EPIC Podcast: Unraveling the Mystery of NoviSurvey (Part 1)

Join us for part one of a two part series on “Unraveling the Mystery of NoviSurvey” with host Yessi Cubillo, Quality Insights ESRD Network 3 Patient Engagement Specialist, and guest Kimberly Hansen, MSN, RN, Acute Care Program Manager within the Health Facility Survey & Field Operations at the New Jersey Department of Health.

For “Part Two” of this series, we need your feedback: Submit your questions.

This material was prepared by Quality Insights Renal Network 3, an End Stage Renal Disease (ESRD) Network under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No. ESRD3-061125-GK-A

Transcript

Welcome everyone to another episode of

the Empowering Partners for Improved

Care Epic podcast. Whether you're a

patient, a family member, a care

provider, or one of our many dedicated

partners, this space is for you. I'm

thrilled to have you join us for another

episode. Together, we'll explore explore

real stories, lived experiences, and

proven practices from across our care

communities. Our guests will share the

challenges they face, the breakthroughs

they've had, as well as the strategies

they're working to remove barriers and

improve outcomes. This podcast is about

partnership and the incredible things we

can achieve when we learn, listen, and

lead together. So get ready to be

inspired, informed, and empowered. I am

Yes, your host and patient engagement

specialist for ESRD Network 3. Today I

am excited to welcome a valued partner

and guest, Kimberly Hansen, who's the

program manager for acute care within

the health facility survey and field

operations at the New Jersey Department

of Health. Kim, we're so glad to have

you with us today. Welcome to this epic

podcast. Thank you so much. I'm happy to

be here. Thank you. Before we dive into

today's conversation, um would you like

to share a little bit about your

background and important work that

you're currently doing? Kim? Sure. So,

I've been with the Department of Health

for 17 years. I am a nurse by trade.

I've been a nurse for 30 years. I do

have my masters in nursing education and

um as program manager. I've been program

manager for 14 years of the acute care

program, but I do I've made my way

around the circle here at the division

of a health facility survey and field

op. So I have been on the training team

um long-term care

uh and then circled back to acute care

where I first came in and um it's a

pleasure to be here. Our focus as with

any of our programs here at um at health

facilities is that you know to be

partners in practice with the facilities

because we all have the same goal to

ensure the health the safety um and care

of the ESRD patients in New Jersey.

Great. And a few weeks ago, you and I

were actually talking about um some of

some of the important things that are

happening in the diialysis community and

we the topic of reporting to the

department of health came up and so we

thought let's put together something

that we can share with the diialysis

facilities. Um and what better way to

get this information out to them than

using this podcast, right? Uh so but

we're doing things a little different

this time rather than having a back and

forth discussion. Um, this episode will

be part one of a two-part series. In

this first part, Kim is going to walk us

through a presentation that she has put

together titled Unraveling the Mystery

of Novi Survey. Uh, for all of you who

are familiar with Novi Survey, you're

going to get some great information. If

you're not familiar with Novi Survey,

um, you're definitely going to still get

a lot more information. So, um, stay

tuned for for that presentation. For

part two, we want to hear from you. Uh,

we've included a link in the podcast

description where you can submit your

questions. Kim and I will then take some

time to review everything you send us.

And in that next episode, we're going to

dive into your questions, clarify any

lingering confusions, and make sure that

you get the answers that you need. But

today, Kim is going to walk us through

that very great presentation that she

has put together. Um, and we're going to

uh hear from her. So, Kim, the floor is

all yours. Take it away. Thank you so

much. Thank you so much. Okay. So, um it

is a pleasure to talk with you today

regarding the NOVI survey and reportable

events. Um

today it's my pleasure to speak to you

about the mysteries of NOVI survey. This

topic um unraveling the mystery of Novi

Novi survey will cover uh reporting

requirements and the vehicle for

reporting which is the Novi survey uh

form.

Um, as a disclaimer,

uh, this presentation and content is

just a summary of information and does

not contain exhaustive content on the

subject. Please always refer to the

current edition of the regulations for

detailed information. Our objectives

today um are for the are for the

participant to develop a deeper

understanding of the mandatory reporting

requirements of the ESRD facilities and

the timelines associated with the

reporting. How to get access to the NOVI

survey reporting platform to report the

events. and we'll take a look at the

NOVI survey form and the information

necessary to include in the report as

well as discuss what happens after a

form is submitted.

