2. The New Survey Process Quality Indicator Survey (QIS) Presented by: Janet McKee, MS, RD, LD President of Nutritious Lifestyles, Inc.

3. QIS DEVELOPMENT §University of Colorado, University of Wisconsin, Maverick Systems, and Alpine Technology  Development from 1998-2005 §Field tests by research, CMS staff, CO, IA, MD, NJ and WI §Demonstration and evaluation by CA, CT, KS, LA, OH 2006

4. QIS DEVELOPMENT §New survey process started in Florida in November, 2006 §Florida statewide rollout- 2007 §Northern Florida first with migration to South

5. QIS PURPOSE AND OBJECTIVES §To guide surveyors through the federal survey process §Improve consistency and accuracy of Quality of Care/Quality of Life problem identification using a more structured process §Comprehensive review of regulatory care areas using current resources

6. QIS PURPOSE AND OBJECTIVES - continued §Enhanced documentation by organizing survey findings through automation §Focus survey resources on facilities with largest number of quality concerns §For providers, makes IDR process more difficult

7. QIS SURVEY Two-stage computer-assisted survey process, which includes 9 Tasks

8. Good News The survey process has changed, but the F-Tags and Interpretive Guidelines are the same.

9. STAGE I PROCESS §Preliminary investigation of residents l Randomly selected by QIS Data Collection Tool (DCT) l Based on a range of care areas covered by the federal regulations l Resident assessments are based on observations, interviews, and review of the clinical records

10. STAGE I PROCESS – continued §The computer selects the residents using the MDS data l Constructs 160 resident outcome and process indicators called Quality of Care Indicators (QCIs) l The computer analyzes the on-site collected data

11. STAGE I PROCESS - continued §The QCIs are then compared to national norms §QCIs that score above the statistical threshold are computer-selected for a detailed in-depth investigation in stage II. §Includes Tasks 1-6 §QIS Manual http://ahca.myflorida.com/MCHQ/Long_Term_Care/LTC/index.shtml http://ahca.myflorida.com/MCHQ/Long_Term_Care/LTC/index.shtml

12. STAGE II PROCESS §In-depth investigation of residents with care areas identified by the computer in Stage I that exceeded thresholds (national norms) §Triggered care areas and residents are systemically investigated using Critical Element Pathways to determine regulatory compliance §Includes Tasks 6-9

13. STAGE I

14. TASK 1: OFF-SITE SURVEY PREPARATION  Review OSCAR 3 report to determine if facility has a history of repeat deficiencies.  Review complaints filed with the agency in order to facilitate investigation during the survey.  Team assignments: census reconciliation, tour, and facility-level tasks  NO review of QI/QM reports

15. TASK 2: ON-SITE ENTRANCE CONFERENCE  Team Coordinator announces survey and introduces team  Immediately obtains an alphabetical resident census with room number, unit, date of birth, and list of residents admitted within last 30 days that reside in the facility

16. TASK 2 ON-SITE ENTRANCE CONFERENCE - continued  Provide signs announcing the survey; to be posted by facility  Obtain a copy of the facility plan  Explain private interviews will be conducted with residents/families  Team will communicate throughout survey and request assistance as needed - NO DAILY MEETINGS  Conduct complaint investigation during the survey, if applicable  List of residents who receive dialysis, on ventilator, on hospice services

17. TASK 2 – Concurrent Activities  Tour  Begin process of finalizing Stage I sample  INITIAL KITCHEN/FOOD SERVICE OBSERVATION WHILE OTHER MEMBERS ARE GATHERING INFORMATION  Schedule time to meet and interview Resident Council President and review meeting minutes

18. TASK 2 – Concurrent Activities §DINING OBSERVATION (starts with first meal that can be observed in full) §MUST IDENTIFY EMERGENCY WATER SOURCE/SUPPLY §MUST PROVIDE SCHEDULE OF MEAL TIMES AND LOCATION OF ALL DINING ROOMS

19. TASK 3: INITIAL TOUR §Obtain BRIEF overall impression of the facility and the resident population §Meet as many staff/residents/families as possible §NOT a method of sample selection §Record egregious resident care situations to be investigated further in Stage II §Document concerns with environment (dining room, cleanliness, smells, etc.) §Ask staff to identify family members that visit regularly

20. TASK 3: INITIAL TOUR - continued  Observe staff/resident interactions (privacy and dignity)  Observe staff availability  Observe activities in progress  Observe characteristics of resident populations, i.e. residents with dementia, rehabilitation, and sub-acute clinically complex residents, residents with special care needs (feeding tubes, ventilators, intravenous fluids/medications, tracheostomy tubes, oxygen therapy)

21. TASK 4: SAMPLE SELECTION  Quality Indicator Survey Data Collection Tool (QIS DCT) provides a systematic automated resident sampling process.  QIS DCT generates 3 Stage I samples from the resident pool  1) MDS sample  2)Admission sample  3)Census sample (subset of resident pool)  Surveyors may generate a non-random, surveyor- initiated sample (subset of resident pool).

