agenda regulatory/department updates compliance trend report compliance tips: deborah cateora hot...
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AgendaRegulatory/Department UpdatesCompliance Trend ReportCompliance Tips: Deborah CateoraHot Topics:
Manager’s Corner: Cory Oace
Regulatory/Department Updates1. Be sure to notify OLRO for change of
Administrator2. Please be timely sending in license renewal
documentation.
New Employees:Sean Scott: Policy Analyst/Corrective Action
Cynthia Vargo: Surveyor Supervisor
Compliance Tips
Deborah Cateora
Deborah Cateora, BSN, RN
MULTIDRUG RESISTANT ORGANISMSMDROs:
Are infectious organisms that no longer respond to most antibiotics or antiviral medications, currently available;
CDC and state Health Departments are taking strong actions to reduce the transmission of drug resistant and multi-drug resistant infections organisms;
Continue to be a growing issue.
MULTIDRUG RESISTANT ORGANISMSEfforts to reduce the transmission of MDROs
include:Aggressive infection control training efforts;
andUse of the MDRO transfer form.
Reduction of infectious organisms non-MDROs and MDROs include:
Hand Hygiene; Respiratory Hygiene; and Appropriate use of Standard and Contact
Precautions.
MULTIDRUG RESISTANT ORGANISMSMore training will be available for caregivers
in all settings in October or November 2014.Effective January 1, 2014 a new law requires
certain facilities to fill out and/or provide a MDRO transfer form to another facility when an individual with a confirmed or suspected MDRO is being transferred to another facility.
MULTIDRUG RESISTANT ORGANISMSCurrently, ALFs/RCFs are not mandated to
create a form but if they receive a MDRO transfer form here is what needs to be done:Assure all appropriate standard precautions
are implemented at all times; Keep the MDRO transfer form with the
resident’s record;Provide a copy to any emergency personnel
(i.e. paramedics etc.) when treating and/or transporting the resident from their home;
MULTIDRUG RESISTANT ORGANISMS
Provide a copy to the facility when a resident is being transferred to the hospital, emergency room, ambulatory surgical center, nursing facility or another licensed or certified care setting; and
Notify the local health department within one working day of the date of transfer.
Example of MDRO transfer forms can be found at:https://public.health.oregon.gov/
DiseasesConditions/CommunicableDisease/HAI/Prevention/Pages/Interfacility-Communication.aspx.
RN DELEGATIONRN Delegation (Division 47) has specific
requirements regarding actions and documentation. Current issues that we see are:Only indicating the resident is “Stable and
Predictable”: This is a statement only and is not the
documentation that supports the statement. Forms that have a check box still have to have supporting data recorded in the residents’ record.
RN DELEGATIONStep-by-step instructions are not unique to the
individual resident: There must be resident specific information
regarding how the caregiver is to perform the task.Step-by-step instructions kept in a central
location: The step-by-step instructions are resident specific
and should be kept with the MAR for that resident.Not watching each caregiver perform the task
both on the initial and subsequent re-evaluations: Must be performed at the frequency ordered.
RN DELEGATIONRN not reviewing the MAR routinely for
medications or treatments specific to the delegated task;
Incoming RN not following the transfer of delegation as outlined in Division 45: The only potential time saver if, after reviewing the step-
by-step instructions, the incoming RN deems sufficient.Caregivers continue to perform delegated tasks
even after the RN has left or quit and the task has not been re-delegated;
Sliding scale information is not addressed adequately;
RN DELEGATIONRN not leaving sufficient instructions on when
to contact the delegating RN immediately; andNot specifying when the re-evaulation will be
completed. In 90 days or 180 days etc. is not sufficient must at minimum indicate the week of or an actual date.
Compliance Trend ReportTop Ten Citations: 4/1/2014-6/30/2014
1: 260 Service Plans (45)
2: 270 Change of Condition(45)
3: 280 Resident Health Services (36)
4: 303 Treatment Orders (32)
5:310 Medication administration (32)
6: 240 Food Sanitation (30)
7: 370 Staffing Training(29)
8: 252 Resident Move in and eval (27)9: 290 Resident Health Services (24)10: 160 Reasonable Precautions (21)999: Technical assistance (52)
Hot Topics
CBC Web Site:http://www.oregon.gov/dhs/licensing/cbc/Pages/index.aspx
Oregon.gov, type in CBC provider tools
Manager’s Corner
Cory Oace, Residential and Assisted Living Manager
Thanks so much!
Next News hour:October, 9th, 2014
CBC web site Address:http://www.oregon.gov/dhs/spd/Pages/provtools/cbc/index.aspx