Before we get into all that, I think

it's important to note uh and to focus

on the regulations um that support this

and under the statutory authority of

title 8 health uh contains the general

lensure regulations and standards that

are applicable to all licensed healthc

care facilities in New Jersey including

ESRD facilities. These requirements are

under chapter 43E

and can be found uh in chapter 10 of

that guidance document under 10.11

where it discusses other reporting

requirements. Um, we'll go into a little

bit more detail in just a moment, but

first I also wanted to

um point out that ESRDS are also under

federal there's some federal reporting

requirements under uh the 42 code CR CFR

uh under appendix H the state operations

manual. Specifically, I think which most

people are familiar with are the Vtags.

So under Vag B767,

it requires the facility to notify the

state agency of any involuntary

transfers or discharges.

Under our general lure regulations, um

you'll see that it's mostly broken down

into two categories.

Um the first one through five uh are

examples of physical plant and

operational uh interruptions and those

would of course involve your heat or air

conditioning, loss of reduction of

water, electrical power and this

includes even if you lose power and go

on backup generator. This is still

reportable. Although the facility may be

receiving power, we we need to know when

power will be restored and if there's

any essential um services that need to

deploy to your area, this helps us

determine if we need to contact other

entities or any other essential utility.

If you have internet that goes down, any

kind of interruption in service, um

cyber attack, anything like that where

it could impact patient care, facility

operations, this is absolutely something

that we would need to know about. fires,

disasters, accidents resulting in injury

or death of patients, employees, if you

have to evacuate for any reason, if

there's a labor stoppage,

um if there's going to be strike at your

facility, if union is a concern, any

kind of temporary closure. I can think

in dialysis sometimes um depending on

weather there could be weather related

events. If you're going to open up late

or if you have to close early or if

there are treatments that need to be

shortened for any reason we consider

those interruptions of normal business

practice and service and those are the

things that you would need to

mandatorily report to us.

Uh and then on the flip side of that,

and we hope that we never have many of

these, but there's also the potentially

criminal acts that could um occur, and

that's if anybody impersonates a

physician, nurse, pharmacist, or any

other licensed health care provider,

including surveyors. We have had that

happen where somebody misrepresented

that they were a surveyor from the

Department of Health, and that's not

true. So, if you ever have any doubts,

please let us know. um an abduction of a

patient,

uh sexual assault,

uh visitor employee or death of a sign

death or significant injury of a patient

visitor or employee.

And then of course um anytime that there

is a um

an involuntary discharge or transfer

which I didn't list because I was just

trying to list just the uh state things

because there's so many components do

that but federally um also we would need

to know for the uh involuntary transport

or discharges.

All right. So now we're going to gear

over to how do you report? So you have a

reportable event that you need to get to

us. So what does that mean for you? So

now we're going to just discuss um the

Novi survey platform. And that platform

replaced what used to be known as

Hypocrates. Uh once upon a time we had a

properties which was a one-stop shop so

to speak. when a reportable event came

in through Hypocrates, it kind of sent

out a blast to all uh a few different

entities including the office of

emergency management. Um and that was

created in response to Superstorm Sandy.

And then as time goes on, the platform

sort of lost its ability uh because it

was built on old technology. So they had

to come up with a with a new a

replacement format for that and that is

how Novi survey actually came about.

Novi survey is a little bit different

than hypocrates as it no longer sends

out a blast to everyone. This is just

specifically to our internal group which

is the acute care survey and

certification. So it doesn't replace any

other reporting requirements. It's no

longer a one-stop shop. So if you have a

reporting requirement at another entity

um you'll have to continue to report

through that. This is just for us and

our reportable events as outlined in the

previous slide.

So how do you get access to NOVI survey?

So I think there's a couple key

information um com pieces that you would

need to know. Number one, NOVI survey is

a uh is a URL that is created. It's an

account and it's a link that's created

specifically to each licensed entity. So

each licensed entity will need its own

URL. And this is really important

because we do get reportables for maybe

a regional person or maybe a facility

administrator that may be over different

clinics or be connected with them in

some way and they may use that URL that

they're familiar with using. However,

when it comes and reports to us, we're

seeing it as the facility URL that they

reported it from and not necessarily

from the facility that the event

occurred at. So, it's very important

that you keep in mind that the URLs are

very sight specific, license specific.

So, please, they're not interchangeable.

So, please do not use another C center's

URL or we are going to assume it's the

facility's URL and it may not be like I

said the uh facility that you're

reporting from. Some other things to

keep in mind is when creating an

account, we ask that we only issue one

URL to an email address. So we ask that

the facilities please create a

generalized mailbox that they provide

administrative staff access to on their

end. And this just helps so that these

URLs do not get used by other entities

as well as ensuring that the URL is

being utilized by the person that has

the um authorization to use it from the

facility.

uh the request. If you don't have one or

you don't know what your is, you can

actually send a request using the

facilities business email um extension

uh to the non

long-term care.reportables do.j.gov

and then we will forward your email over

to the entity that creates um the URLs.

