Wisconsin Health Care Association. Handout: Rolling Out Phase 2: The New Requirements of Participation Made Easy

Transcription

1 Wisconsin Health Care Association Handout: Rolling Out Phase 2: The New Requirements of Participation Made Easy

2 Summary and Objectives Rolling Out Phase 2: The New Requirements of Participation Made Easy Phase 2 rollout of the affectionately called Mega Rule is November 28, There are areas that were partially implemented in, or will have more to implement in. This session will break down what the requirements will be and how facilities can prepare themselves, including behavioral health services, QAPI, Infection control, compliance, and ethics. Verbalize what areas will be required to be implemented by November 28, Discuss what changes need to be made in current processes. Implement strategies to prepare their facilities. Target Audience: SNF providers including Administrators, Assistant Administrators, Owners, Directors of Nursing, Clinical staff, Department Managers.

3 Prepared for Wisconsin Health Care Assocation Rolling Out Phase 2: The New Requirements of Participation Made Easy 2 Implementation Timeline November 28, 2016 Phase 2 November 28, 2017 November 28, R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 1

4 Prepared for Wisconsin Health Care Assocation Phase 2 Implementation November 28, Resident Rights Phase 2 Facility providing contact information for certain organizational units (Aging and Disability Resource Center, Medicaid Fraud Control Unit) Furnish a list of names, addresses, addresses, and telephone numbers of all pertinent state regulatory and informational agencies Freedom From Abuse, Neglect, and Exploitation Phase 2 Regulatory inclusion of Section 1150B of the Act requirements (reporting reasonable suspicion of a crime): This is an existing requirement under the statute 6 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 2

5 Prepared for Wisconsin Health Care Assocation Required Policies and Procedures for Reporting Suspicion of a Crime 7 Required Policies and Procedures for Reporting Suspicion of a Crime Admission, Transfer, and Discharge Rights Phase 2 Transfer/discharge documentation in medical record Basis for the transfer Specific resident needs that cannot be met, attempts to meet those needs, and services available at the receiving facility Documentation by physician when transfer is necessary Receiving facility information must include: Contact information of practitioner responsible for care of resident Resident representative information Advance directive information All special instructions or precautions for ongoing care Comprehensive care plan goals All other necessary information, including discharge summary Other documentation to ensure a safe and effective transition of care 9 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 3

6 Prepared for Wisconsin Health Care Assocation Comprehensive Person-Centered Care Planning Phase 2 Baseline Care Plan Develop and implement a baseline care plan for each resident, including instructions needed to provide effective and person-centered care that meets professional standards of quality Must: Be developed within 48 hours of admission Include the minimum health care information necessary to properly care for the resident, including: Initial goals based on admission orders Physician orders Dietary orders Therapy services Social services PASARR recommendations, if applicable Comprehensive Person-Centered Care Planning Phase 2 Baseline Care Plan Comprehensive care plan may be developed in place of the baseline assessment if: Developed within 48 hours Meets the requirements Summary must be provided to resident and representative Initial goals of the resident Summary of medications and dietary instructions Any services and treatments to be administered by the facility and personnel acting on behalf of the facility Any updated information based on the details of the comprehensive care plan as necessary Comprehensive Person-Centered Care Planning Phase 2 Must: Be developed within 48 hours of admission Include the minimum health care information necessary to properly care for the resident, including: Initial goals based on admission orders Physician orders Dietary orders Therapy services Social services PASARR recommendations, if applicable 12 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 4

7 Prepared for Wisconsin Health Care Assocation Nursing Services Phase 2 Use of the facility assessment in determining sufficient number and competencies of staff Develop and implement processes to evaluate nursing staff competencies Develop system for determining sufficient nursing staff based on facility assessment Behavioral Health Services Phase 2 New requirement Incorporates highest practicable well-being, specialized rehabilitation, and medical social services Ensure necessary care and services are person centered, reflect resident s goals for care, and maximize dignity, autonomy, privacy, socialization, independence, choice and safety Provide meaningful activities Provide environment and atmosphere conducive to mental and psychosocial wellbeing Use pharmacalogical interventions only when non-pharmacological interventions are ineffective or when clinically indicated Behavioral Health Services Phase 2 Also includes mental disorders and substance use disorders Includes depression and anxiety/anxiety disorders Sufficient, competent staff: Trained Skill and competency Requirements for all behavioral health issues, including dementia 15 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 5

8 Prepared for Wisconsin Health Care Assocation Pharmacy Services Phase 2 New requirement related to PRN psychotropic drugs Drug regimen review and reporting: Pharmacist must report irregularities to attending physician, medical director, and DON and reports must be acted on Attending physician must document in the medical record that the identified irregularity has been reviewed; what, if any, action was taken; and the rationale Review of medical chart: Medication regimen review or drug regimen review is a thorough evaluation of meds, with a goal of promoting positive outcomes and minimizing adverse consequences and potential risks Includes review of the medical record Involves collaborating with other members of the IDT, including residents, family, and/or representative Pharmacy Services Phase 2 Definition of psychotropic medication: Any drug that affects brain activities associated with mental processes and behavior Includes: Antipsychotic Antidepressant Antianxiety Hypnotics Dental Services Phase 2 Lost dentures New requirements: May charge a Medicare resident an additional amount for routine and emergency dental services Must have policy identifying circumstances when the loss or damage of dentures is the facility s responsibility May not charge a resident for loss or damage of dentures, determined in accordance with the facility s policy to be the facility s responsibility Must promptly, within three days, refer residents with lost or damaged dentures for dental services If not done within three days, must provide documentation of what the facility did to ensure the resident could still eat and drink adequately while awaiting dental services and of the extenuating circumstances that led to the delay 18 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 6

