Author: IPRO

This resource provides guidance on using the QAPI Tracking and Summary Document to organize, document, and monitor quality improvement initiatives and performance improvement plans (PIPs) in nursing homes.

According to a CMS memo regarding Mental Health/Substance Use Disorder (SUD), CMS has identified a need to improve guidance related to meeting the unique health needs of residents with mental health diagnoses and SUD. CMS clarified that when facilities care for residents with these conditions, policies and practices must not conflict with resident rights or other requirements of participation. They further clarified that facility staff should have knowledge of signs and symptoms of possible substance use, and are prepared to address emergencies (e.g., an overdose) by increasing monitoring, administering naloxone, initiating cardiopulmonary resuscitation (CPR) as appropriate, and contacting emergency medical services.^[1] This naloxone nursing home toolkit is intended to provide easy to adapt policies and procedures for nursing homes that need to implement or improve their emergency response to opioid overdose, which includes naloxone administration.

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[1] Revised Long-Term Care Surveyor Guidance | CMS. www.cms.gov. Accessed January 17, 2023. (https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/revised-long-term-care-surveyor-guidance)

The Nursing Home Naloxone Policy & Procedure Toolkit PowerPoint

This is another resource, designed to be used as an introductory presentation. This slide deck contains an abridged version of the Toolkit and provides a general overview of the Toolkit contents. It includes select references to regulatory guidance, background, need assessment, features, and brief descriptions of the policies, procedures, and resources contained in the Toolkit.

Nursing Home Naloxone Policy & Procedure Toolkit Implementation Checklist

This resource was created to help facilities implement the Nursing Home Naloxone Policy & Procedure Toolkit. This checklist provides an overview for a process to successfully implement select toolkit contents.

This manual is designed to assist organizations in identifying how a resident will “trigger” for a quality measure based on quality measure specifications and the coding of the MDS 3.0 Resident Assessment Instrument (RAI).

The AC Forum, in partnership with FDA, identified seven Core Elements for improving systemic management of anticoagulants. The Playbook, developed with input from more than 30 experts, offers detailed strategies for each Core Element and is designed to be used by organizations establishing or considering Anticoagulation Stewardship programs, as well as those with existing programs in place. While all seven elements are important for implementation of a stewardship initiative, the first Core Element—securing the commitment of administrative leadership—is a foundational priority to ensure success and sustainability.

Safer Medication Management for Better Transition of Care
SHM recognizes the importance of equipping hospital clinicians with evidence-based strategies to prescribe, document, and reconcile medications accurately and safely at times of care transitions.

Medication reconciliation, or med rec, is the process of compiling the most accurate list of medications a patient is taking to avoid dosing or other errors.

Take responsibility for med rec with your patients by:

Leading, coordinating or participating in med rec quality improvement efforts that incorporate best practices to improve patient outcomes.
Grasping key evidence-based interventions, such as obtaining the best possible medication history and effective discharge medication counseling.
Identifying patients who are at high risk for medication discrepancies due to the number and/or types of medications they are prescribed

This checklist helps nursing homes develop, assess, and annually review their emergency preparedness plans. Based on CMS State Operations Manual Appendix Z, it provides a framework for identifying gaps and ensuring key emergency preparedness requirements are addressed.

A quality improvement tool for determining the reliability of a process by assessing the 5 attributes.

The Monthly Pressure Ulcer Tracking Form was developed to assist facilities track their pressure ulcers on a monthly basis with the ability to carry over unhealed/unresolved pressure ulcers unto a new monthly tracking form. It maintains an active list of all current pressure ulcers in real time to assist with the investigation, treatment and provide an important piece in the development of a targeted pressure ulcer prevention program. (See instructions below on how to download the tracking form.)

Complete this form to receive a link to download a zipped folder of the Pressure Ulcer Tracking Resources to include the Excel tracking form as well as a PDF instructional guide that explains the use of the tool.

For questions on the Monthly Pressure Ulcer Tracking Form and Guide, please contact QINQIO@ipro.org.

A link to the most current State Operations Manual (SOM) for Long Term Care Facilities.

The infection and antibiotic tracking form was developed to assist facilities track both their infections and antibiotic use on a monthly basis. It maintains an active list of all infections and antibiotic use in real time. (See instructions below on how to download the tracking form.)

Complete this form to receive a link to download the Infection and Antibiotic Tracking Tool.

 

The National Action Plan for Adverse Drug Event Prevention (ADE Action Plan) was established to address two key objectives: (1) identify common, preventable, and measurable adverse drug events (ADEs) that may result in significant patient harm; and (2) align the efforts of Federal health agencies to reduce patient harms from these specific ADEs nationally.

On the basis of national ADE data from inpatient and outpatient settings, three types of ADEs were considered to be common, clinically significant, preventable, and measurable, and were therefore selected as the high-priority targets of the ADE Action Plan.
The three initial targets of the ADE Action Plan are:
1. Anticoagulants (primary ADE of concern: bleeding)
2. Diabetes agents (primary ADE of concern: hypoglycemia)
3. Opioids (primary ADE of concern: accidental overdoses/over sedation /respiratory depression)

The ADE Action Plan suggests a four-pronged approach to reduce patient harms from these three ADEs: Surveillance, Prevention, Incentives and Oversight, and Research.

The Monthly Falls Tracking Form was developed to assist facilities track their falls on a monthly basis. It maintains an active list of all falls in real time to assist with both investigation and provide an important piece in the development of a targeted fall prevention program. (See instructions below on how to download the tracking form.)

Complete this form to receive a link to download a zipped folder of the Falls Tracking Resources to include the Excel tracking form as well as a PDF instructional guide that explains the use of the tool.

For questions on the Monthly Falls Tracking Form and Guide, please contact us QINQIO@ipro.org.