Survey Paranoia

Some time ago I bought a bunch of nursing home books on ebay and came into possession of a mini-manual from one of the state nursing home associations (which will remain anonymous) on how to effectively manage surveys. Some of it was quite good, such as making sure that staff did not acknowledge guilt. This would be evidenced by a surveyor's statement on the 2567 (Statement of Deficiencies) that stated "The DON admitted that the CNA should have never done that", for instance. Some of it was bad, such as the suggested method for doing mock surveys that I will not go into here. And some of was disturbing. One particular chapter of this manual was devoted to keeping tabs on the surveyors. It actually stated that "an unobtrusive surveillance system to keep tabs on the surveyors...is essential". If that is not possible, the manual states, a staff member should be placed outside the door with walkie-talkie access to the administrator. Now before I go any further, I want to make it clear that this manual was about 15 years old, and would probably no longer be applicable because the state this came from currently utilizes a different type of survey protocol. But is goes to perfectly illustrate the industry's ridiculously paranoid attitude toward regulatory compliance. Interestingly enough, a expose that came out in 1997 ("Patients, Pain, and Politics") described similar behavior going back to the 1960's, when nursing home regulation was nothing compared to what it is today. Even when I worked the floor just a few years back this same attitude was the rigor de norm. Everyone sneaked around, talked in hushed tones, and tried to predict which resident would be interviewed next. As a consultant, I still see this behavior.

Nursing home surveys are nothing to be paranoid about, unless you're trying to hide your substantial noncompliance. Survey protocol is clearly spelled out in the State Operations Manual. It should be no mystery who gets interviewed, because the manual tells you. "But the surveyor's don't do things by the book!", I can hear someone cry. If they don't, then appeal it. That's what IDR and the appeals process is for. The reason that deficiencies happen is primarily because nobody knows the rules of the game called survey. As I cannot emphasize enough, TEACH YOUR STAFF THE STATE OPERATIONS MANUAL!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Of course this is a problem if you don't know it yourself. When a week long DON orientation attempts to cover everything about survey in 45 minutes, and the required text for virtually every AIT program in the country doesn't even mention the word 'survey', it's not entirely your fault. But if you haven't been taught it, you need to learn it for yourself. As anyone who has ever tried to read the watermelon book cover to cover can tell you (myself included), it's one hell of a boring book. Perhaps you could try this instead: Get the forms used in the quality indicator survey and do mock surveys through QAA committee with them. You will learn the rules as you go along because the contain the relevant F tags and the critical elements necessary for demonstrating compliance with them.

You can be paranoid about state if you want, but it's a waste of time and energy you probably don't have. If your facility is not survey ready when they walk in the door, there is only so much you can do to fix things while the surveyors aren't looking. Doing well on survey takes staff education and frequent mini mock surveys conducted over the course of the entire year. Waiting until you're already inside the window is uselsss.

RCA Tutorial

There is a great tutorial on how to do a root cause analysis here. It is from the National Center for Patient Safety at the VA, which has a lot of other wonderful resources too, such as fall prevention tools.

Free Abuse Prevention Training Resources

Get it here.

F281: Professional Standards of Quality Care

Requirement:

Services provided or arranged by the facility must meet professional standards of quality.

Intent:

All services performed in the facility must conform to generally accepted standards of clinical practice. These standards may come from textbooks, current journals, position statements by such organizations as ADA, AMDA, ANA, etc., or clinical practice guidelines published by AHCPR.

Common Reasons for Citing F281:

Improper disposal of controlled substances

Failure to secure controlled substances

Leaving medications at bedside

Failure to assess for dehydration issues

Failure to carry out physician orders

Failing to add new interventions after a fall

No care plans or lack of care plan review for resident care issues

Not monitoring or assessing dialysis access site

Failing to date multidose vials when first opened

Pre-pouring of medications

Improper documentation of medication administration

Preparation:

Frequent education is necessary to make sure that nursing staff understand the standards to which they should be practicing under. Explanation of rationales is vital in this aspect. Working alongside nurses during medication passes is a useful technique for ensuring compliance with this tag and has the potential to improve staff morale if carried out in an appropriate manner. Having generic care plans available for frequently missed areas of care is another useful idea. Frequently missed areas include safe smoking, constipation, weight loss, hydration, fluid restriction, accident prevention and falls, skin breakdown, and hemodialysis.

Free self study modules for CNAs

There is a collection of 16 self study modules here, designed for direct caregivers such as CNAs. Some of the topics include managing challenging behaviors 1 & 2, aspiration, dehydration, infection control, fall prevention, and documentation. It looks very promising and would make a great addition to any facility's staff development program, especially if you rely on self-study to help the aides meet their 12 hour continuing education requirement.

