Besides Xanax, What is the Besides Xanax, What is the CNP’s Role in the Survey CNP’s Role in the Survey

ProcessProcess

• The survey process is probably one The survey process is probably one of the most stressful times for the of the most stressful times for the nursing home staff. Most facilities nursing home staff. Most facilities attempt to manage the process as attempt to manage the process as much as possible, however there are much as possible, however there are ingrained processes that they must ingrained processes that they must follow in the survey.follow in the survey.

The CNP roles begins prior to The CNP roles begins prior to the actual surveythe actual survey

• Always ensure that the Always ensure that the documentation is complete and clear documentation is complete and clear and concise.and concise.

• It goes without sayings, I am sure, It goes without sayings, I am sure, but ensure that there are no but ensure that there are no departmental battles in your notes. departmental battles in your notes. This will send red flags out to the This will send red flags out to the surveyors.surveyors.

General Survey ProtocolGeneral Survey Protocol

• Every facility is different in how they Every facility is different in how they manage the process, however it is manage the process, however it is common practice not to provide any common practice not to provide any copies of information to the surveyor copies of information to the surveyor directly. The surveyor should be directly. The surveyor should be directed to request information from directed to request information from the Administrator or DON.the Administrator or DON.

• It is wise to have a witness with you It is wise to have a witness with you if asked to speak with the surveyor. if asked to speak with the surveyor.

• Only answer the question asked, do Only answer the question asked, do not provide additional information.not provide additional information.

CNP/MD visitsCNP/MD visits

• Residents are required to be seen by Residents are required to be seen by the doctor every 30 days for the first 90 the doctor every 30 days for the first 90 days. It is recommended that the visits days. It is recommended that the visits alternate between the CNP and MD.alternate between the CNP and MD.

• They must be seen every 60 days after. They must be seen every 60 days after.

• A visit is timely if it is within 10 days A visit is timely if it is within 10 days after the due date.after the due date.

Quality MeasuresQuality Measures

• All nursing homes are rated based on All nursing homes are rated based on Quality Measures. These are broken Quality Measures. These are broken down between long term care and short down between long term care and short term residents. For the long term term residents. For the long term residents, the following are the items residents, the following are the items looked at:looked at:

• The percentage of residents experiencing The percentage of residents experiencing one or more falls with a major injuryone or more falls with a major injury

• Percent of long-stay residents with UTIPercent of long-stay residents with UTI

• Percent of long-stay residents who Percent of long-stay residents who self-report moderate to severe pain.self-report moderate to severe pain.

• Percent of long-stay residents with Percent of long-stay residents with pressure ulcerspressure ulcers

• Percent of long-stay residents who Percent of long-stay residents who lose control of their bowels or lose control of their bowels or bladder.bladder.

• Percent of long-stay residents who Percent of long-stay residents who have/had a catheter inserted and left.have/had a catheter inserted and left.

• Percent of long-stay residents who Percent of long-stay residents who were physically restrainedwere physically restrained

• Percent of long-stay residents whose Percent of long-stay residents whose need for help with daily activities has need for help with daily activities has increased.increased.

• Percent of long-stay residents who Percent of long-stay residents who lose too much weight.lose too much weight.

• Percent of long-stay resident who Percent of long-stay resident who have depressive symptomshave depressive symptoms

• Percent of long-stay residents Percent of long-stay residents assessed and given, appropriately assessed and given, appropriately the seasonal influenza vaccine.the seasonal influenza vaccine.

• Percent of long-stay residents Percent of long-stay residents assessed and given, appropriately, assessed and given, appropriately, the pneumococcal vaccinethe pneumococcal vaccine

• Percent of long-stay residents who Percent of long-stay residents who are administered antipsychotic are administered antipsychotic medications.medications.

Short-Stay ResidentsShort-Stay Residents

• Percentage of short-stay resident Percentage of short-stay resident who self-report moderate to severe who self-report moderate to severe painpain

• Percentage of short-stay residents Percentage of short-stay residents who new or worsening Stage II to who new or worsening Stage II to Stage IV pressure ulcersStage IV pressure ulcers

• Percentage of short-stay residents Percentage of short-stay residents assessed and given, appropriately, assessed and given, appropriately, the seasonal influenza vaccine. the seasonal influenza vaccine.

