Long-Term Care Survey Alert

Is your facility meeting federal and state staff training requirements for restorative nursing?

Double check in the light of a recent HHS Office of Inspector General audit that honed in on one facility's failure to meet state requirements for providing annual restorative nursing inservice training. Specifically, the OIG found that Mariner Health in Denver did not provide annual nursing rehabilitation inservice training. Mariner's corporate office had, however, developed a training seminar titled "Run for Restorative," but had not implemented it in the facility the OIG reviewed.

Colorado requires nursing facilities to provide annual inservice education for staff on a number of topics, including infection control, fire prevention and safety, accident prevention, rehabilitation/restorative nursing, dietary, and behavior management. Following the OIG audit, Mariner agreed with the OIG's findings that restorative nursing inservices would help improve patient care.

Stay Up on State Requirements

Nurse staffing and training mandates may vary from state to state - and may be stricter than federal requirements. "States with RUG-based Medicaid systems usually have requirements governing restorative training due to the reimbursement issue," explains Patricia Boyer, MSN, RN, a consultant with the Milwaukee office of BDO Seidman. "Colorado, for example, is a RUG-based state."

Caution: Make sure new staff are up-to-date on restorative nursing requirements in your state. When a state moves to a RUG-based system, state agencies usually do teaching on the requirements, Boyer notes. "But once a facility experiences turnover, new staff doesn't always stay on top of the training and state requirements for restorative nursing," she cautions.

Review the RAI Manual

Facilities should also review the Resident Assessment Instrument user's manual, which spells out Medicare requirements for restorative nursing/nursing rehabilitation services coded by facilities on the MDS. Yet the RAI manual instructions say only that CNAs providing restorative nursing should be trained in techniques that promote resident involvement in the activity.

Thus, facilities have lots of leeway for providing restorative nursing training to meet the rather vague federal specifications. For example, your facility might introduce the whys and hows of restorative nursing as part of general orientation for all caregivers - and then target inservices differently to CNAs and activities staff, suggests Rita Roedel, RN, MSN, also with BDO Seidman.

Train CNAs and licensed nurses on all of the restorative programs outlined in Section P3 of the MDS and for toileting and bladder retraining programs coded in Section H, Roedel suggests. Activities staff would benefit from training on active range of motion and ambulation, as activities departments often oversee exercise and walking programs, Roedel notes. "Activities staff can also use information on eating and swallowing and communication because activities often involve those aspects of care," she adds. "But it doesn't make sense for activities personnel to attend scheduled toileting and bladder training sessions."

Let Outcomes Be Your Guide

How can your facility determine if it's providing enough restorative training? That question might best be answered by the facility's quality assurance committee within the context of the facility's patient population, suggests Richard Butler, JD, a survey consultant in Indianapolis. "If residents' assessed needs require a lot of restorative nursing to be met, then the facility should be providing restorative care and a commensurate level of training," he says.

Get Real: Use your care plans to determine if residents are meeting expected outcomes, Butler suggests. But remember: "Realistic" is the watchword in writing care plan goals. "For example, it's not realistic for a care plan to say a patient with Parkinson's disease won't have any falls in 30 days," Butler cautions.

What To Expect: Restorative nursing is going to become a hotter focus thanks to the quality measures' focus on the prevalence of residents who decline in their activities of daily living, predicts Diane Martinez, RN, NHA, a health care consultant with Parente Randolph LLC in Philadelphia. "The Pennsylvania quality improvement organization (QIO) has made ADL decline one of its quality initiatives," Martinez notes. As a result, "the QIO has been providing training on restorative nursing throughout the state to bring facilities' restorative programs up to speed," Martinez reports. "Such programs are often underutilized," she notes.

Editor's Note: Read the OIG audit report at http://oig.hhs.gov/oas/ reports/region7/70304022.pdf.