State Veterans Home
Clinical & Survey Oversight
Nancy Quest, Chief
Office of Geriatrics and Extended Care
Patient Care Services
Department of Veterans Affairs Central Office
State Home Clinical & Survey Oversight
 Adult Day Health Care Regulation
 Domiciliary Regulation
 Resident Assessment Instrument / Minimum
Data Set
 Reportable Events Handbook
 Upcoming Training Conferences
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State Home Clinical & Survey Oversight
 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.
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State Home Clinical & Survey Oversight
 What to use
– Software – No purchase required!
• MDS generic software “Raven”
– http://www.cms.hhs.gov/MinimumDataSets20/07_RAVEN
Software.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
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State Home Clinical & Survey Oversight
 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
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State Home Clinical & Survey Oversight
 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
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State Home Clinical & Survey Oversight
 Facility Reports (beginning April 5, 2010)
– QM/QI Reports
– Source Data Reports
– Resident Level Summary
 National Reports (beginning ???)
– QM/QI Monthly Reports
– Big Book
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State Home Clinical & Survey Oversight
 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
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State Home Clinical & Survey Oversight
 Reportable Events Handbook
– Team of Stakeholders
• Representatives of the National Association
of SVH
• Representatives of VACO GEC
• VISN liaisons
• VAMC Representatives
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State Home Clinical & Survey Oversight
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
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State Home Clinical & Survey Oversight
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
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State Home Clinical & Survey Oversight
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.
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State Home Clinical & Survey Oversight
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
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State Home Clinical & Survey Oversight
 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
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State Home Clinical & Survey Oversight
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
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State Home Clinical & Survey Oversight
THANK YOU
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