10 Average Citations per Recertification Survey 201 201 2017 1Q 8 7.7 7.3 3 3.3 3..2 2 1 0..80.2.0.8.70.8.17.8.1 7.3 SRO SERO NERO NRO WRO WI 1 Source: WI DQA, March 31, 2017
3% Percentage of Recertification Surveys with Harm or Jeopardy Citations 201 201 2017 1Q 3 27% 2% 2 17% 17% 1% 1% 1 1 % 1 23% 21% 2 % % 1% 1% 1% 27% 1% 1% SRO SERO NERO NRO WRO WI 2 Source: WI DQA, March 31, 2017
1 Percentage of Recertification Surveys with Substandard Quality of Care 201 201 2017 1Q 1% 1% 1 1 1 % % % % % % 13% 11% 1% % % % % % % 7% % SRO SERO NERO NRO WRO WI 3 Source: WI DQA, March 31, 2017
Average Federal Health Citations per Recertification Survey 1Q 2017 S&C PDQ and Data Link Viewer Washington California New Mexico Michigan Idaho Delaware Wyoming Nevada Hawaii Virginia Oklahoma District of Columbia Kansas Colorado Pennsylvania West Virginia Nebraska Montana Minnesota Missouri National Total Texas Illinois Maryland Indiana Wisconsin Oregon New York South Carolina North Dakota Florida South Dakota Arkansas Ohio Kentucky North Carolina Massachusetts Mississippi Alabama New Jersey Iowa Tennessee Arizona Louisiana New Hampshire Utah Maine Georgia Vermont Rhode Island 1 0.7 8. 8.2 8.2 8.12 7.7 7.3 7.31 7.2.82.81...33.8.8.2.3.3.17.08.72.7.7..2.11 3.7 3.7 3. 3. 3.33 3.27 3.2 3.1 3.02 2.8 2.7 2. 2.2 2 1.8 10.7 10.1.8.71 No data for Alaska and Connecticut 0 2 8 10 12 Source: WI DQA, March 31, 2017
Percentage of Recertification Surveys with Harm or Jeopardy Citations 1Q 2017 S&C PDQ and Data Link Viewer Washington Wyoming Montana New Mexico Hawaii Oklahoma Michigan South Dakota Wisconsin Colorado Iowa Maryland Kansas Nebraska Idaho South Carolina North Dakota Illinois Missouri Indiana National Total Oregon Minnesota North Carolina Tennessee Virginia Ohio Arkansas Texas Kentucky Louisiana Pennsylvania California New York West Virginia Vermont Utah Rhode Island New Jersey New Hampshire Nevada Mississippi Massachusetts Maine Georgia Florida District of Columbia Delaware Arizona Alabama 1 11% 1 1 7% 7% 7% 7% % % % % % % 3% 21% 2 2 1% 1 17% 17% 1% 0 0.0 0.1 0.1 0.2 0.2 0.3 0.3 0. 0. 0. 2% 3 33% 3% No data for Alaska and Connecticut Source: WI DQA, March 31, 2017
1.8 Average Federal Health Citations per Complaint Survey 201 201 2017 1Q 1. 1. 1.2 1.1 1 0. 0.8 0.8 0.8 0. 0. 0. 0.2 0.2 0 1.8 1.22 1. 1.1 0. 0.8 0.8 0.8 0.7 0.8 0. 0.7 SRO SERO NERO NRO WRO WI Source: WI DQA, March 31, 2017
2 1 Percentage of Complaint Surveys with Harm or Jeopardy Citations 201 201 2017 1Q 1% 1% 1 1 1 11% 1 1 1 7% % % 17% 1 13% 13% % % % 11% 1 1 SRO SERO NERO NRO WRO WI 7 Source: WI DQA, March 31, 2017
1 Percentage of Complaint Surveys with Substandard Quality of Care 201 201 2017 1Q 1 7% % % % % 3% % 1 7% % % 1% % 3% % % SRO SERO NERO NRO WRO WI 8 Source: WI DQA, March 31, 2017
Pennsylvania South Dakota New Mexico Iowa Montana Kansas Virginia Massachusetts Oregon Wisconsin Arizona Michigan Alabama Minnesota North Carolina Maryland Louisiana New Jersey Ohio Colorado National Total Washington Illinois Maine Texas Arkansas Mississippi Georgia Florida New York Kentucky Missouri California West Virginia Utah Tennessee Oklahoma Nevada Nebraska Indiana Idaho District of Columbia Delaware Connecticut Percentage of Complaint Surveys with Harm or Jeopardy Citations 1Q 2017 S&C PDQ and Data Link Viewer 33% 1% 1% 1% 1 1 11% 1 1 % % 7% % % % 3% 3% 3% 3% 3% 1% 1% 1% 1% No data reported for Alaska, Hawaii, New Hampshire, North Dakota, Rhode Island, South Carolina, Vermont, and Wyoming 2 8 10 10 Source: WI DQA, March 31, 2017
100 Trend in Immediate Jeopardy Citations 2007 - YTD 2017 # IJ citations # facilities with IJ # facilities with multiple IJs 0 8 8 80 70 7 7 7 80 73 0 1 3 1 0 7 8 0 37 37 3 3 30 2 2 20 10 1 1 1 1 1 1 11 1 18 1 0 2007 2008 200 2010 2011 2012 2013 201 201 201 YTD2017 10 Source: WI DQA, March 31, 2017
STATE OF WISCONSIN / DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance / Bureau of Nursing Home Resident Care Nation F323 - supervision to prevent accidents () F1 - infection control (0) F371 - store, prepare, and serve food under sanitary conditions (07) F30 - care promotes highest level of wellbeing (8) F27 - develop comprehensive care plan (32) F31 - labeling of drugs and biological (32) F32 - drug regimen is free of unnecessary drugs (22) F1 - documentation (28) F22 DEVELOP AND IMPLEMENT POLICIES AND PROCEDURES PROHIBITING ABUSE (277) F22 - investigate allegations of abuse (273) TOP TEN FEDERAL HEALTH CITATIONS NATION, STATE, REGIONAL OFFICE 2017 First Quarter State F323 - supervision to prevent accidents () F1 - infection control () F31 - prevention of pressure ulcers (3) F22 - investigate allegations of abuse (3) F371 - store, prepare, and serve food under sanitary conditions (3) F30 - care promotes highest level of wellbeing (32) F31 - services to restore normal bladder function and prevent infection (31) F32 - drug regimen is free of unnecessary drugs (28) F2 - medication system assures accurate receipt and administration (2) F17 PROMPT MD CONSULTATION (18) Southern (Madison) F323 - supervision to prevent accidents (12) F22 - investigate allegations of abuse (10) F32 - drug regimen is free of unnecessary drugs (8) F30 - care promotes highest level of wellbeing () F17 Prompt MD consultation () F31 - prevention of pressure ulcers () F31 - services to restore normal bladder function and prevent infection () F327 OFFERED SUFFICIENT FLUIDS TO MAINTAIN HYDRATION () F371 - store, prepare, and serve food under sanitary conditions () F2 - medication system assures accurate receipt and administration () Southeastern (Milwaukee) F30 - care promotes highest level of wellbeing (1) F323 - supervision to prevent accidents (13) F31 - prevention of pressure ulcers (12) F22 - investigate allegations of abuse (10) F371 - store, prepare, and serve food under sanitary conditions (10) F1 - infection control (10) F31 - services to restore normal bladder function and prevent infection () F32 - drug regimen is free of unnecessary drugs (8) F27 - DEVELOP COMPREHENSIVE CARE PLAN (7) F2 - medication system assures accurate receipt and administration (7) Northeastern (Green Bay) F31 - prevention of pressure ulcers (1) F1 - infection control (1) F31 - services to restore normal bladder function and prevent infection (10) F323 - supervision to prevent accidents (10) F371 - store, prepare, and serve food under sanitary conditions (10) F17 PROMPT MD CONSULTATION (7) F22 - investigate allegations of abuse (7) F2 - medication system assures accurate receipt and administration (7) F1 - DOCUMENTATION (7) F22 develop and implement policies and procedures prohibiting abuse () Northern (Rhinelander) F371 - store, prepare, and serve food under sanitary conditions (7) F323 - supervision to prevent accidents () F1 - infection control () F2 - medication system assures accurate receipt and administration () F278 ASSESSMENT MUST ACCURATELY REFLECT RESIDENT STATUS () F31 - prevention of pressure ulcers () F22 - investigate allegations of abuse (3) F30 - care promotes highest level of wellbeing (3) F32 - drug regimen is free of unnecessary drugs (3) 7 tags with 2 citations each Western (Eau Claire) F323 - supervision to prevent accidents (13) F1 - infection control (11) F31 - prevention of pressure ulcers (7) F278 ASSESSMENT MUST ACCURATELY REFLECT RESIDENT STATUS () F282- Services meet professional standards/provided in accordance with care plan () F30 - care promotes highest level of wellbeing () F31 - services to restore normal bladder function and prevent infection () F318 SERVICES TO INCREASE RANGE OF MOTION OR PREVENT AVOIDABLE DECLINE IN ROM () F22 - investigate allegations of abuse () F280 - periodically review and revise the plan of care () F1 - infection control () F1 - documentation (7) F32 - DRUG REGIMEN IS FREE OF UNNECESSARY DRUGS () F31 LABELING OF DRUGS AND BIOLOGICALS () ITALICS not in State s Top Ten BLUE/SMALL CAPS -new to Top Ten compared to entity s 201 data 11 Source: WI DQA, March 31, 2017
STATE OF WISCONSIN / DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance / Bureau of Nursing Home Resident Care Southern Regional Office (SRO) Top Ten Federal Health Citations First Quarter 2017 SRO 201 Tag 1 1 F323 2 2 F22 3 8 F32 F30 F17 Description of Regulation Facility is free of hazardous environment/supervision and assistive devices to prevent accidents Report and investigate allegations of abuse, mistreatment, neglect and misappropriation Each resident s drug regimen is free of unnecessary drugs Care and services to attain/maintain highest practicable level of wellbeing Consult promptly with physician following significant condition change of Citations of Cites at Harm or IJ 12 2 10 0 8 0 2 2 3 F31 Services and treatment to prevent and/or to heal pressure ulcers 1 F31 Care and services to restore as much normal bladder function as possible 1 F327 Offered sufficient fluids to maintain hydration 2 F371 7 F2 F1 Food stored, prepared, distributed, and served in a manner that prevents foodborne illness Pharmaceutical services ensure accurate acquiring and dispensing of medications Infection control program designed to prevent the development and control the spread of infection 0 0 1 12 Source: WI DQA, March 31, 2017
