minnesota department of health assisted living home care provider licensing surveys surveys...

Minnesota Department of Health Assisted Living Home Care Provider

Licensing Surveys

Surveys Conducted May – October 2005

© Care Providers of Minnesota January 2006

Care Providers of Minnesota analyzed all the ALHCP licensing surveys conducted between the period of May 2005 through October 2005 that were posted by MDH on their web site.

The following slides will show the level of “success” by Assisted Living Providers during that time period. Areas with particularly “poor” survey results (50% or more receiving a correction order) will include examples of what prompted the correction orders to be issued.

Overall, ALHCP’s did worse in this round of surveys than in the previous round. However, this data is based on licensing surveys, not on licensing follow-up revisits. For some reason the state focused on follow-up revisits during this period; those results will be included in this presentation after the licensing survey results.

During this time period, the state conducted:

12 ALHCP Licensing Surveys

42 ALHCP Licensing Follow-up Revisits


#1: The agency only accepts and retains clients for whom it can meet the needs as agreed to in the service plan

8%8%

84%

ALHCP Surveys thatMet the Indicator ofCompliance

ALHCP Surveys thatMet the Indicator ofCompliance, but withEducation Provided

ALHCP Surveys thatreceived a CorrectionOrder Issued withEducation Provided


Failing to have Service Plans signed and dated in a timely manner

Failing to have a registered nurse supervise unlicensed personnel:

Up to 6 months between supervisory visitsNo RN supervisory visit within 14 days of initiation of servicesRN’s not documenting supervisory/monitoring visitsFailing to conduct clients functional status for med administration and the need for central storage of meds…ALL meds were centrally stored without documentation showing the need for centralized storage, and the service plan did not include the service of central med storage

Agency failed to documents the schedule or frequency of supervision/monitoring visits, nor the person(s) who conduct such visits

What observations or findings supported the issuance of this Correction Order?


Failing to ensure that a RN reviewed the clients service plan at least annually or when there was a change in a client condition or a change in service plan

The service plan did not address all services being provided…service plans not kept up-to-date

Failure to get a client’s written authorization to modify a service plan

Service plans did not include the frequency of supervision, the fee for services, and frequency of administration

Failure to have service plans at all!

Service plans were not modified to include fee increases

Continued observations or findings that supported the issuance of this Correction Order…


#2: Agency staff promotes the clients' rights as stated in the MN Home Care Bill of Rights

25%

17%

58%

ALHCP Surveysthat Met theIndicator ofCompliance

ALHCP Surveysthat Met theIndicator ofCompliance, butwith EducationProvided

ALHCP Surveysthat received aCorrection OrderIssued withEducation Provided


#3: The health, safety, and well-being of clients are protected and promoted

0%

58%

42%





Agency failed to provide tuberculosis screening (results must be read) prior to client contact

Agency failed to document infection control training for each employee every 12 months of employment

Agency failed to establish an abuse prevention plan for clients…no plans made or implemented to minimize identified areas of vulnerability

Agency failed to ensure background studies of staff were completed and in staff files prior to individual contact with clients

Agency failed to assure that each employee received orientation to Home Care requirements prior to providing services



#4: The agency has a system to receive, investigate, and resolve complaints from its clients and/or their representatives

100.0%





#5: The clients' confidentiality is maintained

83%

0%

17%

ALHCP Surveys that Metthe Indicator ofCompliance

ALHCP Surveys that Metthe Indicator ofCompliance, but withEducation Provided



#6: Changes in a client's condition are recognized and acted upon

92%

0%8%





#7: The agency employs (or contracts with) qualified staff

0%50% 50%

ALHCP Surveys that Metthe Indicator ofCompliance

ALHCP Surveys that Metthe Indicator ofCompliance, but withEducation Provided



No job descriptions

Failing to train unlicensed staff prior to performing delegated duties, ie: usually observed incorrect staff behavior and no training records or competencies were found to be on file.

Observations of staff not performing job duties properly, ie: eye drops administered wrong, nebulizer mask place upside down, failing to toilet a client despite multiple client requests…(all observed by the surveyor).

