Risk Management

In a SNF, there are a lot of moving pieces, a lot to manage, and a lot can go wrong. Mitigating the risk of adverse events is a daily task. From care systems review and root cause analysis to anticipatory management, the resources below are designed to help you do just that. Protect your staff and residents now before you have to pick up the pieces after the fact. 

  • CMS Online Immediate Jeopardy Update Training (3/19)

    By CMS - March 08, 2019

    The Immediate Jeopardy Update Training introduces surveyors and non-surveyors to the revised Appendix Q–Core Guidelines to Determining Immediate Jeopardy. The Core Appendix Q focuses on the key components necessary to establish immediate jeopardy (IJ) under the regulations. 

    These key components are:

    • Noncompliance.
    • Serious harm, injury, impairment, or death that has occurred or is likely to occur. 
    • Immediate need for action by the provider/supplier to address the noncompliance.

    The Core Appendix Q also contains information about how surveyors should determine whether IJ exists, and it includes a template that surveyors must use to ensure that sufficient evidence exists for each key component of IJ.

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  • CMS Revises Appendix Q, Guidance on Immediate Jeopardy / State Operations Manual (3/19)

    By CMS - March 07, 2019

    Memorandum Summary

    Core Appendix Q and Subparts - Appendix Q to the State Operations Manual (SOM), which provides guidance for identifying immediate jeopardy, has been revised. The revision creates a Core Appendix Q that will be used by surveyors of all provider and supplier types in determining when to cite immediate jeopardy. CMS has drafted subparts to Appendix Q that focus on immediate jeopardy concerns occurring in nursing homes and clinical laboratories since those provider types have specific policies related to immediate jeopardy. 

    Key Components of Immediate Jeopardy – To cite immediate jeopardy, surveyors determine that (1) noncompliance (2) caused or created a likelihood that serious injury, harm, impairment or death to one or more recipients would occur or recur; and (3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.

    Immediate Jeopardy Template – A template has been developed to assist surveyors in documenting the information necessary to establish each of the key components of immediate jeopardy. Survey teams must use the immediate jeopardy template attached to Appendix Q to document evidence of each component of immediate jeopardy and use the template to convey information to the surveyed entity.

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  • CMS Press Release on April 2019 Nursing Home Compare / Five-Star Changes (3/19)

    By CMS - March 05, 2019

    The April 2019 changes include revisions to the inspection process, enhancement of new staffing information, and implementation of new quality measures.

    This includes a lifting of the ‘freeze’ on the health inspection ratings instituted in February 2018. CMS ‘froze’ the health inspection star ratings category after implementing a new survey process for Long-Term Care facilities. Because facilities receive surveys at different times, some facilities would have been surveyed under the old process and others under the new process. Without placing a ‘freeze’ on health inspection star ratings, the facilities would have been scored using two different evaluation processes making the outcomes misaligned and the data inaccurate. CMS ‘froze’ the health inspection star rating score until all nursing homes were surveyed at least once under the new survey process for Long Term Care facilities. Ending the freeze is critical for consumers. In April, they will be able to see the most up to date status of a facility’s compliance, which is a very strong reflection of a facility’s ability to improve and protect each resident’s health and safety.

    Additionally, CMS is setting higher thresholds and evidence-based standards for nursing homes’ staffing levels. Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes. CMS found that as staffing levels increase, quality increases and is therefore assigning an automatic one-star rating when a Nursing Home facility reports “no registered nurse is onsite.” Currently, facilities that report seven or more days in a quarter with no registered nurse onsite are automatically assigned a one-star staffing rating. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days. CMS is also making changes to the quality component on Nursing Home Compare that would improve identifying differences in quality among nursing homes, raise expectations for quality, and incentivize continuous quality improvement.

    To provide further value and remain consistent with CMS’s Meaningful Measures initiative the April 2019 Nursing Home Compare Update includes adding measures of long-stay hospitalizations and emergency room transfers, and removing duplicative and less meaningful measures. CMS is also establishing separate quality ratings for short-stay and long-stay residents and revising the rating thresholds to better identify the differences in quality among nursing homes making it easier for consumers to find the right information needed to make decisions.