9 Prepared for Wisconsin Health Care Assocation Food and Nutrition Services Phase 2 Qualified dietitian or other clinically qualified nutrition professional: Bachelor or higher degree from accredited college, with completion of academic requirements of a program in nutrition or dietetics Completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutritional professional Licensed or certified as a dietitian or nutritional professional by the state Dietitians hired or contracted with prior to effective date Built-in implementation date of five years following the effective date of the final rule (2021) Food and Nutrition Services Phase 2 Food service manager: Designations prior to effective date Built in implementation date of five years following the effective date of the final rule (2021) For designations after November 28, 2016, no later than one year after November 28, 2016: A certified dietary manager, or A certified food service manager, or Has similar national certification for food service management and safety from a national certifying body Has an associate s or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management from an accredited institution Must meet state requirements Receives frequent scheduled consultation from dietitian/nutritional professional Administration Phase 2 Facility Assessment Facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies Review and update plan at least annually Review and update whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment 21 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 7

10 Prepared for Wisconsin Health Care Assocation Administration Phase 2 Facility assessment must address: Facility population, including: Both the number of residents and facility resident capacity Care required by resident population, considering types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within the population Physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility (activities, food, and nutritional services) Administration Phase 2 Facility assessment must address: Facility resources, including: All buildings and/or other physical structures and vehicles Equipment (medical and nonmedical) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies All personnel including managers, staff (both employees and staff who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during normal and emergency operations Health information technology resources such as systems for electronically managing patient records and electronically sharing information with other organizations Quality Assurance and Performance Improvement Phase 2 QAPI Plan As required by Affordable Care Act Present a plan to the state survey agency no later than one year after the promulgation of the regulation (November 28, 2017) Present plan at each annual recertification survey and on request during any other survey Plan must be a written plan containing the process that will guide the nursing home s efforts in assuring care and services are maintained at acceptable levels of performance and continually improved Describes the how the facility will conduct its required QAPI and QAA committee functions 24 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 8

11 Prepared for Wisconsin Health Care Assocation Quality Assurance and Performance Improvement Phase 2 QAPI Plan As required by Affordable Care Act Must describe in detail the scope of the QAA committee responsibilities and activities and the process addressing how the committee will conduct the activities necessary to identify and correct quality deficiencies QAPI plan should be tailored to reflect the specific units, programs, departments, and unique population it services as identified in the facility assessment Plan must describe how the facility will ensure that the care and services delivered meet acceptable standards of quality, identify problems and opportunities for improvement, and ensure that progress toward correction or improvement is achieved and sustained Quality Assurance and Performance Improvement Phase 2 QAPI Plan As required by Affordable Care Act Plan must describe the process for identifying and correcting quality deficiencies; Key components include: Tracking and measuring performance Establishing goals and thresholds for performance measurement Identifying and prioritizing quality deficiencies Systematically analyzing underlying cause of systemic quality deficiences Developing and implementing corrective action or performance improvement activities Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed 26 Plan, Do, Check, Act (PDCA) 27 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 9

12 Prepared for Wisconsin Health Care Assocation PDCA Plan Establish the objectives and processes necessary to deliver results in accordance with the expected target or goals. By establishing output expectations, the completeness and accuracy of the specification is also a part of the targeted improvement. When possible, start on a small scale to test possible effects. 28 PDCA Do Implement the plan, execute the process, make the product. Collect data for charting and analysis in the following check" and act" steps. 29 PDCA Check Study the actual results (measured and collected in do" above) and compare against the expected results (targets or goals from plan") to ascertain any differences. Look for deviations in implementation from the plan and also look for the appropriateness/completeness of the plan to enable the execution (i.e., do ). Charting data can make it much easier to see trends over several PDCA cycles and in order to convert the collected data into information. Information is what you need for the next step ( act. ). 30 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 10

13 Prepared for Wisconsin Health Care Assocation PDCA Act - Request corrective actions on significant differences between actual and planned results. Analyze the differences to determine their root causes. Determine where to apply changes that will include improvement of the process or product. When a pass through these four steps does not result in the need to improve, the scope to which PDCA is applied may be refined to plan and improve with more detail in the next iteration of the cycle, or attention needs to be placed on a different stage of the process. 31 Root-Cause Analysis Get to the root of the problem 32 Getting to the Root of the Problem Root-Cause Analysis Focuses primarily on systems and processes, not individual performance Teach your staff the process 33 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 11

