CSI - Duluth February 6, 2009
Members Present: Members present: Nancy Christensen, Jeri Cummins, Larry Penk, Debbie Stassen, Margie Meyer, Pat Halverson.
Reviewed minutes of January meeting with no changes necessary.
Discussed future goals and how we can go about follow-up of CSI/STRATIS Root Cause Analysis (RCA) education presented in October and December 2008. We’ll begin with a newsletter format to share tips/suggestions about how to use the concepts of RCA for investigation of routine facility concerns.
Reviewed list of IDR surveys, frequency of deficiencies issued (traditional and QIS surveys), deficiency averages per team. Noted that F314 (Pressure Ulcers) and F315 (Incontinence) are among the top 10 deficiencies issued under both traditional and QIS survey processes. We understand that deficiencies in these areas frequently involve “Independent, but Associated Deficiency Citations” as directed by CMS S&C Letter 05-20 (assessment F272, F274 and F276; care plan F279, provision of care according to the plan of care, F282).
Excellent discussion about how to proceed with newsletter format to share information related to the use of simple RCA techniques to investigate the source of problems leading to deficient practice and to develop plans to reduce the likelihood of deficient practice occurrence. The information needs to be practical and concise, yet, contain enough detail to be useful without a lot of extra preparation by facility staff. Hopefully we will get feedback from facilities to help us improve the quality of our newsletters over time.
RCA could help a facility to identify barriers to effective care giving and to develop plans to mitigate those barriers. As a result of this first discussion we have ideas for the following newsletter tip sheets related to F314 and F315. The goal over the next several meetings will be to narrow the focus and put together an outline for each topic. We’ll need to decide how frequently we want to send out the newsletter and how to name/date each one since they will be posted on the CSI internet site.
Suggested topics to date:
RCA based on resident care deficits identified by facility direct care observations.
RCA to gather sufficient information to develop an effective plan of correction.
RCA to ensure comprehensive assessment of risk for development of pressure ulcers/incontinence.
F314 issued at harm (G or above), general information.
F315 issued at harm (G or above, general information.
Case study of resident behind a G level deficiency at F314 and another at F315.