Long-Term Care Survey Alert

Published on Sat Nov 28, 2009 PDF

The watchdog agency's recommendations could affect your facility.

CMS' method for selecting nursing homes for its Special Focus Facility (SFF) program hasn't exactly earned high marks from the Government Accountability Office. According to a new GAO report, CMS should do a better job of identifying the poorest performing facilities for the SFF program, which requires the facilities to either improve their survey performance -- or get booted from Medicare and Medicaid. If adopted by CMS, the GAO's recommendations could affect whether your facility gets targeted for the SFF in the future, which can happen much more easily than many providers realize.

Continence Nursing Education Center. Or you may see "sudden deterioration in the quantity or quality of the granulation tissue, increased exudate, and increased pain." Left untreated, "critical colonization typically progresses to invasive wound or systemic infection," cautions Joyce Black, PhD, RN, CPSN, CWCN, FAPWCA, former president of the National Pressure Ulcer

Advisory Panel and a nursing professor at the University of Nebraska in Omaha. "Usually the bacteria are Staph, Strep, Pseudomonas, although there can be others." A stalled wound may have a biofilm, which is a protective matrix that won't allow antibiotics and antiseptics through. "We are coming to understand that there are probably more biofilms on wounds than we realized," says Black. "And the biofilms seem to delay wound healing.

If you apply topical agents, you're treating the planktonic organisms on the surface and not those behind the biofilm which are the ones causing a problem."

Time to debride: You have to mechanically remove a biofilm. "You can do this by using instrumental debridement or by curettage of the wound surface," Doughty notes.

Once you've "opened the wound up and have bloody tissue, then it's worthwhile to apply an antiseptic or  antibiotic topical preparation for a time," Black says.

Strategy No. 2. Identify signs of invasive skin ulcer infection. These include erythema, increased exudate and wound pain, as well as induration around the wound, "particularly if it extends more than 2 cm from the wound edge," Doughty notes.

Assessment tips: "Be aware that some topical wound products can cause a change in drainage color," advises Carol White, RN, MS, ANPC, GNPC, DNP, CLNC, CEO of NationalHI Inc. in Huntington, Ind. For example, "hydrocolloids may interact with the wound drainage, producing a creamy-colored substance." Some silver-based products may make the wound appear to be producing yellow/black fluid, she adds. And "some of the silver products are actually black in color." Immunocompromised patients or those with poor perfusion will show "more subtle signs of infection," Doughty warns.

You may see a wound with "faint erythema and mild induration," although typically the patient will have increased wound pain, she adds.

Be proactive: The wound care team should assess perfusion to the site of a leg ulcer and evaluate factors that may affect immune function, says Jenny Hurlow, GNP, CWOCN, a geriatric nurse practitioner and wound care specialist with the Plastic Surgery Group of Memphis, Tenn. The list includes age, nutrition, and immune-suppressive drugs, such as steroids, she adds.

Strategy No. 3. Obtain a proper culture of a skin ulcer. "The gold standard for wound culture is tissue biopsy," which requires a physician, physician assistant, or advance practice nurse who can do it, says Mary Arnold Long, MSN, RN, CRRN, CWOCN-AP, ACNS-BC, a clinical nurse specialist at Drake Center in Cincinnati, Ohio. Tissue swabs are an alternative, however, she adds.

To get the best swab culture, use Levine's technique, which involves the following steps, Long advises:

• Cleanse the wound (use saline, advises Doughty);

• Express new exudate;

• Find the least healthy area of the wound;

• Swab rotating the swab 1 cm to each number on the clock face.

"Think of the starting point as a clock, and you're swabbing 1 cm to 12:00, 1 cm to 1:00, etc.," Long suggests.

Beware: The biggest mistake Doughty sees in nursing homes related to assessing wound infection is culturing dead tissue, as this can cause the clinician to order the wrong antibiotic. "You can only get a valid culture if you have viable tissue in the wound," she cautions. "Thus, if it's covered with slough or eschar, you can't do a swab culture." Instead, you either have to debride the wound first or "just begin broad spectrum antibiotics if there is active cellulitis."