14 Prepared for Wisconsin Health Care Assocation Symptom Approach vs. Root Cause Symptom Approach Errors are a result of worker carelessness Need training to motivate people to be more careful Don t get to the bottom of the problem Root Cause Errors are a result of process failure; people are only part of the process Find out why it happened and implement processes so it won t happen again Fix it for good Adapted from NASA Root-Cause Analysis Quality Assurance and Performance Improvement Infection Control Phase 2 Antibiotic Stewardship Develop a program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance Antibiotics prescribed for the correct indications, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms Risk of adverse outcomes associated with inappropriate use of antibiotics, including: Increased adverse drug events and interactions Serious diarrheal infections from C. difficile Disruption of normal flora Colonization and/or infection with antibiotic-resistant organisms such as MRSA, VRE, and multidrug resistance gram negative bacteria (GNB) 36 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 12

15 Prepared for Wisconsin Health Care Assocation Infection Control Phase 2 Antibiotic Stewardship According to CDC, core elements include: Facility leadership commitment to safe and appropriate antibiotic use Appropriate facility staff accountability for promoting and overseeing antibiotic stewardship Accessing pharmacists and others with experience or training in antibiotic stewardship Implementing policies or practices to improve antibiotic use Tracking measures of antibiotic use in the facility (one process and one outcome measure) Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff Educating staff and residents about antibiotic stewardship Infection Control Phase 2 Antibiotic Stewardship Defined Set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use Improving antibiotic prescribing Administration/management practices, thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration The Core Elements of Antibiotic Stewardship for Nursing Homes Infection Control Phase 2 Antibiotic Stewardship According to CDC, core elements include: Facility leadership commitment to safe and appropriate antibiotic use Appropriate facility staff accountability for promoting and overseeing antibiotic stewardship Accessing pharmacists and others with experience or training in antibiotic stewardship Implementing policies or practices to improve antibiotic use Tracking measures of antibiotic use in the facility (one process and one outcome measure) Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff Educating staff and residents about antibiotic stewardship 39 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 13

16 Prepared for Wisconsin Health Care Assocation Infection Control Phase 2 Antibiotic Stewardship Develop a program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance Antibiotics prescribed for the correct indications, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms Risk of adverse outcomes associated with inappropriate use of antibiotics, including: Increased adverse drug events and interactions Serious diarrheal infections from C. difficile Disruption of normal flora Colonization and/or infection with antibiotic-resistant organisms such as MRSA, VRE, and multidrug resistance gram negative bacteria (GNB) Physical Environment Smoking Policies Establish policies regarding smoking, including tobacco cessation, smoking areas, and safety Refer to F689 Accident supervision for smoking safety Designated smoking areas Use of oxygen prohibited in smoking areas Precautions taken for resident safety Informing all visitors of smoking policy and hazards NFPA 101, Life Safety Code at , Smoking Requirements for signage, prohibiting smoking by residents classified as not responsible, disposal of smoking materials 41 Phase 2 Implementation 42 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 14

17 Prepared for Wisconsin Health Care Assocation Enforcement Penalty Delay Phase 2 enforcement penalties will be delayed for one year Civil monetary penalties Denial of payment Termination Educational period Five-star rating for health inspection scores Frozen for any facility surveyed after November 28, 2017 CMS will separately flag nursing facility with serious quality concerns 43 Strategies for Success What should you do now? Strategies for Success Ensure all requirements are in place Phase 2 Develop new policies for replacement of dentures Develop smoking policies Develop policies related to reporting a crime Develop antibiotic stewardship program Develop QAPI plan Determine how your facility will complete baseline care plan within 48 hours Create your plan for a facility assessment 45 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 15

18 Prepared for Wisconsin Health Care Assocation R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 16

19 Prepared for Wisconsin Health Care Assocation Contact Information Patricia Boyer Director of Clinical Services, Health Care Practice wipfli.com/healthcare 50 R o l l i n g O u t P h a s e 2 : T h e N e w R e q u i r e m e n t s o f P a r t i c i p a t i o n M a d e E a s y 17

20 Attachments CMS Overview Checklist F-Tag Crosswalk

21 Last Updated on October 14,2016 New CMS LTCF RoP (Overview Checklist) This checklist provides a high level overview of the changes CMS made to the LTCF Requirements of Participation (RoP) and denotes in which of the three phases of implementation these changes need to be completed. It is intended to give centers an overview of the major changes that are explicitly stated in the new requirements so centers can know where to focus their efforts on meeting the new RoP. It does not describe the implicit changes that may need to occur when implementing the explicit changes. In other words, this document does not provide every action or task a center must take to comply with the new regulations. For example, changes to Policies & Procedures may also require changes in other documentation and staff training in your facility but those are not explicitly stated in the RoP, just the need to have a policy and procedure. It also does no reflect all aspects of the regulatory requirements nor does it reflect changes CMS has made to the format or citations of the existing requirements. Lastly, this document does not outline all the documentation requirements that must be made in the medical record nor the staff competencies that CMS expects. The RoP will be implemented in a 3-year phased-in approach, r : November28,2016 o Phase 2: November28,20L7 r : Novernber28,2019 'We recommend that you focus on requirements since they must be in place by the end of November We also recemmend employing an organized process improvement approach to guide the effective implementation of the various steps as this will help to produce desired results. This is consistent with QAPI approaches which have been repeatedly shown to result in better resident outcomes and Survey compliance. As CMS provides more guidance, Surveyor and Citation (S&C) memos, and updates the State Operating Manual (SOM) over the next 12 to 24 months, we expect some information in this document to change. This document contains explicitly mentioned changes in the RoP related to the following areas: o Policies & Procedures r Programs Plans r StaffPositions & Certification o Forms & Documents In-services & Staff Trainings r Notifications & Resident Rights o Resident Care Plan & Discharge Plan o Processes, Systems & Assessments o Physical Environment l lpage

