36C24218R0185-002.pdf

Exclusionary Review Form

Name of Nursing Home:

Address: City: State: Zip:

Six Digit Provider Number (Facility ID#): VAMC:

Date of Paper Review: Date of On-site Review (if applicable):

This Contract Nursing Home (CNH) Exclusionary Review Form is used to help determine if a CNH should be excluded from participation in the VA’s CNH Program. If the CNH fails 4 or more of the 7 sections listed below, then the CNH should be excluded. However, these criteria are not comprehensive measures, may not account for corrective actions taken by the CNH, and do not replace sound clinical judgment when making a final decision regarding approval of a CNH to participate in the CNH Program.

About F-Tags: The Center for Medicare and Medicaid Services (CMS) uses an alphabet/numeric designation for each nursing home standard called an “F-Tag” (e.g.: F221). “F” pertains to the section of the federal regulations where national nursing home standards are delineated and each standard is tagged (assigned) a unique number. Typically, State teams conduct annual surveys of CNHs to determine compliance with these Standards. Deficient F-Tags are cited on Form CMS-2567 “Statement of Deficiencies and Plan of Correction”. Each deficient F-Tag is also given a Scope and Severity rating that ranges from “A” up to the worst “L.” The deficiencies found on each CNH are listed online at: www.medicare.gov/nursinghomecompare

1. Deficiencies rated G- L: Standard: CNH fails this criterion when there are three or more level G - L deficient standards in the current State survey and subsequent findings as shown in Nursing Home Compare. (Note that G- L deficiencies are equivalent to a Nursing Home Compare “Level of Harm” of 3 or 4.)

F-Tag Scope and Severity (G – L) Title/Description Current

Deficiency

Pass Fail Section # 1 Rating

2. Health Requirement Deficiencies: Standard: CNH fails this criterion when “Total Number of Health Deficiencies” is equal to or greater than twice the State average as reported in Nursing Home Compare for the current annual State survey and subsequent findings as shown in Nursing Home Compare.

Current # at Facility

State Average

Total Health Requirement Deficiencies

Section # 2 Rating Pass Fail

D.9 ATTACHMENT

http://www.medicare.gov/nursinghomecompare

3. Staff Treatment of Residents and Facility Licensure: Standard: CNH fails this criterion when there are one or more E-L deficiencies in the current State Survey and subsequent findings as shown in Nursing Home Compare. (Note that deficiencies rated E-F in Scope and Severity are equivalent to Nursing Home Compare “Level of Harm” of 2 with “Some” or “Many” residents affected; and Scope and Severity G-L deficiencies are equivalent to a Nursing Home Compare “Level of Harm” of 3 or 4)

F-Tag Title Description Pass Fail

F221 Physical Restraints The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.

F222 Chemical Restraints The resident has the right to be free from any chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.

F223 Abuse The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.

F225 Staff Treatment of Residents

The nursing home will not employ individuals who have been:

found guilty of abusing, neglecting or mistreating residents by a court of law;

have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities.

F226 Staff Treatment of Residents

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property.

F241 Dignity The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.

F491 Licensure A facility must be licensed under applicable State and local law.

Section # 3 Rating gggggggggggggggggggggggggggggggggccccccccccccccccccc Section # 3 Rating Pass Fail

4. RN Hours: Standard: CNH fails this criterion when “RN Hours per Resident per Day” are below State average. Use Nursing Home

Compare information only.

Current

Average at Facility

State Average

RN Hours per Resident per Day

Section # 4 Rating Pass Fail

5. Total Nursing Staff: Standard: CNH fails this criterion when “Total number of nurse staff hours per resident per day” are below State average. Use Nursing Home Compare information only.

Current

Average at Facility

State Average

Total number of nurse staff hours per resident per day

Section # 5 Rating Pass Fail

6. Staffing Deficiencies: Standard: CNH fails this criterion when there is one or more F-Tag deficiencies rated as E – L in the current State survey and subsequent findings as shown in Nursing Home Compare. (Note that Scope and Severity deficiencies rated E-F are equivalent to Nursing Home Compare “Level of Harm” of 2 with “Some” or “Many” residents affected, and Scope and Severity G-L deficiencies are equivalent to a Nursing Home Compare “Level of Harm” of 3 or 4.)

