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Long Term Care Quality Indicator (QIS) Survey Readiness

Reducing Survey Stress in an Environment of Change

Belinda Reed

on 27 January 2013

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Transcript of Long Term Care Quality Indicator (QIS) Survey Readiness

Facility Tasks 1. Medication Administration
2. Medication storage
3. Liability notice
4. Infection Control
5. Kitchen
6. Dining
7. Resident Council
8. QA Reducing Survey Stress In An Environment of Change Long Term Care Quality Indicator (QIS)
Survey Readiness Documentation to prepare for
Survey entrance. The importance of keeping a binder and what needs to be included

Survey checklist Communication
the Survey Stage I vs. Stage II Belinda Reed RN
Long term care surveyor
Health Facilities
Emergency Medical Services Division Learning objectives

1. Know what to prepare prior to survey, and how to
prepare your employees for the tasks that
will be observed. Know how this can be made
easier for the residents and how to prepare them as well making it less stressful

2. Know what the surveyors will ask for while in the facility

3. Questions that you would like answered in this session Objectives Information to provide immediately 1. Alphabetical resident Census with room numbers

2. The completed new admission information form

3.Post survey announcement signs

4. Copy of the facility floor plan

5. A copy of staffing schedules for licensed and registered nursing staff for the survey time period (If you know there are variations from the schedule please indicate variation) 6. List of key personnel and their locations

7. Name of resident council president or
an officer/active council member

8. Schedule of meal times and location of dining rooms

9. Schedule of medication administration times

10. Records from the list of Admission Sample residents

11. List of paid feeding assistants WITHIN ONE HOUR OF SURVEY ENTRANCE 12. Complete pages 2 and 3 (see handout provided)

13. Influenza/ pneumococcal policy and procedures

14. List of rooms with variances

15. QA committee information

16. Experimental research

17. Name of contact person for abuse/ Policy and procedure INFORMATION TO PROVIDE WITHIN 4 HOURS 18. Medicare Medicaid application and Resident census and condition forms

19. Request of demand bills

20. Facility affidavit 671

21. Title six checklist

22. Information for emergency
water source and emergency
preparedness INFORMATION TO PROVIDE WITHIN 24 HOURS Stage I For Stage I we are collecting Data and will not be able to elaborate on questions

We are directed by the QIS survey to speak to your direct care staff so please let them know we will be talking to them and you can feel free to talk to them as well to see how their interviews went

We ask that you be patient as we will approach necessary staff for interviews in stage II Stage II This is when we will be interviewing a lot of staff regarding the information we gathered in stage I

We will also be asking for policies and expectations of the facility regarding general tasks and practices

We will be speaking to administrative and management staff at this point as well Exit -An exit will occur with residents and a separate one will occur with management staff

-Please consider room size and appropriate staff to attend

-Exit is a reading of citations and explanation of the process, not a reading of the 2567- It is only preliminary

-Independent dispute committee

-Plan of correction

Are all the questions answered? -Practice with unfamiliar people

-Randomly question the nurses on indications and side effects

-Question your nurses about where to find resources

-Make resources available and uniform in MARs and TARs

-10 Residents and 50 medications must be observed over different shifts with different nurses and routes MEDICATION ADMINISTRATION Medication Storage -Know what your policy is on medication storage

-Know indications for storage (pharmacy consultants are a great resource)

-Read the regulation

-You need to have your narcotics locked, logged and secured

-How are you ensuring the destruction of medications

-Where can your nurses find expiration dates and facility practice on labeling drugs? Liability Notice -Audit your notices

-Ensure that residents are given two days notice prior to discharge

-If there is a reason two days is not given document that reason

-If given verbal notice you still need to send a certified copy of the notice for signature Infection Control Kitchen -We use the Colorado retail Food Establishment Rules and Regulations- Do you have a copy

-Have a non-dietary staff come in and inspect your kitchen just for cleanliness (get a second set of eyes)

-Ensure you are temping your food and holding at the right temperature prior to serving

-Date and label your foods once opened

-Be aware of expiration dates

-Observe your service and ensure that if gloves are being used they are being changed appropriately

-Wear your hairnets -Know your policy

-Do things make sense (cohort)

-Refer to the Center for disease control

-Your infection control logs are there to help you (Can you demonstrate how you use them as tools to reduce/prevent infection)

-Have education that supports your negative findings Dining -Have staff from another facility observe your dining after reading the pathways

-Ensure that people are served in a respectful and timely manner

-Randomly select several residents and ensure they are getting the equipment and assistance during dine that they are care planned and ordered

-Even if nursing staff is helping serve they need to know how to appropriately handle cups and ready to eat food Resident Council -We will be speaking to your resident council president and reviewing your minutes (they should match what the residents are saying)

-Can resident council meet without staff

-Are you addressing resident rights and the ombudsman's contact number

-Does the facility staff address the grievances in resident council in a timely manner to the residents' satisfaction Quality Assurance -The purpose of QA is to help the facility identify issues and areas that need attention

-If you identify a problem and have a functioning QA in process it can make a world of difference

-If you are being asked about a process that is being addressed in QA, reveal your process

-When having a systemic problem in the facility the root cause must be investigated and a reasonable plan must be made to solve that problem

-Think of your facility as a resident and QA as a care plan meeting in which you have to have reasonable goals and approaches discussed to best care for your resident Environment -Have a second set of eyes come into your facility and be critical (look at every scratch on the wall and chip of paint)

-Your laundry needs to be safe and educated on how they contribute to the environment (Lint traps)

-Have your pest control records available and in order
-If the nursing home administrator has to approve all purchases and improvements you may want them to come on the tour

-We make environmental notes on the first day and continue throughout the survey, but wait until the end of the survey to do the tour

-Your dumpsters are a part of the facility that can create hazards and attract pests
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