Strategy No. 4. Track surgical wound progress by obtaining a baseline. The nursing staff should assess the resident's surgical sites when he's admitted to the facility, advises Hurlow. "Carefully assess for any incisional drainage, areas of dried exudate, and any redness or induration along the line of the incision."

Contact the surgeon if you GAO Uncovers Almost 4 Percent Worst Performers Nationwide. Currently, CMS identifies facilities for the SFF program based on a formula that limits the number to 136 at any point in time, due to resource constraints, the GAO notes in its report (www.gao.gov/products/GAO-09-689). Nursing homes with the 15 worst scores in each state become candidates for the program. "CMS has structured the SFF Program so that every state (except Alaska) has at least one SFF even though the worst performing homes in each state are not necessarily the worst performing homes in the nation," the GAO points out.

In its study of the SFF, the GAO identified nursing homes with worse compliance histories than the SFF program candidates. To do this, the GAO researchers applied CMS' "SFF methodology on a nationwide basis" and used "statistical scoring thresholds." And they "incorporated several refinements to the SFF methodology that moderately improve its ability to identify the most poorly performing nursing homes," the report notes.

Based on the GAO's estimate, "almost 4 percent (580) of the roughly 16,000 nursing homes in the  United States could be considered the most poorly performing." And these facilities do "overlap somewhat with the 755 SFF Program candidates -- the 15 worst homes in each state -- and the 136 homes actually selected by states as SFFs," the GAO says.

"For example, GAO's estimate includes 40 percent of SFF Program candidates and about half of the active SFFs as of December 2008 and February 2009, respectively." Yet based on the GAO's estimate, the worst facilities aren't equally distributed across states. Eight states have no such facilities while 10 others have 21 to 52 of the poorest performing facilities.

Report Identifies Characteristics of Poorest Performers Based on GAO's analysis, the poorest performers are more likely to have the following characteristics:

• More D-level or higher deficiencies, more serious deficiencies, and more revisits;

• More likely to be for-profit and part of a chain and have more beds and residents;

• Almost 24 percent fewer registered nurse hours per resident per day. Compared to all other nursing homes, the most poorly performing facilities had actual-harm deficiencies (G through I level) five times as often over the last three survey cycles. "Deficiencies at the immediate jeopardy (J through L) level occurred 15 times as often for the most poorly performing homes."

The GAO also found that the most poorly performing nursing facilities rang up revisits six times more often than all other facilities.

In a nutshell, the GAO wants CMS "to consider an alternative approach for allocating the 136 SFFs across states, by placing more emphasis on the relative performance of homes nationally rather than on a state-by-state basis... ." This could result in some states having only one or no SFFs while other states could end up with more than they are currently allocated, the GAO states.

In response, CMS said it would evaluate using a "hybrid" approach that would assign some SFFs using nursing homes' performance in each state, and other SFFs based on their relative ranking nationally.

In addition, CMS should make these changes, advises the GAO:

1. Consider using a common set of numeric points for identifying evaluating the effect of using the Five-Star nursing home rating system deficiency points for both the SFF and Five-Star program (see below for a table showing comparison of the methods).

2. Assign points to G-level deficiencies in SQC [substandard quality of care] areas equivalent to additional points assigned to H- and I-level deficiencies in SQC areas.

3. Account for a nursing home's full compliance history regardless of technical status changes (e.g., changes resulting in a new provider identification number). The GAO notes that "CMS agreed in principle" with the above three recommendations, although the agency pointed to some potential technical barriers to achieving the last one. Even so, CMS said it "would implement the recommended adjustment to the maximum extent practicable," the GAO notes. "GAO reports are very influential" due in part to the fact that the GAO is a congressional agency and a watchdog with no "axes to grind," says attorney Joseph Bianculli, in private practice in Arlington, Va.

Thus, government agencies "typically at least give lip service to responding" affirmatively to the GAO's reports, he adds.