Fall Region Forums - 2014

1. Home Care Survey Findings (Class A, Class F, and Predicting Comprehensive) Fall Region Forums - 2014 Doug Beardsley VP Member Services Care Providers of Minnesota

2. New MDH Comprehensive Surveys • Zero have been completed yet • BUT – The Class A and Class F surveys have very clear and consistent survey findings - • These survey findings easily align with Comprehensive Statutes expectations.

3. What is being cited during home care surveys?

5. Current home care survey deficiencies issued in 50% or moreof surveys (7-16-13 thru 7/15/14) Class A: Bill of Rights – the right to receive care and services subject to accepted medical or nursing standards Class F:The EXACT SAME requirement Comprehensive:The EXACT SAME requirement They are the EXACT SAME: Nothing Changes!

6. Bill of Rights – the right to receive care and services subject to accepted health, medical, or nursing standards This deficiency is issued when surveyor observations indicate that the service that is being provided by the home care provider is not aligned with commonly accepted medical or nursing standards for the service. It also usually indicates that there is not a different, more specific rule or statute regarding the unacceptable service being provided available to be issued by the surveyor or investigator.

7. Bill of Rights – the right to receive care and services subject to accepted health, medical, or nursing standards Examples of what supports this deficiency: • Client refusal to receive ordered treatments was not properly documented in the record. • Physician was not notified for dressing changes regarding wound care. • Size of wound not measured and not documented in clients clinical record. • No policies regarding tracheotomy care when such services were being performed. • Proper hand washing procedures by employees were not followed. Employee did not change gloves as they left and entered clients’ apartments multiple times. Cross contamination imminent. • There was not an assessment or risk/benefit completed for use of siderails.

8. Bill of Rights – the right to receive care and services subject to accepted health, medical, or nursing standards Examples of what supports this deficiency: • Unsafe siderails used. • No documentation for injection sites of insulin and Lantus. • No falls assessments for clients who experienced falls • Changes in condition occurred without further evaluation by a RN • Pain not assessed • Causes of bruising not assessed • Infection control issues: handwashing, gloving, multiple glucometer use, improper disposal of sharps, etc. • Improper administration of medications: eye drops, inhalers, timing of meds with meals, no indications for use of antipsychotic medications, improper documentation, etc. • Thickened liquids not given as ordered

9. Current home care survey deficiencies issued in 30%-40% of surveys (7-16-13 thru 7/15/14) Class A: Individualized Client Abuse Prevention Plans Class F:The EXACT SAME requirement Comprehensive:The EXACT SAME requirement They are the EXACT SAME: Nothing Changes!

10. Individualized Abuse Prevention Plans - Each home health care agency shall develop an individual abuse prevention plan for each vulnerable adult receiving services from them. The plan shall contain an individualized assessment of: • the person's susceptibility to abuse by other individuals, including other vulnerable adults; • the person's risk of abusing other vulnerable adults; and • statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults. For the purposes of this paragraph, the term "abuse" includes self- abuse.

11. Individualized Abuse Prevention Plans - Examples of what supports this deficiency: • These plans are not part of our normal procedures • No policies or procedures for abuse prevention plans • Unable to locate any plans • Not completed for any client on caseload. • Abuse prevention plans had been completed at admission, but not updated when new identified vulnerabilities surfaced. • Risks were identified, but no specific measure to minimize abuse were developed. • Nursing assessment regarding risk of abuse was not completed. • The interventions/actions to minimize abuse were not individualized per client. • RN assessment for abuse assessment did not include title, dates, or signature of staff member filling out form. • Client who consistently refuses treatments had not been assessed for the potential for self-abuse with planned interventions.

