CHAPTER 11.pdf

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CHAPTER 11.pdf

CHAPTER 11

THE MINIMUM DATA SET, THE CASPER REPORT &

QUALITY INDICATORS


THE RESIDENT ASSESSMENT INSTRUMENT (RIA)

THE MINIMUM DATA SET (MDS)

PURPOSE:

THE MDS WAS CREATED TO PROVIDE A METHOD OF ASSESSING

PATIENT’S NEEDS IN A STANDARD FORMAT.

USES:

1. The M.D.S. tracks over 400 pieces of data on every patient in a nursing home.

2. The M.D.S. is done on every patient within 14 days of their admission, it is updated

quarterly and any time their

Condition changes

3. The answers in the M.D.S. may “trigger” further assessment when these answers

indicate that the resident is at increased risk of developing problems

4. This structured assessment of high risk areas is used to help the facility build a patient

care plan

5. Once the care plan is implemented the patient must be reviewed again to make sure

that the patient responding to the plan (outcome)

6. The data from the M.D.S. is transmitted to the government to allow data to be

collected for all residents in the facility. The facility can then be compared to other

facility’s in the region, the state and the country. This data is now used to identify

residents that will be reviewed during the survey process. (see the OSCAR report)

7. 108 of the M.D.S. data fields are used to assign the resident a rug’s score (resource

utilization group) which is used to determine the reimbursement rate from the

medicare program.

8. Data from the M.D.S. is also used to determine the Quality Indicators which are

published by Medicare to allow the public to compare nursing facilities

9. For more information on the MDS see

https://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp

DEFINITIONS:

R.A.I. – RESIDENT ASSESSMENT INSTRUMENT

M.D.S. – MINIMUM DATA SET

C.A.A. – CARE AREA ASSESSMENT

RUGS – RESOURCE UTILIZATION GROUPS

CASPER – CERTIFICATION AND SURVEY ENHANCED REPORTING

11.2


RESIDENT ASSESSMENT INSTRUMENT

MINIMUM DATA SET (MDS)

CONTAINS OVER 400 DATA ELEMENTS

DIVIDED INTO AREAS OF PHYSICAL, FUNCTIONAL AND PSYCHOSOCIAL

STATUS


TRIGGERS

SPECIFIC RESPONSES TO M.D.S. ITEMS THAT

IDENTIFY RESIDENTS THAT ARE AT

RISK OF DEVELOPING PROBLEMS


CARE AREA ASSESSMENT (CAA)

A STRUCTURED FRAMEWORK FOR ASSESSING

“TRIGGERED” AREAS OF CONCERN AND

BUILDING AN INDIVIDUAL CARE PLAN


COMPREHENSIVE ASSESSMENT

THE DEVELOPMENT OF A PATIENT SPECIFIC CARE PLAN


CARE PLAN IS IMPLEMENTED


EVALUATE EFFECTIVENESS OF CARE PLAN

(i.e. PATIENT OUTCOMES)

RESOURCE UTILIZATION GROUPS (RUGS)

PATIENT IS ASSIGNED TO ONE OF 55 PAYMENT CATEGORIES BASED

ON 108 DATA FIELDS FROM THE PATIENT’S M.D.S.

(RUGS increased from 44 to 53 categories 1/1/2006)

(Reimbursements Range from $170/day to $650/day depending on the RUG score)

