State Veterans Home Clinical & Survey Oversight State Veterans Home Clinical & Survey Oversight Nancy Quest, Chief Office of Geriatrics and Extended Care.

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

22

33


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.

44


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 – [email protected]– Call – (706) 481-6736


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

55


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

66


Facility Reports (beginning April 5, 2010)– QM/QI Reports– Source Data Reports– Resident Level Summary

National Reports (beginning ???) – QM/QI Monthly Reports– Big Book

77


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

88

99


Reportable Events Handbook

– Team of Stakeholders

•Representatives of the National

Association of SVH

•Representatives of VACO GEC

•VISN liaisons

•VAMC Representatives

1010


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

1111


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

1212


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.

1313


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

1414


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


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

1515

1616


THANK YOU

State Veterans Home Clinical & Survey Oversight State Veterans Home Clinical & Survey Oversight Nancy Quest, Chief Office of Geriatrics and Extended Care.

Documents

rca state home

state homes

nursing home facilities

mutual cooperation slide

commercial mds software

assessment initial

assessment document

software vendor