longterm care Assigmt2

General Facility Information – Section 1

Provide a response to each item listed below and adjust spacing as needed for your responses.

SNF Provider Name: Park Pointe Healthcare & Rehab

City and State of the SNF: 1223 Edgewater Morris, IL 60450

Number of Certified Beds: 142

Ownership Type: For profit- Corporation

Health Inspection Details from CMS Compare Website -Section 1

Provide a response using the View Inspection Results, View Staffing Levels, and View Quality Measures information from the CMS Compare Website. Adjust spacing as needed for your responses.

Date of Most Recent Inspection: 02/25/2021

Total Number of Health Citations: 9

Number of Complaint from the Past 3 Years: 8.3 in the US and 11.4 in IL

Average Number of Residents per Day: 73.7

Total Number of Licensed Nurse Staff Hours per Resident per Day: 2 hours and 28 minutes

Registered Nurse Hours per Resident per Day: 28 minutes

Physical Therapist Staff Hours per Resident per Day: 4 minutes

Select 1 Detail that You Found the Most Interesting about this SNF on the CMS Compare Website and Provide the Information Below:

One of the most interesting detail about this SNF on the CMS compare has to do with quality ratings. In almost every aspect, the quality is either average or below average. This shows that the standards are low in this facility.

CMS 5-Star Ratings

Overall Rating

Health Inspection

Staffing

Quality of Resident Care

Average

Average

Much below average

Much below average

Note: Use the Section 1 information, along with any other relevant details, from the CMS Compare Site on your selected facility to complete the rounding questions in Section 3.

CMS 1567 Report: F-Tag Selection Information– Section 2

Provide a response to each item listed below and adjust spacing as needed for your responses.

F-Tag Citation 1 Information

F-Tag Number and Tag Title: F 0552: Level of Harm - Minimal harm or potential for actual harm

Code of Federal Regulations (Regulatory Reference): CFR:483.10 resident rights

Level of Harm (as stated on 2567): Minimal harm or potential for actual harm

Residents Affected (as stated on 2567): Few

F-Tag Citation 2 Information

F-Tag Number and Tag Title: F 0880 - Minimal harm or potential for actual harm

Code of Federal Regulations (Regulatory Reference): 483.80 infection control

Level of Harm (as stated on 2567): Minimal or potential for actual harm

Residents Affected (as stated on 2567): Some

Example of SNF Citation (F-Tag) Information:

(Information can be located under ID Prefix Tag on the 2567 and by using the CMS SNF F Tags List within the assignment prompt.)

F-Tag Number and Tag Title: F572 -Notice of Rights and Rules

Code of Federal Regulations (Regulatory Reference ): 483.10 Resident Rights

Level of Harm (as stated on 2567): Minimal harm or potential for actual harm

Residents Affected (as stated on 2567): Few

Compare Your Selected SNF to 2 Other SNFs: Submit as Part of the Assignment

· Remember to Select 2 Comparable SNFs to your selected SNF (3 SNFs in total), up to a 200-mile radius, using the compare function on the CMS Compare Site.

· You can use the Print function on the CMS Compare website and save the information in PDF format to include the information in your submission. See example PDF in assignment prompt.

Section 3 - Questions to Consider Before Conducting Facility Rounds

Provide a response to question listed below and adjust spacing as needed for your responses.

1) Identify one to three leaders that will conduct rounds with you for your 2567 deficiencies, include their titles and/or department and/or role:

a) Hospital administrator: Oversee the health services and daily activities of the facility

b) Nurse manager: Supervise the nurses

2) Provide two questions to ask your LTC residents and/or short-term stay patients during your rounds. One question must be based on the F-Tag citation as a way to identify how your facility can improve.

a) Has anyone obtain your consent for medication use?

b) What can you say about the level of hygiene in this facility?

3) Provide at least one question to ask your employees during your rounds. These questions should be positive, engaging, and promote an excellent workplace experience while focusing on providing the highest quality of care delivery.

a) Do you have the necessary equipment or items to undertake your duties?

