IHCA
CMS issued a memo to State Survey Agencies on Oct. 25th concerning survey activities during and following the Federal government shutdown. (Click here for the full memo.) Many of the questions and answers in the beginning of the memo deal with the funding of state activities during the shutdown. Beginning in section B several relevant sections address how IJs, CMPs, and DPNA are to be treated post-shutdown. Please note two questions and answers in particular:
• Item B3 about fixing IJs (posed on bottom of page 4 continuing on to page 5 is the one we received most frequently and submitted to CMS). The answer is the time for fixing IJs will be linked to the date the citation was issued not the date of inspection. Also IJs that were issued prior to the shutdown but a revisit was delayed will be considered abated if evidence of fixing the problem is well documented
• Item B5 about CMPs or DPNA (posed on page 5 and continuing onto page 6). If credible evidence is submitted to SSA during the shut-down or is found at revisit that problem was resolved, CMPs or DPNA will be discontinued as of that date (see detailed criteria on page 6 of the memo).
Wednesday, October 30, 2013
CMS Issues Memorandum Concerning CPR in Nursing Homes
CMS has issued S&C Memo 14-01-NH (click here for the full memorandum), “Cardiopulmonary Resuscitation (CPR) in Nursing Homes,” making the following three key points:
• Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident’s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times.
• Facility CPR Policy –Some nursing homes have implemented facility-wide no CPR policies. Facilities must not establish and implement facility-wide no CPR policies.
• Surveyor Implications - Surveyors should ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not reflect instances where CPR was not initiated by staff even though the resident requested CPR or had not formulated advance directives.
The memorandum reiterates the resident’s right to formulate an advance directive, emphasizing the requirement that skilled nursing facilities provide written information to residents about this and other rights at the time of admission. While acknowledging that research shows that CPR is generally ineffective among elderly nursing facility residents, the memo also notes that trends in the nursing facility population including more younger residents, more individuals seeking short-term rehabilitation, and increasing ethnic and cultural diversity and underscores the need for effective, individualized, well-documented and consistently implemented policies and procedures for advance directives.
In this context, CMS clarifies that nursing facilities are not permitted to implement facility-wide no-CPR policies, stating:
“Facility policy should specifically direct staff to initiate CPR when cardiac arrest occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC). Additionally, facility policy should not limit staff to only calling 911 when cardiac arrest occurs. Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest in accordance with that resident’s advance directives or in the absence of advance directives or a DNR order. CPR-certified staff must be available at all times to provide CPR when needed. Facilities must not establish and implement facility-wide no CPR policies for their residents as this does not comply with the resident’s right to formulate an advance directive under F155. The right to formulate an advance directive applies to each and every individual resident and facilities must inform residents of their option to formulate advance directives. Therefore, a facility-wide no CPR policy violates the right of residents to formulate an advance directive.”
• Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident’s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times.
• Facility CPR Policy –Some nursing homes have implemented facility-wide no CPR policies. Facilities must not establish and implement facility-wide no CPR policies.
• Surveyor Implications - Surveyors should ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not reflect instances where CPR was not initiated by staff even though the resident requested CPR or had not formulated advance directives.
The memorandum reiterates the resident’s right to formulate an advance directive, emphasizing the requirement that skilled nursing facilities provide written information to residents about this and other rights at the time of admission. While acknowledging that research shows that CPR is generally ineffective among elderly nursing facility residents, the memo also notes that trends in the nursing facility population including more younger residents, more individuals seeking short-term rehabilitation, and increasing ethnic and cultural diversity and underscores the need for effective, individualized, well-documented and consistently implemented policies and procedures for advance directives.
In this context, CMS clarifies that nursing facilities are not permitted to implement facility-wide no-CPR policies, stating:
“Facility policy should specifically direct staff to initiate CPR when cardiac arrest occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC). Additionally, facility policy should not limit staff to only calling 911 when cardiac arrest occurs. Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest in accordance with that resident’s advance directives or in the absence of advance directives or a DNR order. CPR-certified staff must be available at all times to provide CPR when needed. Facilities must not establish and implement facility-wide no CPR policies for their residents as this does not comply with the resident’s right to formulate an advance directive under F155. The right to formulate an advance directive applies to each and every individual resident and facilities must inform residents of their option to formulate advance directives. Therefore, a facility-wide no CPR policy violates the right of residents to formulate an advance directive.”
