standards for staff training (CNA license)
- resident voice, rights, and advocacy (ombudsman)- on-site or contractual SCW
- surprise HCFA state annual visits (9-15 mo & 2nd cause)
- public disclosure
what instrument came out of the omnibus budget reconciliation act of 1987? what is it used for?
resident assessment instrument
- admission
- annually
- w/ status change
what are the 2 components of the resident assessment instrument and OBRA 87?
- MDS (minimum data sets)
- RAP (resident assessment protocols)
the omnibus budget reconciliation act of 1987 led to the development of what types of changes in NHs?
- increased emphasis on QOL
- QI/QM development
what is the MDS?
minimum data set
- federally mandated process for clinical assessment of all residents in medicare or medicaid certified NHs
- comprehensive assessment of each resident’s functional capabilities & identification of health problems
- resident assessment protocols (RAPs)
what are some improvements that came along with the MDS 3.0?
launches 10/2010
- takes 45% less time to complete
- gives residents a greater voice
- assessment based on evidence, i.e. PHQ-9, depression scale, braden assessment scale, etc
what are the 3 important provisions of OBRA 87?
- QOL: nursing facilities must care for residents in such a manner and in such an environment as will promote maintenance or enhancement of QOL of each resident
- Quality of care: nursing facilities must provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care
- Residents’ rights: nursing facilities must protect and promote the rights of each resident.
How many resident rights are included in OBRA 87?
11
how did OBRA change the care model in nursing homes?
changed the emphasis from a medical model to a psychosocial/holistic model
how did the survey side of HCFA regulate the reform provisions of OBRA?
- defined what constituted compliance
- how and to what extent facilities would be subject to enforcement actions for failing to meet the standards
how did the enforcement side of HCFA regulate the reform provisions of OBRA?
made possible a broader array of potential enforcement actions against nursing facilities, including civil money penalties
what are some of the specific provisions/regulations that OBRA put into place?
- facilities have a medical director
- mandated nurse aide training and certification
- licensed nurses around the clock including RNs every day
- pre-admission assessment
- comprehensive assessments (MDS) w/in 14 days
- plan of care based on above assessment
- quality assurance
- social workers
- qualified dietitian
- activities and programs
- rehab services
- independent consultant monitoring psychopharmacologic drugs
what is the HCFA’s checklist for defining a good nursing home?
- choice in daily routine
- resident well groomed and dressed
- facility looks and smells clean
- staff and residents interact warmly
- choice in food
- religious and spiritual needs met
- robust quality improvement process
how is quality evaluated in NHs?
- dept of health inspections for all facilities participating in medicare/medicaid
- conducted every 12-15 mo (annual survey) as well as complaint surveys
- 180 standards evaluated
what are the 3 types of surveys?
- standard survey
- extended survey
- abbreviated survey
what does the standard survey assess?
- compliance w/ resident’s rights and QOL requirements
- accuracy of comprehensive assessment and adequacy of care plans based on these assessments
- quality of care and services furnished as measured by indicators of medical, nursing and rehab, drug therapy, nutritional services, activities and social participation, sanitation, and infection control
what is the purpose of the extended survey?
conducted after substandard quality of care is found during a standard survey
what is the purposed of an abbreviated standard survey?
focuses on particular tasks that related, for example, to complaints received or a change of ownership, management, or director of nursing
what is the purpose of the standard survey?
- inspections determine “minimum standards”- if standards aren’t met in certain areas, citations are given
- inspection results are public documents
- deficiencies have associated monetary fines and/or other penalties
of whom does the survey team consist?
- trained inspectors
- at least one nurse
in what ways do the surveyors assess each NH?
- review clinical records
- staff and resident interviews
- observation
what tasks are included in each survey?
- off site prep
- entrance conference/onsite prep activities
- initial tour
- sample selection
- information gathering
- a. general observation
- b. kitchen/food service observations
- c. resident review
- d. QOL assessment
- e. med pass observation
- f. quality assessment and assurance review
- g. abuse prohibition
- investigative protocols - information analysis for deficiency determination
- exit conference
what are the 3 quality indicator reports?
- facility characteristics
- facility quality indicator profile
- resident level summary
what does the facility characteristics report describe?
certain population statistics for the selected facility
what does the facility quality measure/indictor report describe?
compares the facility to all others in the state
what does the resident level quality measure/indicator report describe?
lists all residents of a long term care facility and their QI conditions
besides the quality indicator reports, what are some other OFF site survey tasks?
- statement of deficiencies
- OSCAR report 3 history facility profile
- OSCAR report 4 full facility profile
(OSCAR tells how many foleys, how many on psychotropic meds, etc.)
from what report are the oscar reports derived?
the MDS
what factors do surveyors consider when evaluating QOL?
- resident grooming and dress
- staff-resident interaction related to residents’ dignity: privacy and care needs, including staff availability and responsiveness to residents; requests for assistance
- the way staff talk to residents, the nature and manner of interactions, and whether residents are spoken to when care is given
- emotional and behavioral conduct of the residents and interventions by the staff
- resident behaviors and the manner in which these behaviors are being addressed
what are some findings that might indicate that there are care issues, issues with how care is provided, or prevalence of special care needs?