22. TASK 4: MDS SAMPLE REVIEW  Residents whose data trigger the MDS- based Quality Care Indicators (QCIs) will be reviewed in Stage II.

23. TASK 4: ADMISSION SAMPLE REVIEW  Focus is on quality of care within first six months for short stays  Focal points: Nutrition, Rehab, Skin Care  Record review only  Mostly closed records reviews

24. TASK 4: ADMISSION SAMPLE REVIEW - continued §WEIGHT LOSS ANALYSES §SURVEYORS ARE INSTRUCTED TO USE SAME CHARTING DOCUMENTATION SOURCE FOR ALL WEIGHTS, IF POSSIBLE. l FOR EXAMPLE, MARS, TARS, DIETARY, NURSING NOTES, WEIGHT/HEIGHT RECORDS. MDS IS LAST RESORT. §SAMPLE SIZE UP TO 30

25. TASK 4: CENSUS SAMPLE REVIEW  Focus on care of residents currently residing in the facility and encompasses activities of daily living, NUTRITION, medications, ELIMINATION/incontinence, resident room, oral health, quality of life, SKIN CARE  Data collection through observations, interviews, record reviews  Sample size - 40 residents currently residing in the facility

26. TASK 4: CENSUS SAMPLE REVIEW - continued  Collect and record resident specific information which takes into account situation, time, and multiple observations §Set of prescribed questions to review the initial quality assessment of sample residents and facility (see CMS forms on website) §Includes gathering of sample residents’ specific information by observations, interviews and record reviews

27. TASK 4: CENSUS SAMPLE REVIEW - continued §This information will be comprehensively analyzed in Stage II.  Observations concerning compromised quality of care of sampled and non-sampled residents are recorded on surveyor worksheets for further survey or review in Stage II.

28. TASK 4: CENSUS SAMPLE REVIEW - continued §Expect first several days to include a lot of surveyor observations §Surveys are lasting 5 days in Florida §Florida trend - More cites, less severity, more collateral tags

29. TASK 4: CENSUS SAMPLE REVIEW - continued  Surveyors ask questions as written  Select families from various units  Conducted with family or representative that knows the resident and facility’s care well (3 different families/representatives)  Concerns identified need to be investigated immediately, with the family present (see Attachment A).

30. TASK 4: CENSUS SAMPLE REVIEW - continued Family and Resident Interviews  Surveyor questions to Family/Representatives:  Does the facility honor the resident’s desires and preferences?  Does the resident get assistance with meals?  What is the food like here?  Are you able to participation in making decisions regarding food choices/preferences?

31. TASK 4: CENSUS SAMPLE REVIEW - continued Family and Resident Interviews  Surveyor questions to Residents  Is the food appetizing and does it taste good?  Is food served at the proper temperature?  Are you offered fluids between meals? (See Attachments A & B)

32. RESIDENT CHOICES

33. Resident Food Choices: Facilitates Cultural Dining, Customer Satisfaction, and Successful QIS Results §Resident Choice Menu Development §Dessert Cart §Soup Cart §Salad Choice §Bread Basket at Table §Beverage Cart §“Room Service” via carts on floor for Room Trays

34. TASK 4: CENSUS SAMPLE REVIEW - continued Staff Interviews  Conducted with licensed staff (RN/LPN)  Nurse must have frequent and direct contact with the resident  Convenient for the staff  Document what is stated, even if information contradicts information gathered from another source (observation or record review)

35. TASK 4: CENSUS SAMPLE REVIEW - continued Staff Interviews  Question B1: Nutritional supplement, requires facility documentation of a recording and monitoring system (check or %)  Must show surveyors this documentation. (See Attachment C)

36. TASK 4: CENSUS SAMPLE REVIEW - continued Clinical Record Review  Encompasses pressure ulcers, psychotropic medications, and weight loss  Conduct record reviews on the unit to continue observations of activities and staff- resident interactions.

37. TASK 4: SURVEYOR-INITIATED SAMPLE  Chosen by a surveyor at his/her discretion, to be further evaluated during Stage II  Based on resident-specific information obtained from complaints, observations, interviews  Example: dependent diner with a Stage I pressure ulcer who is not being fed and family has verbalized complaints

38. TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS §Hydration l S ources - Resident and staff interviews and observations, MDS l Do you have access to fluids? l Do you receive fluids between meals? l Does the resident show signs of dehydration, such as cracked lips, etc.? l Prevalence of dehydration - output exceeds input (from MDS)

39. TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS - continued §Nutrition – l Sources – MDS, medical records, staff interviews, observations, chart l Prevalence of weight loss (MDS) l Prevalence of significant weight loss that exceeds the interpretive guidelines (MDS/Medical records) Excludes residents with terminal illness and on planned weight loss program l Weight loss since admission: 5% unplanned weight loss of 5% or more within 60 days of admit (MDS/Chart) l No supplements and resident underweight (Observation/chart) l Staff interview: Is the resident receiving a nutritional supplement defined as a high calorie/high protein product with or between meals?