22 Last Updated on October 14,2A16 Policies & Procedures CMS requires that all Medicare and Medicaid certified nursing centers have specific POLICIES & PROCEDURES in place with specific components in each policy. This section outlines all of the new policies that a e required and lists policies & procedures that have always needed to be in place but to CMS has made changes to what is required. Existing policy requirements that did not have any changes are $f listed. Policies & Procedures FR Section Enforced) Notes on Phase-In 1. Have you created all the NEW required policies & procedures? E Visitation rights of residents $483.10(Ð El Grievance policy $ t Loss or damage of dentures E Use & storage of foods brought to residents by famiþothers E infection Prevention and Control Program E Compliance and Ethics $483.5s $ $ Phase 2 Phase I EI Monthly drug regimen review $483.4s o (c)(2) chartreview - Phase2. r (e) Psychotropic drugs - Phase 2 fl Notifying clinicians tr QAPI feedback, data collection, and monitoring n QAPI systematic approach for quality improvement E Smoking $483.s0 $483.7s $483.7s $ Phase 2 2lPage

23 Last Updated on October 14,2O16 Policies & Procedures FR Section Phase (Date Enforced) Notes on Phase-In I Arrangements with other LTC facilities and other providers to receive residents during an event $483.73(b7) November 15th 20r7 Emergency Preparedness Requirements 2. Have you updated and modified existine policies & procedures to which the new RoP require changes? ü Advance directives tr Bed hold policy E RoomChanges I Abuse, neglect and exploitation of residents & property fl Reporting of crime fl Permitting Resident to Return to Facility E Admissions Policy El Staff Treatment of Residents E Influenza and pneumococcal immunizations E Disaster and Emergency Preparedness EI Facility closure EI Administrator's duties & responsibilities $483.10(b8) $483.1s $483.10(b1s) $ $ $483.1s $a83.15(a) $483.12(b)1 $ $483.7s(m) $ $ Phase I Phase 2 Phase I Phase I 3lPage

24 Last Updated on October 14,2016 Programs CMS requires rhat all Medicare and Medicaid certified nursing centers have specific programs in place, each with specific components. This section outlines all of the programs that CMS explicitly states are being required. Programs 1 Do you have all the NE}ry 'þrograms,l as required FR Section Enforced) Notes on Phase-In E Compliance & Ethics program $483.8s ç tr QAPI program fl Infection Prevention and Control program fl Antibiotic Stewardship program $ $ $ Phase 2 Some sections are in phase 2 and two components are in : r Disclosure of information to Survey Agency a83.7s(h); Sancrions (Ð r Linking to facility assessment & antibiotic stewardship - phase 2 r Requirement for an Infection Preventionist -. 4lPage

25 Last Updated on October 14,2016 Programs FR Phase Section (Date Enforced) Notes on Phase-In E Staff training program (see training & in-service section) $483.9s Note: the following need to be implemented in phase 1;483.95(c), $a83.gs(g1), and $483.e5(h). Plans CMS requires that all Medicare and Medicaid certified nursing centers have specific facility PLANS in place, each with specific components. This section outlines all of the facility plans that CMS explicitly states are being required. Plans FR Section Ph se (Date Enforced) Notes on Phase-In 1. Have you created all the NE\ry required facility plans? El Infection Control plan tr QAPIplan E Emergency Plan $ $ $483.73(a) Phase 2 November 15ù 2017 Emergency Preparedness Requirements E Communication Plan about Emergencies $a83.73(c) November 15F 20t7 Emergency Preparedness Requirements SlPage

26 Last Updated on October 14,2O16 Staff Positions & Certification Requirements CMS requires new positions (which can be filled or shared by existing staff) that are required and has made changes to the qualifications for certain existing required positions. Required positions or qualifications (e.g. activities coordinator or feeding assistants) that did not have any changes are not listed here. 1 Staff Positions & Certification Requirements Do you have a person designated for the NEw required positions? FR Section Phase (Date Enforced) Notes on Phase-In fl Compliance Contact (in each facility) fl Person to Oversee Compliance (must be high-level person within the Organization) $a83.8s(c)(1) $483.8s(c)(2) [J Compliance Officer (for Organizationwhen the Orgarnzation has >5 facilities) $483.85(d2) E Compliance Liaison (in each facility when Organization has >5 facilities) E InfectionPreventionist E Grievance Officer $483.8s(d3) $483.80(b) $ Does your EISTING staff who are currently in a required position, meet new changes to those positions? tl Dietician $483.60(a)(1)(i) Dietitians hired before 1l- 28-l6have 5 years to comply tr Food Service Director $483.60(a)(1)(i) Food Service Directors hired before 1 I have 5 years to comply 6lPage

