A: Yes. The DON is responsible for hiring, training and monitoring the staff as well as directing the nursing care. This is exactly what the DON's job is - to direct the clinical care. The DON must know the basic data with regard to all of the residents and take responsibility for the professional staff that is left in charge or delegated responsibility to care for the residents in the DON's absence.
Q: Does that include the rehab dept?
A: No. The DON is not responsible for the rehab dept but the DON is responsible to ensure that the documentation is adequate and appropriate with regards to residents in therapy as well as being responsible for identifying and ensuring that care is provided for those residents who experience a functional decline and require therapeutic treatment to minimize the risk of functional loss.
Q: What role does the DON play with respect to reimbursement and isn't reimbursement the responsibility of the finance department?
A: Nursing is responsible to identify, with the physicians, clinical issues that are the basis for the provision of nursing care as well as therapy and to ensure that documentation exists throughout the course of treatment to indicate the resident's response to nursing care and therapy, including pain management and safety precautions to minimize the risk of any type of injury.
Q: I've noticed that there have been a flood of new laws and regulations which at first glance wouldn't seem to be the concern or to fall within the realm of the DON. Is this an accurate perception?
A: Can you give me an example?
Q: Sure. Let's take the New Jersey Violence Prevention Act. This relatively new law requires that SNF, among other healthcare facilities, develop and implement programs to protect employees from abusive behavior by residents. How might this involve clinical issues that the DON must address?
A: The DON is required to ensure that clinical assessments are conducted for all residents to identify what triggers that so called abusive behavior. For example: unexpressed pain is very often the cause of aggressive behaviors such as resistance to care. Often a psychotropic medication is ordered for the resident to facilitate the time during which care must be provided. An alternative which I have repeatedly seen work wonders is to administer Tylenol an hour or so before the care is to be provided. Often the resident is a different person when the caregiver comes in to provide care an hour or so after the Tylenol is given. Why? Because the Tylenol alleviated the aggressive symptoms that stemmed from the unexpressed pain. The DON is instrumental in assessing this type of intervention as a first step possibility before moving on to a powerful psychoactive medication which carries with it many side effects. This is an example of the critical role that the DON plays in dealing with the many new laws and regulations impacting on our industry. The DON is responsible, with the management team, for the safety of the resident as well as the staff.
Q: I understand now that the DON job may very well be too much for one person to handle by herself and that the DON must rely on a qualified and trustworthy support staff. I can't help but wonder who trains a DON to handle this multifaceted position with all of these very real potential liabilities? Is this something that's taught in nursing school?
A: No. Most DONs will agree that this ability comes from on the job training; you need to learn as you go, very often under "a baptism of fire".
Q: In your experience, what background do most administrators have?
A: Most administrators come right from a college background and most do not have a medical background so it is very difficult for them to identify the areas that are potentially risky; the areas that could lead to potential litigation or deficient practice. Most administrators are not really equipped to help or provide the real clinical support that the DON needs. Yet administrators are responsible for everything that goes on in their facilities.
Q: So there are two distinctly different professionals in a SNF each of whom takes responsibility for a different half of the facility: the administrator for administration and overall responsibility; the DON for clinical responsibility.
A: Yes, in general that's true.
Q: Well if that's the case, how does an administrator know that the DON is doing that which is required by the feds, the state, families, residents, etc.?
A: The only way for the administrator to really know is through the measurement of clinical outcomes with the facility's quality improvement program. The most direct and easiest way to assess the effectiveness of a facility's clinical program is to look at the resident council minutes, resident survey analysis and DOH / Centers for Medicare and Medicaid Services ("CMS") survey results. Unfortunately, the survey results include deficiencies in practice after the fact. All of these sources of information provide the administrator with identification of critical areas of concern about the clinical program. The goal for the administrator and the DON is to provide services through the regulatory process and to identify deficiencies before the federal and state surveyors do.
Q: What do your SNF clients hire you to do?
A: Our clients will call us if they have issues with a survey report, an Ombudsman complaint as well as for quarterly review of their Quality Improvement Program. We review incidents / accidents, infection control, psychotropic documentation and Medicare documentation to enhance the facility's performance and compliance. If there is a new member of the nursing management team, in particular the DON or the Assistant Director of Nursing ("ADON"), we have a mentoring program to guide that professional through the orientation phase and provide on-going mentoring 24/7 to help them deal with any crisis or particular issues that arise.
Q: So in other words, you work on behalf of the administrator to support the on-the job training that you earlier identified is the primary way that a DON learns to do her job?
A: Yes
Q: What are the biggest issues that you are currently offering support of to your client DONs?
A: Documentation issues, DOH survey compliance issues, preparing for case mix, changes in the MDS to the 3.0 system, care planning and mentoring of new DONs.
Q: What roll do you play in supporting a SNF's corporate compliance program?
A: As part of our compliance program that we develop and implement for our SNF clients, we look at where the facility and its clinical programs are, and then we move forward to enhance the current system of care to ensure that everything that's being done is being done correctly. We take into consideration the past and we look forward particularly in the areas of rehabilitation and the billing process to ensure that all of our areas - clinical and billing - are in synch with each other. For example: the UB4 must match the admitting diagnosis which must in turn match the rehabilitation therapy provided.
Q: So you really look at systems.
A: Yes. We are constantly reviewing, developing, implementing, monitoring and auditing clinical and reimbursement systems as well as ensuring the validation of the necessity for the prescribed nursing and rehabilitation therapies to ensure compliance with federal and state laws and regulations.
Q: Thank you very much. Our interview has been very informative.
A: My pleasure.