12. Individualized Abuse Prevention Plans -Issues that tend to trigger the need for an updated abuse prevention plan: • Dialysis • Dementia, Confusion, Cognitive Deficits • Traumatic Brain Injury • Parkinson’s • Socially inappropriate behaviors (sexual) • Hallucinations, Delirium • Elopements • Wandering into other tenants apartments • Aggressive behavior (verbal, physical, threatening, combative) • Inability to summon for assistance • Inability to follow directions • Inability to communicate needs • Behavior symptoms • Sensory limitations • Chronic Pain • Suicidal threats • Frequent falls • Frequent bruising • Lacking ability to adhere to safety precautions consistently • Unsafe smoking

13. Current home care survey deficiencies issued in 30% - 40%of surveys (7-16-13 thru 7/15/14) Class A: Required contents of Service Agreement Class F:Required contents of Service Plan Comprehensive:Required contents of Service Plan They are the ALMOST THE SAME

14. The serviceagreementmustinclude: • Adescriptionofthe servicestobe provided,andtheir frequency; • Identification ofthepersonsorcategories of persons whoaretoprovide the services; • The schedule or frequencyofsessionsof supervisionor monitoringrequired, ifany; • Feesfor services; and • A planforcontingency actionthat includes: • Theactiontobetakenbythelicensee,client, andresponsiblepersons,ifscheduledservicescannotbe provided; • Themethodfora client or responsiblepersontocontact a representative ofthelicenseewheneverstaffare providingservices; • Whotocontactincaseofanemergencyor significant adversechangeintheclient'scondition; • Themethodforthelicenseetocontact aresponsibleperson oftheclient,ifany;and • Circumstancesinwhich emergency medical services are not tobe summoned, • consistentwiththe Adult HealthCareDecisions Act, MinnesotaStatutes, chapter 145B,anddeclarationsmadebytheclientunderthat act. Required Contents of Service Agreement: Class A

15. The service planmust include: • A description of the assisted living home care service or services to be provided and the frequency of each service, according to the individualized evaluation required; • The identification of the persons or categories of persons who are to provide the services; • The schedule or frequency of sessions of supervision or monitoring required by law, rule, or the client's condition for the services or the persons providing those services, if any; • The fees for each service; and • A plan for contingency action that includes: • The action to be taken by the class F home care provider licensee, client, and responsible person if scheduled services cannot be provided; • The method for a client or responsible person to contact a representative of the class F home care provider licensee whenever staff are providing services; • The name and telephone number of the person to contact in case of an emergency or significant adverse change in the client's condition; • The method for the class F home care provider licensee to contact a responsible person of the client, if any; and • The circumstances in which emergency medical services are not to be summoned, consistent with Minnesota Statutes, chapters 145B and 145C, and declarations made by the client under those chapters. Required Contents of Service Plan: Class F

16. The service planmust include: • a description of the home care services to be provided, the fees for services, and the frequency of each service, according to the client's current review or assessment and client preferences; • the identification of the staff or categories of staff who will provide the services; • the schedule and methods of monitoring reviews or assessments of the client; • the frequency of sessions of supervision of staff and type of personnel who will supervise staff; and • a contingency plan that includes: Required Contents of Service Plan: Comprehensive • the action to be taken by the home care provider and by the client or client's representative if the scheduled service cannot be provided; • information and a method for a client or client's representative to contact the home care provider • names and contact information of persons the client wishes to have notified in an emergency or if there is a significant adverse change in the client's condition, including identification of and information as to who has authority to sign for the client in an emergency; and • The circumstances in which emergency medical services are not to be summoned consistent with communicated advance health directives, living wills, POLST forms, etc.

17. The service planmust be written and signed by the home care provider and client or client’s representative. • The service plan must be in place within 14 days after initiation of home care services • The service plan must be revised based on client assessments • The service plan must provide information to the client about changes to the provider's fee for services • The service plan must provide information about how to contact the Office of the Ombudsman for Long-Term Care. • Staff providing home care services must be informed of the service plan • The service plan must be part of the client record • The home care provider must implement and provide all services required by the service plan • Notice of any change in fees must be a part of the service plan Required Contents of Service Plan: Comprehensive

18. Examples of what supports this deficiency: • Lackeddocumentationofthescheduleorfrequencyofsupervisionormonitoring • Lackedacontingencyplanintheeventwhenservicescouldnotbeprovided • Lackedadescriptionofservicesbeingprovided • Lackedthefrequencyofservicesbeingprovided • Lackedidentificationofwhowouldbeprovidingservices • Lackedfees • Lacked licenseecontactnameandnumber(partofcontingencyplan) Service Plans and Service Agreements -

