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. 

  • When Used Weekly, AHRQ Toolkit Reduces Rehospitalizations at SNFs (2/21)

    By AHRQ - February 17, 2021
    From AHRQ News Now:

    Skilled nursing facilities that tested AHRQ’s Re-Engineered Discharge (RED) toolkit found that training during weekly staff meetings was more effective than a single full-day course, according to a study published in Clinical Nursing Research. The RED toolkit, designed for hospitals, was tested by four skilled nursing facilities from 2013 to 2015. They used either standard implementation, which trained staff via weekly meetings, or enhanced implementation, in which staff training was completed during a single full-day course. Standard implementation facilities also had stronger leadership support for revised discharge procedures. While facilities using the enhanced implementation saw no change in rehospitalization rates, standard implementation reduced rehospitalizations by 45 percent at 30 days, 50 percent at 60 days, and 39 percent at 180 days.


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  • National Healthcare Safety Network (NHSN) Long-term Care Facility COVID-19 Reporting Module Website UPDATED (2/21)

    By CDC - February 14, 2021

    CDC’s NHSN provides healthcare facilities, such as long-term care facilities (LTCFs), with a secure reporting platform for reporting outcomes and process measures in a systematic way. Reported data are immediately available for use in strengthening local and national surveillance, monitoring trends in infection rates, assisting in identifying resource insecurities, and informing progress toward infection prevention goals.

    The NHSN Long-term Care Facility Component supports the nation’s COVID-19 response through the LTCF COVID-19 Module. Facilities eligible to report data to NHSN’s COVID-19 Module include nursing homes/skilled nursing, long-term care for the developmentally disabled, and assisted living facilities.

    Data reported into the LTCF COVID-19 Module Surveillance Reporting Pathways facilitate assessment of the impact of COVID-19 through facility reported surveillance data. Examples of data reported in the pathways include:

    ·         Counts of residents and facility personnel newly positive for COVID-19 based on viral test results.

    ·         COVID-19 vaccination status of residents newly positive for COVID-19.

    ·         Re-infections in residents and facility personnel previously infected with COVID-19.

    ·         COVID-19 related death counts among residents and facility personnel.

    ·         Staffing shortages.

    ·         Availability and surge capacity use of personal protective equipment (PPE) and alcohol-based hand rub.

    ·         Monoclonal therapeutic availability and use.

    ·         Ventilator capacity and supplies for facilities with ventilator-dependent units.

    The Point-of-Care (POC) Test Reporting Tool is a separate reporting option for LTCFs to report SARS-CoV-2 test results provided by a POC device. NHSN routes reported POC laboratory test result data to the public health agency at the local or state level with jurisdictional authority and responsibility for receiving those data. Important: the reporting of POC test result data in this tool does not take the place of answering POC related questions in the Resident Impact and Facility Capacity surveillance reporting pathway.

    Weekly reporting of COVID-19 vaccination data for residents and healthcare personnel is another option available to LTCFs. Additional information about surveillance and vaccination reporting, please visit the Weekly HCP & Resident COVID-19 Vaccination webpage.

    LTCF data submission options include manual data entry, CSV file submission by individual facilities or bulk CSV file upload for multiple facilities, and/or NHSN DIRECT CDA Automation for the Point-of-Care (POC) Test Reporting Tool.

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  • AHRQ 2021 Network of Patient Safety Databases Chartbook (2/21)

    By AHRQ - February 13, 2021

    Agency for Healthcare Research and Quality. 2021

    AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2021, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information that has been voluntarily reported by AHRQ-listed Patient Safety Organizations, including a section on nursing homes. The Chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. The iteration of the Chartbook contains reports not included in the prior NPSD Chartbook.

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  • CMS QSO Memo: Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results (2/21)

    By CMS - February 08, 2021

    DATE: June 1, 2020

    REVISED 01/04/2021

    TO: State Survey Agency Directors FROM: Director Quality, Safety & Oversight Group

    SUBJECT: Revised COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality Improvement Activities in Nursing Homes

    CMS is committed to taking critical steps to protect vulnerable Americans to ensure America’s health care facilities are prepared to respond to the CoronavirusDisease2019(COVID-19) Public Health Emergency (PHE).

    • CMS has implemented a new COVID-19 reporting requirement for nursing homes, and is partnering with CDC’s robust federal disease surveillance system to quickly identify problem areas and inform future infection control actions.