F-Tag Title Description Pass Fail

F353 Nursing The facility must provide services by sufficient numbers of personnel on a 24-hours basis to provide nursing care to all residents in accordance with resident care-plans.

F494 Nursing Aide Training Nursing Aides must have completed training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements.

F495 Nursing Aide Competency

Nursing Aides must have completed a State approved training and competency evaluation program; or a competency evaluation program approved by the State as meeting the requirements; have demonstrated competence through satisfactory participation in a State approved nursing aide training and competency evaluation program and have been deemed or determined competent.

F496 Nursing Aide Registry Verification

The facility must receive registry verification that the individual has met/completed training.

F497 Regular In-Service Training

The facility must complete a performance review of every nursing aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews.

F498 Proficiency of Nursing Aides

The facility must ensure that nursing aides are able to demonstrate competency in skills and techniques necessary to care for resident assessments, and described in the plan of care.

F499 Staff Qualifications The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements.

Professional staff must be licensed, certified, or registered in accordance with applicable State laws.

Section # 6 Rating Pass Fail

7. Quality Measures: Standard: CNH fails this criterion when 6 or more of the CMS Quality Measures listed in Nursing Home Compare are worse than the State average. (Note: 6 QMs were added to Nursing Home Compare in spring of 2016)

Quality Measures Facility Percent

State Average

Flagged (because worse than State average)

Percentage of short-stay residents who made improvements in function.

Percentage of short-stay residents who were re-hospitalized after a nursing home admission.

Percentage of short-stay residents who have had an outpatient emergency department visit.

Percentage of short-stay residents who were successfully discharged to the community.

Percent of Short Stay Residents Who Self Report Moderate to Severe Pain Percent of Short Stay Residents with pressure Ulcers That are New or Worsened Percent of Short Stay Residents Assessed and Given, Appropriately, the Seasonal Influenza Vaccine Percent of Short Stay Residents assessed and Given, Appropriately, the Pneumococcal Vaccine Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication Percent of Long-Stay Residents Experiencing One or More Falls With Major Injury Percent of Long-stay Residents with a Urinary Tract Infection

Percent of Long-Stay Residents Who Self-Report Moderate to Severe Pain

Percent of Long-Stay High-Risk Residents With Pressure Sores

Percent of Long-Stay Low-Risk Residents Who Lose Control of Their Bowels or Bladder

Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder

Percent of Long-Stay Residents Who Were Physically Restrained Percentage of long-stay residents whose ability to move independently worsened.

Percent of Residents Whose Need for Help With Daily Activities Has Increased Percent of Long-Stay Residents Who Lose Too Much Weight Percent of Long-Stay Residents who Have Depressive Symptoms

Percentage of long-stay residents who received an antianxiety or hypnotic medication.

Percent of Long-Stay Residents Assessed and Given, Appropriately, the Seasonal Influenza Vaccine Percent of Long-Stay Residents assessed and given, Appropriately, the Pneumococcal Vaccine Percent of Long-Stay Residents Who Receive an Antipsychotic Medication

Section # 7 Rating Pass Fail

Summative Assessment: Did the CNH pass 4 or more sections of this Exclusion Review Form? Yes No

(If “No,” then CNH should not be allowed to participate in the VAMC’s CNH program unless a “Request for Exclusionary Criteria Exemption” has been approved by the Medical Center Director, VISN Network Director, and submitted by the VISN to VA Central Office GEC Operations staff for review and approval)

Additional information reviewed by the CNH Review Team includes:

• Date of most recent State survey (including Form CMS- 2567; “Statement of Deficiencies and Plan of Correction”)

• Date of most recent annual Fire Safety Inspection

• Plan of Correction submitted by CNH to the State & approved by State regulatory agency? Yes; No

• Based on review of Nursing Home Compare and other data, is a site visit planned? Yes ; No

PROPOSED ACTIONS

Establish contract authorization Renew/continue contract authorization

Suspend placement of veterans Remove, transfer veterans on contract

Do not renew/establish contract authorization Terminate the contract Comments:

VA Team Members participating in review:

Name/Title Date

Name/Title Date

Name/Title Date

Name/Title Date