40. TASK 4: NUTRITION/HYDRATION/ TUBE FEEDING QUALITY OF CARE INDICATORS USING SAMPLED RESIDENTS - continued §Tube Feeding l Sources – MDS/Chart l Prevalence of tube feeding (MDS) l Significant weight loss on tube feeding (MDS/Chart)

41. TASK 4 : RELEVENT FINDINGS  Document observed problems  Document areas of concern  Document date, time, and source  Document person interviewed and title  IDRs will be difficult

42. TASK 5: FACILITY-LEVEL SURVEY AREAS Survey tasks to be completed: 1. Demand billing 2. Dining observation (see attachment D) 3. Infection control 4. Kitchen/Food Service Observation (see attachment E) 5. Med Pass

43. TASK 5: FACILITY-LEVEL SURVEY AREAS - continued 6. Nursing services, sufficient staffing* 7. Personal funds* 8. QAA Review 9. Resident Council president interview 10. Abuse prohibition review* 11. Admission, transfer, discharge review* 12. Environmental Observations *completed only if triggered by complaints or Stage I interviews, observations or record reviews.

44. TASK 5: DINING OBSERVATION  Focuses: enough staff, positive dining experience, residents’ choice  Begins with the first full meal that occurs after the team enters the facility (see handout)  If concerns identified, watch a different meal to see if problem exists during that meal

45. TASK 5: DINING OBSERVATION - continued  If more than one dining room, observe all dining rooms plus residents dining in-room  If there are problems identified, the surveyor can initiate the full dining observation at any point  Focus on residents who require the most assistance. (See Attachment D)

46. TASK 5: DINING OBSERVATION - continued  Dining observations will also occur during Stage II for sampled residents with nutrition-related concerns, such as weight loss, decline in eating ability, or dehydration, using the nutrition critical pathway  Names of residents observed not receiving needed services, positioning, or adequate assistance will be recorded on the dining room worksheet to further investigate in Stage II.

47. TASK 5: DINING OBSERVATION - continued  Family and residents with dining concerns should be documented for private follow- up. Interviews will be conducted.  If surveyor identifies concerns (e.g. resident complaints or high prevalence of unintended weight loss), surveyor may request sample tray (same process as current procedure)

48. TASK 5: DINING OBSERVATION - continued  Test tray will be sent to unit the furthest distance away  Test tray is to be done when the last resident is served. If concerns are identified, such as F371 or F364 - unpalatable food or at improper temperatures or unsanitary conditions, the surveyor is to initiate the appropriate tag and document concerns in the computer to address further in Stage II

49. TASK 5: DINING OBSERVATION - continued  Multiple meal observations through survey  Work sheet entered in computer during Stage II

50. TASK 5: DINING OBSERVATION - continued Examples of Questions on Dining Observation Tool:  Are staff members assisting with dining at scheduled times, providing timely and appropriate assistance?  Are staff members talking with residents?  Are staff members allowing residents adequate time to eat?  Are meal substitutes offered when meals are refused?

51. TASK 5: DINING OBSERVATION - continued §Are residents positioned to maximize eating abilities? §Are dining rooms free of offensive odors? §Does staff utilize hygienic practice? §Does the facility offer sufficient liquids with meals? §Does the facility serve meals in an attractive manner? §Are residents’ desires taken into account when using clothing protectors? §Are adaptive devices utilized to promote independence? (See Attachment D)

52. TASK 5: KITCHEN/FOOD SERVICE OBSERVATION ● Brief visit during initial tour ● Observe general sanitation practices, cleanliness of the kitchen, and any practices that might indicate potential for food-borne illness ● Complete rest of worksheet during repeated focused visits to the kitchen. ● Unannounced ● Make observations, conduct staff interviews. (See Attachment E).

53. TASK 5: KITCHEN/FOOD SERVICE OBSERVATION - continued Focus Areas of Kitchen Observation §Is food stored at appropriate temperatures? §Is food stored under sanitary conditions? §Were dishes cleaned and stored properly? §Does the facility prohibit staff with open wounds, signs and symptoms of infection or indications of illness from handling food? §Was food served in a sanitary manner that preserves nutritional value?

54. TASK 5: KITCHEN/FOOD SERVICE OBSERVATION - continued Focus Areas of Kitchen Observation §Is food placed on the steam table two or more hours prior to service? §Are hot foods (above 140 0 F) cooled to 70 0 F to 41 0 F within 4 hours? §Is food and equipment clean and in working order?

