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Using Federal Regulations to Support Culture Change in ICFs/MR (DD5) 9:30 AM – 11:30 AM October 10, 2007 Joyce L. Halling, QMRP, BA, LPN, LNHA Ann E. Lee, QMRP, MSW, SMQT Get on TRAC , Inc. Sandy, Utah. The surveyors wrote us out for that last year What about infection control?

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Using Federal Regulations to Support

Culture Change in ICFs/MR (DD5)

9:30 AM – 11:30 AM

October 10, 2007

Joyce L. Halling, QMRP, BA, LPN, LNHA


Get on TRAC, Inc.

Sandy, Utah

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The surveyors wrote us out for that last year

What about infection control?

But the “W” tags say we have to do it this way

I can’t get it all done now, how do you expect me to do one more thing?

But we’ve always done it that way

We can’t make the clients do that, the rules say so

The client won’t be safe if we do that

The client’s family said “Nuh-Nuh”, “No way”, “Not in my life time”

The client has a right to refuse treatment/care

The doctor didn’t order that

Have you ever heard . . . ?

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How do you view the regulations?

Do they confine you?

Do you use them?

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Learning Objectives

  • Understand the survey process and how it can be utilized to your advantage;

  • Understand federal certification regulations and how they can be used to create an effective, compliant, culture change environment;

  • Identify the unique strengths and challenges of your program/clients and how to create the environment that will maximize client potentials;

  • Steps that will promote the creative nature and potential of your clients and staff; and,

  • How to effectively deal with surveyor “latitude and attitude!”

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Understanding the Survey –Philosophical Underpinnings

  • Support the person in their own homes and communities

  • Person-centered planning

  • Person-centered services

  • Focus on the person’s preferences, goals and aspirations

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Understanding the Survey –Philosophical Underpinnings

  • Support the person to reach aspirations

  • Outcomes relate to choice, control, relationships, and community inclusion

  • Focus on satisfaction with life, services, and supports

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Understanding the Survey – Types of Regulations

  • Structural

    Requirement must be met in the absolute sense in order to be certified (room size, HVAC)

  • Process

    Requirement must be complied with but how it is achieved is facility determined (IPP, IDT comprehensive assessment)

  • Outcome

    Requirement reflects the processes experienced by the client and may be negative or positive (active treatment)

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Understanding the Survey –ICF/MR Conditions of Participation (CoPs)

  • Governing Body and Management

  • Client Protections

  • Facility Staffing

  • Active Treatment

  • Client Behavior and Facility Practices

  • Health Care Services

  • Physical Environment

  • Dietetic Services

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Understanding the Survey – Four Types of Surveys

  • Complaint (focused)

  • Full (initial)

  • Extended

  • Fundamental

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Full Survey

  • Initial request for Medicaid certification

  • If a CoP level deficiency was found on previous annual survey

  • The facility’s Time Limited Agreement (TLA, Medicaid contract) is < 12 months as a result of deficiencies found on the previous survey

  • Evidence of “diminished capacity” of the facility is found based on other sources i.e., state licensure survey, complaints

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Extended Survey

If surveyors have found or have reason to believe that a Condition level deficiency exists in any of the four fundamental survey CoPs, an extended survey reviews all standards under the fundamental CoPs will be initiated

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Focus of theFundamental Survey

  • Choice and community participation

  • Personal finances and possessions

  • Personal relationships and privacy

  • Client and family participation in the IDT/IPP

  • Service delivery

  • Client rights and protections

  • Health status

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Elements of theFundamental Survey

  • Eight survey tasks

  • Focuses on 56 tags, primarily outcome oriented

  • Concentrates on provider compliance with outcome regulations but provider must meet all structural and process requirements

  • Requires compliance with 4 Conditions of Participation

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CoPs Addressed by a Fundamental Survey

  • Client Protections

  • Active Treatment

  • Client Behavior and Facility Practices

  • Health Care Services

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Elements of a Fundamental Survey =Client Protections (42 CFR 483.420)

  • W124 – W130, Inform of rights, Exercise rights, Manage finances, Not subject to abuse or punishment, Unnecessary drugs, Opportunity for personal privacy, Ensure privacy during treatment

  • W133, Communicate, associate privately

  • W136, Participation in social, religious and community groups

  • W137, Retain and use personal possessions

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Elements of a Fundamental Survey =Client Protections (cont.)