    • Following the March 6, 2020 survey prioritization, CMS has relied on State Survey Agencies to perform Focused Infection Control surveys of nursing homes across the country. We are now initiating a performance-based funding requirement tied to the Coronavirus Aid, Relief and Economic Security (CARES) Act supplemental grants for State Survey Agencies. Further, we are providing guidance for the limited resumption of routine survey activities. CMS has revised the criteria requiring states to conduct focused infection control surveys due to the increased availability of resources for the testing of residents and staff and factors related to the quality of care.

    • CMS is providing Frequently Asked Questions related to health, emergency preparedness and lifesafety code surveys

    • CMS is also enhancing the penalties for noncompliance with infection control to provide greater accountability and consequence for failures to meet these basic requirements. This action follows the agency’s prior focus on equipping facilities with the tools they needed to ensure compliance, including 12 nursing home guidance documents, technical assistance webinars, weekly calls with nursing homes, and many other outreach efforts. The enhanced enforcement actions are more significant for nursing homes with a history of past infection control deficiencies, or that cause actual harm to residents or Immediate Jeopardy.

    • Quality Improvement Organizations have been strategically refocused to assist nursing homes in combating COVID-19 through such efforts as education and training, creating action plans based on infection control problem areas and recommending steps to establish a strong infection control and surveillance program.

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  • CMS COVID-19 Nursing Homes Best Practices Toolkit and New QIN-QIO Virtual Assistance UPDATED (2/21)

    By CMS - January 31, 2021

    New tool provides innovative solutions for states and facilities to protect our nation’s vulnerable nursing home residents during emergency

    CMS has released a new toolkit (updated 2/3/21) developed to aid nursing homes, Governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. The toolkit builds upon previous actions taken by the Centers for Medicare & Medicaid Services (CMS), which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency. The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

    “The coronavirus presents a unique challenge for nursing homes. CMS is using every tool at our disposal to protect our nation’s most vulnerable citizens and aid the facilities that care for them. This toolkit will support state, local leaders and nursing homes in identifying best practices to protect our vulnerable elderly in nursing homes” said CMS Administrator Seema Verma.  

    The toolkit provides detailed resources and direction for quality improvement assistance and can help in the creation and implementation of strategies and interventions intended to manage and prevent the spread of COVID-19 within nursing homes. The toolkit outlines best practices for a variety of subjects ranging from infection control to workforce and staffing. It also provides contact information for organizations who stand ready to assist with the unique challenges posed by caring for individuals in long-term care settings. Each state was involved in the creation of this toolkit, resulting in a robust resource that may be leveraged by a variety of entities serving this vulnerable population.

    Additionally, CMS has contracted with 12 Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) to work with providers, community partners, beneficiaries and caregivers on data-driven quality improvement initiatives designed to improve the quality of care for beneficiaries across the United States. The QIN-QIOs are reaching out to nursing homes across the country to provide virtual technical assistance for homes that have an opportunity for improvement based on an analysis of previous citations for infection control deficiencies using publicly available data found on Nursing Home Compare.

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  • AHRQ: Treatments for Acute Pain: A Systematic Review (1/21)

    By AHRQ - January 24, 2021

    Main Points

    • Opioids are probably less effective than nonsteroidal anti-inflammatory drugs (NSAIDs) for surgical dental pain and kidney stone pain and might be similarly effective to NSAIDs for low back pain.
    • Opioids might be and NSAIDs are probably more effective than acetaminophen for surgical dental pain, but opioids are probably less effective than acetaminophen for kidney stone pain.
    • An opioid might be more effective than gabapentin for acute neuropathic pain.
    • Opioids are probably associated with increased risk of short-term adverse events versus nonopioid pharmacologic therapy for acute pain, including any adverse event, study withdrawal due to adverse events, nausea, dizziness, and somnolence, but serious adverse events are uncommon in randomized trials.
    • Being prescribed an opioid for acute low back pain or postoperative pain might be associated with increased likelihood of use of opioids at long-term followup versus not being prescribed.
    • Heat therapy is probably effective for acute low back pain, spinal manipulation might be effective for acute back pain with radiculopathy, massage might be effective for postoperative pain, and a cervical collar or exercise might be effective for acute neck pain with radiculopathy.
    • Research is very limited on the comparative effectiveness of therapies for sickle cell pain, acute neuropathic pain, neck pain, and management of postoperative pain following discharge.

    Structured Abstract

    Objectives. To evaluate the effectiveness and comparative effectiveness of opioid, nonopioid pharmacologic, and nonpharmacologic therapy in patients with specific types of acute pain, including effects on pain, function, quality of life, adverse events, and long-term use of opioids.