19. Examples of what supports this deficiency: • Lacked anameandphonenumberofapersontocontactincaseofanemergencysituationorclientchangeincondition(partofcontingencyplan) • Did not identify thecircumstanceswhenemergencymedicalservicesarenottobesummoned(partofcontingencyplan) • Nodescriptionsofwhatwasincludedina“bundled”service • BilledservicesdidnotmatchfeesinServiceAgreement • ServicePlansnotsigned • ServicesincludedintheAgreementdidnotmatchservicesbeingprovidedtoclientsduringthesurveyperiod(alarms,medicationstorage,treatments,oxygen,CPAP,nebulizers,toileting,bloodglucoseetc.) Service Plans and Service Agreements -

20. Current home care survey deficiencies issued in 30% - 40% of surveys (7-16-13 thru 7/15/14) Class A: Required contents of the Client Record Class F:Required contents of the Client Record Comprehensive:Required contents of Client Record They are the ALMOST THE SAME

21. Class A, Class F, and Comprehensive: Required Contents of Client Record Class A and Class F required contents of the Client Record are worded differently. However, they are almost identical in expectations, just worded differently. Comprehensive home care blended the two and created 15 required elements of the client record -

22. Contents of a client record include the following for each client: Required Contents of Client Record: Comprehensive • identifying information, including the client's name, date of birth, address, and telephone number; • the name, address, and telephone number of an emergency contact, family members, client's representative, if any, or others as identified; • names, addresses, and telephone numbers of the client's health and medical service providers and other home care providers, if known; • health information, including medical history, allergies, and when the provider is managing medications, treatments or therapies that require documentation, and other relevant health records;

23. Contents of a client record include the following for each client: Required Contents of Client Record: Comprehensive • client's advance directives, if any; • the home care provider's current and previous assessments and service plans; • all records of communications pertinent to the client's home care services; • documentation of significant changes in the client's status and actions taken in response to the needs of the client including reporting to the appropriate supervisor or health care professional; • documentation of incidents involving the client and actions taken in response to the needs of the client including reporting to the appropriate supervisor or health care professional;

24. Contents of a client record include the following for each client: Required Contents of Client Record: Comprehensive • documentation that services have been provided as identified in the service plan; • documentation that the client has received and reviewed the home care bill of rights; • documentation that the client has been provided the statement of disclosure on limitations of services; • documentation of complaints received and resolution; • discharge summary, including service termination notice and related documentation, when applicable; and • other documentation required under this chapter and relevant to the client's services or status.

25. Examples of what supports this deficiency: • It took more than two weeks to enter first entry into client’s clinical record. • The client’s clinical record did not show physician orders for treatments • The client’s record did not record if licensed or unlicensed personnel provided services. Content of Client Record Deficiencies

26. Examples of what supports this deficiency: • The client’s record did not record the reason for the termination of treatment • The record did not show whether client’s condition improved where they did not need services or declined where client needed different services • Significant events or changes in condition not documented in the client record – NOTE: communication books and logs issue • Condition of client did not match what was described in client record Content of Client Record Deficiencies

27. Examples of what supports this deficiency: • Visits to doctor, ER, hospital not documented • The condition of client was not included in the discharge summary • No reason provided when client terminated services and switched provider • No discharge summary was included in client clinical history Content of Client Record Deficiencies

28. Current home care survey deficiencies issued in 30% - 40% of surveys (7-16-13 thru 7/15/14) Class A: Tuberculosis (infection control) Class F:The EXACT SAME requirement Comprehensive:The EXACT SAME requirement They are the EXACT SAME: Nothing Changes!

29. TB: Class A, Class F, and Comprehensive A home care provider must establish and maintain a TB prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). Components of a TB prevention and control program include: • Screening all staff providing home care services, both paid and unpaid, at the time of hire for active TB disease and latent TB infection. • Developing and implementing a written TB infection control plan.