Delegated nursing procedures performed by unlicensed staff were not documented in the client records.



#8: Medications are stored and administered safely

8%

59%

33%ALHCP Surveys thatMet the Indicator ofCompliance




Agency failed to have a system for disposition of medications…expired or discontinued medications continued to be stored

Agency failed to provide locked, affixed storage of schedule II medications:

Utilized a locked box in a locked drawer, but nothing was affixed to the physical plantUtilized a locked container inside a locked cupboard, but the container was not permanently affixed inside the locked cupboard.Note – the concept is that a person should not be able to “walk-off” with a container of narcotics

Agency failed to ensure that a RN was informed when unlicensed personnel gave medications prn

Failing to document why a medication was not given as ordered



Medication dose changes were not dated in the record

Agency failed to ensure that a RN conducted nursing assessments of the clients’ functional status and need for assistance with medication administration

Licensed staff failed to document weekly medication set-ups (name-date-time-quantity) and unlicensed staff administering the medications failed to document each medication that was administered to clients

Agency failed to forward written orders to the prescribing physician for signature for verbal or telephone orders

Continued observations or findings that supported the issuance of this Correction Order…


#9: Continuity of care is promoted for clients who are discharged from the agency

92%

0% 8%





#10: The agency has a current license

92%

8% 0%





83.4%

58.3%

50.0%

58.3%

The Agency only accepts and retains clients for whom it can meet the needs as agreed to in the service plan.

The health, safety, and well-being of clients are protected and promoted.

The Agency employs (or contracts with) qualified staff.

Medications are stored and administered safely.

If you operate an ALHCP, and were to be surveyed by MDH TODAY…

These indicators of compliance are where your Quality Improvement plans and routine audits should be focused!

What are odds you will receive a correction order for the most common Indicators of Compliance issues?

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

SurveysCompletedMay 2005 -October2005

SurveysCompletedJan 2005 -April 2005

The Agency only accepts and retains client for whom is can meet the needs as agreed to in the service plan

Agency staff promote the clients’ rights as stated in the MN Home Care Bill of Rights

The health, safety, and well-being of clients are protected and promoted

Continuity of care is promoted for clients who are discharged from the agency

The agency has a current license

Medications are stored and administered safely

The agency employs or contracts with qualified staff

Changes in clients condition are recognized and acted upon

The agency has a system to receive, investigate and resolve complaints

The clients confidentiality is maintained

How did this “round” of published survey outcomes compare to the last round that was analyzed by Care Providers of Minnesota?

BIG

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BIG

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BIG

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BIG

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BIG

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What were the results of the 42 Licensing Follow-Up Revisits?

42 unannounced revisit surveys reviewed the progress on 147 separate correction orders that had previously been issued due to findings of non-compliance.

139 (95%) of the previously issued correction orders were found to be in full compliance upon resurvey.

8 (5%) were determined to be still out of compliance.


The 8 previously issued correction orders that were determined to still remain out of compliance upon resurvey were issued the following fines:

$50 1 (Incomplete Documentation)

$250 1 (Service Agreements)

$300 3 (staff orientation, training, meds)

$350 2 (Supervision, Meds)

$500 1 (Tuberculosis Screening)


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The key to having a “successful” ALHCP survey is to understand all 10 indicators of compliance, know what Minnesota Statutes and Rules make up the indicators of compliance, and know how your business and service delivery model operates.

If you know all that, AND you know what areas are most frequently found to be out of compliance, you can develop systems, audits, and quality improvement programs to keep your operation in full compliance!


Care Providers of Minnesota hopes that this information is useful in helping you to operate a successful Assisted Living Facility or Residence and be compliant with ALHCP requirements.

Please provide feedback regarding how this information could be presented in a more meaningful manner to:

Doug BeardsleyDirector of Quality Improvement and Regulatory AffairsCare Providers of [email protected]


mailto:[email protected]

minnesota department of health assisted living home care provider licensing surveys surveys...

Documents

wellbeing of clients

clients rights

clients condition

clients andor

clients confidentiality

agency staff

continuity of care

round of surveys