By William M. Vaughan, Vice President, Education and Clinical Affairs, Remedi SeniorCare
Ask most people what the Affordable Care Act has to do with nursing homes, and you’ll likely get answers centered on health insurance. Many would be surprised to learn that Section 6102 (c) of the Affordable Care Act directed CMS to establish and implement a Quality Assurance Performance Improvement program for nursing facilities. Phases 2 and 3 of the “Mega Rule” bring with them new regulations developed to meet this mandate.
While the QAPI regulations significantly expand upon current quality assurance requirements, regulatory insight can be gained by reviewing what has been cited recently under F 520 (Quality Assessment and Assurance). According to nursing home compare, there were 758 deficiencies cited at F 520 during the period 1/1/2017 through 11/1/2017. Put in perspective, those deficiencies represents approximately 1 % of all health deficiencies (69,981) cited nationwide during the same period.
It’s notable that 27 deficiencies were cited at a severity level of “actual harm” (G, H) meaning that the surveyor determined the failure of the facility’s quality assurance process at least contributed to “harming” a resident. A review of the language from those deficiencies, cited in nursing homes from multiple states, revealed the following trends and patterns:
- The Quality Assurance Committee … failed to develop and implement corrective action for pressure ulcer care and prevention that resulted in actual harm to resident #148
- The facility failed to ensure the QA program was effective in preventing repeat deficiencies at F-323 and F-514. The facility failed to prevent accidents, which resulted in a fall with a [Fracture] for Resident #1.
- Based on record review and staff interviews, the facility failed to provide a comprehensive wound assessment, initiate treatment and monitor a newly identified Suspected Deep Tissue Injury (DTI) to the left heel resulting in worsening of the DT. The re-citation of F314 and F157 during the last year of federal survey history showed a pattern of the facility’s inability to sustain an effective QAA program.
- The facility failed to identify and implement preventative measures to reduce the amount of facility acquired pressure sores through a quarterly Quality Assurance Performance Improvement (QAPI) program for one of four (1 of 4) quarters reviewed.
- The facility failed to ensure the Quality Assurance (QA) Committee had an effective plan to monitor for continued compliance of deficiencies and issues identified and cited on previous recertification survey and complaint surveys … Deficient practice at F309 was found again for failure to coordinate care regarding pain management and medication administration as documented for Resident #79 and lack of care coordination for Resident #257 regarding lack of communication between the Licensed Practical Nurse (LPN) and Registered Nurse (RN) concerning dehydration … Deficient practice at F514 was found again cited regarding the facility’s failure to ensure clinical records were complete and accurate for 2 of 6 sampled residents by not accurately documenting a resident’s resuscitation status for 1 (Resident #180) of 1 resident reviewed for Hospice and not accurately transcribing a medication order for 1 (Resident #79) of 5 residents reviewed for unnecessary medications.
Several themes emerge from this focused review of quality assurance related deficiencies. Not surprisingly, clinical processes and outcomes related to pressure ulcer development, falls with fractures, dehydration, weight loss, pain management, unnecessary medications and resident rights continue to be regulatory “barometers” of quality. Additionally, facilities that fail to follow plans of correction for previously cited deficiencies or are unable to maintain ongoing compliance with regulations face additional deficiencies which often prompt sanctions including civil money penalties. While QAPI does represent a paradigm shift for both facilities and regulators, quality issue, such as those described above, tend to stand the test of time.
Note: Bill was a surveyor with the Maryland State Survey Agency from 1988 until 2001. He became Chief Nurse of the agency in 2001 and remained in that position until joining Remedi SeniorCare in 2013.
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