Section 3 - Rounding Experience Simulation

Visualize your SNF as though you are rounding with your leadership team, consider your F-tag citations, and provide a response with supporting external scholarly evidence, as needed, for each question. Adjust spacing as needed for your responses.

1) Based on your first citation discussed in Section 2, and based on your research regarding your F-Tag citation, what will be two to three items that you will look for during your rounds and why?

a) Drug administration by the nurses

b) Medication care plan for the patients

2) Based on your second citation discussed in Section 2, and based on your research regarding your F-Tag citation, what will be two to three items that you will look for during your rounds and why?

a) Infection control practices in the facility

b) Hygiene levels in the facility

3) Describe in one to two paragraphs, how you will identify other areas of concern during your rounds? Be sure to include a specific process on how you will note such potential areas of concern.

One of the areas of concern would be nurse education or qualification. Some of the issues identified include hygiene in the facility and infections. Additionally, some patients intimated that there was a failure to obtain drug use consent. It would be important to identify the level of qualifications for the nurses to understand whether they understand their roles, objectives, and responsibilities. During the rounds, the nurses would be asked questions, especially about obtaining consent, and professional and ethical responsibilities.

Section 3 - QAPI Tool for Rounding Follow-Up Leadership Meeting

Provide a response to each question below, adjust spacing as needed, and be sure to include scholarly external evidence.

1) You are going to redesign your QAPI Program. Your first step will be to identify your QAPI Steering Committee. Identify the SNF Department Leaders that will be on your QAPI steering committee.

a) Nurse Managers

b) Departments heads

c) Hospital administrator

d) A staff member

e) A resident

Information from the QAPI at a Glance Guide from CMS and the AHRQ to assist you with the question presented above (Agency for Healthcare Research, 2021):

Here are some ways leadership can take action:

Develop a steering committee, a team that will provide QAPI leadership: The steering committee has overall responsibility to develop and modify the plan, review information, and set priorities for PIPs. The steering committee charters teams to work on particular problems. It reviews results and determines the next steps. The steering committee must learn and use systems thinking—a nursing home has many competing interests and needs.

Top leadership such as the Administrator and the Director of Nursing must be part of this structure.

It is also important to have a medical director who is actively engaged in QAPI. It is possible to adapt your Quality Assurance committee to become your “Steering committee” to oversee QAPI. For this to work, the QA Committee may need to meet more often, include more people, and establish permanent and time-limited workgroups that report to it (p.9).

2) Based on the two F-Tags that you presented in Section 2, describe what some of the potential best practices are to resolve your citations, ways you want to approach these deficiencies to prevent them in the future, or provide other relevant information to addressing these areas of concern. Your response should be two to three paragraphs long and include scholarly supporting external evidence.

One of the issues cited is prevalence of infections among the patients. Health care-associated infections (HAI) are responsible for some of the major health challenges. They normally affect the quality of life, mortality and morbidity. According to Storr et al. (2017), healthcare facilities should introduce infection prevention and control programs to curtail the rate of infections. On the other hand, Godfrey and Schouten (2014) indicate that surveillance, hand hygiene and outbreak management are some of the best practices critical for infection control. Finally, nurses should understand that it is a legal, ethical and professional requirement to obtain consent from patients when engaging in practices such as drug administration and use (Hail et al., 2012).

3) Based on your SNF rounding simulation, in one to two paragraphs, share your thoughts on this experience include items such as benefits, challenges, new knowledge obtained, greatest learning opportunity, or any other factor that you would like to share from an AIT student viewpoint.

One of the lessons learned is that hospital rounds are critical in identifying some of the issues that affect both patients and nurses. Additionally, I have also learned that patients play a critical role in helping to solve some of the challenges manifest in healthcare facilities. On the other hand, the nurses need resources such as personal protective equipment (PPE) to undertake their responsibilities. In conclusion, more stakeholders should be involved in QAPI to come up with holistic solutions affecting both patients and nurses.