1 State of Michigan Department of Community Health Bureau of Health Systems Division of Operations Roxanne Perry February 28, 2008

2 Welcome

3 Clinical Process Guidelines Green Bill

4 Clinical Process Guidelines Clarification Work Group Clinical Advisory Panel

5 Purpose of CPGs To provide a uniform definition of the issue To provide a uniform definition of the issue To establish clinical/research evidence as the basis for management To establish clinical/research evidence as the basis for management To provide a format for analysis To provide a format for analysis To provide a standard of practice To provide a standard of practice To provide a template for action, documentation and monitoring To provide a template for action, documentation and monitoring

6 Format of CPGs Care Process StepExpectationsRationale Recognition/Assessment Diagnosis/ Cause Identification Treatment/Management Monitoring

7 Example: CPG-Evaluation of Falls/Falls Risk Memorandum to LTC facilities from Clinical Advisory Panel Memorandum to LTC facilities from Clinical Advisory Panel The Basic Care Process defined The Basic Care Process defined Process Guideline Process Guideline Documentation Checklist Documentation Checklist MDS/Fall RAP Key guidelines Assessment and Problem Definition, Care Plan MDS/Fall RAP Key guidelines Assessment and Problem Definition, Care Plan Tables and illustrations Tables and illustrations Checklist for Assessment Checklist for Assessment References References

8 Clinical Process Guidelines Topics Topics ~ Guideline for Use of Bed Rails in Long Term Care Facilities (April 2001) ~ Evaluation of Falls/Fall Risk (October 2001) ~ Pain Management (March 2002) ~ End of Life Care (March 2002) ~ Medication Management and Reduction of Adverse Drug Reactions (October 2002) ~Prevention and Management of Pressure Ulcers (February 2003)

9 Clinical Process Guidelines Topics Topics ~ Behavior Management and Antipsychotic Medication Prescribing (October 2003) ~ Acute Change of Condition (June 2004) ~ Maintaining Hydration/Electrolyte Imbalance (September 2005) ~ Altered Nutritional Status (September 2005) ~ Depression (November 2006) ~ Heart Failure (December 2007)

10 New Applications for Use May be provided as a “recommendation” in enforcement letter. May be provided as a “recommendation” in enforcement letter. May be used as developmental structure by Clinical Advisor May be used as developmental structure by Clinical Advisor May be included in Directed Plan of Correction/Directed In-service May be included in Directed Plan of Correction/Directed In-service May be used as a framework for establishing compliance (and past non-compliance) May be used as a framework for establishing compliance (and past non-compliance)

11 Past Non-Compliance

12 Criteria for Past Non-Compliance To cite past non-compliance, all three(3) criteria must be met: 1. The facility must not have been in compliance with a regulatory requirement at the time the situation occurred, i.e. the facility must have had a violation; and with a regulatory requirement at the time the situation occurred, i.e. the facility must have had a violation; and 2. The situation of non-compliance must have occurred after the exit date of the last survey, and before the current survey (standard, complaint, revisit); and

13 Criteria for Past Non-Compliance cont’d 3. There must be specific evidence that the facility corrected the non-compliance (at the time of the incident) and is in substantial compliance at the current survey.

14 Facility Past Non-Compliance Form Date of Report:Administrator Name: Date of Report:Administrator Name: Facility name: Facility name: Address: Address: Phone #: Phone #: Resident Name: Date of Birth: Resident Name: Date of Birth: Room #: Room #: Diagnosis: Diagnosis: Date of event: Date of event: Was the resident injured? Was the resident injured? If yes –Describe injury: If yes –Describe injury:

15 Facility Past Non-Compliance Form cont’d Description of deficient practice: (Why and how did it happen?) Plan of Correction:  In-depth analysis of how the deficiency occurred.  How facility identified resident affected and residents having potential to be affected by the same deficient practice.  Corrective action taken for resident affected.  Measures or systemic changes made to ensure that deficient practice will not occur and affect others.  How facility monitors its corrective actions to ensure deficient practice is corrected and will not recur. Date of completion of plan of correction. Attach documents for evidence of compliance. Name (printed) and Signature of person completing form

16 Documentation of Past Non-Compliance 1.Past non-compliance that is not Immediate Jeopardy and for which a quality assurance program has corrected the non-compliance, should not be cited. Note: The facility needs to bring this to the attention of the surveyor. The facility must provide the evidence to the surveyor who will contact his/her manager to review the information and make a determination if the evidence meets the criteria for past non-compliance. 2.Past non-compliance identified as immediate jeopardy is entered on CMS 2567 under the specific deficiency tag, scope and severity with supporting documentation. 3.The CMS 2567 should include the appropriate F-tag, date of deficiency, the date of past non-compliance, the evidence of past non-compliance and implementation of a plan of correction so that the civil money penalty can be determined.

17 Documentation of Past Non-Compliance cont’d  NOTE: The generic F698 has been discontinued Enforcement Action on Immediate Jeopardy Past Non-Compliance 1. Civil money penalty is required for immediate jeopardy. Usually a per instance CMP is jeopardy. Usually a per instance CMP is imposed. imposed.  NOTE: Past non-compliance does not apply to State Nursing Home Rules and the Public Health Code. A State of Michigan-tag (M-tag) may be cited.

18 Documentation of Past Non-Compliance cont’d  IDR 1. Will be allowed for past non-compliance cites. 1. Will be allowed for past non-compliance cites. i.e.: To contest whether a deficiency occurred. i.e.: To contest whether a deficiency occurred. 2. Can IDR whether a past non-compliance citation is a deficiency. deficiency. 3. Cannot IDR whether a deficiency (cite) is past non-compliance.

19 Putting it all together Use the Clinical Process Guidelines as a problem solving tool and to assure ongoing compliance. Use the Clinical Process Guidelines as a problem solving tool and to assure ongoing compliance. Identify the use of the CPGs when offering evidence of past non-compliance. Identify the use of the CPGs when offering evidence of past non-compliance. Maintain a clear file of QA efforts in a manner that can be provided to surveyors. Maintain a clear file of QA efforts in a manner that can be provided to surveyors. Continually monitor and document the monitoring of all QA efforts. Continually monitor and document the monitoring of all QA efforts.

20 Revisits Revisits may be conducted at any time for any level of non-compliance. Revisits may be conducted at any time for any level of non-compliance. Revisits are required for: Revisits are required for: 1) Non-compliance at F (substandard quality of care) 2) Harm level citations 3) Immediate Jeopardy

21 Evidence in Lieu of Revisit In some cases, acceptable level of compliance may be submitted in lieu of a revisit. In some cases, acceptable level of compliance may be submitted in lieu of a revisit. Evidence of compliance in lieu of a revisit is not acceptable after a second revisit has been conducted. Evidence of compliance in lieu of a revisit is not acceptable after a second revisit has been conducted.

22 Evidence in Lieu of Revisit Examples of acceptable evidence are: Examples of acceptable evidence are: 1) Invoice or receipt verifying repairs, purchases, etc. 2) Sign-in sheets for in-service training verifying attendance 3) Contact with resident council

23 Resources Bureau of Health Systems State Operations Manual (CMS) Appendix P Appendix PP

24 Resources cont’d Clinical Process Guidelines Deborah Ayers, DCH QI Nurse Consultant: