Long-term care facilities are busily working to ensure compliance with the third and final phase of the Centers for Medicare and Medicaid (CMS) Final Rule—Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities. More specifically they are doubling down on their QAPI (Quality Assurance and Performance Improvement) and assessment plans to make those as comprehensive as possible.
The goal is to be ready for review and assessment, but there could be one big problem: Does everyone on staff know what’s in those documents? If not, much of this hard work is likely going to waste. Why? Because surveyors don’t just talk to administrative staff and supervisors when they visit facilities. In fact, they often seek out frontline staff first to get a sense of how well a facility is operating when it comes to hands-on patient care and service delivery.
“One of the first things they may do when they walk into a facility is go talk to a CNA or housekeeper and talk to them about their role in quality assurance,” says Ellen Kuebrich, Senior Director of Business Development at HealthStream. “It’s very clear that's where surveyors are finding a lot of their initial information about the efficacy of a program. It’s not whether or not that staff is being trained, but more about whether that training is effective and whether they feel comfortable doing their job.”
Part of the problem is that sometimes a competency program gets knotted up with employee training. Successfully completing a training should be the floor for competency, not the ceiling—the employee actually needs to do the work over time in order to improve performance and achieve a desired comfort level. Trouble is, sometimes supervisors equate having a training regimen with a skill set that is not yet in place.
“A lot of times when you talk to administrative staff, they're able to explain to you exactly what the QAPI [Quality Assurance and Performance Improvement] program is, what it consists of, and how it's implemented,” notes Tracey Cooley, RN, BSN, a master trainer and surveyor and Vice President of Training at HealthStream. “But when you start talking to frontline staff, and by that, I mean laundry staff, dietary staff, housekeeping, maintenance, CNAs and direct-care nurses, they'll say, ‘That’s performance improvement.’ That's a key indicator that there's not an effective program in place.”
And if those staffers are consistently saying that specific things aren’t happening, that’s a good indication that competency is not being achieved. Next step? Go back to the earlier stages of the Final Rule and look at the tools CMS provided, namely the facility assessment that was required for phase two, Kuebrich says.
“Let's remember what the purpose of the facility assessment was,” Kuebrich says. “It was intended to make sure the facility has the resources needed to take care for the people it admits. Competent staff is a resource that should absolutely be considered in conjunction with a changing resident population. The first thing I would do is pull out the facility assessment and look at the analysis of everybody brought into the building over the last six to 12 months.”
When that’s done, she recommends drilling down to look for:
Afterwards, it is necessary to tabulate how often these populations are being treated or admitted. Once a facility does that, then it can better assess what services to provide, how much and what type of staff it needs, and how that workforce should be scheduled, she predicts.
“What competencies do those staff need to be able to provide these services to take care of these residents? And then what physical resources do we need to be able to do our jobs here? This is a very relevant document that should be considered as you look at competencies,” Kuebrich says. “In your QAPI program, find areas where you're not performing as well as you would like, or that are not up to the current standard of care. Look at the competencies associated with that area of care. It's rare that you find a failure on the floor and it's all systemic. It's maybe some gaps in your competency program, or you don’t have the right training cogent or delivery mechanism.
For instance, she adds, “it could be as simple as someone not wanting a sheet telling them how to do something, but rather they want a supervisor to show them, to provide a demonstration.”
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