Deficiency Citations in Nursing Homes That Predominantly Serve Residents With Serious Mental Illness

Abstract Studies suggest that nursing homes (NHs) that predominantly serve residents with serious mental illness (SMI) are of worse quality due to poor resources (i.e., high Medicaid-paying census) and lower staffing. We used national Certification and Survey Provider Enhanced Reports (CASPER) data to examine the deficiencies issued to NHs from 37,800 recertification inspections of 14,582 unique NHs from 2014 to 2017. NHs were categorized into “low-SMI” and “high-SMI” facilities using the lowest and highest quartiles, respectively, of the proportion of residents in the NH with SMI. Bivariate analyses were used to assess for differences between low-SMI and high-SMI NHs in the number of deficiencies, the deficiency score (a point-based metric developed by the Centers for Medicare & Medicaid Services), and the scope and severity of deficiencies. In total, there were 245,178 deficiencies issued. In comparison to low-SMI NHs, high-SMI NHs received a greater deficiency score and more deficiencies per survey (p<.001). Deficiencies given to high-SMI NHs were associated with greater risk of harm (p<.001) and were of wider scope (p<.001). High-SMI NHs were cited 215% more often for resident abuse or neglect and 61% more often for the policies that prohibit and monitor for risk of abuse and neglect in comparison to low-SMI NHs. In conclusion, high-SMI NHs were documented for providing worse care to residents, with one particular area of concern being the heightened risk of resident abuse and neglect. Implications for policy and practice will be discussed.

care can be challenging, and this issue appears to be more pressing with people living with dementia. Using the Positive Approach® to Care (PAC) model, a 2-hour module for new staff nursing home orientation curriculum was designed to help introduce the concept of working with people living with dementia. Twelve undergraduate students participated in a beta-test of the nursing home orientation. A pre-and-post 38-item survey was administered to measure knowledge level and improvement. Participants also responded to qualitative semi-structured questions after the orientation. Descriptive statistics and bivariate analysis were conducted. Results indicated an improvement on dementia-related knowledge in most of the survey items (21 of 34 items). Examples of statistically significant differences in the pretest and posttest identified are knowledge on the effect of pressure in the palm to comfort a person with dementia (p-0.039), vision as the most powerful sensory input during dementia caregiving (p-0.001), and functionalities lost when the left temporal lobe shrinks (p-0.014). The qualitative evaluation showed that most of the participants indicated a change in dementia caregiving views -including how to pause if permission is not given to engage, and to respect personal space. These findings prove important because the PAC orientation curriculum was successful in improving the students' knowledge and perspectives on dementia. This training program could be a useful tool if implemented into nursing home employee orientation.

CALCULATING THE TRUE COSTS OF FOOD SERVICE IN LONG-TERM CARE: DEVELOPMENT OF A COSTING METHODOLOGY
Mikaela Wheeler, 1 Karen Abbey, 2 and Sandra Capra, 2 1. University of Queensland, Queensland, Australia, 2. University of Queensland, Brisbane, Queensland, Australia As population's age and the need for long term care (LTC) increases, so too does the focus on the costs to provide that care. Providing food, oral nutrition supplements and meals, can be a considerable expense to a home. The objective of this research was to develop a valid foodservice costing tool (FCT), to calculate the real cost of providing foods and meals in LTC. Current costing methodologies are not specific to LTC and do not account for all costs of a foodservice, including staff, procurement and nutrition supplements. An initial tool was developed using the systems approach in conjunction with literature and professional knowledge. This was piloted in real world contexts, using volunteer LTC homes. Four iterations of the tool were completed to assess its feasibility in calculating costs and useability. Managers were interviewed after completing the tool to gather an understanding of how the tool was interpreted and to refine completion. Following feedback, the resulting tool consists of nine sections, measuring both costs incurred in meal production and service as well as analysis of staff workloads. Preliminary results show consistency between homes within Australia, indicating that the true cost is much higher than that reported in the literature to date. The development of a comprehensive, usable tool which captures the total cost of foodservice allows homes to accurately report and understand costs from a systems level. This information can be used to demonstrate cost effectiveness of a foodservice and the potential to justify and plan future system changes.