    Data sources. Electronic databases (Ovid® MEDLINE®, PsycINFO®, Embase®, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews) to August 2020, reference lists, and a Federal Register notice.

    Review methods. Using predefined criteria and dual review, we selected randomized controlled trials (RCTs) of outpatient therapies for eight acute pain conditions: low back pain, neck pain, other musculoskeletal pain, neuropathic pain, postoperative pain following discharge, dental pain (surgical or nonsurgical), pain due to kidney stones, and pain due to sickle cell disease. Meta-analyses were conducted on pharmacologic therapy for dental pain and kidney stone pain, and likelihood of repeat or rescue medication use and adverse events. The magnitude of effects was classified as small, moderate, or large using previously defined criteria, and strength of evidence was assessed.

    Results. One hundred eighty-three RCTs on the comparative effectiveness of therapies for acute pain were included. Opioid therapy was probably less effective than nonsteroidal anti-inflammatory drugs (NSAIDs) for surgical dental pain and kidney stones, and might be similarly effective as NSAIDs for low back pain. Opioids and NSAIDs were more effective than acetaminophen for surgical dental pain, but opioids were less effective than acetaminophen for kidney stone pain. For postoperative pain, opioids were associated with increased likelihood of repeat or rescue analgesic use, but effects on pain intensity were inconsistent. Being prescribed an opioid for acute low back pain or postoperative pain was associated with increased likelihood of use of opioids at long-term followup versus not being prescribed, based on observational studies. Heat therapy was probably effective for acute low back pain, spinal manipulation might be effective for acute back pain with radiculopathy, acupressure might be effective for acute musculoskeletal pain, an opioid might be effective for acute neuropathic pain, massage might be effective for some types of postoperative pain, and a cervical collar or exercise might be effective for acute neck pain with radiculopathy. Most studies had methodological limitations. Effect sizes were primarily small to moderate for pain, the most commonly evaluated outcome. Opioids were associated with increased risk of short-term adverse events versus NSAIDs or acetaminophen, including any adverse event, nausea, dizziness, and somnolence. Serious adverse events were uncommon for all interventions, but studies were not designed to assess risk of overdose, opioid use disorder, or long-term harms. Evidence on how benefits or harms varied in subgroups was lacking.

    Conclusions. Opioid therapy was associated with decreased or similar effectiveness as an NSAID for some acute pain conditions, but with increased risk of short-term adverse events. Evidence on nonpharmacological therapies was limited, but heat therapy, spinal manipulation, massage, acupuncture, acupressure, a cervical collar, and exercise were effective for specific acute pain conditions. Research is needed to determine the comparative effectiveness of therapies for sickle cell pain, acute neuropathic pain, neck pain, and management of postoperative pain following discharge; effects of therapies for acute pain on non-pain outcomes; effects of therapies on long-term outcomes, including long-term opioid use; and how benefits and harms of therapies vary in subgroups.

    Citation

    Chou R, Wagner J, Ahmed AY, Blazina I, Brodt E, Buckley DI, Cheney TP, Choo E, Dana T, Gordon D, Khandelwal S, Kantner S, McDonagh MS, Sedgley C, Skelly AC. Treatments for Acute Pain: A Systematic Review. Comparative Effectiveness Review No. 240. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 20(21)-EHC006. Rockville, MD: Agency for Healthcare Research and Quality; December 2020. 

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  • Considerations for Use of SARS-CoV-2 Antigen Testing in Nursing Homes (1/21)

    By CDC - January 16, 2021
    This document provides a summary of considerations for use of SARS-CoV-2 (the virus that causes COVID-19) antigen testing in nursing homes and is intended for nursing home providers and state and local public health departments.

    Also see: Guidance for SARS-CoV-2 Point-of-Care Testing

    UPDATE: 

     

    As of January 7, 2021

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  • World Health Organization: Updated COVID-19 Interim Guidance for LTC Facilities (1/21)

    By WHO - January 12, 2021
    Infection prevention and control guidance for long-term care facilities (including NFs and SNFs) in the context of COVID-19 Interim guidance

    8 January 2021

    This document is an update of the guidance published on 21 March 2020 and contains new evidence and guidance, including the following:

