1 Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities Educational Training for Nursing Homes 2008

1

Tennessee Department of HealthTennessee Department of HealthBureau of Health Licensure and Bureau of Health Licensure and

RegulationsRegulationsDivision of Health Care FacilitiesDivision of Health Care FacilitiesEducational Training for Nursing Educational Training for Nursing

HomesHomes20082008

2

Appendix Q Guidelines for Appendix Q Guidelines for Determining Immediate JeopardyDetermining Immediate Jeopardy

3

PREAMABLE FOR APPENDIX QPREAMABLE FOR APPENDIX Q

CONCERNSCONCERNS

That the health and safety for individuals That the health and safety for individuals in crisis situations at risk are:in crisis situations at risk are:• Accurately identifiedAccurately identified• Thoroughly investigatedThoroughly investigated• Resolved as quickly as possibleResolved as quickly as possible

4


CONCERNSCONCERNS

Standardization definition for all Standardization definition for all provider types except CLIA the provider types except CLIA the definitions for:definitions for:• Immediate JeopardyImmediate Jeopardy• AbuseAbuse• NeglectNeglect

5


In the interest to eliminate abuse and In the interest to eliminate abuse and neglect to all beneficiaries surveyors are neglect to all beneficiaries surveyors are cautioned:cautioned:– When abuse or neglect has been identified that When abuse or neglect has been identified that

a thorough investigation must be conducted to a thorough investigation must be conducted to determine if Immediate Jeopardy exists.determine if Immediate Jeopardy exists.

See Appendix Q PreambleSee Appendix Q Preamble

FOR MORE INFO...

6

DEFINITIONSDEFINITIONS

IMMEDIATE JEOPARDY:IMMEDIATE JEOPARDY:– A situation in which a provider’s A situation in which a provider’s

noncompliance with one or more requirements noncompliance with one or more requirements of participation has caused or is of participation has caused or is likely to likely to cause,cause, serious injury, harm, impairment, or serious injury, harm, impairment, or death to a resident.death to a resident.

See: 42 CFR Part 489.3See: 42 CFR Part 489.3

FOR MORE INFO...

7


Abuse: The Abuse: The willful inflictionwillful infliction of of injury, unreasonable injury, unreasonable confinement, intimidation, or confinement, intimidation, or punishment with resulting harm, punishment with resulting harm, pain, or mental anguish.pain, or mental anguish.


FOR MORE INFO...

8


Neglect: Failure to provide Neglect: Failure to provide goods and services necessary to goods and services necessary to avoid physical harm, mental avoid physical harm, mental anguish, or mental illness.anguish, or mental illness.


FOR MORE INFO...

9

GOAL OF SURVEY PROCESSGOAL OF SURVEY PROCESS

To insure the provisions of quality care to To insure the provisions of quality care to all individuals receiving care or services all individuals receiving care or services from a certified Medicare/Medicaid entity. from a certified Medicare/Medicaid entity. The identification and removal of The identification and removal of Immediate Jeopardy, either psychological Immediate Jeopardy, either psychological or physical, are essential to prevent or physical, are essential to prevent serious harm, injury, impairment, or death serious harm, injury, impairment, or death for individualsfor individuals

10

PRINCIPLESPRINCIPLES

Only one individual needs to be at risk. Only one individual needs to be at risk. Identification of Immediate Jeopardy for one Identification of Immediate Jeopardy for one individual will prevent risk to other individual will prevent risk to other individuals in similar situations.individuals in similar situations.

Serious harm, injury, impairment does Serious harm, injury, impairment does NotNot have to occur before considering Immediate have to occur before considering Immediate Jeopardy. The high potential for these Jeopardy. The high potential for these outcomes to occur in the very near future outcomes to occur in the very near future also constitutes Immediate Jeopardy.also constitutes Immediate Jeopardy.

11


Serious harm can result from both abuse and Serious harm can result from both abuse and neglect.neglect.

