Update survey revisions - changes in the survey process of the Health Care Financing Administration

Nursing Homes, August, 1999 by Beth A. Klitch

Since mid-February, the Health Care Financing Administration (HCFA) has released successive revisions to Appendix P, Survey Protocol for Long Term Care Facilities. The most recent draft release as of press time was dated May 5, with implementation planned for July 1. HCFA has used this draft version to conduct surveyor training and to educate providers about expected changes in the survey process. Let's take a closer look at some of the key provisions.

Quality Indicators

One of the most significant aspects of change in the new survey process is the incorporation of Quality Indicator (QI) information, primarily in the Offsite Survey Preparation task, the Sample Selection task and the various Investigative Protocols. Let's review the selected Quality Indicators for various domains, based upon the MDS 2.0, that surveyors will use in evaluating quality of care.

Accidents

1. Incidence of new fractures 2. Prevalence of fails

Behavior/Emotional Patterns

3. Prevalence of behavioral symptoms affecting others

High-risk Low-risk

4. Prevalence of symptoms of depression

5. Prevalence of symptoms of depression without antidepressant therapy

Clinical Management

6. Use of 9 or more different medications

Cognitive Patterns

7. Incidence of cognitive impairment

Elimination/Incontinence

8. Prevalence of bladder or bowel incontinence

High-risk Low-risk

9. Prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan

10. Prevalence of indwelling catheter

11. Prevalence of fecal impaction Infection Control

12. Prevalence of urinary tract infection

Nutrition/Eating

13. Prevalence of weight loss 14. Prevalence of tube feeding 15. Prevalence of dehydration

Physical Functioning

16. Prevalence or bedfast residents 17. Incidence of decline in late-loss ADLs 18. Incidence of decline in ROM

Psychotropic Drug Use

19. Prevalence of antipsychotic use in the absence of psychotic or related conditions

High-risk Low-risk

20. Prevalence of antianxiety/hypnotic use

21. Prevalence of hypnotic use more than two times in the last week

Quality of Life

22. Prevalence of daily physical restraints 23. Prevalence of little or no activity

Skin Care

24. Prevalence of stage 1-4 pressure ulcers

High-risk Low-risk

Three of the above QIs are indicated in bold type to indicate that they are considered "sentinel health events" QIs. This means that the QI represents a significant occurrence that surveyors will select as a concern "even if it applies to only one or a few residents." The presence of a sentinel health event QI means that the resident(s) with the problem(s) will definitely be included in the sample selection for the survey. In addition, surveyors will focus on flagged QIs, i.e., the facility percentage of occurrence is at or above the 90th percentile, and might focus on unflagged QIs, i.e., the facility is at or above the 75th percentile. The key to understanding your facility's QI percentiles is that the higher your numbers, the more likely that surveyors will target those items for closer review.

Three QI reports serve as Sources of information for surveyors during the offsite survey team meeting. All of these are now in final form. The first report, "Facility Characteristics," lists demographic information about the resident population (in percentages) for a single facility compared to all other facilities in the state. The second report, "Facility Quality Indicator Profile," details a single facility's performance for each of the Domains and QIs compared to all other facilities in the state. This report also indicates whether the facility "flags" any individual QIs at or above the 90th percentile. The third report, "Resident Level Summary," provides resident-specific information, including MDS dates and types of assessments, the applicable QIs for each resident, and the total number of QIs flagged for each resident.

Investigative Protocols

HCFA has added some new investigative protocols, and has indicated its intent to develop and integrate yet more investigative protocols into future versions of the survey process. Let's review a list of the newly proposed investigative protocols, which were subject to revision at press time, but with no major changes anticipated for their final release this summer.

Adverse Drug Reactions (ADR)

The survey team will determine if the resident is experiencing any ADRs as a result of receiving one or more of the medications identified as having high potential for moderate-to-severe ADRs. The survey team will also determine whether the facility's drug regimen review process identified and reported any potential irregularities associated with the use of such medications and whether there was any response to this notification. (This protocol is used for residents who are over 65 years old, have resided in the facility for more than seven days, and are receiving any of the medications with a high potential for ADRs.)

Pressure Sore/Ulcer

The survey team will determine if the identified pressure sore/ulcer was avoidable or unavoidable, and will determine the adequacy of the facility's pressure sore/ulcer treatment and prevention. The survey team will observe care delivery to determine if the interventions identified in the care plan have been implemented. (This protocol will be used for a sampled resident with a pressure sore/ulcer from either the high- or low-risk group.)