    • updated results from published studies on:
      • the epidemiology and extent of SARS-CoV-2 infection among residents and staff in long-term care facilities (LTCFs);
      • the effectiveness of infection prevention and control (IPC) precautions to prevent SARS-CoV-2 transmission in LTCFs;
      • the impact of IPC precautions on mental and physical health and well-being of older people, and in particular people with dementia or other mental health or neurological disorders;
    • updated advice on IPC precautions to prevent the spread of SARS-CoV-2 and to protect health workers and caregivers of patients with suspected or confirmed COVID-19 in LTCFs;
    • advice on early detection of and testing for SARS-CoV-2 among residents and staff in LTCFs;
    • advice on policies for visitors to LTCFs and additional considerations on minimizing the mental and physical health impacts of restrictions and IPC precautions implemented in the context of COVID-19.
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  • FDA Alert: SARS-CoV-2 Viral Mutation Could Cause False Negatives on Tests, but Overall Risk Is Low (1/21)

    By FDA - January 11, 2021

    The U.S. Food and Drug Administration is alerting clinical laboratory staff and health care providers that the FDA is monitoring the potential impact of viral mutations, including an emerging variant from the United Kingdom known as the B.1.1.7 variant, on authorized SARS-CoV-2 molecular tests, and that false negative results can occur with any molecular test for the detection of SARS-CoV-2 if a mutation occurs in the part of the virus’s genome assessed by that test. The SARS-CoV-2 virus can mutate over time, like all viruses, resulting in genetic variation in the population of circulating viral strains, as seen with the B.1.1.7 variant. The FDA is taking additional actions to ensure authorized tests remain accurate by working with test developers and conducting ongoing data analysis to evaluate all currently authorized molecular tests. The FDA believes the risk that these mutations will impact overall testing accuracy is low.

    “The FDA will continue to monitor SARS-CoV-2 genetic viral variants to ensure authorized tests continue to provide accurate results for patients,” said FDA Commissioner Stephen M. Hahn, M.D. “While these efforts continue, we are working with authorized test developers and reviewing incoming data to ensure that health care providers and clinical staff can quickly and accurately diagnose patients infected with SARS-CoV-2, including those with emerging genetic variants. At this time, we believe the data suggests that the currently authorized COVID-19 vaccines may still be effective against this strain. The FDA will continue to keep health care providers and the public informed of any new information as it becomes available.”

    The FDA has been monitoring SARS-CoV-2 viral mutations, and potential impact on testing, throughout the pandemic. The presence of SARS-CoV-2 genetic variants in a patient sample can potentially change the performance of a SARS-CoV-2 test. Tests that rely on the detection of multiple regions of the genome may be less impacted by genetic variation in the SARS-CoV-2 genome than tests that rely on detection of only a single region.

    Three currently authorized molecular tests, MesaBiotech AcculaTaqPath COVID-19 Combo Kit, and Linea COVID-19 Assay Kit, may be impacted by genetic variants of SARS-CoV-2, but the impact does not appear to be significant. Importantly, the detection pattern that appears with the TaqPath and Linea diagnostic tests when certain genetic variants are present may help with early identification of new variants in patients to reduce further spread of infection. The recently identified B.1.1.7 variant has been associated with an increased risk of transmission, therefore early identification of this variant in patients may help reduce further spread of infection.

    The FDA has reminded clinical laboratory staff and health care providers about the risk of false negative results with all laboratory tests, including molecular tests. Laboratories should expect some false results to occur even when very accurate SARS-CoV-2 tests are used. Today’s announcement also provides important information and recommendations for clinical laboratory staff and health care providers who use molecular tests for the detection of SARS-CoV-2.

    The FDA will continue to communicate with the public as we have additional information to share. The FDA encourages stakeholders to report any adverse events or suspected adverse events experienced with molecular tests for detection of SARS-CoV-2. Voluntary reports can be submitted through MedWatch, the FDA Safety Information and Adverse Event Reporting program. Health care personnel and clinical laboratory staff employed by facilities that are performing COVID-19 testing should follow the reporting requirements for authorized laboratories as specified in the test’s Emergency Use Authorization. Prompt reporting of adverse events can help the FDA identify and better understand the risks associated with medical devices.

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  • CDC COVID-19 Vaccination Toolkit for SNFs/NFs (1/21)

    By CDC - January 05, 2021

    Long-Term Care Facility Toolkit: Preparing for COVID-19 Vaccination at Your Facility

    Answering Common Questions About COVID-19 Vaccines

    This toolkit provides long-term care facility (LTCF) administrators and clinical leadership with information and resources to help build vaccine confidence among healthcare personnel (HCP) and residents. You play a critical role in providing trusted information and ensuring high COVID-19 vaccination coverage in your facility.