• The percentage of short-stay The percentage of short-stay residents assessed and given, residents assessed and given, appropriately, the pneumococcal appropriately, the pneumococcal vaccinevaccine

• The percentage of short-stay The percentage of short-stay residents who are newly residents who are newly administered antipsychotic administered antipsychotic medications.medications.

• Based on these measure, we can Based on these measure, we can obviously control some of them, obviously control some of them, however, not all. Most facilities try to however, not all. Most facilities try to manage these situations as much as manage these situations as much as possible, however there are always possible, however there are always situations we cannot control. This is situations we cannot control. This is when the ongoing documentation to when the ongoing documentation to “prove” the actual situation becomes “prove” the actual situation becomes vital. vital.

FallsFalls

• We would all love to have a “fall free We would all love to have a “fall free facility”, however that is impossible. facility”, however that is impossible. This is why we need to review each fall This is why we need to review each fall on an ongoing basis and add some on an ongoing basis and add some type of interventions. It truly takes a type of interventions. It truly takes a team approach to be as creative as we team approach to be as creative as we need to with interventions related to need to with interventions related to fall. It is important as well, to rule out fall. It is important as well, to rule out medical issues.medical issues.

Urinary Tract InfectionsUrinary Tract Infections

• Again, we really cannot control this Again, we really cannot control this area 100% ! area 100% !

• As the CNP, you need to ensure that As the CNP, you need to ensure that treatment is rendered as needed and treatment is rendered as needed and appropriate and that for the resident appropriate and that for the resident with frequent UTI’s all appropriate with frequent UTI’s all appropriate interventions are in place.interventions are in place.

• Educate residents, families and staff.Educate residents, families and staff.

Pain ManagementPain Management

• This is always a challenging area to This is always a challenging area to ensure that triggers do not occur. We ensure that triggers do not occur. We all have the resident who will smile, all have the resident who will smile, show absolutely no s/s of pain, but will show absolutely no s/s of pain, but will rate their pain at 9 – 10. We basically rate their pain at 9 – 10. We basically need to show that we are attempting to need to show that we are attempting to assess and address the pain, and again assess and address the pain, and again educate residents on pain and educate residents on pain and document.document.

Loss of Bowel or Bladder Loss of Bowel or Bladder ControlControl

• Again, we wish we could control ones muscle Again, we wish we could control ones muscle control, however…….control, however…….

• This is related to low risk residents who do not This is related to low risk residents who do not have severe memory losses and/or severe have severe memory losses and/or severe limitations in mobilitylimitations in mobility

• We always need the appropriate We always need the appropriate documentation to explain why declines have documentation to explain why declines have occurred and to show that we have made all occurred and to show that we have made all appropriate referrals and attempts to control appropriate referrals and attempts to control what we can.what we can.

CathetersCatheters

• I certainly don’t need to tell you about the I certainly don’t need to tell you about the risks related to catheters!risks related to catheters!

• The CNP/MD need to ensure that all The CNP/MD need to ensure that all attempts have been made to discontinue attempts have been made to discontinue the use of a catheter. If unable, we need the use of a catheter. If unable, we need to show that the urologist was involved, to show that the urologist was involved, that appropriate medications were that appropriate medications were attempted and that the appropriate attempted and that the appropriate diagnosis is in place.diagnosis is in place.

Appropriate DiagnosesAppropriate Diagnoses

• Obstructive uropathyObstructive uropathy

• Neurogenic bladderNeurogenic bladder

• Treatment of stage III or IV pressure Treatment of stage III or IV pressure ulcer for an incontinent resident.ulcer for an incontinent resident.

Physical RestraintsPhysical Restraints

• Most facilities refuse to use any Most facilities refuse to use any physical restraints. physical restraints.

• If there is a situation where a If there is a situation where a restraint is used, please ensure that restraint is used, please ensure that there is appropriate documentation there is appropriate documentation to justify the temporary use of and to justify the temporary use of and removal of the restraints.removal of the restraints.

ADL’sADL’s

• Obviously, the need for assistance with Obviously, the need for assistance with ADL’s is one of the main reasons residents ADL’s is one of the main reasons residents are admitted to facilities. When a resident are admitted to facilities. When a resident needs more assistance with eating, needs more assistance with eating, transferring, changing position in bed and transferring, changing position in bed and toileting, our quality measures change.toileting, our quality measures change.

