|
|
For FADONA Members Only Just
Ask FADONA Back in 2003 FADONA added a new
member benefit and incorporated it into the association’s newsletter and Web
site at www.
fadona.org. We hope you find it useful. Here’s
are some of the questions we’ve fielded since Just Ask FADONA was started. Q: Must nursing homes only use LPNs who have completed the
requirements or can we still have LPNs working in our buildings as long as we do
NOT call them "charge" nurses or supervisors? A: The LPN supervision
rule came from a reinterpretation of the Nurse Practice Act. In that process,
the Board of Nursing (BON) felt that the process of assessment was not properly
interpreted and that LPNs who were designed to be bedside nurses were permitted
and encouraged to make determinations and decisions that would affect clinical
outcomes, hence requiring assessment. In this process, it was brought
forward that patient assessments required information gathering and collection
of data that LPNs are viewed as able to do. But for the final conclusion, an
assessment must be completed by an RN. The BON stated at a meeting attended by
FADONA 2nd
VP Robin Bleier, that the process of gathering objective facts and extra-polating
a conclusion or clinical direction for the purpose of outcome direction or
conclusion requires an assessment that LPNs do not have the education or skill
to be able to perform. Although the new 30-hour rule,
which came about to allow LPNs under certain circumstances as set forth in the
rule, to have supervisory roles, it never included the performance of
assessments. The new law was enacted to allow nursing home LPNs to continue
doing business, although it was determined that many LPNs had been allowed to
cross the line and that a nursing home’s ability to function without them
would be negatively impacted. It was written to address the strong lobbying done
by FHCA and FADONA. No other clinical care institutions allow LPNs to supervise
whether the LPN has taken this program or not. Yes, LPNs can work in our centers
without having taken the program if they are in positions that do not require
supervision. Obviously, position descriptions must be carefully reviewed to
assure that they do not say or imply supervision. An example of this would be
for a charge nurse. Between state regulation and the connotation of this, people
may want to change the title to something else if an LPN, who has not completed
the 30-hour program, has the duties typical of this (pass meds, tx, orders,
etc., for a group of SNF residents). The fact that this new rule most
likely will increases wages, is also noted, but the new staffing requirements of
SB1202 had actually already created an enormous supply and demand issue
resulting in higher wages for staff with fewer qualifications (CNAs are also now
under the BON in Florida and a few other states). A suggestion for new LPN usage is
called direct care nurse (DCN). These folks actually fill a CNA slot for direct
patient care. They do not pass medications, although I think if they have the
ability to do treatments on their patients and or document on same, that is
fine. I count them with CNAs in my 2.3 at this point; they do not pass routine
or PRN meds, have floor responsibilities, and I use them on the MCR unit so we
can provide a better level of care to our most ill. They get paid starting LPN
wages and after six months (if they are a new LPN) they begin to undergo
training to become a charge nurse. Some stay as they are; they like it and see
themselves as almost primary nursing as in the acute care setting. Lastly, the state regulations for
the use of RNs in-house did not change. LPNs who have successfully completed the
30-hour supervision rule cannot replace an RN, they may simply supervise other
LPNs, CNAs, and HAs. Q: What
is the difference between risk management and quality assurance?
A: Risk
management and quality assurance are both important, yet separate aspects of
facility operations, growth, and improvement. Although aspects of this can be
done concurrently they are separate processes and both deserve the same
attention to attain optimum outcomes. In a nutshell, risk management is
a three-stage process used to: 1. Identify potential risk, 2. Respond to actual
risk, and 3. Re-evaluate systems that relate to risk. Quality assurance can take a
beneficial leap from your risk process in that once you have completed step 3 of
risk management, you then may revaluate and or reset your systems to improve
quality. Kaizen, which is the Japanese
system of incremental improvement, is a process whereby with attention to our
systems we make ongoing revisions to them and improvements through small, yet
ongoing steps forward, for a better outcome. Based
on this it could be said that risk management can be dynamic in assisting us to
improve our systems for ongoing quality improvement and ultimately assurance. Q:
Where does dental services show up on the MDS and does the lack of
dental/oral services handicap a facility and its Quality Indicators? Please
explain the relationship. . . Thanks. A:
Dental services are outside services that are not on the MDS. There are two
places one can find the most supportive information on dental — the oral
hygiene sections (RAP 15 Dental), and physical functioning (RAP 5). Sadly, the government does not
value or feel the need to pay for dental services to much of a degree and less
and less often. Medicaid recipients really have little support and if the
problem manifests medically (infected gums, pain, loss of weight related to lack
of dentures, malodorous breath related to decaying teeth, etc.) it falls on the
facility. Due to our Medicaid and Medicare
contracts we are not allowed to admit and/or retain individuals whose needs
cannot be met in our facility (financial, clinically, or otherwise). Q.
Staffing for Smaller SNFs My administrator and I debate this
all the time: I know that with SB1202 the DON, ADON, MDS & SDC hours cannot
be counted for direct care, but can they be counted in homes with less than 60
beds? I have been told by several administrators of small homes that they can,
and I know that by federal standards they can, but I have a tough time reading
SB1202 and haven’t seen it stated that those hours can be counted. What do you
say? A.