Residential Care Facility – September Deficiency and Offense Citation Update
There were 32 deficiency citations and 3 offense citations issued to Residential Care Facilities in September (click here for a summary of the September deficiency and offense citations). A total of 8 citations were issued for Tag 217 concerning use of appropriately trained staff to complete resident evaluations and service plans, and review, revision and resident agreement with those evaluations and plans. All but one of the citations were due to residents, or their representatives, not signing the service plan. The ISDH interprets its regulation concerning service plans to require residents, or their representatives, to sign the service plan every time it is evaluated and whether or not changes are made to the service plan. Service plans must, at a minimum, be updated semiannually or upon a substantial change in condition. Tag 217 is now tied for 1st as the most often cited deficiency tag in 2013 (tied with Tag 273, concerning kitchen sanitation and food handling, which was cited 3 times in September; each have been cited 34 times in 2013).
September also saw 4 citations for Tag 117 concerning sufficient staffing, qualifications, and training. This tag was cited 3 times in August as well, but only 4 other times in 2013 before the last two months. This appears to be the beginning of a trend and facilities should focus some attention to ensuring compliance. In addition, Tag 241 continues to be cited with regularity for alleged failure to dispense medications with only either licensed nurses or QMAs. Lastly, the following were cited for the first time in 2013 at the deficiency level: Tag 45 (resident notification regarding interfacility transfer); Tag 86 (compliance with all applicable laws); and Tag 118 (providing ADL assistance by unlicensed personnel that are not either a CNA or HHA).
Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk. It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement. Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.
September also saw 4 citations for Tag 117 concerning sufficient staffing, qualifications, and training. This tag was cited 3 times in August as well, but only 4 other times in 2013 before the last two months. This appears to be the beginning of a trend and facilities should focus some attention to ensuring compliance. In addition, Tag 241 continues to be cited with regularity for alleged failure to dispense medications with only either licensed nurses or QMAs. Lastly, the following were cited for the first time in 2013 at the deficiency level: Tag 45 (resident notification regarding interfacility transfer); Tag 86 (compliance with all applicable laws); and Tag 118 (providing ADL assistance by unlicensed personnel that are not either a CNA or HHA).
Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk. It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement. Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.
IJ/SSQC Update – August and September 2013
Due to delays in obtaining IJ/SSQC data from August, no update was provided last month. However, data has been obtained for August and September and can now report to catch up on the year to date. Through July of 2013, there had been 7 events leading to IJ tags, and 8 events leading to SSQC tags. August and September, combined, saw 5 events leading to IJ tags and 6 events leading to SSQC tags. There were a couple of IJ/SSQC citations issued that had not risen to that level in more than 3 years (F311, F333, F520). Click here for the August and September surveys, as well as the year to date summary.
• August Summary
In August a facility was cited for alleged failure to timely report allegations of abuse to the administrator and to timely investigate said allegations. The first issue appeared to stem from alleged rough care/physical abuse that was verbally reported to her by an Activity Aide, but that SSD did not report it to either the DON or Administrator and admitted that she had forgotten to do so. The SSD was approached about the alleged verbal abuse when the QA Consultant approached her about it after having received an allegation of abuse report. A second issue for this facility related to an incomplete and inconsistently documented abuse allegation investigation. Both F225 and F226 were cited.
Also in August, F309 was cited for a facility’s alleged failure to ensure availability of CPR certified staff on each shift for residents with full code status, and for residents that wish to have full resuscitation in the event of cardiopulmonary arrest. Based on the survey document, the facility has residents that were documented as full code for all hours of the day, however the facility also documented that did not have CPR certified staff 24 hours per day. The DON herself had let her CPR certification lapse and only 4 of 10 licensed staff were CPR certified at that time. A separate facility was cited for a violation of F329 related to PT/INR monitoring and PICC line complications. The issue here appeared to be related to confusion on when the PT/INRs were supposed to be conducted.
