2014 Survey Trends in NJ: The Administrator, the Lawyer and the Regulator
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1 2014 Survey Trends in NJ: The Administrator, the Lawyer and the Regulator Linda M. Elizaitis, President CMS Compliance Group, Inc. T:
2 Survey Trends Overview: 2013 New Jersey Top Deficiencies F 281 F 323 F 371 F 279 F 441 F 431 F 329 F 309 F 425* F 332* F 441 F 371 F 323 F 329 F 309 F 279 F 431 F 241 F 514 F 281 National Top Deficiencies 2
3 Survey Trends Overview: 2014 New Jersey Top Deficiencies F 281 F 323 F 371 F 441 F 329 F 309 F 431 F 332 F 425 F 465 F 282 F 441 F 371 F 323 F 309 F 329 F 431 F 279 F 241 F 514 National Top Deficiencies 3
4 NJ Top Deficiencies 2013 vs F 281 Services Provided Meet Professional Standards F 323 Free of Accident Hazards / Supervision / Devices F 371 Food Procurement, Store / Prepare / Serve Sanitary ( ) F 279 Develop Comprehensive Care Plans F 441 Infection Control, Prevent Spread, Linens F 431 Drug Records, Label/Store Drugs & Biologicals F 329 Drug Regimen is Free of Unnecessary Drugs F 309 Provide Care/Services for Highest Well Being F 425 Pharmaceutical Svc Accurate Procedures, RHP F 332 Free of Medication Error Rates of 5% or more 2014 (data through 7/14) F 281 Services Provided Meet Professional Standards ( ) F 323 Free of Accident Hazards / Supervision / Devices ( ) F 371 Food Procurement, Store / Prepare / Serve Sanitary ( ) F 441 Infection Control, Prevent Spread, Linens ( ) F 329 Drug Regimen is Free of Unnecessary Drugs ( ) F 309 Provide Care/Services for Highest Well Being ( ) F 431 Drug Records, Label/Store Drugs & Biologicals ( ) F 332 Free of Medication Error Rates of 5% or more ( ) F 425 Pharmaceutical Svc Accurate Procedures, RHP ( ) F 465 Safe/ Functional / Sanitary/ Comfortable Environment (NEW) 4
5 #1. F 281 Services Provided Meet Professional Standards Medication order clarification Timely record completion Hand washing Foley catheter insertion Medication Administration Infection Control practices related to treatment administration Special needs not being met Restraints 5
6 #2. F 323 Free of Accident Hazards / Supervision / Devices Falls Transfer assistance Swallowing concerns Unsafe smoking Water temperatures PMP equipment Elopement Prevention Securing Med/Tx carts Securing Housekeeping chemicals 6
7 #3. F 371 Food Procurement, Store / Prepare / Serve Sanitary Conditions Temperature guidelines not followed Handling of potentially hazardous foods Kitchen equipment /storage Adequate guidelines for food deliveries Labeling and dating of food items in refrigerators Cleanliness of storage racks/ storage areas Chemical sanitizer for dish machine Staff job performance 7
8 #4. F 441 Infection Control, Prevent Spread, Linens Following wound care protocol Hand washing Sanitizing shower equipment Clean linen handling Glucometer cleaning/disinfection Staff knowledge of precautions/ppe use Supplies outdated/expired 8
9 #5. F 329 Drug Regimen is Free of Unnecessary Drugs Gradual Dose Reduction Behavior monitoring not documented Justification for use Administration of med continued after being discontinued Antipsychotic med without acceptable rationale PRN use of psychoactive medication Non pharmacological interventions not implemented Polypharmacy identified by R.PH and MD follow up 9
10 #6. F 309 Provide Care/Services for Highest Well Being Pain and scheduling of pain medication Policy for expression of suicidal ideation Pacemaker checks not done Provision of appropriate consistency of food Hemodialysis issues Observed pain during wound treatment Dementia care End of Life/Hospice 10
11 #7. F 431 Drug Records, Label/Store Drugs & Biologicals Controlled substance storage in refrigerator Expiration dates Discontinued medication removal Medication cart security Usage, reconciliation and accountability documentation Contents/Temperature of medication refrigerator Contents of controlled substance cabinet Omissions in shift to shift counts Sharing of keys to controlled substance cabinet 11
12 #8. F 332 Free of Medication Error Rates of 5% or more Dosage timing Physician s order/facility protocol Expired medications Manufacturer Instructions /Pharmacy cautionary statements Med pass exceeds time limit for administration Crush without may crush order Instructions for administration not followed 12
13 #9. F 425 Pharmaceutical Svc Accurate Procedures, RHP Clarification of orders requiring a stop date Timing of medication administration Multi dose container dating when opened/discarding Discarding expired Hyperalimentation bag Borrowing/transfers of narcotic medication Medication not being available for administration Borrowing of medication Clarification of Physician orders Expired medications not removed from active stock 13
14 #10. F 465 Safe/ Functional / Sanitary / Comfortable Environment Medication carts Soiled light fixtures under kitchen hood Maintenance of pantries and medication rooms Urine odors Functional/clean kitchen equipment Ice build up in freezers Freezer/refrigerator doors not closing properly Visibly soiled equipment 14
15 Other Gs and IJs F 225 Failure to investigate bruise of unknown origin (S/S: L) F 279 Unsafe smoking no CCP (S/S: G, also S/S: K ) F 309 Positioning of resident receiving enteral feeding and Hospice aide training for enteral feeding (S/S: J) F 309 Monitoring of resident at risk for choking / aspiration (S/S: J) F 323 Residents sustaining serious injuries (S/S: H) F 371 Dairy products not stored at proper temperature (S/S: L) 15
16 Session Panel Moderator: Linda Elizaitis, CMS Compliance Group Panelists: Joanne Maxwell, New Jersey Department of Health Stefanie Mozgai, New Jersey Department of Health Brian Rath, Buchanan, Ingersoll and Rooney PC Janice Testa, Consultant 16
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