The Agency for Health Care Administration says that a nursing administrator with
a title of DON, ADON, or MDS coordinator cannot be counted in daily
staffing for either the nursing or direct care daily requirements. You reference SDC. Technically,
the regulations do NOT address whether that title is to be counted or
not. Of course, only nurses involved in nursing care can be counted so it is on
the honor system, not per regulation. Facilities that are certified for
121 or more beds MUST have an ADON. Remember, the census does not
determine this, but rather the actual number of legal certified beds. Facilities that are certified for
120 or less beds do NOT have to have an ADON UNLESS the DON has
other outside responsibilities. A common example of this could include a SNF DON
or a 120 or less bed facility who is also responsible for an ALF. In such a case
the DON must have an ADON due to his or her other responsibilities. Facilities with 60 beds or less
are allowed to count the DON as a charge nurse. However, this would not be
advisable. What I have seen some folks do is have the DON in the 60 or less bed
facility also sign MDSs as RN coordinator and the MDS coordinator is titled
something different like resident care coordinator, works assessments on the
floor, and even if an RN does NOT sign MDSs this is counted and they do not
count the DON and do not have an ADON titled person either. Federally this is not mandated. F
353 says that you have to have adequate staff working who are trained and
supervised well to meet the needs of the residents. Again, SDC is not a discussed
title. CNA Training Reimbursement Q: We
are having CNAs ask our corporation for reimbursement for their training. This
came up at the Nurse Leadership Conference during the CNA Train-the-Trainer
course. No one was aware that the testing agency is putting on their testing
forms that employers must reimburse them for training received up to one year
prior to their being hired. The FHCA "Medical Record Documentation &
Understanding Legal Aspects for Certified Nursing Assistants" states that
in Section 483.152 the STATE is responsible for reimbursement. Please clarify this for us. As you
can imagine, it is creating quite a problem. A: Reimbursement
is required by federal regulations pursuant to 42 CFR 483.152 (c) (1)-(2). The
testing agency is simply communicating the require-ment to the CNA testers. The
state is responsible for reimbursement and this is how it works: The new CNA
brings receipts and evidence of payment to the facility (which the facility
should have in writing as part of their facility policy for reimburse-ment). The
facility submits to the state via their Medicaid area office using AHCA form
5210-001, or AHCA form 05/01/99 (they are the same form). The state reimburses the facility
a portion of the costs based upon the percentage of Medicaid occupancy for the
month prior to billing. The facility turns around and fully reimburses the CNA.
The facility may put into place other administrative protocol, i.e., being past
the probation period, but the important thing to remember is that any such
policy must be applied uniformly to all. I would recommend companies
familiarize themselves with the federal citation above as well as the Florida
Medicaid Nursing Facility Services Coverage and Limitations Handbook (link
below): http://floridamedicaid.consultec-inc.com
See page 1.6 to see what exactly
is reimbursable (tuition, books) versus what is not (shoes, uniforms) and then
look at the Appendix to get the AHCA form referenced above. There is also a time
limitation (within 1 year of training/testing). If the CNA has been employed
elsewhere prior to coming to your facility, you might want to make sure he/she
did not receive reimbursement at that facility. Also, a student who received
some kind of loan or scholarship that took care of tuition would not be eligible
for reimbursement. Hope this helps. Lee Ann Griffin, CNA, Policy &
Quality Assurance Specialist, Staffing Citations An unexcused absence occurred
Monday morning bringing the facility’s staffing within 98 percent of the
required 2.6 direct care and 1.0 skilled nursing requirement. The next day,
another unexcused absence occurred, which could not be corrected, resulting in
97 percent of the staffing requirements being made. The question came up during
an adverse incident review by the Agency for Health Care Administration (AHCA)
during a staffing review. The AHCA surveyor found that the facility did not
place itself on a self-imposed moratorium. How Could This Happen? In discussion with the director of
nursing (DON) and administrator, their reason for this was a misunderstanding of
the regulation. It was stated that, "We thought that as long as we make the
97 percent we are OK." For the record, this was not
"OK" and not only did the facility get cited for staffing N63 but they
were cited for N69 (not putting themselves on a self-imposed moratorium). In
addition, the facility was cited for F353 (federal staffing cite as during one
of the days when under the required staffing (although they were at 97 percent
or above yet under 100 percent of the requirement), a resident fell, broke a
hip, was being assisted by only one staff member without a gait belt when the
care plan stated to use two for all transfers with a gait belt. During the interview portion of
the citation, the CNA involved told the surveyor, "I could not find anyone
to help me so I did it myself," referring to the transfer, which
unfortunately resulted in the resident being lowered to the floor as she lost
her balance. What You May Want to Do: When
planning your staffing, be sure to have a plan that deals with unexcused
absences. Work with your administrator and corporate offices to assure that you
do not cut it too close. More importantly, have good human resource programs in
place to address attendance. Certainly there are times when an employee’s
absence cannot be helped, but there are also times when they can. You know who
your chronic folks are. Address it and them. Doing this makes your staff
members, who rarely if ever call out, feel more appreciated and valued. We all
know it is easier said than done. Be strict about call outs. In the long run,
everyone really does benefit from it. Q.