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  • AHRQ Surveys on Patient Safety Culture Nursing Home Survey: 2019 Database Report (2/19)

    By AHRQ - February 14, 2019

    The most recent AHRQ Nursing Home Survey on Patient Safety Culture Database Report presents data from 191 nursing homes and 10,499 nursing home respondents who completed the survey between January 2016 and July 2018 and submitted data to the Nursing Home SOPS database. The report presents statistics (averages, standard deviations, minimum and maximum scores, and percentiles) on the patient safety culture composite measures and items from the survey. Appendixes A and B present overall results by nursing home characteristics (bed size, ownership, census region, and urban/rural status) and respondent characteristics (job title, nursing home work area, interaction with residents, shift worked most often, and tenure in nursing home). The report contains data voluntarily submitted by participating nursing homes and is not representative of all U.S. nursing homes.


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  • All Cause Harm Prevention Webinar Recording Available (2/19)

    By NNHQIC - February 14, 2019

    All Cause Harm Prevention in Nursing Homes Applying Strategies from the New CMS Change Package

    Thursday, January 24, 2019, 3:00pm ET (1 hour) Recording Available.

    One-third of SNF residents experience an adverse or temporary harm event, and the majority of those are preventable. As part of CMS’s focus on raising awareness of nursing home safety and to support safer nursing home care across the nation, CMS and the Quality Innovation Network National Coordinating Center released a new resource: a Change Package to prevent all cause harm in nursing homes. The Change Package is a compendium of successful practices of high-performing nursing homes, illustrating how they prevent harm while honoring each resident’s rights and preferences.

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  • National Fire Protection Association (NFPA) 99 Health Care Facilities Code Training (NFPA99) (2/19)

    By CMS - February 14, 2019
    The NFPA 99 online training will be a self-paced, on-demand, asynchronous Federal training for all surveyors who have completed the necessary prerequisites. It will be housed on the ISTW. The NFPA 99 training is intended to cultivate and refine surveyor skills, foster understanding of the NFPA 99 requirements, and enhance surveyors’ overall ability to survey health care services or systems based on risk to the patients, staff, or visitors to minimize the hazards of fire, explosion, and electricity in health care facilities. The overall goal of this NFPA 99 Health Care Facilities Code training is for the learner to effectively survey for NFPA 99 compliance.
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  • Emergency Preparedness- Updates to Appendix Z of the State Operations Manual (1/19)

    By CMS - February 05, 2019

    CMS is updating Appendix Z of the SOM to reflect changes to add emerging infectious diseases to the definition of all-hazards approach, new Home Health Agency (HHA) citations, and clarifications under alternate source power and emergency standby systems.


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  • Nursing Home Compare Claims-based Measures Technical Specifications Plus Appendix Updated (12/18)

    By CMS - December 07, 2018

    Nursing Home Compare Claims-based Measures Technical Specifications -Update December 2018  plus Appendix


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  • Infection Prevention and Control Audits: Start with Hand Hygiene

    By Caralyn Davis, Staff Writer - November 26, 2018

    Nursing homes can have the most beautiful policies and procedures for infection prevention and control in the world, but if staff aren’t following through on them, they are a waste of paper, notes Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, an infection prevention and control consultant and faculty member at the Association for Professionals in Infection Control and Epidemiology (APIC) in Arlington, VA.

     

    “So monitoring and auditing infection prevention processes in the facility is a critical component of quality care,” says Burdsall. “Unfortunately, the focus on infection prevention has not always been well-supported because infection surveillance, monitoring whether proper supplies are available and used correctly, and watching whether staff are performing hand hygiene and correctly using personal protective equipment all take time, which means the effort costs money.”

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  • Influenza: How to Prevent or Minimize Outbreaks

    By Caralyn Davis, Staff Writer - October 25, 2018

    Through Oct. 13, influenza activity remained low across the United States. However, the Centers for Disease Control and Prevention (CDC) expects flu outbreaks to increase in the coming months. Avoiding and minimizing flu outbreaks not only protects residents and staff, it protects the facility as well given the laser focus on infection prevention and control that state surveyors have had during the first year of the Long-term Care Survey Process (LTCSP).