If you're in a facility where don't know

what that general email box is, your

facility no longer has access to that

box, please reach out to your IT and see

if you can work with them on getting

access back to the generalized mailbox.

You can also uh give us a call. Um the

800 number is our hotline and uh we will

get back to you and we also have a fax.

And then if you have uh any questions

regarding um the reviewing of the

regulations, I just put in here the um

the link for that as well.

All right. So now that you've

established your URL and it's time for

you to report in, um when you first

click on your URL, this is the screen

that you're going to see. It's going to

ask for your login, your password. You

should have all that information and

once that's entered um it's going to

move you through some uh through the

actual three pages of the form. Um some

general information about the form

itself. It is three pages. The uh the

boxes in the form are expandable.

The information fields populate based on

the selected type of event. We're going

to go through that in just a moment. The

fields can accommodate up to 400

characters. So, just keep in mind it is

character restricted. So, if you're

typing away and you're up to 5,000

characters, we're only seeing 4,000 of

those. Um,

if you leave something that's blank,

there will be an error message

notification to you. There is an option

for continuing later. So, if you started

then have to go handle something and

come back, you should be able to pick

right up where you left off. there is a

help information um that's located on

each page and what you want to do is

provide as much detail as possible. The

more specific and clear information that

you provide um it really helps us in

understanding what the issue is and what

the impact is and what kind of follow-up

questions that we need to ask. um if

needed or if it's all great and it seems

like you covered everything, we just we

won't even need to ask follow-up

questions. She'll just ask us, you know,

we may ask to either keep us informed

until the event has resolved or uh or we

can just go ahead and close it out

depending on what type the event is.

All right. So, on the page one of the of

the NOV form, it's talking about, you

know, facility information. um and the

reporting category. So, it's going to

ask you your the name of your facility.

And even though it's asking for the name

of your facility, it will come up to us

that your ABC facility. Um your state

license number, your contact name, the

title, the role, the phone number, your

contact backup phone number, and your

cont your your email address.

If the report is being submitted by

someone other than the contact person,

we will ask to provide the reporter's

name, phone number, and email address.

Um, the really key to this is is putting

in the individual that will most likely

have the answers to the questions that

we may have. So, we usually ask the

person most associated with the event

that has the information to be the one

that is going to be our contact person.

It doesn't necessarily need to be the

person that is submitting the reportable

event.

All right. On page two, it's going to

ask you for the type of event. So, this

is where you're going to it'll give you

a drop down and it's going to ask you,

is this an interruption of service or is

this an other event?

And then you'll click whichever one is

applicable. And then it's going under

electrical power. electric power where

it says select one. You're going to see,

for example, it'll say normal, no

service, partial service, or um

scheduled outage. And this is just an

example of one of those pieces under the

event that could happen. And then this

is where you're going to put as much in

information as you can in there

regarding the disruption, the impact,

um

for whatever it may be. you know, if

you're having HVAC system issues, I will

say that some of the things that we will

ask and if it's pertinent to include is

current temperatures in the facility,

how often the facility is going to be

monitoring those temperatures and kind

of a mitigation uh plan and the

workaround for that. So, that's just an

example of the information that you can

expand on if it's considered electric.

Let's just say a power line went and

PSEG needs to come out and fix the power

line. They'll be in contact with the

ESRD facility and the ESRD facility can

just include in the NOI survey what the

expectation is for repair and what the

facility plans to do your own backup

generator. um you're able to continue

service as normal or your backup

generator is not working for whatever

reason and you need to come up with yet

another mitigation plan. Whether that is

to um you know depending on what it is

you know and what your medical director

determines whether or not it's you're

going to delay treatments or maybe you

need to cancel treatments and patients

are okay with that or if they need to go

to another center whatever that may be.

But um you also will enter the date and

the time that um the event occurred.

