State Veterans Home Clinical & Survey Oversight State Veterans Home Clinical & Survey Oversight Nancy Quest, Chief Office of Geriatrics and Extended Care.
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State Veterans Home Clinical & Survey Oversight
State Veterans Home Clinical & Survey Oversight
Nancy Quest, ChiefOffice of Geriatrics and Extended Care
Patient Care ServicesDepartment of Veterans Affairs Central Office
State Home Clinical & Survey State Home Clinical & Survey OversightOversight
Adult Day Health Care Regulation
Domiciliary Regulation
Resident Assessment Instrument /
Minimum Data Set
Reportable Events Handbook
Upcoming Training Conferences
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Resident Assessment Instrument (RAI) Minimum Data Set (MDS) – 38 CFR Part § 51.110 Resident assessment
• (d) Submission of assessments. Each assessment (initial, annual, change in condition, and quarterly) using the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Minimum Data Set, Version 2.0 must be submitted electronically to VA at the IP address provided by VA to the State within 30 days after completion of the assessment document.
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What to use– Software – No purchase required!
• MDS generic software “Raven” – http://www.cms.hhs.gov/MinimumDataSets20/07_
RAVENSoftware.asp
– Commercial MDS software can be used
Where to begin– First step
• Contact Janet Barber, Chief MDS Program – Email – janet.barber2@va.gov– Call – (706) 481-6736
State Home Clinical & Survey State Home Clinical & Survey OversightOversight
When to transmit– Transmissions became effective May 29,
2009• All data from May 29, 2009 to present
Who is included– Transmissions include data for all residents
**Veteran **Spouse **Gold Star Parent
Why transmit– Comprehensive overview of facility residents– Data used in resident-centered surveys– Comprehensive reports
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Current status
– 131 nursing home facilities
– 117 of 131 facilities transmitted data
– 9 of 117 facilities have not transmitted in
2010
– 14 of 131 facilities have not transmit
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Facility Reports (beginning April 5, 2010)– QM/QI Reports– Source Data Reports– Resident Level Summary
National Reports (beginning ???) – QM/QI Monthly Reports– Big Book
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Coming Soon MDS 3.0
– Facilities certified by CMS are required to
use MDS 3.0 effective October 1, 2010
– Facilities that do not participate in CMS
may continue using MDS 2.0
Note – those continuing with V2.0 should check with software vendor to ensure continued support of V2.0
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Reportable Events Handbook
– Team of Stakeholders
•Representatives of the National
Association of SVH
•Representatives of VACO GEC
•VISN liaisons
•VAMC Representatives
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THE VISION
– Includes all reporting requirements currently
in the Federal Regs and replaces all other
previous guidance
– Minimizes the burden on State Homes and VA
– Limits reporting to those items of greater
significance
– Encourages mutual cooperation
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MAJOR ELEMENTS A distinction between “Required” and
“Requested” reports No requirement for RCA State home may report using their own format
(with some guidelines) Reporting timeframes are provided Not all adverse events need reporting Responsibility on local facility to create issue brief
as needed
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REQUIRED REPORTS
Reports required by Federal Regulation
– Sentinel Events
– Change in administration
• The State agency and individual responsible for oversight of a
State home facility
• The State home administrator
• The state employee responsible for oversight of the State
home facility if a contractor operates the State home.
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REQUESTED REPORTS
Elopements pursuant to state regulations
Infectious outbreaks – events reportable to
public health agencies pursuant to state
regulations
Resident to resident altercations resulting in
any injury that is other than minor
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Adverse Events Inspections or Surveys by oversight
agencies:– Copies of annual surveys conducted by state
licensure oversight agencies– Unexpected surveys or inspections by
governing oversight agencies when a deficiency is cited and a plan of correction is required.
Information regarding the SVH that appears in local or national media
State Home Clinical & Survey State Home Clinical & Survey OversightOversight
Upcoming Training Conferences
1.MDS 3.0 Regional Training Conferences – Eastern Region (VISN 1-12) – 7/20-22 in Atlanta– Western Region (VISN 15-23) – 8/17-19 in
Denver Contact Janet Barber if you are interested in having your facility
MDS Coordinator attend
2.Clinical & Survey Oversight– Eastern Region (VISN 1-8) – 7/20-22– Central Region (VISN9-16 & 23) – 8/10-12– Western Region (VISN 17-22) – 8/24-26
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THANK YOU
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