Training your CNAs

In the vast majority of nursing homes, CNAs are taught from the immensely popular How To Be a Nurse Assistant. Published by the American Healthcare Association, it is one of their best sellers (right after their reprint of the CMS State Operations Manual). Irregardless of how good the book is, nurse aides quickly find it to be useless in the real world. Despite all of the skills taught in the book, it doesn’t adequately cover the three things that the average CNA spends 90% of their time doing: skin care (turning, positioning, changing, bathing), providing assistance with eating, and dealing with psychosocial issues.

It is no secret that training programs for nurse aides are not only irrelevant to what really goes on, but are also of an inadequately short length. Whatever notion you may have to the contrary, the CNA is not an unskilled worker. Although some of the physical tasks probably would be considered menial, that is not the point here. As Lori Porter pointed out in her autobiographical Everything I Learned in Life...I Learned in Long Term Care, a nurse aide has the power to either promote a resident’s physical, mental, and psychosocial well-being, or completely destroy it and take that individual’s last shred of dignity away from them.

Either we forget (or simply have never realized) the enormous power we have entrusted to these folks – power that oftentimes goes unchecked. If we are to fulfill our legal obligations as nurses and/or administrators to maintain the health and welfare of our residents, it is simply incomprehensible to think that we would delegate this enormous task to unskilled workers. Thus we must transform the workforce, which can be achieved in one of two ways.

The first way is to change the way that CNA classes are conducted. Consider lengthening the course from two weeks to three weeks. The current practice is to have the students spend a week in class, then a week on the floor. What I suggest is that you combine class time with floor time. After three days or so in the classroom dealing with non-clinical topics, slowly introduce the students to the residents. Let them know what is going on with them from a medical and from a psychosocial standpoint so that they can truly see in action the conditions they are learning about. Have the students spend time on the floor during its busiest times, and then during the lulls have them to return to the classroom to talk about clinical issues. Don’t be limited by the textbook – allow the student’s minds to go above and beyond the norm. It seems that every nursing home wants well trained staff but they don’t want to put forth any effort to achieve that dream.

Although some corporate owners and administrators may balk at this approach, citing increased costs, it is actually a worthwhile investment. It is common knowledge that the vast majority of CNAs quit soon after being hired so it is prudent to keep a proverbial safety net under them for an extended period of time. With this paradigm in place, the students will have a supporting framework when things get rough. During the latter part of the second week or the early part of third would be an excellent time to begin peer mentoring.

Happy Nursing Home Week!!

I would like to just take a moment to wish everyone a happy national nursing home week. Thank you for all that you do. As nursing home providers, you take care of those who can't take care of themselves, despite being ridiculously overworked, underpaid, and sorely underappreciated. Thank you.

Acuity Based Staffing

Sometimes staffing is based on resident acuity levels. This is usually calculated by averaging the RUG scores. However, this causes a big problem: Higher acuity levels don't necessarily mean that more CNA care is required, just more skilled nursing and/or rehab. CNA staffing should be based on average ADL scores. Doing so will eliminate complaints that you are being unfair about making assignments (ie, "on the ICF wing we've got 12 patients each that are all total care and Susie on skilled only has 8 patients that don't need a mother flipping thing").

F309: Quality of Care

Requirement:

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care.

Intent:

It is the nursing home’s responsibility to make sure that residents either get better or stay the same (within the resident’s right to refuse treatment), within the limits of the resident’s medical condition and/or the normal effects of aging.

Common Reasons for Citing F309:

The most common reason this tag is cited is for failure to reposition. For example, a resident is observed sitting in the same position for 3 hours, even though they are care planned to be repositioned every 2 hours. Another common reason for this tag is missing lab work. Other reasons that have been used to justify this citation include failing to properly manage pain, noting that residents are not wearing TED hose that has been care planned, failure to protect fragile skin, and lack of foot pedals when their use is obviously necessary. F309 is a sort of catchall citation and is frequently cross referenced to other tags.

Preparation:

Because of the vague nature of F309, it is often difficult to adequately plan for this. Missing lab work can be oftentimes be prevented by requiring nurses to maintain a log of lab work or having all labs being coordinated through just one individual, usually a RN supervisor or administrative nurse. Issues with repositioning can be handled by educating and monitoring staff on its importance. Some facilities have attempted to tackle persistent repositioning problems by keeping underpads in three different colors and requiring direct care staff to change the existing pad to one of another color every two hours. The resident will be repositioned in the process of the pad change, and it becomes rather easy to monitor staff compliance by just checking to see what color the pad is. The other issues can be addressed by frequently walking around and observing how residents are cared for.