27 Last Updated on October 14,2416 Staff Positions & Certification Requirements FR Section Phase (Date Enforced) Notes on Phase-In E Social Worker $483.70(p1) Forms & Documents CMS requires certain documents, assessments, or plans be used that have a standard set of information in or on them, which we are labeling as "forms." CMS allows the facility to design their own forms. (Note: This does gg! contain list of "forms" a facility may need to develop to help them implement some of the RoP. This section does g!summarize all the required documentation in the medical record.) New forms FR Phase Enforced) Notes on Phase-In 1. Have you updated or created all the NEW forms? E Discharge Summary $a83.15(c)2 $a83.21(c)2 Phase 2 Discharge swnmary requirements are in two sections. E Discharge plan for each resident $ Phase I E Resident assessment $483.1s E Baseline Care Plan $ Phase 2 tr Drug regime review report $a83.as(c)3 Phase I tr Facility-wide assessment $a83.70(e) Phase 2 TlPage

28 Last Updated on October j4,2016 In-services & Staff Trainings cms requires new in-services for staff, some prior to orientation, some once and others annually. some apply to all staff and others to specific staff on specific topics. This section lists the required in-services and staff who need to receive the training. It does not address trainings identified through facility assessment or QAPI prograrn; nor does it address assessment of staff competencies, which are all required as well. It also does not include existing required staff trainings that were not modified by cms or specifîed in S&c memos. In-services & Staff Trainings (specifïcally required) FR Section Phase (Date Enforced) Notes on Phase-In 1. Do you have in-services for all the newlv required in-services? Û Abuse, Neglect and Exploitation $483.9s(c) tr Quality Assurance and performance Improvement $483.es(d) ñ Compliance and Ethics $483.es(Ð û Behavioral Health $483.es(Ð 2. Have you updated existins in-services with the new information or new staff required to be included in these in-services? 'F Nurse aide training to include following components: fl dementia management ((g)2) E residentabuse ((g)2) E care of the cognitively impaired, if applicable ((g)4) E Nurse aide training on areas of weakness determined by performance reviews and the facility assessment $a83.es(g)( 2) and (e ) $a83.es(g)(3) SlFage

29 Last Updated on October 14,2016 In-services & Staff Trainings (specifically required) F'R Section Enforced) Notes on Phase-In E Communication $a83.es(a) E Resident Rights and Facility Responsibilities $483.e5(b) E Infection Control $a83.es(e) E Emergency Preparedness Training and Testing $483.73(d) November 15th 2017 Emergency Preparedness Requirements 9lPage

30 Last Updated on October 14,2A16 NotÍfications & Resident Rights CMS requires nev/ information be included in various notifications to residents (and/or representative) at various times throughout the resident's stay. This list only includes notifications that are NEW or MODIFIED and does not include existing notifications that did not change. Resident Notilïcations & Resident Rights 1. Have you updated required notification information to be included at time of...? E Admission E Before Transfer or Discharge FR Section $ 483 I 5 (a ) $483.15(c)3,4, 5 &6 Phase (Date Enforced) Notes on Phase'In fl Orientation about Discharge or Transfer El Resident Rights (including how to file grievance or complaint) tr Participating and updating Care planning process E Participating and updating Discharge plan $483.1s(c)7 $483.10(i)3 $483.21(b)1(iv) & 2(ÐE $483.21(c)1(v) 2. Have you updated required notification information about.....? E Baseline Care plan developed within 48 hours of admission tr Bed hold policy $483.21(a)3 $483.15(d) Phase 2 l0lpage

31 Last Updated on October 14,2016 Resident Notifications & Resident Rights FR Section Phase (Date Enforced) Notes on Phase-fn tr Facility charges $483.10(Ð -10, tt &17 Phase I E Choosing their physician $483.10(d4) tr Signing of care plan $a83.10(c)(2)(v) ' tr Significant change in mental health - Health authority notiûr State Mental $483.20(k)4 Phase I fl Abnormal lab or radiology results to the clinician $483.s0(a)2(ii) $483.s0(b)2(iÐ lllpage

32 Last Updated on October 14,2016 Resident Care Plan & Discharge Plan CMS requires changes to the resident care plan. This section highlights some of those changes. For details review section $ of the RoP. We will be providing more information in checklists and templates in the future. Resident Care Plan & Discharge Plan FR Section Phase (Date Enforced) Notes on Phase-In 1. Have you created a Baseline Care Plan to be developed within 48 hours of admission? fl Does it include the resident's goals? $a83.21(a)1(ii) Phase 2 fl Does it include all of the required orders þhysician, dietary, therapy, social services and PASARR recommendations)? $a83.21(a)1(ii) Phase 2 2. Have you uodated the format of your Resident Care Plan to incorporate resident-centered information and discharge plan? EI Have you update the resident assessment to incorporate person-centered? $483.21(b)1 E Have you incorporated resident-centered goals and wishes about their care, activities, and lifestyle into the resident's carcplan? E Have you included resident's preferences for future discharge? $483.21(b)1(iv) $a83.21(b)1(iv) t Have you added new staff to the interdisciplinary team signing off on care plan? $483.21(b)2(ii) tr Are the services in the care plan culturally competent? $483.21(b)3(iiÐ l2 lfage

