Although survey citation rules can vary from state to state, nursing home operators can implement broad steps to avoid deficiencies if they focus on the often overlooked easy fixes as well as the more complicated overlaps between disparate areas of care – ranging from food safety and mental health documentation to infection control.
Certain trends persist across the board, and to successfully issue a plan of correction for a survey deficiency, operators may need to take a multidisciplinary approach, according to Amy Greer and Alicia Cantinieri of Zimmet Healthcare Services Group (ZHSG).
Simple solutions in infection control, which remains a significant concern even in the post-Covid era, involve keeping in place stringent infection prevention protocols. Meanwhile, another relatively undemanding area to keep up with is food safety and procurement, but it often gets overlooked.
At the end of the day, though, it’s all about care planning to include resident-specific solutions. And these range in complexity, with the ones used to address behavioral issues and mental health concerns being on the complicated end.
Nevertheless, paying attention to resident-centered care with collaboration from staff across all areas of the facilities will result in better outcomes for care, and fewer deficiencies, experts said.
For example, Greer said that the surveyor will look to see that operators are doing resident-specific interventions for patients when they have any kind of mental health related behaviors or issues.
“You want to make sure that, you know, your clinical team is involved, your medical director,” Greer said. “A lot of times, activities can be very useful. Sometimes [non-clinical staff] know the residents really well. They know what games they like or what is good for a distraction for them. So it’s really important to make sure that your whole team is involved when you’re dealing with something like that, especially if you’re cited on [psychiatric medication] use or behaviors.”
And, both experts point to the value of carefully maintaining documentation to support coding decisions, particularly since inaccuracies in Minimum Data Set (MDS) with Section GG for resident assessments are on the rise.
A multidisciplinary approach to addressing these issues
Greer said that since the Centers for Medicare & Medicaid Services (CMS) started doing five chart reviews in every nursing home facility in the country, they are using reports to track trends or items that are being miscoded so they can identify issues that need to be clarified in the Resident Assessment Instrument (RAI) Manual.
And so,as clarifications are made, she said, operators should try and keep up to avoid getting tagged.
“That is slowly on the rise, and I think that is going to be one of the little consequences of these five-chart reviews that every facility is having,.” Greer said.
Addressing deficiencies requires a collaborative effort across the facility, Greer said.
If inadequacies are identified, the facility’s Quality Assurance (QA) team can be instrumental in devising strategies for correction, and regular interdisciplinary meetings can foster effective problem-solving and innovative solutions, Greer said.
As an example of this approach, Greer recalled the Zimmet team working with a facility to successfully correct deficiencies related to gradual dose reductions (GDRs) in psych medications. The facility introduced resident-specific interventions for behavioral issues and mental health concerns.
“It’s very hard to find on-site providers, especially for the geriatric population, that go into nursing homes. So even during Covid, where we saw a lot of telehealth, they brought in the little monitor and you would talk through it, which was good to some point,” she said, adding, “But I think that they really want to see that there’s that person-to-person engagement, that [GDRs] are being followed up.”
Another change to watch for that could benefit from a multidisciplinary approach, Greer said, is how CMS is monitoring certain measures. The federal agency is going to make sure, for instance, that such measures as the Abnormal Involuntary Movement Scale (AIMS) assessments are being done properly, which will require monitoring more carefully residents who are on antipsychotic drugs, that they aren’t presenting with any side effects that can happen from long-term use.
“Another big shift is that if you have a resident with behaviors and these psych issues, mental health issues, now they want to see that you’re also doing resident-specific interventions for that person,” she said. “If the resident is having a bad day or they’re very agitated, [CMS] doesn’t just want to just see – ‘Oh, yeah, we gave them Ativan or we gave them alcohol.’” CMS now wants to see that the care plan includes resident-centered approaches.
Overcoming staffing challenges
Shortages in staffing can pose challenges to correction efforts. Cantinieri emphasized the importance of staff education, regardless of whether the staff is full-time, agency-based, or temporary.
“It always goes back to education, empowering your staff, especially the CNAs,” she said. “I think so often that you don’t get their perspective. I know in some places they’re really trying to pull them in to being part of these care plan meetings.”
She added that since it is difficult to pull a CNA off the floor, it’s a tough line to tiptoe across.
“You want to make sure that you’re taking care of the resident, but that all that pertinent information is being output in the care plan and you know that the families are aware,” she said.
Greer said that with repeat issues, trying to figure out the root cause is important if the facility followed a plan of correction the first time, but discovered it was unsuccessful.
“You know, maybe that plan of correction may have worked for that point in time, but now it no longer is, and it just kind of needs to grow and kind of expand into something else,” she said. “[Facilities need to] really utilize any other new tools, any other new information that comes out that just kind of helps fortify the previous plan of correction.”
Benefits of working with external partners
Bridgette Hill, market director of Clinical Services with Longevity Health Plan, an Institutional Special Needs Plan (I-SNP), which partners with operators across the country, said that the initiatives that Longevity has implemented for providers revolve around what nurse practitioners within the facility can influence.
“We’ve collaborated with facility leadership to provide educational support,” she said. “We participate in their quality improvement meetings to provide support and feedback related to falls risk mitigation plans and other quality improvement initiatives.”
She said her recommendation for facilities on a broad scale is to ensure they fully utilize the capabilities of external partners already present in their facility.
“One of our partnered operators has several facilities, and we collaborate with them closely,” she said. “In two of their facilities, we have a nurse practitioner who has achieved good quality scores.”
Hill said that although it’s still early for the program, and she can’t provide clinical outcomes yet, they’ve established an incentive program that allows staff to focus specifically on reviewing their surveys.
“This way, we can work with them on a targeted level without the everyday patient care distractions,” she said.
Companies featured in this article:
CMS, Longevity Health Plan, Zimmet Healthcare Services Group
