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How we can help |
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Today, more than ever, nursing facilities must be prepared to demonstrate compliance with federal and state regulations not only at survey time, but all year long. Survey results are now available to the general public and are used by the public in choosing a nursing home. Plaintiff attorneys look at survey results, too, often before they file a lawsuit.
Survey teams can appear at any time to conduct complaint investigation surveys. And these days, they are likely to begin surveys at nontraditional times and on weekends. These changes in the frequencies, times and types of surveys make it imperative that facilities be prepared at all times.
With rapidly increasing turnover rates for nursing staff and managers, facility staff might not be familiar with surveyors' procedures, care observations, interviews, and record reviews and could be unprepared to meet these challenges. At Mitigation Solution, we can help.
In order to adequately prepare staff to succeed at survey time, and to ensure that the facility complies with regulations, the consultants at Mitigation Solution can perform periodic mock surveys, which can be an important feature of a facility's quality assurance process by:
- Enlisting "fresh eyes" to see existing problems clearly.
- Replicating "real" survey procedures as faithfully as possible. Our observation and survey sample methods select residents according to survey guidelines and interview the same residents and staff that actual surveyors are likely to interview.
- Providing an “exit interview” on site so staff know immediately their weak areas.
- Following up with a detailed report not only of the findings during the mock survey, but recommendations for the facility to become survey compliant in that area.
Once state/federal surveyors have completed the survey and a Statement of Deficiencies is received, the consultants at Mitigation Solutions can help you not only formulate your Plan of Corrections, but advise and assist your facility on the best route for facility compliance in time for your Follow-Up survey.
If you feel the Statement of Deficiencies is inaccurate, Mitigation Solution can guide you through the process of Informal Dispute Resolution (IDR). Through this process, information to refute the deficiencies is gathered by the facility, and staff then present this information to the reviewing agency (differs via state) for a final decision. The consultants at Mitigation Solutions can easily guide you through this process by using their own resources, knowledge, and experience. Each case is personally and professionally evaluated, and an honest opinion will be rendered. We can assist you in writing the request and deciding on exhibits.
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The following are examples of Programs available to clients. Many additional programs are also available. |
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1. Safety and Risk Reduction
The facility will have a multi-disciplinary Safety Committee, which is comprised of at least the following members; Administrator, Director of Nursing, Maintenance supervisor, MDS coordinator and Housekeeper. The committee meets monthly and reviews all resident, employee and visitor incidents. Resident Incidents are entered and transmitted to Mitigation Solution for addition to the master database. Incidents are tracked and trended with review done by the committee. Policies are in place, which details the items to report, a logging mechanism and reporting of potential and actual claims. Resident incidents resulting in injury are reported to Mitigation Solution for follow-up and review. Any potential liability issues are then forwarded to the Insurer. All requests for medical records, demand letters, potential liabilities and petitions are forwarded to the Risk Manager for review and conveyed to the Insurer.
2. Staff Education and Training
New patient care employees attend/complete an orientation program within the first week of hire. Patient safety and risk management topics are included on a checklist which, when completed is placed in the employee’s personnel file. Competency/skills are validated for new employees at the time of hire and for current employees on an annual basis per policy. Nursing assistants also receive additional training of at least 12 hours per year based on identified need per employee. Each facility has a mandated list of annual inservices that are completed and copies maintained in a global book in addition to employee files. The Risk Manager conducts training for facilities at least annually and provides additional training at site visits. The Facility conducts patient quality of care training several times a year.
3. Reduction of Falls
All residents are assessed for fall risk at the time of admission, quarterly and as needed based on change of condition. The facility will have a comprehensive assessment and prevention program. It will encompass Safety Assessment and Fall Education to residents, families and staff members. Residents, who are identified with weakness, gait problems or balance issues are referred for therapy evaluation. Residents with a history of falling are assessed for causal factors and input and suggestions are sought from their family members. Following a fall, a post fall assessment is completed to determine what the cause of the fall was and to identify needed adjustments to interventions on the careplan. Family members are called to both notify them and seek their input on adjustments to the careplan. The resident admission contract specifies that restraints will not be used with the exception of devices such as side rails on beds and safety belts in wheelchairs for those residents who have been assessed as needing them.
4. Skin Care and Decubitus Prevention
Residents are assessed for skin breakdown each day during routine care and more thoroughly at the time of their bath. Residents are assessed for risk of pressure sore development at the time of admission, quarterly and as needed based on condition change. Regardless of the risk score, any resident with a pressure sore is automatically treated as high risk. Each facility has a variety of special support surfaces available to buy or rent dependent on the type required by the resident. A monthly audit is completed on all residents with pressure sores. The audit is reviewed by the Quality Assurance committee. Residents with pressure sores are treated per specific wound care protocols. The pressure sores that are developed in house are evaluated as to cause and to determine if the areas were clinically unavoidable.
5. Prevention of Medication Errors
The facility has contracted pharmacy consultation services. Each resident’s medication administration record is reviewed monthly for possible errors. Problems are communicated in writing to the Director of Nursing and the physician together with any recommendations. The pharmacist also attends the Quality Assurance committee meeting at least quarterly to provide input on educational needs and to review and comment on any medication errors occurring over the quarter. The facility uses administrative nurses and the contracted pharmacy to conduct unannounced medication pass audits for the licensed nurses and medication technicians (in the states that allow medication technicians.) Medication errors are entered on a report and reviewed by the Director of Nursing, the Administrator and the resident’s physician. A copy of the report is maintained in the nurse’s file and is used as the basis for future monitoring, education and discipline as needed.
6. Significant Condition Change
The facility nurses use a 24 Hour Report for all residents that have had an incident or change of condition. The charts are placed on a “hot rack” which signifies that follow-up and a note must be made every shift. Only the Director of Nursing or her/his designee can place the chart back into the general rack which signifies that the condition is abated. The 24 Hour Report is reviewed on a daily basis by the Director of Nursing and Administrator during the Morning Meeting. This allows pertinent resident issues to be relayed to all department heads as needed. Training with licensed staff will be completed at the time of hire and annually on various medical conditions common to the elderly that can result in a significant condition change.
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