  • W143 – W148, Promote participation, Answer communications, Promote visits at reasonable hours, Promote visits within facility areas, Promote leaves of absence, Notify of significant occurrences

  • W153 - W157, Investigate allegations abuse and neglect, Evidence of investigations, Prevent further abuse, Results reported, Corrective action taken

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Elements of a Fundamental Survey =Active Treatment (42 CFR 483.440)

  • W196, Continuous active treatment

  • W197, Not include independent clients

  • W209, Client/family participation

  • W227, Specific objectives to meet assessed needs

  • W240, Interventions to support independence

  • W242, Training in personal skills

  • W247, Choice and self-management opportunities

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Elements of a Fundamental Survey Active Treatment (cont.)

  • W249, Sufficient frequency and number of interventions

  • W255 - W257, Program monitoring and change

  • W262 - W263, Specially constituted committee to monitor management of inappropriate behavior

  • W120, Outside resources meet needs

  • W186, Sufficient direct care staff

  • W436, Maintain and teach use of assistive devices

  • W448 - W449, Evacuation drills

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Elements of a Fundamental Survey =Client Behavior and Facility Practices (42 CFR 483.450)

  • W285, Safeguard rights while managing inappropriate behavior

  • W286 - W288, Behavior management never used for disciplinary purposes, Convenience of staff, or Active treatment substitute,

  • W291, Time out room uses

  • W293, Protection while in time out

  • W301 - W302, Check and release while in restraint

  • W313, Drugs to control inappropriate behavior, benefits outweigh side effects

  • W314, Drug regimen review

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Elements of a Fundamental Survey =Health Care Services (42 CFR 483.460)

  • W322, Annual physical exam as well as routine preventative care

  • W331, Nursing services in accordance with client needs

  • W338, Medical care plan (if needed) results in necessary medical intervention

  • W356, Dental care

  • W369, Medications administered without error

  • W371, Self administration of medications taught if appropriate

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Ever Wondered SurveyHow or Why

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Sample Selection Survey

150 Bed facility, sample size 10%, 15 clients

  • 15 residents have mild mental retardation, 10% = 1 resident

  • 26 residents have moderate mental retardation, 17% = 3 residents

  • 47 have severe mental retardation, 31%, 5 residents

  • 62 have profound mental retardation, 42%, 6 residents

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Sample Variables Survey

  • Sample is not statistically valid

  • All living areas represented

  • All day/school programs represented

  • Surveyors can add clients as they deem appropriate

    • Clients with obvious maladaptive behaviors

    • Unaddressed developmental needs

    • Unaddressed medical needs

    • Client with complaints

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What does it mean? Survey

  • CMS regulations are not prescriptive on how you do it, just do it!

  • Surveyors should focus on just the fundamental requirements as long as you can meet the intent of the regulation

  • Surveyors should focus on the clear language of the regulation, not on best practice or opinion

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What does it mean? Survey

  • Facility rationale must be supported by a comprehensive assessment

  • Share the ‘blame’ - No one person determines client or facility services, the IDT does

  • You can make an educated guess about who will be sample residents

  • The only constant about change is the continuing need to change!

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Culture Change Survey

Do you feel like the sign on the

psychiatric hospital that says:

“Please do not disturb

any further”

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Core Concepts – Culture Change Survey

  • Start at ‘normal’

  • Give quality supports, both client and staff

  • Purposeful activity

  • Build on preferences

  • Foundation of staff investment

  • Match client needs to staff strengths

  • Involved leadership

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Culture Change as SurveyActive Treatment

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Culture Change Steps Survey

  • Facility Comprehensive Change Assessment

  • Interdisciplinary ChangeTeam

  • ChangeImplementation Plan

  • Implement Change Program

  • Change to Changes

  • Change Monitoring

  • Change Documentation

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T Surveyraining


Assessment, and


Get on TRAC, Inc.

Joyce =

Ann E. =