11.3


Report Date: January 6,

2010

Region Psychoactive Antipsychotic

American Society of Consultant Pharmacists

CMS OSCAR Data

11.4

Antianxiety

Antidepressant Hypnotic Total Total

Code State Meds Meds Meds Meds Meds Residents Facilities

United States 65.10% 25.20% 20.10% 48.10% 7.50% 1,402,485 15,720

1 CT 68.20% 0.3 0.2 50.10% 7.50% 26,114 239

MA 71.40% 28.30% 19.80% 55.60% 3.40% 43,282 429

ME 71.30% 24.50% 0.2 0.6 4.50% 6,458 109

NH 70.40% 28.20% 20.90% 54.50% 0.1 6,941 80

RI 0.7 23.40% 14.40% 56.60% 4.20% 8,059 86

VT 69.20% 26.80% 16.90% 53.40% 5.70% 2,987 40

2 NJ 56.90% 22.10% 17.20% 39.10% 0.1 45,782 359

NY 0.6 23.50% 0.1 39.10% 4.80% 109,910 640

PR 0.4 4.90% 6.80% 10.70% 23.30% 103 7

VI 21.40% 10.70% 7.10% 7.10% 3.60% 28 1

3 DC 43.10% 20.20% 9.90% 24.20% 4.20% 2,531 19

DE 61.10% 23.10% 21.80% 45.20% 6.20% 4,264 46

MD 57.40% 20.40% 14.50% 42.90% 5.90% 25,028 231

PA 66.60% 24.10% 21.20% 51.80% 5.70% 80,608 713

VA 63.70% 23.90% 22.30% 47.70% 8.30% 28,347 281

WV 0.7 23.90% 22.50% 50.50% 4.20% 9,639 128

4 AL 70.80% 27.60% 24.70% 0.5 7.70% 23,251 231

FL 66.60% 23.80% 26.40% 48.70% 13.30% 71,679 676(6)

GA 69.40% 30.30% 21.80% 51.50% 8.60% 35,022 360

KY 71.10% 26.30% 27.80% 53.80% 0.1 23,361 287

MS 68.40% 28.80% 18.90% 50.50% 9.80% 16,330 202

NC 67.40% 22.80% 26.10% 51.50% 10.90% 37,570 424

SC 63.60% 22.60% 23.20% 46.30% 8.60% 17,210 178

TN 73.30% 29.90% 28.30% 57.20% 10.30% 32,109 320

5 IL 66.80% 32.80% 20.50% 44.30% 6.60% 75,752 794(4)

IN 65.90% 23.60% 0.2 50.50% 7.10% 39,099 503

MI 61.90% 17.20% 17.80% 47.70% 3.40% 40,237 429

MN 63.20% 21.40% 13.90% 0.5 0.0 30,025 385

OH 68.90% 26.60% 23.50% 52.50% 7.60% 80,034 962(3)

WI 64.80% 19.80% 19.30% 51.20% 3.50% 31,565 391


Nursing Home Compare

Detailed Information About Your Selected Nursing Home

BERNARD L SAMSON NURSING CENTER

What is this?

Contact

Information

255 59TH ST N

SAINT PETERSBURG,

FL 33710

(727) 345-2775

Mapping & Directions

• Initial Date of Certification:

07/01/1985

• Type of Ownership: Non profit

- Corporation

• Participates in Medicare

• Participates in Medicaid

11.5

• 180 Certified Beds

Print This Page

• Not a Continuing Care

Retirement Community

• Resident Councils Only

• Not a Multi-Nursing home

(chain) Ownership

View all Nursing Home Characteristics

Click on the links below to expand and view information about Health Inspections, Nursing Home

Staffing, Quality Measures, and Fire Safety Inspections.

Show All | Hide All

Date of last standard health

inspection:

Quality Indicator Survey Yes

Dates of Complaint

Investigations:

Total number of Health

Deficiencies for this nursing

home:

Average number of Health

Deficiencies in Florida

Average number of Health

Deficiencies in the United

States:

Range of Health

Deficiencies in Florida

How to Read a Health /

Fire Safety Deficiency

Chart

Health Inspections

Lists the health requirements that the nursing home failed to

meet.

05/14/2010

View Previous Inspection Results

09/01/2009 - 11/30/2010

7

8

8

0 - 31

1 out of 5 stars


Quality Care Deficiencies

View Previous Inspection Results

Inspectors determined

that the nursing home

failed to:

1. Give proper treatment to residents

with feeding tubes to prevent

problems (such as aspiration

pneumonia, diarrhea, vomiting,

dehydration, metabolic

abnormalities, nasal-pharyngeal

ulcers) and help restore eating skills,

if possible.

2. Make sure that each resident's

nutritional needs were met.

Nutrition and Dietary Deficiencies

View Previous Inspection Results

Inspectors determined

that the nursing home

failed to:

3. Store, cook, and give out food in a

safe and clean way.

Environmental Deficiencies

View Previous Inspection Results

Inspectors determined

that the nursing home

failed to:

4. Make sure that the nursing home

area is free of dangers that cause

accidents.

5. Keep all essential equipment

working safely.

