Scaling Survey Hurdles

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In today's increasingly outcomes-driven healthcare environment, more skilled nursing operators are stressing quality. Unfortunately, operators have learned that this heightened concern doesn't always translate to brag-worthy survey scores – or their ability to dodge deficiencies that dogged them in the past.  

Indeed, when it comes to survey data, certain areas continue to plague many facilities. In 2011, roughly 30% of facilities were cited for at least one of the top three deficiencies: presence of accident hazards, food preparation/storage, and infection control. Beyond that, more than 20% of all facilities were cited for at least one serious clinical deficiency, including failure to achieve the highest level of practical well-being and failure to produce comprehensive care plans, said Sheila Lambowitz, former director of the Centers for Medicare & Medicaid Services' division of institutional post-acute care, and current president of Lambowitz & Associates.

“The only surprise is that these same deficiencies were among the top six deficiencies in 2009 and 2010, as well as in 2011,” she noted. “The real question, then, is not why a facility is cited for a deficiency, but why so many are cited for the same deficiencies.”

Preparation pays

A number of factors contribute to a facility's likelihood of receiving a repeat citation. Facility-specific data, including previous surveys, Minimum Data Set information and quality measures reports are all key go-to resources for a surveyor.

“If you were cited for infection control problems last year, for example, it's a near certainty that the surveyors will carefully investigate the protocols you have in effect this year,” warned Lambowitz.

Avoiding a repeat deficiency – or at least reducing the risk for one -- requires calculated due diligence. An ongoing review of the previous year's survey report is essential, as is a detailed audit to pinpoint current weaknesses and policy and procedure changes that address past deficiencies, experts noted. Proactive use of predictive analytics tools also goes a long way toward helping providers identify their risks and sidestep survey problems.

“Analytics play an important role in the survey success because they help a facility get a handle on their greatest risk exposure. Good data helps you stay on top of past problems and determine your greatest citation risks, so you can make the necessary changes and improvements before the surveyors walk through the door,” said Mary Chmielowiec, PointRight's executive vice president of insurance services. What's more, quarterly analytics reports allow operators to benchmark against other survey districts and identify specific surveyor citation “hot spots” in their area or across a specific region or state.

“We analyze every facility [customer] to help make an informed judgment on what happened in the past and what's happening now. We can measure these changes over time and anticipate trends,” Chmielowiec continued. Further, PointRight monitors regulatory and surveyor focus changes within CMS, and offers educational webinars, so its approximately 3,500 facility customers can stay informed of the latest hot-button issues. “We also provide a report on which citations pose the greatest litigation risk.”

Ensuring patient dignity as part of ongoing care is just one of CMS's current focus areas. As a result, this deficiency citation has moved from the thirteenth spot in 2009 to the ninth in 2011, said Lambowitz. Moving forward, operators should also prepare for a greater focus on medication-related issues. The current focus on antipsychotic drug use for elderly nursing home residents may give way to polypharmacy, physician response to consultant pharmacist findings during monthly drug regimen reviews, and quality of life concerns, such as resident refusal of medication, according to Linda Elizaitis, president of CMS Compliance Group. “Medication concerns deserve the attention they are getting. They require an interdisciplinary approach to providing quality of care, as well as quality of life.”

If CMS guidelines change, staff policies and practices should change to accommodate them. If a facility finds that no significant changes were made to address new CMS deficiencies or guideline changes, Lambowitz said an operator already has a clear preview of their next survey outcome. “After all, Albert Einstein defined insanity as doing the same thing over and over, but expecting a different [result].”

QA/PI program paramount

Regardless of the deficiency or inspector focus area in question, one thing remains certain: facilities that consistently capture and analyze their performance data, and develop comprehensive quality assurance and performance improvement plans to address their risks will earn the best survey scores.

“QA/PI is huge with surveyors. They want to be sure a facility knows where its problems are, is monitoring them effectively and continually trying to improve them,” explained Marie Adamczyk, RN, a risk analyst for PointRight. “They want to see that you are focusing on your problem areas. And if a plan of correction was written, they want to see that the change that was made is being maintained.”

Experts largely agree that interdisciplinary QA/PI committees are also paramount to success. Committee members must be committed to honest discussion on what is and isn't working in their facility, said Elizaitis. “Consistently reporting 100 percent compliance in areas being reviewed means you are not working on identifying areas where performance improvement is needed.”

Recognizing the root cause of a deficiency is equally essential for identifying and implementing the most appropriate fix to a specific problem. A care planning deficiency, for example, doesn't mean that staff neglected to complete care plans. As Lambowitz explained, a citation will be much more specific and may include detailed examples of services that were care planned, but not rendered, or services that were assessed, but not care planned.

“Selecting an appropriate intervention to prevent these care planning errors from occurring is still a function of the human brain,” she reasoned, adding that once the required change is determined by the QA/PI team, an automated tool can then be used to monitor the resident's progress.

Monitoring reports regularly to ensure that interventions identified and implemented are actually working as anticipated is essential. If it's determined that interventions aren't leading to better outcomes,  adjustments should be made and documented.

“There's no guaranteed technique for reducing repeat citations,” acknowledged Lambowitz. “But facilities that put in the work to correct prior deficiencies and monitor progress on an ongoing basis are more likely to see improvement.”

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