DAL DAL 16 12 Guide for Quality Assurance in Adult Care Facilities Attachment

Transcript

1 Guide for Quality Assurance (QA) in Adult Care Facilities to assist The purpose of this guide is to serve as a resource Adult Care Facility administrators , operators and staff with understa nding the basic principles of (ACF) QA and to assist them with applying these principles when /Quality Improvement (QI) devel oping and implementing their QA/QI plan(s) for each area of operation in their facility. I. Quality Assurance Regulatory Requirements Chapter 735, Section 1 of the Social Service Law 461- a(2)(c) effective August , requires operators of an “Adult Home or Residences for Adults 2, 1994, to develop, biannually update and implement plans for quality assurance activities for each area of operation. Quality assurance activities include but are not limited to, development and maintenance of performance standards, measurement of adherence to such standards and to applicable state and local laws and regulations, identification of perf ormance failures, design, and implementation of corrective action.” Adult Care Facility Regulation 18 NYCRR 487.10(d)(5)(ix) requires “at a minimum, the operator shall maintain records documenting the development, implementation and, at a minimum, the bi -annual updating of quality assurance activities for each area of facility operation. These must include, at a minimum, the development and maintenance of performance standards, m easurement of adherence to such standards and to applicable state and local laws and regulations, identification of performance failures, design and impl ementation of corrective action.” II. Effective Quality Assurance ssurance is a system for evaluating performance that focuses on Quality A structure, process and outcomes to reduce or resolve identified problems or improve operations. Quality Assurance Programs are planned, objective, comprehensive, systematic, measurable and ongoing. Qualit y Assurance: • is an ongoing process and acts as a system of “checks and balances” for the organization through the development of standards with measurable goals, documentation of policies and procedures, staff training and review of data associated with standards; • assist in adheri ng to standards and regulations; • includes monitoring activities to assure or improve the quality of care and services through: o identification of areas in need of improvement ; to address areas of deficiencies and actions ive o development of correct 1 11 of Page

2 o -up monitoring to ensure effectiveness of corrective action s taken follow . to rectify concern(s) III. Quality Assurance Plan provides a framework to ensure delivery of quality The Quality Assurance Plan and services and to facilitate the establishment of quality assurance care . The Quality Assurance P lan activities should define objectives, roles and responsibilities along with planned monitoring activities that are updated twice per year . IV. Quality Assurance Committee (Recommended Not R equired) The Q Assurance Committee meet s periodically to review findings from uality monitoring activities, evaluate effectiveness of corrective actions, and identify trends and improvement activities. C ommittee representation m ay include the administrator, operator , emplo yee from eac h area of operation, and the Resident Council President or other resident representative. Information obtained from QA/QI activities is also shared with staff. Quality Assurance Process V. Plan, Do, Check, and Act is one method of approaching QA. P lan, D o, The heck, and A ct method includes four steps: C 1. Plan. Recognize an opportunity for improvement and plan a change (e.g. specify problem areas for improvement based on the root cause obtained from the analysis ). Root Cause Analysis : a) What is the problem? b) Why did the problem happen (the causes)? Drill down each cause to its root by asking Why? Why? Why? c) What specifically should be done to overcome the problem or to prevent the problem from happening again? 2. Do. Identify , develop, implement and test corrective actions (e.g. change process based on recommended corrective actions , develop new policies based on revised process , implement revised process and , inservice staff identify person responsible for monitoring ). Keep it simple and communicate your actions to all staff ! (with QA Committee members, staff involved in the 3. Check . Review findings of corrective actions an .), analyze the results review process, etc d identify 2 11 of Page

3 what you’ve learned (e.g. evaluate the effectiveness of /ineffectiveness corrective interventions) . Act. Take action based on lessons learned. If the change did not work, 4. based on findings the cycle again with a revised plan and lessons perform learned . If you were successful, incorporate what you learned into other areas of the facility’s operations where applicable (e.g. food services, environmental, medication assistance, case management, facility records) . Use what you learned to plan new improvements, beginning the cycle again. (Monitor and modify services and operations on an ongoing basis based on lessons learned) . Don’t wait for the DOH to issue a finding or violation! –Check– Plan –Do Act Example Steps for Continuous Improvement : PLAN VI. Areas for Improvement 1. Identifying Possible sources : -Resident Council minutes -Food Committee minutes -Resident Suggestion Box -Employee Suggestion Box -Family meetings , suggestions, grievances conversations with residents, family, staff -Informal -DOH Inspection Reports 3 11 of Page