• We need to ensure that we are doing We need to ensure that we are doing everything possible to maintain their level everything possible to maintain their level of functioning with either therapy referrals of functioning with either therapy referrals or restorative nursing programs.or restorative nursing programs.

• If there is a sudden decline in ones If there is a sudden decline in ones abilities, is there a medical reason for abilities, is there a medical reason for this which obviously needs addressed.this which obviously needs addressed.

• If there is a slow steady decline, it If there is a slow steady decline, it may be the normal aging process.may be the normal aging process.

• Or, there may be a temporary decline Or, there may be a temporary decline related to an acute medical situation.related to an acute medical situation.

•DOCUMENT WHAT YOU FINDDOCUMENT WHAT YOU FIND

Weight LossWeight Loss

• Obviously with weight loss, the CNP Obviously with weight loss, the CNP will work closely with the facility will work closely with the facility Dietician to ensure all appropriate Dietician to ensure all appropriate interventions are in place to prevent interventions are in place to prevent weight loss.weight loss.

• Rule out medical issues that could be Rule out medical issues that could be associated with the weight loss.associated with the weight loss.

•DocumentDocument

Influenza and Pneumococcal Influenza and Pneumococcal VaccinesVaccines

• The primary role of the CNP in this The primary role of the CNP in this area is education of residents and area is education of residents and family to encourage the use of the family to encourage the use of the vaccines. Again, it certainly does not vaccines. Again, it certainly does not hurt to document the reasons for the hurt to document the reasons for the refusals, however this area is refusals, however this area is basically documented in numbers.basically documented in numbers.

Depressive SymptomsDepressive Symptoms

• This is a very difficult area. On one end of the This is a very difficult area. On one end of the spectrum, a facility get reimbursed more for spectrum, a facility get reimbursed more for residents with s/s of depression being present. residents with s/s of depression being present.

• We all know that with all of life losses that our We all know that with all of life losses that our residents are facing, depression is very residents are facing, depression is very prevalent.prevalent.

• This measure monitors the increase in signs This measure monitors the increase in signs and symptoms, therefore the appropriateness and symptoms, therefore the appropriateness of treatment is very important.of treatment is very important.

• Most social workers will notify the Most social workers will notify the CNP/MD of significant scored on the CNP/MD of significant scored on the PHQ9. This is the assessment we use PHQ9. This is the assessment we use for mood. for mood.

• We need to show that we have made We need to show that we have made attempts both non-pharmacy related attempts both non-pharmacy related and pharmaceutical as needed.and pharmaceutical as needed.

• We need to show the team approach We need to show the team approach to attempts at treatment and again to attempts at treatment and again the appropriate documentation the appropriate documentation needs to be in place.needs to be in place.

Psychoactive MedicationsPsychoactive Medications

• The nursing facility is mandated to The nursing facility is mandated to decrease the use of psychoactive decrease the use of psychoactive medications by 25% by the end of medications by 25% by the end of 2015 and by 30% by the end of 2016.2015 and by 30% by the end of 2016.

• This being said, we also have behaviors This being said, we also have behaviors that need to be treated. The goal is to that need to be treated. The goal is to reduce the use of medication with the reduce the use of medication with the black box warning.black box warning.

Each resident’s drug regimen must be free from unnecessary Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drugdrugs. An unnecessary drug is any drug when usedis any drug when used::

• (i) In excessive dose (including duplicate therapy); or

• (ii) For excessive duration; or • (iii) Without adequate monitoring• (iv) Without adequate indications for

its use; or • (v) In the presence of adverse

consequences which indicate the dose should be reduced or discontinued

That is great but…….That is great but…….

• The CNP need to monitor PRN meds and The CNP need to monitor PRN meds and discontinue when they are not needed.discontinue when they are not needed.

• Consult with the MD about the Consult with the MD about the medications and document the effects. medications and document the effects.

• If a dose reduction is attempted and is If a dose reduction is attempted and is not successful, you need to ensure that not successful, you need to ensure that there is adequate documentation to there is adequate documentation to justify failure of the attempted reduction.justify failure of the attempted reduction.

Pressure UlcersPressure Ulcers

• Ensure that your notes indicate that Ensure that your notes indicate that the ulcer/s are unavoidable.the ulcer/s are unavoidable.

• You are encouraged to document all You are encouraged to document all known attempts at avoiding the known attempts at avoiding the development of ulcers as well as development of ulcers as well as non-compliance on the part of the non-compliance on the part of the residents.residents.