30. TB DeficienciesExamples of what supports this deficiency: • Community risk assessment was not completed by the facility/organization(see CDC form and MDH instructions) • No staff person was identified as being responsible for infection control or TB • There were no specific written policies and procedures regarding prevention and control of tuberculosis – all staff interviewed stated they were unaware of the need for a TB program • Personnel files (or staff medical files) lacked evidence of two-step TB skin test at time of employment • Home care staff were unable to locate personnel files and therefore was unable to provide documentation that TB screen and testing had been completed

31. TB DeficienciesRequiredcomponentsweremissing: • The employee file indicated that the employee had direct contact with clients before acquiring the first-step results of TB skin test • No infection control plan had been developed by the home care provider • TB skin test was not measured in mm as required in CDC guidelines • Only the first step of the two-step mantoux was completed or documented (note – shortage of tuberculin serum in some parts of the state)

32. Current home care survey deficiencies issued in 30% - 40% of surveys (7-16-13 thru 7/15/14) Class A: Two or More Quality Assurance Initiatives per year Class F:No such requirement Comprehensive:One or more Quality Management Initiatives per year They are the ALMOST THE SAME

33. Quality Assurance: Class A The Class A home care provider shall establish and implement a quality assurance plan, described in writing, in which the provider must: • Monitor and evaluate two or more selected components of its services at least once every 12 months; and • Document the collection of data • Document the analysis of data • Document actions taken (if any) as a result of the initiatives

34. Quality Management: Comprehensive • The Comprehensive home care provider shall engage in quality management appropriate to the size of the home care provider and relevant to the type of services the home care provider provides. • The quality management activity means evaluating the quality of care by periodically reviewing client services, complaints made, and other issues that have occurred and determining whether changes in services, staffing, or other procedures need to be made in order to ensure safe and competent services to clients. • Documentation about quality management activity must be available for two years. • Information about quality management must be available to surveyors or investigators at the time of the survey, investigation, or license renewal.

35. Quality AssuranceExamples of what supports this Class A deficiency: Based on interview and record review, the licensee failed to establish and implement a quality assurance plan, in writing, that identified required elements. The findings include: • During the entrance conference, employee X verified the licensee had not implemented a quality assurance plan. • During the entrance conference, employee Y verified the licensee had not established a quality assurance plan. • A review of the licensee’s administrative manual revealed a lack of evidence of a quality assurance plan. • Program had a complying policy and procedure in place, but it had not been followed. • When queried regarding a quality assurance plan, employee X stated: • I just work on communications randomly • Client’s call and say “thank-you”

36. Current home care survey deficiencies issued in 20% - 30% of surveys (7-16-13 thru 7/15/14) Class A: Supervision of Home Health Aides Class F:Supervision of Unlicensed Personnel Comprehensive:Supervision of Unlicensed Personnel They are the ALMOST THE SAME

37. Supervision of Home Health Aides: Class A Supervision or monitoring of Home Health Aides must be provided no less often than the following schedule: • Within 14 days after initiation of home health aide tasks; and • Every 14 days thereafter, or more frequently if indicated by a clinical assessment, for home health aide tasks such as medication management or delegated nursing tasks. • Every 60 days thereafter, or more frequently if indicated by a clinical assessment.

38. Supervision of Unlicensed Personnel: Class F Supervision or monitoring must be provided no less often than the following schedule: 1. Within 14 days after initiation of assisted living home care services that require supervision by a registered nurse; and 2. At least every 62 days thereafter, or more frequently if indicated by a nursing assessment and the client's individualized service plan.

39. Supervision of Unlicensed Personnel: Comprehensive • Staff who perform delegated nursing or therapy home care tasks must be supervised by an appropriate licensed health professional or a registered nurse periodically where the services are being provided to verify that the work is being performed competently and to identify problems and solutions related to the staff person's ability to perform the tasks. • Supervision of staff performing medication or treatment administration shall be provided by a registered nurse or appropriate licensed health professional and must include observation of the staff administering the medication or treatment and the interaction with the client. • The direct supervision of staff performing delegated tasks must be provided within 30 days after the individual begins working for the home care provider and thereafter as needed based on performance.