33 Last Updated on October 14,2016 Resident Care Plan & Discharge Plan FR Section Enforced) Notes on Phase-In El Have you incorporated trauma-informed care into the care plan? $483.21(b)3(iiÐ 3. Have you added a Ð!$åa gg-bþ! as part of the resident's care plan? E Does your Discharge Plan contain all the information required in a plan? fl Have you incorporated resident discharge goais and wishes into the resident's care Plan? EI Have you involved the interdisciplinary team in developing and signing offon discharge care plan? E Have you shared the discharge plan with the resident and their representative? $483.21(c) $a83.21(c)1(vi) $a83.21(c)1(v) $a83.21(c)1(v) l3lpage I

34 Last Updated on October 14,2016 Processes, Systems & Assessments CMS specifies throughout the new RoP that centers should conduct assessments, monitor systems, and collect data. This section highlights some of those requirements but wili be added to over time as more are defined by CMS in SOM, S&C memos, etc. Processes, Systems & Assessments FR Section Phase (Date Enforced) Notes on Phase-In 1. Have you created systems to collect data, track performance, and assess the facility? E Have you created a grievance process? $483.1o E Have you created a system for the accounting of each resident's personal funds? $ fl Have you created a discharge planning process? $ E Have you developed a monthly drug regimen review process? E Have you created a facility wide assessment? $ $ Phase 2 E Have you created a system to track, report, identify and prevent adverse events? $ F Have you created a system to obtain feedback from staff, residents and families? E Have you created a system to collect data from all departments, including the establishment and monitoring of performance indicators? $483.7s $483.7s l4 lfage

35 Last Updated on October 14,2016 Processes, Systems & Assessments FR Phase Enforced) Notes on Phase-In E Have you developed a system to prevent, identify, report, investigate, and control infections and communicable diseases for residents, siaff etc.? s Phase 2 E Have you developed a system to monitor antibiotic use? Phase 2 E Have you developed a system to detect ethical and compliance violations and allow staff to report incidents? $483.8s fl Have you created a process to ensure the integrity of reported data? $483.8s E Have you developed a system that allows residents to call staff directly for assistance? $ fl Have you developed a system to track the location of on-duty staff and sheltered residents during and after an emergency? $483.73(b2) November 15th 2017 Emergency Preparedness Requirements F Have you developed a process for cooperation and collaboration with local, tribal, regional, State or Federal emergency preparedness officials? $483.73(a)(a) November l5th 20t7 Emergency Preparedness Requirements lslpage

36 Last Updated on October 14,2016 Physical environment CMS is requiring all Medicare and Medicaid certified nursing centers that are constructed, re-constructed, or newly certified after the effective date of November 28,20L6 to accommodate no more than two residents in a bedroom. CMS is also requiring centers that are constructed, or newly certified after the effective date of this regulation to have a bathroom equipped with at least a commode and sink in each room. Physical Environment ;FR Section Phase (Date Enforced) Notes on Phase-In 1. Have you addressed the changes to physical environment? E Have you conducted a regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identiûr areas of possible entrapment? $a83.e0(c) Phase I El Have you checked construction and reconstruction plans to ensure that bedrooms accoírmodate no more than two residents? $483.e0(e)1(i) Only applies to facilities that receive approval of conskuction or reconstruction or a newly certified after November 28,2016. E Have you checked that the resident has a separate bed of proper size and height for the safety and convenience ofthe resident? $a83.90(e2i Phase I E Have you checked that each resident room has its own bathroom equipped with at least a commode and sink? $483.e0(Ð Phase I Only applies to facilities that receive approval of 16 lpage ê G ã 3 Ò. --,en -- Û'.-^.? ^-\.ê -'.\ -\ t? \., 2 4\ G; 3 a\ a\ L' /) a

37 Last Updated on October 14,2016 Physical Environment FR Section Phase (Date Enforced) Notes on Phase-In construction or reconstruction or a newly certified after November 28,2016. il Is the center adequately equipped to allow residents to call for staff assistance through a communication system from each resident's bedside? $483.e0(gxl) E Have you established smoking areas that takes into account nonsmoking residents and complies with applicable Federal, State, and local laws and regulations regarding smoking, smoking areas, and smoking safety? $483.e0(hxs) Phase 2 This tip sheet has not been approved by the Centers for Medicare & Medicaid Serviccs (CMS) or any other fedcral or state agency. This document is not intendcd as legal or operational advice and should not be used as or relied upon as iegal or operational advice. It is for general informational pr rposes only in lightofthemodifiedrequirementsofparticipationfoundat42c.f.r.ç483.1 etseq.andmaynotbesubstitutedforlegaloroperationaladvice. Specificlegal and operational advice is crucial when ensuring compliance with the requirements of participation found at 42 C.F.R. $ et seq. ALWAYS SEEK THE ADVICE OF KNOWLEDGEABLE COUNSEL TO PROVIDE ADVICE THAT IS TAILORED TO THE ACTUAL FACTS AND CIRCUMSTANCES AND TAKES INTO ACCOI-INT ALLRELEVANT LAW. ltlpage

