2012 State Veterans Homes VA Survey Deficiency Overview JoAnne Parker Kelly Mingle Office of GEC Operations (10NC4)

Discussion Topics All Deficiencies cited in 2012 Top 10 Deficiencies Discussion Bonus – Recognition updates

Background Information Current SVH Program Structure offering three levels of care: – 143 State Veterans Home Facilities 134 Nursing Home Care programs (24,526 beds) 53 domiciliary care programs (5,801 beds) 2 adult day health care programs (85 participant slots)

FY12 Types of Surveys Survey TypeSurveys% of Total Annual % For Cause32.00% Recognition128.00% Total150100%

Comparison – Surveys Types (FY10-12)

Totals for FY12 Total Number of Nursing Homes Surveyed 150 Total Number of Surveys with Deficiencies 65 Total Nursing Home Deficiencies 285 Average Number of Deficiencies Cited per Survey 1.90

IJs for FY12 CFR#Tag# TimesReason Failure to complete assessment for smoking residents/ Accidents: Failure to develop smoking policy and supervise residents smoking/Resident smoking with oxygen and without supervision/Failure to implement, monitor, and supervise fall interventions Failure to follow care plans/supervise residents that smoke 1C1611 Failure to ensure three (3) residents from self harm/ Failure to document attempted suicide Failure to provide adequate fire safety systems Failure to use resources effectively to maintain the highest practical, physical, mental, and psychological well being of each resident Failure to ensure nurse aides able to demonstrate competency to care for residents’ needs Failure to correct quality deficiencies within established time period Failure to provide appropriate supervision to the residents while in the shower room Lack of functional water thermometer on ARJO tubs Failure to ensure safe smoking practices Failure to ensure safe smoking practices Failure to implement, monitor and supervise residents that smoke/Failure to develop and implement appropriate plans of action

IJs for FY12 CFR#Tag# TimesReason Failure to complete assessment for smoking residents/ Accidents: Failure to develop smoking policy and supervise residents smoking/Resident smoking with oxygen and without supervision/Failure to implement, monitor, and supervise fall interventions Failure to follow care plans/supervise residents that smoke 1C1611 Failure to ensure three (3) residents from self harm/ Failure to document attempted suicide Failure to provide adequate fire safety systems Failure to use resources effectively to maintain the highest practical, physical, mental, and psychological well being of each resident Failure to ensure nurse aides able to demonstrate competency to care for residents’ needs Failure to correct quality deficiencies within established time period Failure to provide appropriate supervision to the residents while in the shower room Lack of functional water thermometer on ARJO tubs Failure to ensure safe smoking practices Failure to ensure safe smoking practices Failure to implement, monitor and supervise residents that smoke/Failure to develop and implement appropriate plans of action

10 Ten Deficiencies FY12 Standard Number of Deficiencies - FY 12Percentage Physical Environment % Resident Assessment % Quality of Care % Quality of Life % Residents Behavior and Facility Practices103.57% Administration93.21% Infection Control82.86% Dietary Services51.79% Resident Rights51.79% Nursing Services20.71% Total280100%

Deficiencies by Type FY 12

Deficiencies by Type FY 11

Deficiencies by Type FY 10

DOM Totals FY12 Total Number of Domiciliary Surveyed59 Total Number of Surveys with Deficiencies Cited23 Total Domiciliary Deficiencies Cited27 Average Number of Deficiencies Cited per Survey 0.46

Top DOM standards FY12 Tag Regulation Number StandardFrequency % of All Tags 4E181.4 e Primary care medical services are provided for domiciliary patients as needed 27.41% 11A a Medical records are completely legible and accurately documented, readily accessible, and systematically organized to facilitate retrieving and compiling information 27.41% 4F182.4 fEach patient has a complete medical re-evaluation annual and as needed13.70% 5C190.5 cNursing services rendered are documented in the patient's medical record13.70% 5D191.5 d Nursing service participates in the establishment and maintenance of a treatment plan for each domiciliary patient 13.70% 7A196.7 A qualified social worker is on staff or the facility has a written agreement with a qualified social worker or recognized social agency for consultation on a regularly scheduled basis 13.70% 7B-C197.7 b-c A written psychosocial assessment is maintained in each patient's medical record 13.70% 7C198.7 c Results of social services rendered are documented in the patient's medical record 13.70% 7D199.7 dThe facility has an organized procedure for discharge and transfers13.70% 9D210.9 dEach patient's activity plan is a part of the overall treatment plan13.70% 10A aA registered pharmacist is responsible for pharmacy services13.70% 13A aPatients are treated with respect and dignity13.70% 13E e Patients are oriented to the policies and procedures concerning the rights and responsibilities of the domiciliary patient 13.70%

DOM Comparison FY

A Closer Look Based on frequency of issue: – Physical Environment – Assessments – Quality of Life – Quality of Care Based on level of improvement: – Dietary

Physical Environment Tag Regulation Number StandardFY11FY12% change a Life Safety from Fire % b1-4Emergency Power %

Assessments Tag Regulation Number StandardFY11FY12% change b1 Resident Assessment: Comprehensive Assessments of residents needs % d1 Resident Assessment: Comprehensive Care Plan % d2 Resident Assessment: Comprehensive Care Plan % d3Resident Assessment: Periodic Review %

Quality of Care Tag Regulation Number StandardFY11FY12% change a1-3 Quality of Care: Reporting of Sentinel Events % d Quality of Care: Pressure Sores % i1-2Quality of Care: Accidents %

Quality of Life Tag Regulation Number StandardFY11FY12% change a/b Quality of Life: Dignity % g1Quality of Life: Patient Activities %

Dietary Tag Regulation Number StandardFY11FY12% change dFood % hSanitary Conditions %

Recognition Update New State Veterans Homes 06/29/2012Tyler, TX100-Bed NHC 07/12/2012Tucson, AZ120-Bed NHC Pell City, AL174-Bed NHC, 80-Bed DOM Black Mountain, NC100-Bed NHC Changes to Existing State Veterans Homes 03/09/2012Marshalltown, IA180-Bed Replacement 03/22/2012Bangor, MENew Therapy Unit and Transitional Wing 08/12/2012Milford, DE30-Bed Addition 08/02/2012Charlotte Hall, MDConverted 8 DOM beds to NHC 10/25/2012Spring City, PA120-Bed NHC Replacement 08/23/2012Minneapolis, MN100-Bed NHC Replacement 35-Participant ADHC 02/01/2013Scranton, PAConverted 12 DOM beds to NHC

Take Away SVHs hard working to secure Veterans Safety Relationship between SVHs and VA is important Moving Forward