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Thresholds Determine Need For In-Depth Investigation

Dr. Andy Kramer
Provider Magazine – June 2009


The care needs of residents newly admitted to nursing facilities are quite different from the needs of residents who are residing long term in the building.

Providing high-quality care to this varied group of residents with unknown prognoses is a true challenge for nursing facilities.

The admission sample is designed to assess the care for these types of residents during the period following admission or readmission to the nursing facility.

The admission sample Quality of Care and Life Indicator (QCLI) related to rehabilitation gives the rate at which residents receiving rehabilitation services were not discharged to the community in 60 days, excluding residents with cognitive impairments, receiving end-of-life care, or previously residing in a long-term nursing facility. If this QCLI rate exceeds the thresholds, it triggers a Stage II review using the rehabilitation/community discharge critical element pathway.

To examine issues related to the provision of skilled nursing services during this vulnerable period in the 30 days following admission there are two QCLIs from the admission sample chart review: nonelective hospitalizations and deaths among residents not receiving end-of-life care. Like all Stage I QCLIs, this is only preliminary information. However, if the thresholds are exceeded, then the hospitalization or death critical element pathway
is used to determine the underlying issues and whether the facility did not comply with regulations with respect to assessment, care planning, provision of services, and professional standards.

Two other issues evaluated on the admission sample are “new pressure ulcers since admission” and “weight loss since admission” in residents not receiving end-of-life care.

The admission period is a time when residents are at increased risk for both of these occurrences, so the admission sample chart review captures pressure ulcer and weight information, prompting review using the pressure ulcer or nutrition critical element pathway.

Thus, the admission sample is used for several important purposes that relate to types of care provided by most nursing facilities.

In QIS the admission sample is larger and its purpose is much broader than the traditional survey’s closed record reviews. In nursing facilities that admit very few residents, the admission sample will not be 30, and these issues will not be emphasized like they will in facilities treating more short-term residents or long-term residents with unstable medical conditions requiring more frequent acute hospitalizations.

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