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Trends in Long-Term Care Deficiencies Howard Roitman Division Director Health Facilities & Emergency Medical Services Division Colorado Department of Public Health and Environment Colorado Medical Directors’ Association Annual Conference April 29, 2011. - PowerPoint PPT Presentation
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• Top 5 deficiencies, FFY 2007-2010
• Recent citations under top 5• Colorado survey trends• National, regional survey
trends• Trends in IDRs• Trends in IJs and SQCs
• QIS Process
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FFY 2007FFY 2008
Tag Regulation323 Accidents, Supervis309 Quality of Care371 Kitchen Sanitation279 Care Plans329 Unnecessary Drugs
FFY 2009
Tag Regulation 323 Accidents, Supervis309 Quality of Care279 Care Plans371 Kitchen Sanitation281 Standards of Practice
Tag Regulation 323 Accidents, Supervis281 Standards of Practice371 Kitchen Sanitation309 Quality of Care279 Care Plans
FFY 2010
Source: Aspen ReportsFederal Recertification Data
Tag Regulation 323 Accidents, Supervis281 Standards of Practice309 Quality of Care279 Care Plans 371 Kitchen Sanitation
•Falls• Unsafe smoking•Resident-to-resident abuse in cognitively impaired
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Recent Citations Under F323Accidents, Supervision
Source: Aspen Reports
•Medication administration errors•Nursing practice with medication pass•Lack of signing off on MARs•Not verifying orders•Not transcribing orders•Poor practice with medication pass
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Recent Citations Under F281Professional Standards
Source: Aspen Reports
•Pain•Blood sugar•Failure to implement care plans generally•Diabetic care with insulin administration•Lack of ulcer care/treatments
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Recent Citations Under F309 Quality of Care
Source: Aspen Reports
•No individualistic care plans•Not including all problem areas/interventions•Not comprehensive
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Recent Citations Under F279 Comprehensive Care Plans
Source: Aspen Reports
•Hand hygiene!•Food temperatures•Kitchen sanitation•Improper handling of food delivery•Sanitation in the dining room during service•Sanitation assisting residents
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Recent Citations Under F371 Kitchen Sanitation
Source: Aspen Reports
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Federal Recertification Data
Source: Aspen Reports
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Federal Recertification Data
Source: Aspen Reports
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Federal Recertification Data
Source: Casper Reports
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Federal Recertification Data
Source: Casper Reports
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Source: Aspen Reports
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Source: Aspen Reports
Year# Complaint
Surveys# Deficiency Free Surveys
Average # Citations
FFY 2004 325 216 1.9FFY 2005 326 193 0.9FFY 2006 307 173 1FFY 2007 256 89 2FFY 2008 253 100 1.6FFY 2009 234 106 1.6FFY 2010 241 93 2.1
•Smoking with oxygen (2) F323 K•Hot beverage temperatures not within safe parameters (2) F323 K•Gaps between mattress and rails/bars (3) K•Hypoglycemic episodes (1) J
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Source: Aspen Reports
•Smoking with oxygen (1) F 323•Hypoglycemia episodes (1)F309 •Resident-to-resident abuse (1) F323
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Source: Aspen Reports
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Source: Aspen Reports
886 Tags Overall
•26 QIS surveys completed•6.8 average number of days on site•17.4 average number of citations per survey•3.8% of QIS surveys result in IJ citation•3.6 % of QIS deficiencies are cited at G or above
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QIS Data for 1st Half FFY 2011
Source: Aspen Reports
•Difficulty meeting workload•Longer to complete surveys•Increased surveyor turnover•Negative ergonomic implications•Longer training period•Dependence on technology
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Impact of QIS Project for 1st Half FFY 2011
Source: Aspen Reports
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