- skin conditions
- skin tears, bruising, or evident fractures
- dehydration risk factors
- edema, emaciation, and fractures
- poor positioning and use of physical restraints
- side effects of antipsychotic drug use such as tardive dyskinesia
- presence or prevalence of infections
- pre-selected concerns and potential residents
- observations of all residents during the tour
- pressure sores
- amputation
- significant weight loss
- feeding tubes
- ventilators, oxygen, or IV therapies
what are surveyors looking for in a closed record review?
- information such as assessment and care of infections, pressure sores, significant weight loss, restraints, multiple falls or injuries, discharge planning, transfer and discharge requirements
- disposition of personal effects
- closure of medical record with physician discharge summary w/in 30 days
what qualities are surveyors looking for when assessing the activities at the facility?
- care planning individualized
- activity care plan goals are measurable and focused on a desired outcome
- activities must match the skills, abilities, needs, and desires or the resident
- does the staff know their role in providing activities if activity staff is not available?
- calendar should reflect religious and cultural interests of residents
what are some specific standards with which NHs must be complaint?
compliance with
- unnecessary drugs
- drug regimen review
- pressure sores
- pressure sore tx
- comprehensive care plans
- hydration
- comprehensive assessment
- comprehensive care plans
what is the objective of the exit conference?
inform the facility of the survey team’s observation of preliminary findings
who is invited to the exit conference?
- ombudsman
- residents
- president of the resident council (or designated member)
- management
- staff
- board members
- medical director
what are some key regulations by which NHs must abide?
F223 abuse: resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion
F279 refusal of tx: residents have the right to refuse tx
- guidelines state facility must show that they provided adequate info to resident so that they could make an informed choice - does POC reflect efforts to find alternative means to address problem? resident have capability to make healthcare decision
F323 accidents: facility must ensure that resident environment remains free from accident hazards as is possible; each resident must receive adequate supervision and assistance devices to prevent accidents
what are the 2 factors that help determine compliance or compliance issues?
scope and severity
how are scope and severity scored?
scope: number of residents potentially or actually affected
- isolated
- pattern
- widespread
severity: level 1-4, effect on resident outcome
- no actual harm w/ potential for minimal negative impact
- no actual harm with potential for more than minimal harm that is no immediate jeopardy
- actual harm that is not immediate jeopardy
- immediate jeopardy to resident health and safety
what are some strengths of facility surveys?
- comprehensive
- unannounced
- onsite visit by trained inspectors
- federal quality checks - federal surveyors check on the work of state surveyors
what is a limitation of the facility surveys?
variation between states
what is the purpose of nursing home ratings?
- created to help consumers, families, and caregivers compare nursing homes
- result of QI campaign Advancing Excellence in America’s Nursing Homes
on what factors are nursing home ratings based?
- staffing
- health inspections
- quality measures
what does each CMS five-star rating scale represent?
quality compared to other nursing homes in that state 1 star = much below average 2 stars = below average 3 stars = average 4 stars = above average 5 stars = much above average
what are some long-stay prevalence measures used to rate nursing homes?
- change in ADLs
- changes in mobility
- high-risk pressure ulcers
- long-tern catheters
- physical restraints
- UTIs
- pain
what are some short-stay prevalence measures?
- delirium
- pain
- pressure ulcers
on what is the rating of staffing based?
- based on avg number of direct care hours per resident per day
- includes care provided by RNs, LPNs, and CNAs
how do they determine staff needs?
adjusted for case-mix using RUGs scores (determines resident acuity), meaning a home that has residents with more intensive care needs would be expected to have more staff
medicare and medicaid pay approx how much of LTC bill in US?
60%
how many hrs of direct resident care for each resident in PA?
2.7 hours
what is the national citizens coalition for nursing home reform’s recommendation for minimum staffing level?
4.13 hours per resident per day
benefits of the 5 star rating system?
- easily accessible to consumer
- quality ratings are updated monthly
limitations of the 5 star rating system?
- doesn’t account for state variations
- data is self-reported on staffing and QMs
- system doesn’t rate family or resident satisfaction
what is a CQI cycle?
- planned sequence of systematic and documented activities aimed at improving a process
- improvement can be affected by improving the process itself or improving the outcomes of the process
what are the 4 steps of the CQI cycle?
- plan
- do
- study
- act
what is the purpose of the “plan” step of the cqi cycle?
- define the objective, questions, and predictions
- plan to answer the questions who, what, where, and when
- plan data collection to answer the questions
what is the purpose of the “do” step of the cqi cycle?
- carry out the plan
- collect the data
- begin analysis of the data
what is the purpose of the “study” step of the cqi cycle?
- complete the analysis of the data
- compare data to predictions
- summarize what was learned
what is the purpose of the “act” step of the cqi cycle?
- plan next cycle
- decide whether or not change can be implemented