STATE OF WISCONSIN / DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance / Bureau of Nursing Home Resident Care Northern Regional Office (NRO) Top Ten Federal Health Citations First Quarter 2017 NRO 201 Tag 1 1 F371 2 2 7 F323 2 F1 F2 Description of Regulation Food stored, prepared, distributed, and served in a manner that prevents foodborne illness Facility is free of hazardous environment/supervision and assistive devices to prevent accidents Infection control program designed to prevent the development and control the spread of infection Pharmaceutical services ensure accurate acquiring and dispensing of medications of Citations of Cites at Harm or IJ 7 0 1 0 0 F278 Assessment must accurately reflect resident status 0 F31 Services and treatment to prevent and/or to heal pressure ulcers 1 7 10 F22 Report and investigate allegations of abuse, mistreatment, neglect and misappropriation 3 0 7 8 F30 Care and services to attain/maintain highest practicable level of wellbeing 3 1 7 F32 Each resident s drug regimen is free of unnecessary drugs 3 0 10 7 tags with 2 citations each 13 Source: WI DQA, March 31, 2017
STATE OF WISCONSIN / DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance / Bureau of Nursing Home Resident Care Northeastern Regional Office (NERO) Top Ten Federal Health Citations First Quarter 2017 NERO 201 Tag Description of Regulation of Citations of Cites at Harm or IJ 1 F31 2 1 F1 Services and treatment to prevent and/or to heal pressure ulcers Infection control program designed to prevent the development and control the spread of infection 1 1 0 3 2 F31 Care and services to restore as much normal bladder function as possible 10 0 3 3 F323 Facility is free of hazardous environment/supervision and assistive devices to prevent accidents 10 1 3 F371 Food stored, prepared, distributed, and served in a manner that prevents foodborne illness 10 0 F17 Consult promptly with physician following significant condition change 7 2 7 F22 Report and investigate allegations of abuse, mistreatment, neglect and misappropriation 7 0 F2 Pharmaceutical services ensure accurate acquiring and dispensing of medications 7 0 F1 Documentation meets professional standards 7 0 8 F22 Policies to prohibit abuse 0 F32 Free of unnecessary drugs 2 F31 Labeling of medications 0 1 Source: WI DQA, March 31, 2017
STATE OF WISCONSIN / DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance / Bureau of Nursing Home Resident Care Southeastern Regional Office (SERO) Top Ten Federal Health Citations First Quarter 2017 SERO 201 Tag 1 3 F30 2 1 F323 3 2 F31 Description of Regulation Care and services to attain/maintain highest practicable level of wellbeing Facility is free of hazardous environment/supervision and assistive devices to prevent accidents Services and treatment to prevent and/or to heal pressure ulcers of Citations of Cites at Harm or IJ 1 7 13 2 12 F22 Reporting and investigating allegations of abuse, mistreatment, neglect and misappropriation 10 1 7 F371 Store, prepare, and serve food under sanitary conditions 10 0 F1 Infection control program designed to prevent the development and spread of infection 10 0 7 F31 Services to restore normal bladder function and prevent infection 0 8 F32 Each resident s drug regimen is free of unnecessary drugs 8 0 F27 Develop comprehensive care plan 7 0 8 F2 Pharmaceutical services ensure accurate acquiring and dispensing of medications 7 0 F1 Documentation meets professional standards 7 0 1 Source: WI DQA, March 31, 2017
STATE OF WISCONSIN / DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance / Bureau of Nursing Home Resident Care Western Regional Office (WRO) Top Ten Federal Health Citations First Quarter 2017 1 WRO 201 1 Tag F323 Description of Regulation Facility is free of hazardous environment/supervision and assistive devices to prevent accidents of Citations of Cites at Harm or IJ 13 3 2 1 F1 Infection control program designed to prevent the development and control the spread of infection 11 1 3 F31 Services and treatment to prevent and/or to heal pressure ulcers 7 1 F278 Assessment must accurately reflect resident status 0 F282 Services meet professional standards and are provided in accordance with care plan 0 F30 Care and services to attain/maintain highest practicable level of wellbeing 2 10 F31 Care and services to restore as much normal bladder function as possible 0 F318 Services to increase range of motion or prevent avoidable decline in range of motion 0 7 F22 Report and investigate allegations of abuse, mistreatment, neglect and misappropriation 0 F280 Periodically review and revise the plan of care 0 1 Source: WI DQA, March 31, 2017