Psychological harm is as serious as physical Psychological harm is as serious as physical harm.harm.

When it is established by investigation that a When it is established by investigation that a resident was harmed by a cognitively impaired resident was harmed by a cognitively impaired individual due to the entity’s failure to provide individual due to the entity’s failure to provide care and services to avoid physical harm, mental care and services to avoid physical harm, mental anguish, or mental illness, this should be anguish, or mental illness, this should be considered neglect.considered neglect.

12


Any time a team cites abuse or neglect, Any time a team cites abuse or neglect, Immediate Jeopardy will be considered.Immediate Jeopardy will be considered.

Upon recognizing a situation which may Upon recognizing a situation which may constitute Immediate Jeopardy, the constitute Immediate Jeopardy, the investigation will continue until Immediate investigation will continue until Immediate Jeopardy is confirmed or ruled out.Jeopardy is confirmed or ruled out.

The serious harm, injury, impairment or death The serious harm, injury, impairment or death may have occurred in the past, may be may have occurred in the past, may be occurring at present, or may be likely to occur occurring at present, or may be likely to occur in the very near future.in the very near future.

13


After determining that the harm or potential After determining that the harm or potential for harm meets the definition of immediate for harm meets the definition of immediate jeopardy the survey team will consider the jeopardy the survey team will consider the following points concerning entity following points concerning entity compliance.compliance.– The entity either created a situation or allowed a The entity either created a situation or allowed a

situation to continue which resulted in serious situation to continue which resulted in serious harm or a potential for serious harm, injury, harm or a potential for serious harm, injury, impairment or death to an individual.impairment or death to an individual.

– The entity had an opportunity to implement The entity had an opportunity to implement corrective or preventive measures.corrective or preventive measures.

14

IMMEDIATE JEOPARDY IMMEDIATE JEOPARDY TRIGGERSTRIGGERS

Table found in appendix Q that lists issues with Table found in appendix Q that lists issues with associated triggers. This guide includes situations associated triggers. This guide includes situations that most likely create jeopardy to an individual’s that most likely create jeopardy to an individual’s psychological and/or physical health and safety.psychological and/or physical health and safety.

Triggers assist the surveyor in considering Triggers assist the surveyor in considering Immediate Jeopardy. Immediate Jeopardy.

Harm does not have to occur before considering Harm does not have to occur before considering immediate Jeopardy. Survey teams will consider immediate Jeopardy. Survey teams will consider both potential and actual harm when reviewing the both potential and actual harm when reviewing the

triggerstriggers..

15


Failure to protect from Failure to protect from abuseabuse

1. Head trauma or 1. Head trauma or fracturesfractures

2. Non-consensual 2. Non-consensual sexual interactionssexual interactions

3. Unexplained 3. Unexplained serious injuries not serious injuries not investigatedinvestigated

4. Staff striking, 4. Staff striking, yelling, swearing or yelling, swearing or gesturing derogatory gesturing derogatory names.names.

FOR MORE INFO...

See Triggers Appendix Q

16


Failure to protect from Failure to protect from neglect.neglect.

1. Lack of timely 1. Lack of timely assessment past injury.assessment past injury.

2. Lack of supervision with 2. Lack of supervision with known needs.known needs.

3. Repeated occurrences 3. Repeated occurrences e.g., falls.e.g., falls.

4. Failure to carry out 4. Failure to carry out physician orders.physician orders.

5. Access to chemical and 5. Access to chemical and physical hazards by physical hazards by individuals at riskindividuals at risk.

FOR MORE INFO...

See Triggers AppendixAppendix Q

17



6. Non-functioning call 6. Non-functioning call system.system.

7. Unsupervised smoking by 7. Unsupervised smoking by an individual with a known an individual with a known safety risk.safety risk.

8. Lack of supervision of 8. Lack of supervision of cognitively impaired cognitively impaired individuals with know individuals with know elopement risk.elopement risk.