38 As of: 07/18/2017 Phase 2 Tag Crosswalk - Effective November 28, 2017 Tag # (As of Nov. 28, 2017) SQC Tag? = Yes Tag Title CFR Regulatory Groupings Tags / Subparts Implemented in Old Tag (Taken from App PP ) RegulationText that was Moved to New Tag F540 Definitions F F550 Resident Rights/Exercise of Rights (a)(1)(2)(b)(1)(2) Resident Rights F151 F240 F (b)(1)(2) (a)(1)(2) (a)(1) F551 Rights Exercised by Representative (b)(3)-(7)(i)-(iii) Resident Rights F (b)(3)-(7) F552 Right to be Informed/Make Treatment Decisions F553 Right to Participate in Planning Care (c)(2)(3) Resident Rights F554 F555 F557 F558 F559 Resident Self-Admin Meds-Clinically Appropriate Right to Choose/Be Informed of Attending Physician Respect, Dignity/Right to have Personal Property Reasonable Accommodations of Needs/Preferences Choose/Be Notified of Room/Roommate Change (c)(1)(4)(5) Resident Rights F (c)(1)(4)(5) F154 F (c)(7) Resident Rights F (c)(7) (c)(2)(iii) (c)(2)(i)(ii)(iv)(v)(3)(i)-(iii) (d)(1)-(5) Resident Rights F (d)(1)(2)(4)(5) (e)(2) Resident Rights F (e)(2) (e)(3) Resident Rights F (e)(3) (e)(4)-(6) Resident Rights F175 F (e)(4)(5) (e)(6) F560 Right to Refuse Certain Transfers (e)(7)(i)-(iii)(8) Resident Rights F (e)(7)-(8) F561 Self Determination (f)(1)-(3)(8) Resident Rights F242 F (f)(1)-(3) (f)(8) F562 Immediate Access to Resident (f)(4)(i)(A)-(G) Resident Rights F (f)(4)(i) F563 Right to Receive/Deny Visitors (f)(4)(ii)-(v) Resident Rights F (f)(4)(ii)-(v) F564 Inform of Visitation Rights/Equal Visitation Priviledges F565 Resident/Family Group and Response (f)(5)(i)-(iv)(6)(7) Resident Rights F566 F567 F568 F569 Right to Perform Facility Services or Refuse Protection/Management of Personal Funds Accounting and Records of Personal Funds Notice and Conveyance of Personal Funds (f)(4)(vi)(A)-(D) Resident Rights F (f)(4)(vi)(A)-(D) F243 F (f)(5)(i)-(iii)(6)(7) (f)(5)(iv) (f)(9)(i)-(iv) Resident Rights F (f)(9) (f)(10)(i)(ii) Resident Rights F158 F (f)(10)(i) (f)(ii) (f)(10)(iii) Resident Rights F (f)(10(iii) (f)(10)(iv)(v) Resident Rights F (f)(iv) F570 Surety Bond Security of Personal Funds (f)(10)(vi) Resident Rights F (f)(10(vi) 1

39 As of: 07/18/2017 Phase 2 Tag Crosswalk - Effective November 28, 2017 Tag # (As of Nov. 28, 2017) F571 SQC Tag? = Yes Tag Title CFR Regulatory Groupings Limitations on Charges to Personal Funds Tags / Subparts Implemented in Old Tag (Taken from App PP ) (f)(11)(i)-(iii) Resident Rights F (f)(11)(i)-(iii) RegulationText that was Moved to New Tag F572 Notice of Rights and Rules (g)(1)(16) Resident Rights F (g)(1)(16) F573 F574 Right to Access/Purchase Copies of Records Required Notices and Contact Information (g)(2)(i)(ii)(3) Resident Rights F (g)(2)(3) (g)(4)(i)-(vi) Resident Rights F (g)(4) F575 Required Postings (g)(5)(i)(ii) Resident Rights F (g)(5) F576 Right to Forms of Communication with Privacy (g)(6)-(9) Resident Rights F170 F171 F (g)(8)(i)(9)(i)-(iii) (g)(7)(ii)(iii) (g)(6)(7)(i) F577 F578 F579 F580 F582 F583 Right to Survey Results/Advocate Agency Info Request/Refuse/Discontinue Treatment;Formulate Adv Directives Posting/Notice of Medicare/Medicaid on Admission Notify of Changes (Injury/Decline/Room, Etc.) Medicaid/Medicare Coverage/Liability Notice Personal Privacy/Confidentiality of Records (g)(10)(11) Resident Rights F167 F (g)(10)(i)(11) (g)(10)(ii) (c)(6)(8)(g)(12)(i)-(v) Resident Rights F (c)(6)(8)(g)(12) (g)(13) Resident Rights F (g)(13) (g)(14)(i)-(iv) Resident Rights F (g)(14) (g)(17)(18)(i)-(v) Resident Rights F (g)(17)-(18) (h)(1)-(3)(i)(ii) Resident Rights F164 F (h)(1)(3)(i) (h)(3)(ii) F584 Safe/Clean/Comfortable/ Homelike Environment (i)(1)-(7) Resident Rights F252 F253 F254 F256 F257 F258 F (i)(1)(i)(ii) (i)(2) (i)(3) (i)(5) (i)(6) (i)(7) (i)(4) F585 Grievances (j)(1)-(4) Resident Rights F165 F (j)(1) (j)(2-4) F586 Resident Contact with External Entities (k) Resident Rights F (k) F600 Free from Abuse and Neglect (a)(1) Freedom from Abuse, Neglect, and Exploitation F (a)(1) F602 Free from Misappropriation/Exploitation Freedom from Abuse, Neglect, and Exploitation F223/ F