Inspection

Date

Date of

Correction

11.6

Level of

Harm

(Least -

> Most)

11/20/2009 12/10/2009 4 = Immediate

jeopardy to

resident health or

safety

05/14/2010 06/05/2010 2 = Minimal harm

or potential for

actual harm

Inspection

Date

Date of

Correction

Level of

Harm

(Least -

> Most)

05/14/2010 06/05/2010 2 = Minimal harm

or potential for

actual harm

Inspection

Date

Date of

Correction

Level of

Harm

(Least -

> Most)

11/20/2009 12/10/2009 4 = Immediate

jeopardy to

resident health or

safety

05/14/2010 06/05/2010 2 = Minimal harm

or potential for

actual harm

Residents

Affected

(Few -> Some -

> Many)

Some

Few

Residents

Affected

(Few -> Some -

> Many)

Few

Residents

Affected

(Few -> Some -

> Many)

Some

Few


Administration Deficiencies

View Previous Inspection Results

Inspectors determined

that the nursing home

failed to:

6. Be administered in a way that

leads to the highest possible level of

well being for each resident.

7. Make sure that nurse aides show

they have the skills to be able to

care for residents.

Inspection

Date

Nursing Home Staffing

Date of

Correction

11.7

Level of

Harm

(Least -

> Most)

11/20/2009 12/10/2009 4 = Immediate

jeopardy to

resident health or

safety

11/20/2009 12/10/2009 4 = Immediate

jeopardy to

resident health or

safety

Information comes from data that the nursing home reports

to its state agency. It contains the nursing home staffing

hours for a two-week period prior to the time of the state

inspection. CMS receives this data and converts it into the

number of staff hours per resident per day.

National

Average

Average

in

Florida

RN Staff Only 1 Not Available Not Available

Residents

Affected

(Few -> Some -

> Many)

Some

Some

4 out of 5 stars

BERNARD L SAMSON

NURSING CENTER

3 out of 5 stars

Total Number of Residents 93.9 111.2 171

Total Number of Licensed Nurse Staff

Hours per Resident per Day

1 hour

24 minutes

1 hour

36 minutes

1 hour

34 minutes

RN Hours per Resident per Day 36 minutes 36 minutes 32 minutes

LPN/LVN Hours per Resident per Day 48 minutes 1 hour

CNA Hours per Resident per Day

2 hours

24 minutes

3 hours

6 minutes

How to Read a Staffing Chart | About Staff Roles

1 hour

1 minute

2 hours

54 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs

have between 2 and 6 years of education.

Quality Measures

Information comes from data that the nursing homes

regularly report on all residents. It includes aspects of

residents' health, physical functioning, mental status and

general well being.

Quality Measures National

Average

Average in

Florida

1 out of 5 stars

BERNARD L

SAMSON

NURSING

CENTER


Long-Stay Residents Read why Quality Measures are important to you

NOTE: For the following measures, higher percentages are better.

Percent of long-stay residents given influenza

vaccination during the flu season

Percent of long-stay residents who were

assessed and given pneumococcal

vaccination

92% 87% 94%

90% 87% 98%

NOTE: For the following measures, lower percentages are better.

Percent of long-stay residents whose need for

help with daily activities has increased

Percent of long-stay residents who have

moderate to severe pain

Percent of high-risk long-stay residents who

have pressure sores

Percent of low-risk long-stay residents who

have pressure sores

Percent of long-stay residents who were

physically restrained

Percent of long-stay residents who are more

depressed or anxious

Percent of low-risk long-stay residents who

lose control of their bowels or bladder

Percent of long-stay residents who have/had

a catheter inserted and left in their bladder

Percent of long-stay residents who spend

most of their time in bed or in a chair

Percent of long-stay residents whose ability to

move about in and around their room got

worse

Percent of long-stay residents who had a

urinary tract infection

Percent of long-stay residents who lose too

much weight

14% 12% 18%

3% 2% 1%

11% 12% 17%

2% 2% 2%

3% 3% 2%

14% 10% 19%

51% 54% 55%

5% 5% 6%

4% 4% 4%

11% 9% 18%

9% 11% 16%

8% 8% 6%

Short-Stay Residents Read why Quality Measures are important to you

NOTE: For the following measures, higher percentages are better.

Percent of short-stay residents given

influenza vaccination during the flu season

Percent of short-stay residents who were

assessed and given pneumococcal

vaccination

85% 80% 77%

84% 81% 87%

NOTE: For the following measures, lower percentages are better.

Percent of short-stay residents who have

delirium

Percent of short-stay residents who had

moderate to severe pain

Percent of short-stay residents who have

pressure sores

1% 1% 0%

19% 17% 18%

12% 14% 19%

11.8


11.9

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