9. Use of chemical/physical 9. Use of chemical/physical restraints without adequate restraints without adequate monitoring.monitoring.

FOR MORE INFO...

SeeSee Triggers Appendix Q

18



10. Failure to adequately 10. Failure to adequately monitor and intervene for monitor and intervene for serious medical/surgical serious medical/surgical conditions.conditions.

11. Improper 11. Improper feeding/positioning of feeding/positioning of individual with known risk individual with known risk for aspiration.for aspiration.

12. Inadequate 12. Inadequate supervision to prevent supervision to prevent physical altercations.physical altercations.

FOR MORE INFO...


19


Failure to protect from Failure to protect from psychological harm.psychological harm.

PLEASE SEE PLEASE SEE TRIGGERS IN TRIGGERS IN APPENDIX Q FOR APPENDIX Q FOR ADDITIONAL LISTS ADDITIONAL LISTS THAT ARE NOT ALL THAT ARE NOT ALL INCLUSIVEINCLUSIVE

FOR MORE INFO...


20

Locating Appendix QLocating Appendix Q

http://cms.hhs.gov/manuals/Downloads som107ap_q_immedjeopardy.pdf

FOR MORE INFO...

21

AoC VS PoCAoC VS PoC

Corrections

22

Plan of CorrectionPlan of Correction

A plan of correction (POC)

is an allegation of substantial compliance with program requirements. (Regulatory reference: SOM,

7304D – Acceptable Plan of Correction)

23

AoC vs PoCAoC vs PoC

Allegation of compliance (AoC) to remove the immediacy of jeopardy

When IJ is identified, required to submit AoC to remove immediacy & PoC for all other deficiencies (SOM, 7308)

Acceptable plan of correction (PoC) required to determine substantial compliance

24

Cases of Immediate JeopardyCases of Immediate Jeopardy

Facility must submit an allegation of removal of the IJ (AoC)

CMS & State Survey Agency (SSA) will request an AoC & PoC

CMS & SSA review the AoC to determine if acceptable

AoC must include:- date the IJ was removed - sufficient detail to demonstrate that the IJ has been addressed

25

Cases of Non-Immediate Cases of Non-Immediate JeopardyJeopardyPoC required for deficiencies cited

higher than level 1 {A, B, or C}PoC must be submitted within 10

calendar days of receipt of SODFailure to submit an acceptable PoC

will delay revisitsAccepted by SSA

26

PoC is Considered PoC is Considered Acceptable Only When…Acceptable Only When…

Corrective action for residents affected are stated Identifying potential for others affected is indicated Systemic changes are implemented Monitoring to sustain compliance is detailed Implementing dates are provided Possible roadblocks are avoided

27

Corrective Action for Corrective Action for Residents AffectedResidents Affected

Corrective action Steps taken Specific interventions Completion dates Individual(s) implementing

28

Identify Potential for Others Identify Potential for Others AffectedAffected Factors to consider in other residents that

have the potential to be affected by the same deficient practice– Specific population potentially affected– Review the deficient practice– Scope and severity of the tag– Specific system

29

Measures for Systemic ChangesMeasures for Systemic Changes Address what measures will be put into

place or systemic changes made to ensure that the deficient practice will not reoccur– not just the immediate issue – broaden the view to a systemic problem

Policies and/or procedures How and where issues fit into the system

30

Measures for Systemic Changes Measures for Systemic Changes (continued)(continued)

In-service programs – Date implemented – Who attended– Date initiated– Staff not in the building– New employees– Agency personnel

