Report by Ingrid Constalie, Government Relations Chair Wisconsin Representatives of Activity Professionals
Information presented by Joy Jordan, RN, MSN, National Director of Quality Surveys
Boyer & Associates, LLC at the October 2011 Leading Age Conference
Joy provided 8 1/2 hours of information during this 90 -minute session! There is a lot of information and a lot of change.
A successful survey is being in compliance and having staff portray that compliance with confidence. The Quality Indicator Survey (QIS) will not be starting in Wisconsin and some other states in 2012 as originally planned due to lack of funds for computers and training, but it will be starting. This is reminiscent of implementation of the MDS 3.0! It allows additional time to prepare, so use this advantage! The objectives are to improve survey consistency and objectivity by using a more structured process. It will have a greater focus on regulations regarding quality of life. Because of computer records it will have enhanced efficiency and documentation and it will target facilities with the largest number of quality concerns. This is very important that it supposedly will target poor performing facilities.
In comparing the QI survey vs. the traditional survey the survey “tasks” remain the same though given different names: Task 1-offsite prep & sampling (ombudsman concerns are looked at in the off site), Task 2-on site survey and entry conference, Task 3-initial tour, Task 4-Stage I tasks, Task 5-non staged survey tasks, Task 6-Transition from Stage I to Stage II, Task 7-Stage II tasks, Task 8-analysis & decision making—integration of information and Task 9-exit conference.
There are many changes. The new process is composed of two stages. Stage I is a preliminary investigation of regulatory issues, and random selection of 40 residents to sample. It will likely involve more surveyors, so if past teams have been 3-4, expect 4 or 5 with the QIS. It is a silent data collecting and validating and is a more objective process. It is not meant to be adversarial. The big difference is that everything is structured; interviews, observations, reviews. They won’t look where they aren’t led. Stage II is an in-depth investigation of Care Areas based on exceeding thresholds in stage I. A threshold is the rate established by national norms to determine the decision whether or not to conduct a Stage II investigation. A threshold will control the next group of investigations. Surveyors should not pursue anything that doesn’t trigger. They do not have to investigate something that is border-line. Comments will tell if there is truly an issue. Surveyors do not have to share threshold levels, but they are available on computer programs.
When the survey team enters the building they will need an alphabetical resident listing identifying room numbers/units, a list of new admissions in the last 30 days, information on meal times and med pass, staffing schedules for nursing staff and information on residents with complex care. It is guaranteed that anyone on a ventilator, dialysis or end of life will be reviewed. They do not need a resident roster sample matrix right away. If they ask for one say, “No, you don’t need it at this point and time.”
The facility tour will be very quick, just a brief overview of the facility. They are not looking at concerns yet, but things in general. They will watch how staff and residents are interacting. There will be a particular focus on staff interactions with residents. This should last 15-20 minutes. No tours will be done during meals. If they arrive during a meal the team will go directly to dining areas to observe. They will stay until the last resident has finished eating and looking at the whole mealtime process. Be survey ready!
Observation and interview drives stage I. There is no group interview anymore. Rather, surveyors will meet with a designated resident asking prescribed questions, not their own. The areas of review are similar to traditional survey group questions. The surveyor is not to lead the resident. A staff member can’t be present. This is private. A resident deemed “non-interviewable” obviously cannot be interviewed. If no one can be interviewed, ALL will be observed.
The QI survey is an automated process. No paper is used in stage I. Surveyors will utilize personal computers (PC’s) to gather information and the computer will analyze the information to determine where the problems are. There will be structured interviews, observations and clinical record reviews, including structured protocols for facility tasks. 50% of the data will come from resident and family interviews with a focus on choices. “Do you get a choice of food? Does that matter to you?” Only two scripted questions will indicate whether a problem exists so the resident can’t be led on. The focus will be on resident preferences and quality of life in addition to quality of care. Get a copy of the QI surveyor guidelines from the CMS website.
Other differences include the length of survey will vary from three days to more than a week, but typically be completed within one week. Facilities can still have a cite free survey, though generally, there will be an increase in the number of deficiencies—particularly in quality of life areas, but a decrease in scope and severity (S/S). There is no provision for exit surveys. They will tell us nothing in the first two days, but they have nothing to tell since the thresholds have not yet been run. Maybe by noon the second day, but they are not mandated to tell. They only exit you may have is at the end. They are all required to do that. This makes people nervous. Per CMS, the provider should have the opportunity to see what was found and to provide additional information. The Informal Dispute Resolution (IDR) process to revisit past cites to have them changed or reviewed is the same.
Facilities are directed to go to the CMS website for all of the survey forms and surveyor’s guide to educate staff to the process. Go there and pull them off. Use them to train staff to increase comfort and competence answering the questions. It is important to know what they are and have copies for staff to carry during the QI survey. That way the surveyors will know that you know their process. You should talk to them about this process, refer to it and observe to see they are following it.