The last issue in August resulted in F333 and F520 being cited at the IJ level for first time in more than 3 years. According to the survey documentation, a resident was administered his roommates medications after the resident was not identified correctly by the LPN who administered the medications (F333 was cited). A citation as also issued for the alleged failure of the QA committee to implement plans of action for a number of concerns identified by the committee, nor was there evidence of a system being in place to monitor implementation of plans to address issues identified by the QA committee (F520 was cited).
• September Summary
A facility was cited for alleged violation of F225 and F226 for issues related to timely reporting of abuse allegations and failures to perform criminal history checks on employees. The reporting of abuse citation stemmed from an incomplete abuse investigation and failure to report the incident to the ISDH. In addition, a second issue was noted concerning another incomplete abuse investigation. Regarding criminal history checks, the surveyor noted that there were seven then-current employees for whom a completed criminal history check could not be found or produced by facility staff. It appeared there was a gap as to who was assigned responsibility for performing criminal history checks due to the absence of a business office managed that used to perform them, but was no longer employed. This facility was also cited F311 for alleged failure to ensure a resident received restorative services to prevent loss of ability to ambulate. It appeared that the facility’s therapy company had discontinued services at the facility due to a dispute with the facility, and adequate therapy staffing had not been found to provide services thereafter.
Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk. It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement. Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.
• August Summary
In August a facility was cited for alleged failure to timely report allegations of abuse to the administrator and to timely investigate said allegations. The first issue appeared to stem from alleged rough care/physical abuse that was verbally reported to her by an Activity Aide, but that SSD did not report it to either the DON or Administrator and admitted that she had forgotten to do so. The SSD was approached about the alleged verbal abuse when the QA Consultant approached her about it after having received an allegation of abuse report. A second issue for this facility related to an incomplete and inconsistently documented abuse allegation investigation. Both F225 and F226 were cited.
Also in August, F309 was cited for a facility’s alleged failure to ensure availability of CPR certified staff on each shift for residents with full code status, and for residents that wish to have full resuscitation in the event of cardiopulmonary arrest. Based on the survey document, the facility has residents that were documented as full code for all hours of the day, however the facility also documented that did not have CPR certified staff 24 hours per day. The DON herself had let her CPR certification lapse and only 4 of 10 licensed staff were CPR certified at that time. A separate facility was cited for a violation of F329 related to PT/INR monitoring and PICC line complications. The issue here appeared to be related to confusion on when the PT/INRs were supposed to be conducted.
The last issue in August resulted in F333 and F520 being cited at the IJ level for first time in more than 3 years. According to the survey documentation, a resident was administered his roommates medications after the resident was not identified correctly by the LPN who administered the medications (F333 was cited). A citation as also issued for the alleged failure of the QA committee to implement plans of action for a number of concerns identified by the committee, nor was there evidence of a system being in place to monitor implementation of plans to address issues identified by the QA committee (F520 was cited).
• September Summary
A facility was cited for alleged violation of F225 and F226 for issues related to timely reporting of abuse allegations and failures to perform criminal history checks on employees. The reporting of abuse citation stemmed from an incomplete abuse investigation and failure to report the incident to the ISDH. In addition, a second issue was noted concerning another incomplete abuse investigation. Regarding criminal history checks, the surveyor noted that there were seven then-current employees for whom a completed criminal history check could not be found or produced by facility staff. It appeared there was a gap as to who was assigned responsibility for performing criminal history checks due to the absence of a business office managed that used to perform them, but was no longer employed. This facility was also cited F311 for alleged failure to ensure a resident received restorative services to prevent loss of ability to ambulate. It appeared that the facility’s therapy company had discontinued services at the facility due to a dispute with the facility, and adequate therapy staffing had not been found to provide services thereafter.
Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk. It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement. Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.
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