31

Monitoring to Sustain ComplianceMonitoring to Sustain Compliance

Outline plans to monitor Indicate individual(s) responsible for

monitoring– how this will be reviewed

– frequency that new implementation is re-evaluated

Develop a plan with detail Integrate into quality assurance system

32

Implementation DatesImplementation Dates

Include corrective action completion dates– must be acceptable to the SSA

If the PoC is acceptable, the SSA will notify the facility

Facilities are ultimately responsible for their own compliance

33

RoadblocksRoadblocks

Denial Brevity Repetition Generalizations In-Services

34

DenialDenial

PoC is not the forum for disputing deficient practice– will postpone corrective actions needed for implementation

AND MAY RESULT IN TERMINATION OF YOUR PROVIDER AGREEMENT FOR MEDICARE AND MEDICAID

35

BrevityBrevity

Information to indicate who, where, when, how & what of corrective action is critical

Detail is necessary

Ensure sustaining substantial compliance

36

RepetitionRepetition

Make certain the corrective action has removed the deficient practice

Identify specifics for each tag cited

Copy and paste

37

GeneralizationsGeneralizations

Committee, Team, Frequent, Often, Random

Identify information

Explain who, when, what and how of corrective actions

Do not cross reference

38

In-ServicesIn-Services

Include: content who presented the information target audience dates initiated how addressed for staff not present include new hires/agency personnel evaluate/monitor for comprehension &

implementation

39

Identify Systemic ProblemsIdentify Systemic Problems

Human

Mechanical

Corporate

40

HumanHuman

Education

Burnout

Agency personnel

41

MechanicalMechanical

Environment Equipment Natural disasters Implementing manufacturer’s

recommendations Monitoring Maintenance

42

CorporateCorporate

Philosophy

Support

Involvement

43

Road to ComplianceRoad to Compliance

For IJ:

accepted AoC (by CMS & SSA)

revisit for removal of IJ

submit PoC (followed by acceptance)

revisit to determine compliance

For non-IJ: accepted PoC (by surveying entity)

revisit to determine compliance

44

Citation TrendsCitation Trends

45

F-224 Staff Treatment of F-224 Staff Treatment of ResidentsResidents

FOR MORE INFO...

See CFR 483.13(c)

Based on observation, record review and interviews, it was determined that the facility failed to investigate Resident to Resident altercations in order to prevent and protect Residents from reoccurrence. The facility failed to identify, correct and intervene in situations which abuse of Residents is more likely to occur for 9 Residents(#5, #11, #21,#22, #24, #25,#29, #38, #50) of 51 Residents sampled, placing all Residents in the facility in Immediate Jeopardy.

46

Based on observation, interview and record review, it was determined the facility failed to thoroughly investigate incidents of Resident to Resident altercations, failed to report injuries of unknown origin and Resident to Resident altercations to the State Agency for 10 Residents(#5, #11, #21, #22, #24, #25, #29, #38, #46, &#50 ) of the 51 sampled Residents. This facility failure resulted in placing all Residents in thefacility in Immediate Jeopardy.

F-223 ABUSEF-223 ABUSE

See CFR 483.13(c)

FOR MORE INFO...

47

F-309 Highest Practicable Well F-309 Highest Practicable Well being (Quality of Care)being (Quality of Care)

Based on medical record review, observation,

and interview, the facility failed to follow

physician's orders for two (#17, #2) of twelve

residents receiving Coumadin therapy. The

facility's failure to ensure physician orders were

followed placed resident #17 in Immediate

Jeopardy.