    Directors of nursing services (DNSs) can work with the interdisciplinary team, residents, and families to reduce the risk of influenza transmission and minimize any outbreaks that occur. Limiting transmission requires a bundled approach, including the following steps:

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  • Nursing Home Staff Influenza Vaccinations Still Lag Behind Other Settings (9/18)

    By CDC - September 28, 2018

    Health care personnel working in long-term care settings, the majority of whom work as assistants or aides, have lower influenza vaccination coverage than do health care personnel working in all other health care settings, which puts the elderly in long-term settings at increased risk for severe complications for influenza. Implementing workplace strategies shown to improve vaccination coverage among health care personnel, including vaccination requirements and active promotion of on-site vaccinations at no cost, can help ensure health care personnel and patients are protected against influenza. 


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  • Antibiotic Stewardship: Fluoroquinolones and Black Box Warning Update (9/18)

    By CDC - September 06, 2018

    The U.S. Food and Drug Administration (FDA) Recently Strengthened its Black Box Warning About Fluoroquinolone Use

    Appropriate fluoroquinolone prescribing is important for patient safety. A recent study published in Clinical Infectious Diseases reports that fluoroquinolones are commonly prescribed for conditions when antibiotics are not needed at all, or when fluoroquinolones are not the recommended first-line therapy.

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  • Nursing Home Compare & PBJ Updates: Long-stay Resident Hospitalization Rate to Be Added to NHC / Five Star; Non-Nursing Staff for PBJ to Be Posted; Health Inspection Freeze to End (6/18)

    By CMS - June 22, 2018
    • In October 2018, the long-stay hospitalization measure will be posted on the Nursing Home Compare website as a long-stay quality measure. In the spring of 2019, this quality measure will be included in the Five Star Quality Rating System.  Additionally, in July 2018 we will update the other claims-based quality measures reported on the Nursing Home Compare website.
    • To increase transparency, CMS will begin posting the number of hours worked by other staff (i.e., non-nursing) in July 2018. Facilities are required to submit hours for all other staff as listed in Table 1 of the PBJ Policy Manual. We will also distinguish between hours submitted for direct employees and contract staff. 
    • In October 2019, CMS will resume posting the average number of citations per inspection for each state and nationally. CMS is monitoring outcomes of the new inspection process and plans to resume health inspection rating calculations (i.e., end the freeze) in the spring of 2019. CMS will communicate more details about this prior to its implementation.



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  • 13 Best Practices to Prevent High-Scope Citations for F686 (Skin Integrity)

    By Jessica Kunkler, MA, Staff Writer - June 19, 2018

    Since the new Long-Term Care Survey Process (LTCSP) launched on November 28, 2017, 702 citations have been given for F686 (Skin Integrity). 22% of those tags are a G scope or above. Many of the citations are for:

    ·         Failure to provide care to treat and/or prevent worsening pressure ulcers

    ·         Failure to prevent facility-acquired pressure ulcers

    ·         Failure to develop and/or follow the care plan

    ·         Failure to ensure accurate assessment, obtain treatment orders, or communicate with other professional staff

    ·         Failure to prevent infection of wounds

    Widespread pressure ulcer issues are no surprise when facilities don’t have proper protocols in place for prevention, early identification, and treatment, according to Wendy DeCarvalho, MS, BSN, RN, DNS-CT, Director of Nursing for Scotia Village in North Carolina. As a DNS and clinical nurse consultant in long-term care facilities nationwide, DeCarvalho has worked to improve Quality Measures, including those for pressure ulcer rates. “If the staff doesn’t have protocols in place, pressure ulcers often go unchecked, untracked, and untreated,” she says. She recommends the following best practices.

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  • Fall Prevention: It’s Easy to Miss What You’re Not Looking For

    By Linda Shell, DNP, MA, RN, DNS-CT - June 19, 2018
    Does this sound familiar? Mary, an 87-year-old memory care resident and recurrent faller, has another fall in her room. A housekeeper spots her lying on the floor. Staff members rush to help. Alarm, floor mat, low bed? What will it be this time? The nurse completes an incident report and an intervention is care planned. The same scenario with Mary repeats itself over and over. She falls, a new intervention fails, her family grows concerned, staff members become frustrated, and the resident and facility are at risk.
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