What is the FADONA-endorsed exam? A. The FADONA
endorsed examination (Advanced Nursing Administrator) was developed for the
nursing administrator that has already become a certified director of nursing
through NADONA and has practiced in our State which is known to hold it self out
for exceptionally high standards. Q.
My Question: I am new in a facility, and currently am only acting as an ADON, I
have mentioned to the DON that when feeding residents an aide should be focusing
only on one resident, I was told very rudely that an aide can feed two residents
and cue two more at the same table. The facility I worked at before was sited
for this, who is right? A.
An excellent question and one that bears significant scrutiny. There are several
precursor questions that must be answered first. Q.
I am looking for a comprehensive assessment tool to evaluate a resident for
electric wheelchair. The resident lives in a long term care facility. Is there a
location I can research for such a tool? Thanks LC
Q.
I currently work in an Assisted Living Facility that provides medication
administration for our residents. I would like to know if anyone currently
working in an ALF has a Lovenox administration policy, and does the policy cover
all administration indications? NOTE 1 from Robin: I recommend that we advise this person to check with their pharmacy. Personally I would not suggest a sep PP for this particular drug and typically as it relates to classes such as in LTC to psychoactive and for SNFs and ALFs alike for trial drug usage. I was a DON at a CCRC with different levels of ALF services and a lot depends on if ECC or LN or LMS Licensure. Also, recently had a negative exp while looking for ALFs in my area for a friend’s mom. All (even the good ones) clearly exceed the ALF medication administration practice as they even titrated medications based on lab (without home health) as per the admission info (and then charge more money for this while medications would be ADMINISTERED by a med tech [who was not even a CNA]…). I could go on so just some risk food for thought. I am sure all have an opinion and Diane being our other LHCRM of our group may want to chime in now too. NOTE 2 from DI: We use a protocol, not a policy that is directly from PharMerica. I faxed him the protocol which advises to check with the personal physician prior to implementing the protocol. The protocol includes labs that need to be checked etc. This drug merits periodic assessment by a Registered nurse or physician. Thanks Di Q.
I am uncertain how the Quality Indicator Profile is calculated. My percentile
rank is 100% for Prevalence of Falls. 44 resident MDS entered for the month of
September 13 residents triggered for falls. (Num # 34 , Dem # 145) I feel this
is a miscalculation. I am unable to come up with 100% of any possible way to
calculate. Who do I contact to understand how it is calculated? A.
There is a great manual that all MDS nurses and Dons should have. It is from
Briggs. The name is "How to interpret Your Facility Quality Indicator
Report." Stock # 7602 Q.
What is the Board of Nursling's stand on LPNs in a LTC facility that are
supervising RNs. Who is liable if an RN is working and the Supervisor is an LPN.
A1.
LPNs cannot supervise RNs in FL whether they have taken the DOH approved LPN
supervisory class or not to the best of my recollection. I taught this for FHCA
when it first came out. A2.
According to the Nurse Practice Act...Section 64B9-16.002 Supervision by
Licensed Practical Nurses in Nursing Homes Facilities "There shall be a RN
providing supervision of the LPN. Tasks and activities shall be delegated by the
LPN to the CNA or "UP (unlicensed professional) if... the task is within
the area of responsibility of the nurse delegating the task, the task is within
the knowledge, skills, and ability of the nurse delegating the task, Teresa NOTE from Di:
I agree. To add a caveat, surveyors in the Q.
I have been told that; the standard of care, is to NOT use egg crate mats on
beds or chairs. We do not use them on beds on our SNF but do still use them on
our ALF and as chair cushions. If we go to some other product, what can we
replace them with at an affordable price. Please give suggestions… Thank You
(a new assistant director) A. There are many suppliers today with a multitude of styles, with differing features and prices. Direct Supply, AliMed, MedLine to name a few. Each corporation usually has a formulary of products that the facility has to order from, so check with your central supply person for a list of vendors that you can use. We use an inexpensive gel cushion at my facility from Direct Supply. We get four of them for around $100. Phone numbers for these vendors are as follows.. Direct Supply 1-800-634-7328 www.directsupply.net Sammons
AliMed 1-800-225-2610 MedLine 1-800-633-5463 www.medline.com I
hope this helps. Teresa Goss RN-CDONA,
NOTE from Robin: Egg crates are not considered pressure relieving devices per the MDS coding guidelines, hence the standard comment. I In truth there are many inexpensive products that can well meet the need and are covered so they can be cleaned in the event of incontinence. Q.
Please send me the information or the contact person so that I could obtain
guidelines for a SNF on how long to maintain information such as staff
schedules, CNA assignments, 24-hour report etc. I am in a new position and find
myself with information saved for 10 plus years. Would like to clean house and
tidy up. FADONA/LTC
|