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  • COVID-19 Vaccinations: Importance for Residents and Staff (12/20)

    By CDC - December 29, 2020
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  • ACIP Interim Recommendation for Use of Pfizer-BioNTech and Moderna COVID-19 Vaccines (12/20)

    By CDC - December 24, 2020
    The Advisory Committee on Immunization Practices’ Interim Recommendation for Use of Pfizer-BioNTech COVID-19 Vaccine — United States, December 2020 Early Release / December 13, 2020 / 69


    Summary

    What is already known about this topic?

    On December 11, 2020, the Food and Drug Administration issued an Emergency Use Authorization for the Pfizer-BioNTech COVID-19 vaccine.

    What is added by this report?

    On December 12, 2020, after an explicit, evidence-based review of all available data, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Pfizer-BioNTech COVID-19 vaccine in persons aged ≥16 years for the prevention of COVID-19.

    What are the implications for public health practice?

    The recommendation for the Pfizer-BioNTech COVID-19 vaccine should be implemented in conjunction with ACIP’s interim recommendation for allocating initial supplies of COVID-19 vaccines.


    The Advisory Committee on Immunization Practices’ Interim Recommendation for Use of Moderna COVID-19 Vaccine — United States, December 2020

    Summary

    What is already known about this topic?

    On December 18, 2020, the Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Moderna COVID-19 vaccine.

    What is added by this report?

    On December 19, 2020, after a transparent, evidence-based review of available data, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of the Moderna COVID-19 vaccine in persons aged ≥18 years for the prevention of COVID-19.

    What are the implications for public health practice?

    Use of all COVID-19 vaccines authorized under an EUA, including the Moderna COVID-19 vaccine, should be implemented in conjunction with ACIP’s interim recommendations for allocating initial supplies of COVID-19 vaccines.

     


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  • CDC Strategies for Optimizing the Supply of PPE and Other Equipment (12/20)

    By CDC - December 22, 2020

    The Centers for Disease Control and Prevention (CDC) offers strategies for optimizing the supply of:

    N95 respirators

    Face masks

    Isolation gowns

    Eye Protection

    Gloves

    Powered Air-Purifying Respirators (PAPRs)

    Elastomeric respirators

    Ventilators

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  • Dec. 22 CMS-CDC Nursing Home Stakeholder Call on COVID-19 Vaccinations

    By CMS and the CDC - December 21, 2020

    Date:                          Tuesday, December 22

    Time:                          1:00 – 2:00 pm ET

    Toll Free Dial-In:       833-614-0820  

    Access Passcode:     7979889

    Overview: Please join CDC and CMS for this call with Nursing Homes focused on COVID 19 vaccination among residents and staff. During this call, you’ll receive:

     

    ·         Updates on Pharmacy Partnership for Long-Term Care Program;

    ·         Critical clinical, safety, and infection prevention and control considerations associated with implementation;

    ·         Communication resources you can use to address resident and staff questions and concerns; and

    ·         General reminders for the holiday season.

    ·         A questions and answer session will follow updates.

     

    Conference lines are limited. We encourage you to join via audio webcast, either on your computer or smartphone web browser. These calls are not intended for the press.

     

    For More Information:

    ·         Coronavirus.gov

    ·         CMS Current Emergencies

    ·         Podcast and Transcripts  view transcripts and listen to audio recordings of COVID-19 calls

    ·         Coronavirus (COVID-19) Partner Toolkit view this webpage for the most current information including call schedule changes.

     

     


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  • AHRQ Study: Transforming Medication Regimen Review With Telemedicine to Prevent Adverse Events (12/20)

    By AHRQ - December 21, 2020
    Transforming the medication regimen review process using telemedicine to prevent adverse events

    AHRQ News Now:

    KaneGill SL, Wong A, Culley CM, et al. J Am Geriatr Soc. 2020;Epub Nov 25.

    Medication reconciliation and medication regimen reviews can reduce adverse drug events (ADEs) in older adults. This study assessed the impact of a pharmacist-led, patient-centered telemedicine program to manage high-risk medications during transitional and nursing home care. The program included telemedicine-based medication reconciliation at admission and medication regimen reviews throughout the nursing home stay, coupled with clinical decision support. Residents in the program experienced fewer adverse drug events compared to a usual care group. This innovative model has the potential to further reduce medication errors in nursing home residents.

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