4 2. Prioritizing -Identify and l ist all areas in need of improvement . -Prioritize areas in need of improvement and re- list in order of importance; the most important first, the least important last. -Identify solutions (corrective actions) for each of the areas including resources: money, equipment, training, personnel (including experts from the community), time com mitment, and any other factors that may be helpful. - Identify monitoring measures (e.g. state inspection reports , resident satisfaction) . - Identify reporting process for monitoring activities (Committee, Administ rator, etc.) . 3. Do corrective actions. For example, -Obtain necessary resources to implement trainers for staff training, exterminator for bedbugs, new equipment, etc.). -Develop educational information, policies, procedures, etc. pertinent to corrective actions. -Educate and train staff, residents, and families (as necessary) to the changes ). Engage your local ombudsman. upcoming corrective actions ( -Develop monitoring forms if indicated and i mplement monitoring activities (record reviews, observations, satisfacti on surveys, checklists). -Implement corrective actions as planned. Check 4. -Observe effects of corrective action( s) . Did the actions resolve the problem or improve the areas in need of improvement as intended? -Are there any undesired effects related to the implementation of the corrective action( s) ? Is there a need for additional c orrective actions ? (If so, the planning section) repeat the steps outlined in . -Consult with residents, staff, families, resident council and food committee Did the corrective action( s) result in change that met their members, etc. expectations? 5. Act -Continue with the corrective action( s) once the imple mentation/evaluation process is complete and reflect s improvement in identified areas. -Determine method to ensure ongoing effectiveness of corrective action. This monitoring of each area that confirm as appropriate to should include periodic improvement and/or correction is sustained (e.g. resident, staff and continued family satisfaction surveys ; visual monitoring of operations; periodic review of 4 11 of Page

5 ; or any other method for monitoring ). finance reports or medication records monitoring Assign a area timeframe for each and person responsible for follow -up. review effectiveness of to -Identify process for the operator/administrator . corrective action(s) and provide feedback on next steps Dev. 03/16 5 11 of Page

6 Attachment I: Example of a Quality Assurance Plan ACF (Name) Quality Assurance Plan A. OVERVIEW The (ACF Name ) QA Committee is the forum for identifying areas for improvement and monitoring activities for the (ACF Name) QA Program. Areas for improvement will include, but are not limited to, any process or system areas that affect the quality of (ACF Name) services, activities and outcomes of the facility. QA monitoring activities and their findings are reviewed by the Committee to evaluate the overall quality and effectiveness of services provided by (ACF Name). The QA Plan is reviewed annually by the (ACF Name) QA Committee . A biannual written evaluation of the QA Program will be distributed to Committee members and staff (identify) . Findings from monitoring activities will : • serve as the facility’s benchmark to describe over time the quality, effectiveness, and consistency of services and activities provided. • enable staff to continually identify areas in need of improvement. • provide a mechanism for communicating quality to appropriate parties, , administrative and executive staff; residents, but not limited to including, facility family members, staff and New York State Department of Health surveillance staff. (DOH) ents • serve as a mechanism for communicating accomplishm to appropriate parties including, but not limited to, Boa rd of Directors, administrative and , residents, family members, facility staff and DOH. executive staff Goals of the QA Program : • improve facility operations, communication and the qualit y of resident life and services. • improve effectiveness of staff through training, competency review and ongoi ng review and revision of policies and procedures . regulations and ensure (ACF Facility Name) is compliant with state statutes, • facility policies and procedures. assist in early identification of trends and emer ging issues (e.g. • emergency/disaster events and/or new regulations, etc.) or concerns that may Name adversely affect (ACF ) services, activities and/or operations. 6 11 of Page