Stage II is an in-depth review and is a lot more than observation. It is very involved. Information gathering includes quality of care and quality of life probes. There are four types of resident samples; admission, census, MDS and surveyor (this last one won’t happen very often). The MDS sample will include all residents with an MDS in the past six months. It reflects quality of care data on all residents treated in the facility during a time frame. It is used late in the process mainly for data. The admission sample is a clinical record review. The census sample is resident interviews & observations, family interviews, staff interviews with a clinical record review. They will observe a resident who is not interviewable and will discontinue an interview if they’re not getting good information. A computer program such as QI Wizard Pro 33 will pull this data from responses to interview questions to calculate thresholds. We were directed to go to the CMS website and pull data gathering and interview forms.
There is the potential they could do 70 resident reviews, but this is not likely because many overlap. They will sample 40 people; 20 will be interviewed and observed, 20 will be observed. The number of residents sampled from tour observations or complaints are minimal. All census sample residents will be observed for the following: cleanliness/grooming, dressing, contractures, skin, pain, positioning, resident room, incontinence, activities, abuse, potential restraints, hydration, and potential safety hazards. It will be multiple observations, not just one, to determine if there is a problem. They will observe on ALL 3 SHIFTS. There will be a focus on high -risk residents.
Family interviews will be completed for non-interviewable residents within the sample. Surveyors want to talk to someone who truly knows what’s going on day- to -day with the resident and visits frequently. They will be asked the same type of questions as the resident interview. Three family interviews will be completed in each survey. Surveyors may talk to the “daughter from hell”, but if she’s not in the sample they won’t enter the data because it would skew the results. They will let staff know about issues brought up during these interviews.
Staff members assigned to the sample resident will be interviewed. This is a scheduled event and the surveyor will make an appointment, but it is ok to have another staff member present. This should not be adversarial. Calling staff at home is not allowed. Staff will need resident diagnosis, flow sheets, weights etc. so be prepared to bring these things with. Again, they will be asked set questions—this is scripted data gathering and looking at high- risk areas. There are six key areas that they will ask about; catheter use (reason for use), nutrition (supplement use & need to verify), skin care/pressure ulcer (number and stage), side rails, contractures and falls/fractures. They will go through the nursing process and intervene where they find the most problems. They may say, “Let me see your CAAs”. Take heed; “A smart surveyor always reads CAAs. They say why or why not you’re going to do anything and what”. It is a good idea to talk about and practice these interviews with staff to increase their comfort and confidence. They should sound intelligent and competent.
The record review will happen at the nurse’s station. Facilities need to think about space for them and being prepared to have a surveyor present. They will be looking at MDS data, specifically comatose, bed mobility, transfer, nutritional diagnosis, stability of conditions, pressure ulcers, psychotropic medications, height & weight (closest to today’s date—a data collection tool or DCT determines percentage of weight loss). THAT’S ALL their going to take off the MDS. They won’t scrutinize dates unless they observe problems. All 40 sample residents will have their records reviewed. Reviews will also be conducted on the nursing unit to allow for observation. Surveyors will be out and about most of the time.
The admission sample can be open or closed records. It is specific and focused. It will only look at community discharge, rehab services, admission source, death, hospitalization, pressure ulcer (present on admission, developed within 30 days or worsening), and weight loss on admission 15, 30 and 60 days after admission.
Mandatory tasks done for every single survey include demand billing, dining observation, infection control/immunization (done during the entire survey), kitchen/food service observation (the first meal looks at the dining process. They will do two others), med administration and storage (they will do 50 observations with 10 residents looking at insulins, eyedrops, nebs. Expired meds are always an issue), quality assessment & assurance QA&A, resident council president/representative interview. There is a form for each of these.
Transitioning from Stage I to Stage II surveyors will merge data in to one computer. Quality Care Indicators (QCIs) will be calculated and compared to national rates. If rates exceed thresholds, in-depth investigation is required. Surveyors will be controlled and not allowed to go after their “pet issue”. For every issue found there will be three more further investigations looking for negative outcomes. It is possible not to go to Stage II and have a “cite” free survey.
Care area investigations involve 16 specific critical element pathways that are used to guide the reviews and to assist surveyors in completing a consistent, organized, prescribed and systematic review of triggered care areas to determine whether the facility meets the regulatory requirements. They incorporate the resident care process. They are activities, ADL’s/cleanliness/grooming, behavioral/emotional status, bowel/bladder functioning, communication/sensory problems, dental, hospitalization/death, nutrition, hydration, tube feeding, pain, restraints, pressure ulcers, psychoactive meds, and rehab/discharge. A general critical element pathway is used for care areas with out a specific critical element pathway; accidents, fecal impaction, other skin conditions and infections other than UTIs. Surveyors are guided by the State Operations Manual. At this point, it is a good idea to pull it out and read the regulations. If any of the following areas trigger during Stage I the surveyors have to proceed; abuse prohibition, admission/transfer/discharge, environmental observations, personal funds, and sufficient nursing staff.
Stage II investigations are done at both the resident and facility level and involve the critical element pathways. They integrate information from various data sources and rate the severity of deficient practice.
Stress is placed on using the nursing process of identify, evaluate, implement, monitor and modify. If this is used and monitored staff can be taught how to follow the QI survery.
Take advantage of any opportunity for additional training and education regarding the QIS survey process. As with the MDS 3.0, increased exposure to the material will improve confidence and knowledge. Look to the CMS website for additional resources.