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2015 State Veterans Homes VA Survey Deficiency Overview
For NASVH Summer ConferenceSandusky, OH
Valarie DelankoJoAnne Parker
Office of GEC Operations (10NC4)
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Discussion Topics
• Overview of SVH survey deficiencies – January through March 2015
• Immediate Jeopardies• Sentinel Event Reporting• Falls Collaborative Update• Recognition Survey Updates
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SVH Program Census
Current SVH Program Structure offering three levels of care:– 152 State Veterans Home Facilities• 143 Nursing Home Care programs
(25, 216 beds)• 55 Domiciliary Care programs (6,176
beds• 2 Adult Day Health Care programs
(85 participant slots)
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# of Recognized SVHs 2008 - 2015
2008 2009 2010 2011 2012 2013 2014 2015125
130
135
140
145
150
155
137 137 138
142 143146
149152
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Surveys Types 2010 – June 2015
2010 2011 2012 2013 2014 20150
20
40
60
80
100
120
140
160
87
134 135 140150
87
4 11 12 10 11 76 3 3 1 1 1
Total Survey Types
#Annual #Recognition #For Cause
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Totals
Function March 2015
2014 2013
Number of nursing home care surveys
47 146 142
Number of nursing home care deficiencies
159 464 385
Avg. number of deficiencies per survey 3.38 3.18 2.71
Number of domiciliary surveyed 18 57 55
Number of domiciliary deficiencies 8 53 55
Avg. number of deficiencies per survey .44 .93 1.00
Number of adult day health care surveys
1 2 3
Number of adult day health care deficiencies
1 0 0
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Nursing Home Citing's - CategoryCategory Jan. to
March 2015
Jan. to March 2014
Jan. to March 2013
Resident Rights 51.70 2 0 2
Resident Behavior and Facility Practice 51.90
19 8 6
Quality of Life 51.100 9 2 9
Resident Assessment 51.110 28 30 17
Quality of Care 51.120 43 26 20
Nursing Care 51.130 1 0 1
Dietary Services 51.140 6 3 0
Physician 51.150 0 0 0
Specialized Rehabilitation Services 51.160
0 0 0
Pharmacy Service 51.180 4 3 2
Infection Control 51.190 7 3 4
Physical Environment 51.200 39 72 36
Administration 51.210 1 2 0
Domiciliary Citing's - CategoryCategory Jan. to
March 2015
Jan. to March 2014
Jan. to March 2013
Governance and Administration 0 0 0
Safety 4 14 11
Physical Environment 1 0 0
Medical Care 1 1 0
Nursing Service 0 1 0
Rehabilitation 0 0 0
Social Services 0 0 0
Dietetics 0 1 1
Resident Activities 1 0 0
Pharmacy 0 0 0
Medical Records 0 0 0
Quality Assurance 0 0 0
Quality of Life 1 0 0
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Immediate Jeopardy Numbers
2010 2011 2012 2013 2014 20150
2
4
6
8
10
12
14
16
18
0
810
4
1614
June 2015
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Justification for IJ:
2015Regulation Issues - 6
51.190 Resident Behavior-Abuse #65 #66
• Residents have had multiply verbal and physical altercations with other residents and staff;
• Bed lowered on resident foot by staff during transfer;
• (2) Residents with multiple elopements w/ no investigations;
• Neglect in wake of tornado warning;
• Referral to Urologist was not submitted.
2014Regulation Issues - 2
51.190 Resident Behavior-Abuse #65 #66
• Resident in fear of care by CNA;
• New resident with elopement risk but was not accessed in 7 days and had 2 departures from facility.
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Justification for IJ:
2015Regulation Issues - 5
51.120 Quality of Care -Accidents #108
• Residents with multiple falls, in adequate falls program and policy;
• Resident cognitive impaired with burns from hot liquids;
• Facility is a no smoking facility, but 3 residents identified as smoking;
• Residents with 2nd degree burns from coffee;
• Resident assessed to need WanderGuard but did not have one.
2014Regulation Issues - 8
51.120 Quality of Care -Accidents #108
• Coffee burn;
• Widespread falls concerns (2);
• Eating vs NPO;
• Unsafe smoking practices(2),;
• High water temperatures in bathroom sinks;
• High instances of physical aggression.