7 B. (optional; not required by regulation) COMMITTEE MEETINGS Periodic Quality Assurance Committee meetings are held to review findings from quality assurance monitoring activities and to identify future quality initiatives or areas in need of improvement. QA Committee membership consists of (identify individuals who will serve as Committee members ). Meeting minutes, including quality assurance reports from monitoring activities, are distributed to committee members and (identify). C. KEY QUALITY INDICATORS (areas for improvement and monitoring activities) : Compliance with Adult Care Facility Regulations (example) • Periodic reviews are performed to assess compliance with Adult Care Facility Regulations for (identify area of regulation being monitored). Issues identified are discussed with (identify staff mem ber) for follow -up and/or corrective action when indicated. Monthly compliance reports are provided to (identify) and discussed at the QA Committee meeting. Compliance with Medication Documentation Standards (example) : reviews are performed to assess medication documentation compliance Periodic • -up with ACF Regulations. Issues identified are discussed with (identify) for follow eports are provided to (identify) and and/or corrective action when indicated. R . hly QA Committee meeting discussed at the mont D. QUALITY ASSURANCE MONITORS (examples for sources of information) Resident Satisfaction : • Periodic resident satisfaction surveys will be conducted to identify overall resident satisfaction with care, services and activities provided. F indings will be improvement. Issues identified are discussed utilized to identify areas in need of with staff and dur the QA Committee meeting. ing Incident/Complaint Reports : • Monthly reports of incident and/or complaints received will be reviewed by the QA Committee to identify trends (e.g., incident/complaint type). Appropriate follow -up actions will be performed when indicated. Trending of incidents/complaints is performed for early identification and resolution of potential quality issues relating to the (ACF Name ) provision of care, services or activities. Focus QA Reviews : Focus QA reviews (identify area of operation) will be performed to identify • compliance with ACF regulations. Issues identified are discussed with (identify) for follow -up and/or corrective action when indicated. Findings from focus review -up actions will be discussed at the QA Committee . meeting activities and follow 7 11 of Page

8 Attachment II: Additional QA Requirements for Adult Care Facilities under the conjoined jurisdiction of the N YS Department of Health and The Justice Center for the Protection of People with Special Needs Arti cle 11, Social Services Law §490 requires an Incident Management Program in I. which : • all reportable incidents are identified and reported in a timely manner ; • all reportable incidents are promptly investigated; • individual reportable incidents, and incident patterns and trends, are reviewed to identify and implement preventive and corrective actions, which may include, but shall not be limited to, ary action staff retraining or any appropriate disciplin by ; or contract, as well as opportunities for improvement allowed law • patterns and trends in t he reporting and response to allegations of reportable incidents are reviewed and plans of improvement are timely developed based on such reviews; • information regarding indi vidual reportable incidents, incident patterns and trends, and patterns and trends in the reporting and response to reportable the justice center, in the incidents is shared, consistent with applicable law, with form and manner required by the enter and, for facilities or provider Justice C agencies that are not operated, with the applicable state oversight agency state which shall provide such inform ation to the Justice Center; • Incident Review C ommittees are established; provided, however, that the regulations when may authorize an exemption from this requirement, appropriate, based on the size of the facility or provider agency or other relevant factors. Such committees shall be composed of members of the governing body the D of the facility or provider agency and other persons identified by irector of the facility or provider agency, including some members of the following: direct support staff, licensed health recipients and care practitioners, service acy organizations, but not representatives of family, consumer and other advoc the of the facility or provider agency. Director o Incident R eview Committee s shall meet regularly to:  review the timeliness, thoroughness and appropriateness of the facility or provider agency's responses to rep ortable incidents; recommend additional opportunities for improvement to the director  or p of the facility rovider agency, if appropriate; review incident concernin trends and patterns  g reportable incidents; 8 11 of Page

