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Long-Term Care Survey Alert

SURVEY MANAGEMENT:

Follow These 'Lessons Learned' for Staying Off CMS' Special Focus Facility List

Published on Wed Jan 28, 2009

Find out how a once troubled facility moved ahead of the QI curve.

Learning that your facility has been tapped for CMS' Special Focus Facility (SFF) list of poor performers destined to improve or get the boot from Medicare/Medicaid isn't an ideal way to start a new job. Brian Ruede heard that news when he took the helm as administrator of a small, rural New York nonprofit nursing home. And he and the interdisciplinary team quickly galvanized efforts that have led the nursing facility into best practice territory.

Great news: The facility not only graduated from the SFF program -- it now has systems that preempt problems before they morph into F tags. And their efforts hold "lessons learned" for all facilities that in today's survey climate could themselves be a survey away from major regulatory woes.

Background: "In 2006, the facility had a state and federal survey resulting in an immediate jeopardy (IJ) citation," reports Ruede. The facility got hit with $128,000 in civil monetary penalties, as well as legal and consulting fees and loss of Medicare and Medicaid payments to the tune of least $300,000 total. "It was a huge financial expense for a small, rural facility," he says.

"The survey in 2006 found many problems areas, including restraints, safety issues, resident assessments and care planning ... and a lot of system related issues. The facility had another IJ citation in 2007 for a resident elopement, which probably led to the facility's SFF designation," says Ruede.

Being in the SFF program meant the nursing facility received unannounced monthly visits from surveyors at the New York State Department of Health.

Implementing a Multi-Prong Approach

The facility team took numerous steps to get and keep its care systems on track, including:

• Weekly quality-of-care meetings.

These focus on residents with pressure ulcers, end-of-life concerns, significant weight changes or a change in status due to medical issues. And Ruede found that attending the weekly meeting gave him "some good insights" into where the facility's problems lie and where to focus his time. "One of those areas was obtaining accurate weights on residents," he says. In fact, the facility now has an interdisciplinary team that weighs residents, if needed, at the same time and in a consistent manner each week.

Perk: The weekly meeting "truly involves all departments, including activities," says Naomi Bell, RN, RAC-CT, the MDS coordinator for the facility. "We recognize problems before they turn into a big problem -- for example, if a resident loses a couple of pounds, we take a look at what's going on."

• "Discovery Memos." The memos "report changes, such as pressure ulcers, hydration, nutrition, and weight loss issues, or a change in ambulation or mental status," etc., says Ruede. Staff follow-up on the memos by drilling down with "why questions" until the team taps the "true root cause of a problem."

Listening is key: The facility also now has "people in administrative positions who listen to concerns before they become a fiasco," says Bell. "Becoming a SFF didn't happen over night."

• A divide and conquer approach. Team members took on different aspects of quality improvement. For example, the quality assurance nurse focused on medicationrelated areas, says Ruede. "The director of nursing (DON) took the lead on pressure ulcer management."

• A graphic approach to tracking pressure ulcers. The DON's office wall now includes information that easily shows which residents have pressure ulcers and how long they have had them -- and how the pressure ulcers are progressing, Ruede relays.

• Tapping grants for quality improvement efforts. The grants include one through the New York Association of Homes & Services for the Aging for use of its MDS-driven predictive pain model (see the lead front-page story in this issue).

"We also participate in another dementia grant from the New York State Department of Health, and another grant from New York State Health Facilities Association that assisted us in developing a geriatric career ladder," reports Ruede.

The grants gave the facility access to professional advice "and people to reach out to and talk with," says Ruede. "The career ladder program helped us provide training for CNAs to develop xpertise in dementia, pain management, and mentoring other CNAs." Ruede notes that some people thought he was "over-extending" the facility somewhat by signing up for the grants. But he believed correctly that the grants could provide access to educational programs that the facility had not been able to offer or afford in the past.

Participating in grants also shows the state agency that the facility is "taking positive steps" to improve and monitor services and systems, Ruede adds.

Tip: In working with troubled facilities, consultant Robin Bleier, RN, LHRM-FACDONA, recommendsthe plan of correction require various team members to join their respective professional organizations, including the medical director, nurses, activities, therapy, and dietary staff. "That provides a way for these professionals to have access to evidence- based information," says Bleier, in Palm Harbor, Fla.

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