DEFICIENCY CITATIONS IN NURSING HOMES THAT PREDOMINANTLY SERVE RESIDENTS WITH SERIOUS MENTAL ILLNESS
Dylan Jester, 1 Kathryn Hyer, 1 and John Bowblis, 2 1. University of South Florida, Tampa,Florida,United States,2. Miami University,Oxford,Ohio,United States Studies suggest that nursing homes (NHs) that predominantly serve residents with serious mental illness (SMI) are of worse quality due to poor resources (i.e., high Medicaid-paying census) and lower staffing. We used national Certification and Survey Provider Enhanced Reports (CASPER) data to examine the deficiencies issued to NHs from 37,800 recertification inspections of 14,582 unique NHs from 2014 to 2017. NHs were categorized into "low-SMI" and "high-SMI" facilities using the lowest and highest quartiles, respectively, of the proportion of residents in the NH with SMI. Bivariate analyses were used to assess for differences between low-SMI and high-SMI NHs in the number of deficiencies, the deficiency score (a point-based metric developed by the Centers for Medicare & Medicaid Services), and the scope and severity of deficiencies. In total, there were 245,178 deficiencies issued. In comparison to low-SMI NHs, high-SMI NHs received a greater deficiency score and more deficiencies per survey (p<.001). Deficiencies given to high-SMI NHs were associated with greater risk of harm (p<.001) and were of wider scope (p<.001). High-SMI NHs were cited 215% more often for resident abuse or neglect and 61% more often for the policies that prohibit and monitor for risk of abuse and neglect in comparison to low-SMI NHs. In conclusion, high-SMI NHs were documented for providing worse care to residents, with one particular area of concern being the heightened risk of resident abuse and neglect. Implications for policy and practice will be discussed.

. Teepa Snow, Efland, North Carolina, United States
The diverse needs of persons living with dementia in nursing home settings presents challenges for Certified Nursing Assistants (CNAs) to provide quality care. There is a lack of educational preparedness among nursing home CNAs regarding dementia knowledge and skills required to care for a person living with dementia. As direct caregivers for persons living with dementia, CNAs play an important role in long-term care. This pilot study evaluated the dementia knowledge and caregiving skills of newly trained CNA students. The students were trained by an instructor certified using Teepa Snow's Positive Approach to Care (PAC) curriculum. Conducted in a rural southwestern Indiana community, this study evaluated CNA students' knowledge and perception of dementia, as well as their skill performing the Positive Physical Approach™ (PPA™) technique to approach and connect. A 38-item knowledge and perception survey and a 12-step observed skills assessment using a standardized patient encounter were administered to CNA students. Data were analyzed using descriptive statistics and bivariate analysis. Preliminary results indicate that 100% of students correctly answered the survey item regarding non-confrontational body language, while 29% of students correctly performed the corresponding PPA skill. There is a statistically significant association between the knowledge that people find pressure in their palm comforting and the ability to perform the corresponding Hand-under-Hand® and PPA techniques. Incorporation of PAC into current CNA curriculum may equip CNAs with the knowledge and skills required to provide better care, with the potential to improve the overall quality of life for persons living with dementia.

DOES NURSING HOME RESIDENTS' RIGHT TO SELF-DETERMINATION IMPROVE THEIR QUALITY OF LIFE IN SOUTH KOREA?
Minhong Lee, 1 Kyeongmo Kim, 2 and Sok An, 3 1. Busan,Republic of Korea,2. Virginia Commonwealth University,Richmond,Virginia,United States,3. Korea Rural Economic Institute,Austin,Texas,United States Background and Purpose: Addressing issues of quality of life of nursing home residents based on the human rightsbased approach has been a top priority in the long-term care system in Korea but no study has yet examined the relationship between self-determination of nursing home residents and their quality of life. This study aimed to examine whether greater levels of self-determination in the provision of daily care were associated with higher levels of quality of life of the residents. Methods: We collected data from 332 residents (+65) at 20 nursing homes in a metropolitan city. We measured residents' right to self-determination using the autonomy scale of the Client-centered Care Questionnaire.
We also included quality of life, socio-economic characteristics, ADLs, depressive symptoms, and social networks. We ran multiple regression analysis using SPSS 26.0. Results: The findings of this study revealed that greater levels of residents' right to self-determination were associated with higher levels of quality of life (β =-.425, p <.0001). Older residents who were higher levels of depressive symptoms were likely to have lower levels of quality of life (β = -.265, p < .001). Conclusions and Implications: This study adds to the growing literature on the ways nursing home residents' self-determination contributes to their quality of life. More opportunities for self-determination in their treatment should be given to promote recovery and to encourage participation in the decision-making process. Nursing practitioners and policymakers in Korea should develop programs and/or services that enhance residents' self-determination to improve their quality of life. A qualitative study based on structured interviews with 21 healthcare leaders from CCRC's, In-Home Care Agencies, or Medicare PACE facilities was conducted. Implications of electronic assisted living technologies on caregiver workforce were assessed. The use of assisted living technology was shown to have implications for workforce support and the alleviation of demands on caregivers. Communication and assessment tools were also found to be useful in the reduction of caregiver stress. There is optimism regarding the effectiveness of high-tech platforms in easing caregiver burden but there is skepticism about the return on investment given the initial cost and time needed for onboarding and data organization. The lack of user-friendliness and the required time to train to use tech are also barriers. The use of technology for remote check-ins and to monitor vitals is