2015 Nursing Home Survey and Enforcement Actions

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Presentation transcript:

2015 Nursing Home Survey and Enforcement Actions Annual Inspections Complaint Investigations Office of Health Assurance and Licensing July 2016

Number of Health Surveys per CY Data as of July 8, 2016

Number of Health Deficiencies per CY Data as of July 8, 2016

Number of Deficiency Free Annual Surveys per CY *The above graph represents facilities that have had no LSC, Health or Licensure deficiencies on their annual surveys. Data as of July 8, 2016

Substandard Quality of Care Data as of July 8, 2016

Immediate Jeopardy (Health and LSC) Data as of July 8, 2016

Health Deficiencies Level G and Above Data as of July 8, 2016

Informal Dispute Resolution (IDR) Number of Deficiencies Disputed Data as of July 8, 2016

Informal Dispute Resolution (IDR) - CY 2015 401 IDR Deficiencies Disputed 211 Event IDs Data as of July 8, 2016

Informal Dispute Resolution (IDR) Level 2- CY 2015 84 IDR Level 2 Deficiencies Disputed 50 Events Data as of July 8, 2016

Informal Dispute Resolution (IIDR) CY 2012 - 2015 2013 2014 2015 Affirmed 23 17 29 30 Deleted 4 10 8 Revised 7 2 5 Withdrawn 5* Total 34 48 43 *These IDRs were not conducted due to conflicts between the dispute resolution processes of CFR 488.331 and 488.431. Data as of July 8, 2016

Facilities with Imposed Remedies Data as of July 8, 2016

Imposed Remedy Summary CY 2011 - 2015 Remedy Description 2011 2012 2013 2014 2015 CMPs 126 124 139 137 146 Denial of Payment (Discretionary and Mandatory) 20 21 11 17 19 Directed In-Service 26 8 2 Termination 3 State Monitoring 1 Suspension of Payments Data as of July 8, 2016

Top Ten 2015 Health Deficiencies - Nursing Homes F323 - Accidents & supervision (305) F309 - Quality of care (266) F441 - Infection control (235) F329 - Unnecessary drugs (229) F371 - Sanitary conditions, food prep & service (212) F225 - Investigate/report allegations (151) F226 - Develop/implement abuse & neglect policies (151) F157 - Notify of changes (Injury/decline/room) (145) F514 - Resident records complete/accurate/accessible (137) F279 - Develop comprehensive care plans (136) Data as of July 8, 2016

Top Ten 2015 Life Safety Code Deficiencies - Nursing Homes K144 - Inspect, test and maintain generators (238) K038 - Exits readily accessible at all times (213) K062 - Automatic sprinkler systems are operable (195) K052 - Fire alarm system (186) K050 - Fire drills (178) K147 - Management of electrical equipment (144) K056 - Automatic sprinkler exist and installed properly (133) K018 - Corridor doors (131) K029 - Hazardous areas (129) K025 - Smoke barriers (110) Data as of July 8, 2016