48

F 332 483.25(m)(1) MEDICATION ERRORS

Based on review of the "Nursing 2006 Drug

Handbook 26th Edition", review of "Common

Insulins: Pharmacokinetics, Compatibility, and

Properties" from the American Society of

Consultant Pharmacists, medical record review,

observations and interviews, it was determined

the facility failed to ensure

49

6 of 8 (Nurse #1, 2, 3, 5, 6 and 7) nurses on 4 of 4 (Halls 100, 200, 300 and 400) resident hallways and on 3 of 3 (Days, Evenings and Nights) shifts nurses administered medications without a medication error rate less than 5 percent (%). A total of 9 errors were observed out of 43 opportunities for error, resulting in a medication error rate of 20.93%. Failure of 5 of 8 (Nurses #1, 3, 5, 6 and 7) to calculate sliding scale insulin doses correctly, or timely administration of fast acting insulin before meals for 6 of 9 (Residents #5, 8, 14, 15, 21 and 25) residents observed receiving sliding scale insulin during the medication administration pass on 4 of 4 (Halls 100, 200, 300 and 400) resident hallways and 3 of 3 (Days, Evenings and Nights) shifts resulted in Immediate Jeopardy in insulin administration. These residents were receiving insulin administration by subcutaneous injection by insulin syringe.

50

.Based on review the Pharmacy Consultant Services Agreement, review of drug regimen reviews, medical record review, observations and interviews, it was determined the facility failed to ensure that residents were free of medication errors including significant medication errors. Re-certification orders for the "calculation based scales" (dosages) of sliding scale insulin were not accurately transcribed. The nursing staff failed to accurately calculate and administer "calculation based scales" (dosages) of sliding scale insulin in accordance with physician orders. The nursing staff also failed to consistently round up or down after the resultant dosage calculation for the insulin was obtained. Administration and Pharmacy demonstrated no knowledge of the existing inconsistencies and errors in the administration of the "calculation based scale“ dosages of sliding scale insulin and did not provide in-services for the calculation of the “calculation based scale" dosages of sliding scale insulin.

51

F 323 483.25(h) ACCIDENTS AND SUPERVISION

Based on review of facility policy, observation and medical record review, it was determined the facility failed to provide a safe environment by not ensuring a defined process for the safe use and secure storage of razors after a resident with a history of aggressive behaviors threatened to use a razor against others on two secure units. The failure of the facility to provide a defined process for safe use and secure storage of razors for cognitively impaired residents, resulted in a

Serious and Immediate Threat to the health and safety of all the residents on the secure units.

52

K-072 K-072 Fire drills Fire drills Based on observations, review of local fire department

response to fire alarms, review of resident council minute reports, staff interviews and resident interviews regarding their perception of the staff during emergency evacuation it was determined the facility staff on 1 of 3 floors of the facility (the second floor) were not familiar with procedures to exit the building incase of an emergency and/or fire as evidenced by

three staff members who did not know the code for the key pad to open the locked exit door to the outside stairwell on the second floor. The failure of the staff to know the code to open the locked exit door placed the residents on the second floor in a serious and immediate threat to their health and safety if an evacuation was needed through the locked door to the stairwell.

53

K 038Exit access is readily available at all times

At approximately 9:15 AM,

inspection of the exit doors located on the second floor revealed the doors were locked and the staff were unable to unlock the doors. Only one staff member had the keys and was not present on the floor. NFPA 101, 19. 2.2.2.4

54

Top Immediate Jeopardy Citations Top Immediate Jeopardy Citations for 4for 4thth Quarter 2007 Quarter 2007

1. Notification of Changes……… F-157

2. Social Services…………………F-250

3. Comprehensive Assessments.F-272

4. Comprehensive Care Plans…..F-280

5. Accidents………………………..F-323

55

Top Immediate Jeopardy Citations Top Immediate Jeopardy Citations for 4for 4thth Quarter 2007 Quarter 2007

6. Special Needs………………......F-328 7. Administration……………….....F-490 8. Notice of Rights and Services.F-156 9. Staff Treatment of Residents………F-22410. Quality of Care………………………..F-309

56

QUESTIONSQUESTIONS

All questions will be recorded with answers sent to all nursing homes in Tennessee.

57

Thank YouThank You

Health Care Facilities Offices

MTRO: (615) 650-7100: Nashville

ETRO: (865) 588-5656: Knoxville

WTRO: (731) 423-6454: Jackson

Central Office number: Nashville

(615) 741-7221

Documents

1 Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities Educational Training for Nursing Homes 2008