All right. And then on um page three,

this is just a little bit more of um

about the event. Um and it has some

duplicative information in it. It'll ask

whether or not this was a significant

event.

um who else was notified about the event

and it'll give you um an opportunity to

also provide you know um patient

information. So I do want to say that

this is completely internal. So any kind

of patient information this is encrypted

and there is no um uh worries as long as

our information stays between our our

website or I mean our email address and

your entity that is contained it's

encrypted. So um just just be mindful of

that. Um I know there has been some

questions in the past regarding um you

know HIPPO compliance and protection of

uh you know health information. We may

ask for things such as you know

narratives of the events if it's

specific to a patient. We may ask about

plan of care. Um the facility's

investigations and findings and

conclusions whether or not the doctor's

been notified in any referrals. If the

facility wants to get out ahead of that

and include all that information into

the NOV survey form um and send

attachments if needed, that would be

perfect because then that decreases the

amount that we have to have the back and

forth with the facility regarding that.

All right. So, I want to say that if I

hadn't mentioned it already, um when you

read in the

um general regulations, it does talk

about a timetable and that timetable

means immediately upon knowing or

becoming aware of the issue and within 3

hours of the of it occurring. So, they

kind of give you a we need it right

away, but we'll give you up to three

hours to report, but really we want you

to report as soon as possible.

All right. So, after we receive this,

um, this goes to our mailbox. It goes

straight to that non-long-term care, uh,

reportable event mailbox, which is

monitored,

um, by supervisor staff. The supervisors

are the only ones that deal with our

reportable events.

And we do have an individual that um,

basically it's their only job is to look

at reportable events. We get quite a few

with over 2,000 um licensed healthcare

entities in the state. You can imagine

there we get a lot of reportable events.

So that's why also it's very helpful um

that we have as much detailed

information as possible. So once this is

received, the supervisory staff will

review this. They'll be looking at the

information that was provided. We'll

look at uh to determine the impact um on

patient safety and then we'll respond to

the facility to determine if there's any

additional information that we need or

you know as I stated previously maybe

it's you did a great job and we have all

the information that we need and now all

we're looking for is just some from some

updates. Is PSENG going to um you know

what's the repairs look like and then

just keep us updated. We have this we

have this much fuel um left in our

generator. We're good to go. They said

the repairs will be done at 12. Great.

Just keep us updated. If there's any

impact or any interruption in service

other than the fact that there's no

electrical power, if the um generator

goes down or if you know something

happens and it alters from your

mitigation plan, just reach out to us.

Just keep us informed and you know all

should be good. And then once we have

resolution, we either close it out or it

may trigger an on-site. Now, typically

on-sites are triggered when there's um

information that doesn't seem to to

jive. It just says kind of doesn't make

sense to us and we feel that maybe it

would be best if we go out and take a

look to see what is actually going on.

incomplete information that's not clear

and disorganized sometimes will also

trigger onsites for the most part. We do

not typically go out on reportable

events unless

um you know we are confused about what

may have occurred.

So in summary of the key information um

I just want to say that reporting is a

mandatory both federal and state. It is

part of our regulations. It needs to be

immediately reported in within three

hours. Um the types of reportables are

usually physical plant and operation

interruptions or issues, any potential

or actual criminal acts, any involuntary

discharges or transfers,

and then you're going to report using in

on the NOV survey. You can request the

account using the facility's email. Use

a generalized mailbox that permits the

administrative staff to access. Do not

share your URLs as they're sight

specific. You want to complete the form

and include as much information as

possible uh as content to be clear and

detailed. And ensure your main point of

contact is the individual that's

knowledgeable about the event and can

answer any follow-up questions.

And I thank you.

Back to you, Yassie. Well, thank you so

much. Uh uh that was a lot of

information, good information. We want

to provide everyone now with the

opportunity that you've heard Kimberly's

uh presentation. Um now it's your turn.

We want to be able to to to hear from

you. And so we want to make sure that

part two of this series speaks directly

to your needs as our listeners, our

viewers. So, if you have any questions,

any thoughts, or anything that you'd

like us to cover during that second

part, please use the link that we

included in the episode's description to

submit those questions. Submit those

thoughts. No question is too big, no

question is too small. If you're

wondering about it, if you're thinking

about it, if it came to your mind during

the presentation, chances are someone

else is um also thinking about it, but

maybe they're they're holding back on

sending a question. Don't hold back.

Send us all of your questions. Kim and I

are going to sit together, review them,

and then we're going to talk about it

during that podcast. All right. Well,

that brings us to the end of part one of

our special epic podcast series on

reporting requirements and Novi survey.

A huge thanks to you, Kimberly, for

sharing your expertise and helping us

break down this topic. We'll be back, as

I said, for part two to unpack the

questions and provide even more clarity.

Until then, thank you for tuning in and

remember, empower partners make powerful

change. Stay con connected, stay

informed, and we'll see you soon. Thank

you. Thank you.