55. PRESIDENT OF RESIDENT COUNCIL IS INTERVIEWED §May be questioned about food satisfaction, cold food complaints, poor quality, sanitation, service, honoring preferences, etc.

56. STAGE II

57. TASK 6: TRANSITION FROM STAGE I TO STAGE II  Team of surveyors meet  Surveyors verify items completed in Stage I  Computer verification and printing of reports and findings  Calculated Quality of Care results, identifying residents and core areas for inclusion in Stage II

58. TASK 7: CRITICAL ELEMENT PATHWAYS § Identified areas have a set of Critical Element (CE) Pathways l Guide the investigation. l Assist in completing a consistent, organized, systematic review of triggered areas l Computer-assisted to identify all care areas

59. TASK 7: CRITICAL ELEMENT PATHWAYS - continued §Help surveyors determine compliance. §Incorporate each step of the resident care process reflected in the regulations: l Assessment l Care Planning l Implementation of Care l Care Plan Revision l Provision of care and service to meet the needs of resident (outcomes)

60. TASK 7: CRITICAL ELEMENT PATHWAYS - continued Critical Element Pathways: 1. Activities 2. ADLs and/or ROM 3. Behavioral/Emotional Status 4. Bowel & Bladder/Catheters 5. Communication/Sensory Problems 6. Dental Status/Services 7. DIALYSIS 8. General 9. HOSPICE/PALLIATIVE CARE

61. TASK 7: CRITICAL ELEMENT PATHWAYS - continued 10. Hospitalization or Death 11. NUTRITION, HYDRATION, TUBE FEEDING STATUS 12. Pain Management 13. Psychoactive Medications 14. Physical Restraints 15. PRESSURE ULCERS 16. Rehab/Community Discharging 17. Ventilators

62. TASK 7: CRITICAL ELEMENT PATHWAYS - continued  Stage II Survey of residents  Residents whose in-depth review of quality of care indicators exceeds thresholds in Stage I process and residents selected by surveyors.  Minimum of three residents for each triggered care area.  For example, nutrition, hydration and tube feeding are three care areas with one CE pathway. Therefore, a minimum of three residents will be selected for each triggered care area.

63. CRITICAL ELEMENT PATHWAY: NUTRITION, HYDRATION, TUBE FEEDING STATUS §In-depth, detailed review of residents that have triggered care areas. §Observations §Medical record reviews §Resident/Representative Interviews.

64. TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING STATUS - QUESTIONS, DIRECTIVES AND OBJECTIVES Samples of Questions:  Were fluids provided at meals?  Was the resident encouraged to drink?  If the resident has dysphagia, what measures were taken to ensure adequate fluid intakes?  Did the initial assessment include a baseline BMI, height, weight, and weight history?  Were calorie, protein, and fluid needs assessed? (See Attachment F)

65. TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING STATUS – QUESTIONS - continued §Does the resident have sunken eyes, nausea/vomiting, edema, muscle wasting? §Observation of staff providing appropriate assistance for residents dependent upon staff for care. §Are supplements given to minimize interference with meal intakes? §Does the resident consume supplements and to what extent? (from medical records)

66. TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING STATUS – QUESTIONS – continued §Is family involved in the plan of care re: nutrition? (Family interview) §Are the resident’s preferences honored regarding choices, portion sizes, nourishments, fluid restrictions?

67. TASK 7: NUTRITION/HYDRATION/ TUBE FEEDING STATUS – QUESTIONS – continued  Did the facility identify labs suggestive of dehydration?  Were preventive plans of care in place to promote a specific amount of fluid to prevent hydration?  Were methods in place to record food intakes and report deviations?

68. TASK 7: CRITICAL ELEMENT PATHWAYS - continued Potential Critical Element Pathway citations for Nutrition, Hydration, and Tube Feeding Status: F272, F279, F280, F281, F282, F321, F325, F327, F328 (See Attachment F)

69. TASK 7: GENERAL CRITICAL ELEMENT PATHWAYS  General CE Pathways: – For core issues not already addressed – Accidents (Falls) – Fecal impaction – Other skin conditions (burns, skin tears) – Non-UTI infections – DM, COPD, CHF, Wound Care (excluding pressure ulcers) – Includes probes

70. TASK 8: ANALYSIS, DECISION- MAKING AND INTEGRATION OF INFORMATION  Analysis of information  Integration of facility-level information  Integration of Critical Elements  Analysis/assignment of scope and severity, and team decision-making

71. TASK 9: EXIT CONFERENCE §Surveyors will use a potential citation report to guide the exit §Will provide list of residents if facility requests §Report finalization §Revisit if needed

72. THE END

73. THANK YOU Janet S. McKee President of Nutritious Lifestyles, Inc. 918 Lucerne Terrace Orlando, Fl 32806 407-894-1444 Nlifes8314@aol.com