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Justification for IJ:
2015Regulation Issues - 2
51.200 Physical Environment-Life Safety #147 - DOM #167
• Fire monitoring company has not received fire alarm signals for 3 months, fire doors held open;
• Fire alarm not communicating with fire monitoring company for 2 weeks, no fire watch implemented;
2014Regulation Issues - 2
51.200 Physical Environment-Life Safety #147 - DOM #167
• Fire pumps (2) operational for only one (1) hour;
• Dish machine wash temperature utilized to clean dishes below manufactures required safety temperature.
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Justification for IJ:
2015Regulation Issues - 1
51.111 • Residents with tracheostomy tubes at risk because trach emergency kit not available and no current training for RNs to reinsert.
2014Regulation Issues - 0
51.111
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Sentinel Events §51.120 Quality of care.
Sentinel Event Reporting
State Veterans Homes must report sentinel events to the VA Medical Center of Jurisdiction as outlined in 38 CFR Part 51 and 52.
(a) Reporting of Sentinel Events—(1) Definition. A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function.
(2) Examples of sentinel events are as follows:
(i) Any resident death, paralysis, coma or other major permanent loss of function associated with a medication error; or
(ii) Any suicide of a resident, including suicides following elopement (unauthorized departure) from the facility; or
(iii) Any elopement of a resident from the facility resulting in a death or a major permanent loss of function; or
(iv) Any procedure or clinical intervention, including restraints, that result in death or a major permanent loss of function; or
(v) Assault, homicide or other crime resulting in patient death or major permanent loss of function; or
(vi) A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall.
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Sentinel Events §51.120 Quality of care.
(3) The facility management must report sentinel events to the director of VA medical center of jurisdiction within 24 hours of identification. The VA medical center of jurisdiction must report sentinel events by calling VA Network Director (10N 1-22) and Chief Consultant, Office of Geriatrics and Extended Care (114) within 24 hours of notification.
(4) The facility management must establish a mechanism to review and analyze a sentinel event resulting in a written report no later than 10 working days following the event. The purpose of the review and analysis of a sentinel event is to prevent injuries to residents, visitors, and personnel, and to manage those injuries that do occur and to minimize the negative consequences to the injured individuals and facility.
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Falls Collaborative: 2015
Preventing Falls and Fall Related Injuries for Veterans
• Continuing collaboration between NASVH and the National Center for Patient Safety (NCPS).
• AIM: Reduce preventable falls & reduce injurious falls.• Special thank you to Eric Jordon, Julia Neily and Pat
Quigley.• Program caped at 30 SVHs due to resources and
availability of coaches from NCPS. 5 total coaches.• 3 SVH facilities returned from 2014 program.• Participating States: WA, SC, NC, WI, VA, TX, LA, OK,
CA, MI, NM, KY, ME, UT, NJ, NY• Utilization of Survey Monkey tool for immediate
feedback.
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Falls Collaborative: 2015
Formal Program Outline• May 1– applications had to be submitted to be a part of
total 30.• June 1 & 5 – Pre-work calls – 90% participation• June 30 – SVH baseline reports due (PP template) - 67%• July & August – Meet & greet calls between NCPS
coaches and the assigned SVHs.• September 10 – “Overview of the Science for Fall
Prevention in LTC”• October 8 – “VeHU Preventing Fall Related Injuries”• November 5 – “Types of Falls and Decision Tree”• December 3 – “Injury Reduction Strategies”• January 31, 2016 – SVH submits final summary of
changes
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Falls Collaborative: 2015
Informal Program Outline• September 24 – Open forum, discussion and
implementation• October 10 – SVH facilities submit monthly report
of progress• October 22 - Open forum, discussion and
implementation• November 10 – SVH facilities submit monthly report
of progress• November 19 - Open forum, discussion and
implementation• December 10 - SVH facilities submit monthly report
of progress• December 17- Evaluation of Post Falls Huddles
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Recognition Update: 2/2015 – 7/ 2015
Approved Recognitions
Redding, CA 60-Bed NH
West Los Angeles, CA 84-Bed DOM Addition(Total of 168 DOM Beds)72-Bed NH
Marshalltown, IA 509-Bed NHC (66-Bed Reduction)
Fresno, CA 180-Bed DOM
West Lafayette, IN 337-Bed NH (128-Bed Reduction)80-Bed DOM (35-Bed Reduction)
Lebanon, OR 154-Bed NH
Bennington, VT 130-BH NH (41-Bed Reduction)
Pending Recognition
Hilo, HI 24-Participant ADHC
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Questions?
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Contacts
• Valarie Delanko, RDN, LDN, CPHQ National Program Manager SVH Quality &
Survey Oversight814-860-2201• Jo Anne Parker, MHA
National Program Manager SVH Survey
Process202-623-8328