9  make recommendations to the D irector of the facility or provider ents; agency to assist in reducing reportable incid  Members of the C shall be trained in confidentiality laws ommittee with section seventy -four of the and regulations, and shall comply Officers’ Law. Public Notwithstanding any other provision of law, except as may be provided by • section 33.25 of the mental hygiene law, records, reports or other information maintained by the justice center, state oversight agencies, delegate investigatory entities, and facilities and provider agencies regarding the deliberations of an Incident Review C ommittee shall be confidential, provided that nothing in this article shall be deemed to diminish or otherwise derogate the information legal privilege afforded to proceedings, records, reports or other relating to a quality assurance function, including the investigation of an incident reported pursuant to section 29.29 of the mental hygiene law, as provided in section six ty-five hundred twenty -seven of t he E ducation Law. For purposes of this section, a quality assurance function is a process for systematically monitoring and evaluating various aspects of a program, service or facility to ensure that standards of care are being met. • No member of an Incident Review C ommittee performing a quality assurance judicial function shall be permitted or required to testify in a or administrative ions, recommendat findings, pro ceeding with respect to quality assurance evaluations, opinions or except that thi s provision is not intended taken, actions tate oversight agency, delegate investigatory entity, facility or to relieve any S agency, provider or an agent thereof, from liability arising from treatment of a service recipient. • There shall be no monetary liability on the pa rt of, and no cause of action for damages shall arise against, any person on account of participating in good faith possession and with reasonable care in the communication of information in the Incident Review C of any ommittee, or on account of such person to an or evaluation regarding the conduct or practices of any recommendation custodian that is made in good faith and with reasonable care. • With respect to the implementation of incident management plans in residential facilities located schools or outside of New York State , each S tate oversight agency shall require that: (a) the Justice C enter, the applicable State oversight agency and any local social services district and/or local educational agency placing an individual chool or State placement of an agency funding the with such facility or s individual or student be notified immediately of any allegation of abuse or neglect involving that individual or student; by the justice center, or where that is not conducted (b) an investigation be prac y or other entity authorized or required to ticable, by a state agenc 9 11 of Page

10 investigate complaints neglect under the laws of the S tate in of abuse or which the facility or school is located; and (c) any findings of such inv estigation be forwarded to the Justice C enter and each placing entity tate within ninety days. or funding agency in New York S Failure to comply with the requirements of this section shall be grounds for revocation or suspension of the license or approval of the out of S tate facility or school. s: Adult Care Facility Regulation II. Incident Review C 18 NYCRR Part 487.14 (g) requires that ommittees are • established; provided, however, that the Department may consider and approve requests for exemptions on a case- by-case basis, based on the size of the facility or provider agency or other relevant factors. A request for an exemption must include a written justification. The facilities Incident Review C ommittee shall consist of persons identified by the D irector of the facility, including some members of the following: at least two (2) direct support staff, two (2) licensed wo family members, but not the health care practitioners, two residents and t Director of the facility or provider agency. Such committee shall meet to: review the timelines (a) s, thoroughness and appropriateness of the facility or provider agency’s responses to reportable incidents; (b) recommend additional opport unities for improvement to the D irector of the facility or provider agency, if appropriate; (c) review incident trends and patterns concerning reportable incidents; and irector of the facility or provider agency (d) make recommendations fo r the D to assist in reducing reportable incidents. Such meetings shall occur within one month following the issuance of findings associated w ith the investigation of an incident, and in the absence of such incident, no less than quarterly. Members of the C ommittee shall be trained in confidentiality laws and regulations, and shall comply wi th section seventy -four of the P ublic Officers’ Law. • 18 NYCRR Part 488.15 (g) requires that incident review committees are established; provided, however, that the Department may consider and approve by-case basis, based on the size of the facility requests for exemptions on a case- or provider agency or other relevant factors. A request for an exemption must include a written justification. Such committee shall consis t of persons identified irector of the facility, including some members of the following: by the D • at least two (2) direct support staff, two ( (a) 2) licensed health care , but not the D practitioners, two residents and two family members irector of the facility or provider agency. 10 11 of Page

11 (b) su ch committee shall meet to review the timeliness, thoroughness and responses to appropriateness of the facility or provider agency’s ties for improvement reportable incidents; recommend additional opportuni irector of the facility or provider agency, if appropriate; review to the D incident trends and patterns concerning reportable incidents; and make Director of the facility or provider agency to recommendations for the assist in reducing reportable incidents. such (c) meetings shall occur within one month following the issuance of findings associated with the investigation of an incident, and in the absence of such incident, no less than quarterly. Members of the committee shall be trained in confidentiality laws and regulations, and shall comply with section 74 of the Public Officers Law. 11 11 of Page

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