40. Staff Supervision Examples of what supports this deficiency: • Supervisory visits not done or not documented. • Plan of Care stated the RN needed to provide supervisory visits every 14 days for client. These visits were not completed or not documented. • Plan of Care state the RN needed to provide supervisory visits at least every 62 days for client. These visits were not completed or not documented. • Medication administration in Class A requires RN supervision of every 14 days. However, chart reflected RN supervisory visits occurred only every 60 days.

41. Staff Supervision Examples of what supports this deficiency: • RN did not complete initial 14 days assessment and supervision, or completed it outside of the 14 day time period. • All correction orders were issued because of failure to follow the timelines for staff supervision visits. (Many seemed to either make up their own schedules or disregard the regulations all together.) • The licensee did not have a policy or procedure pertaining to the frequency of required supervisory visits.

42. Current home care survey deficiencies issued in 20% - 30% of surveys (7-16-13 thru 7/15/14) Class A: Competency Testing of Home Health Aides for Delegated Nursing Tasks Class F:Competency Testing of Unlicensed Personnel for Delegated Nursing Tasks Comprehensive:Competency Testing of Unlicensed Personnel for Delegated Nursing Tasks They are the ALMOST THE SAME

43. Competency Testing: Comprehensive • A registered nurse or licensed health professional may delegate tasks only to staff who are competent and possess the knowledge and skills consistent with the complexity of the tasks and according to the appropriate Minnesota practice act. • Training and competency evaluations of unlicensed personnel providing comprehensive home care services must be conducted by a registered nurse, or another instructor may provide training in conjunction with the registered nurse.

44. Competency Testing: Comprehensive • When the registered nurse or licensed health professional delegates tasks, they must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each client and are able to demonstrate the ability to competently follow the procedures and perform the tasks. • If an unlicensed personnel has not regularly performed the delegated home care task for a period of 24 consecutive months the unlicensed personnel must demonstrate competency in the task to the registered nurse or appropriate licensed health professional.

45. Competency Testing: Comprehensive • The registered nurse or licensed health professional must document instructions for the delegated tasks in the client's record.

46. ULP Competency TestingExamples of what supports this deficiency: Competency testing was not conducted, or not properly documented, with unlicensed personnel by a registered nurse before the following procedures were completed: • Refilling portable oxygentanks • Conducing blood pressure checks • Performingcathetercare • Using chair alarms • Conductingneurological assessments • Nasal cannula fit and distribution of oxygen • Conductingblood glucose testing. • Administration of Insulin via Insulin pens or pre-dosed syringe • Preparingthickened liquids • Usingmechanical lifts • Assisting with CPAPs

47. ULP Competency TestingExamples of what supports this deficiency: • Instructions specified how to administer insulin with syringes and a vial but did not specify how to administer insulin with insulin pen (pen was being used). • Specific instructions regarding the procedure to fill portable oxygen were not completed. • Specific instructions for staff to check oxygen tanks every two hours were not included. • Instructions provided on insulin administration were not specific to individual client.

48. Current home care survey deficiencies issued in 20% - 30% of surveys (7-16-13 thru 7/15/14) Class A: Spread across multiple requirements Class F:Medication Records Comprehensive:Documentation of Administration of Medications and Medication Set-up They are the ALMOST THE SAME

49. Medication Records: Class F • The name, date, time, quantity of dosage, and the method of administration of all prescribed legend and over-the-counter medications, and the signature and title of the authorized person who provided assistance with self-administration of medication or medication administration must be recorded in the client's record following the assistance with self-administration of medication or medication administration. • If assistance with self-administration of medication or medication administration was not completed as prescribed, documentation must include the reason why it was not completed and any follow up procedures that were provided.

50. Medication Records: Comprehensive • Each medication administered by comprehensive home care provider staff must be documented in the client's record. The documentation must include the signature and title of the person who administered the medication. The documentation must include the medication name, dosage, date and time administered, and method and route of administration. • The staff must document the reason why medication administration was not completed as prescribed and document any follow-up procedures that were provided to meet the client's needs when medication was not administered as prescribed and in compliance with the client's medication management plan. • Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.