40 As of: 07/18/2017 Phase 2 Tag Crosswalk - Effective November 28, 2017 Tag # (As of Nov. 28, 2017) SQC Tag? = Yes Tag Title CFR Regulatory Groupings Tags / Subparts Implemented in Old Tag (Taken from App PP ) RegulationText that was Moved to New Tag F603 Free from Involuntary Seclusion (a)(1) Freedom from Abuse, Neglect, and Exploitation F (a)(1) F604 Right to be Free from Physical Restraints (e)(1) (a)(2) Resident Rights Freedom from Abuse, Neglect, and Exploitation F221 F (e )(1), (a)(2) (e )(1), (a)(2) F605 Right to be Free from Chemical Restraints (e)(1) (a)(2) Resident Rights Freedom from Abuse, Neglect, and Exploitation F (e )(1), (a)(2) F606 Not Employ/Engage Staff with Adverse Actions (a)(3)(4) Freedom from Abuse, Neglect, and Exploitation F (a)(3)(4) F607 Develop/Implement Abuse/Neglect, etc. Policies (b)(1)-(4) Freedom from Abuse, Neglect, and Exploitation (b)(4) - Will not be in ASPEN until F (b)(1)-(4) F608 Reporting of Reasonable Suspicion of a Crime (b)(5)(i)-(iii) Freedom from Abuse, Neglect, and Exploitation No Associated Tag F609 Reporting of Alleged Violations (c)(1)(4) Freedom from Abuse, Neglect, and Exploitation F (c)(1)(4) F610 Investigate/Prevent/Correct Alleged Violation (c)(2)-(4) Freedom from Abuse, Neglect, and Exploitation F (c)(2)-(4) F620 Admissions Policy (a)(1)-(7) F621 Equal Practices Regardless of Payment Source (b)(1)-(3)(c)(9) F622 Transfer and Discharge Requirements (c)(1)(i)(ii)(2)(i)-(iii) F623 F624 F625 F626 F635 Notice Requirements Before Transfer/Discharge Preparation for Safe/Orderly Transfer/Discharge Notice of Bed Hold Policy Before/Upon Transfer Permitting Residents to Return to Facility Admission Physician Orders for Immediate Care (c)(3)-(6)(8) (c)(7) (d)(1)(2) (e)(1)(2) Admission, Transfer, and Discharge Admission, Transfer, and Discharge Admission, Transfer, and Discharge Admission, Transfer, and Discharge Admission, Transfer, and Discharge Admission, Transfer, and Discharge Admission, Transfer, and Discharge F208 F207 F201 F202 F203 F204 F205 F (a)(1)-(7) (b)(1)-(3)(c)(9) (c)(1)(i)(ii) (c)(2)(i)-(iii) (c)(3)-(6)(8) (c)(7) (d)(1)(i)-(iv)(2) (e)(1)(2) (a) Resident Assessments F (a) 3

41 As of: 07/18/2017 Phase 2 Tag Crosswalk - Effective November 28, 2017 Tag # (As of Nov. 28, 2017) SQC Tag? = Yes Tag Title CFR Regulatory Groupings Tags / Subparts Implemented in Old Tag (Taken from App PP ) RegulationText that was Moved to New Tag F636 Comprehensive Assessments & Timing (b)(1)(2)(i)(iii) Resident Assessments F272 F273 F (b)(1) (b)(2)(i) (b)(2)(iii) F637 F638 F639 F640 Comprehensive Assmt After Significant Change Quarterly Assessment At Least Every 3 Months Maintain 15 Months of Resident Assessments Encoding/Transmitting Resident Assessment (b)(2)(ii) Resident Assessments F (b)(2)(ii) (c) Resident Assessments F (c ) (d) Resident Assessments F279 F (d) (d) (f)(1)-(4) Resident Assessments F (f)(1)-(4) F641 Accuracy of Assessments (g) Resident Assessments F (g) F642 F644 Coordination/Certification of Assessment Coordination of PASARR and Assessments (h)-(j) Resident Assessments F (h)-(j) (e)(1)(2) Resident Assessments F (e) F645 PASARR Screening for MD & ID (k)(1)-(3) Resident Assessments F (k)(1)-(3) F646 MD/ID Significant Change Notification (k)(4) Resident Assessments F (k)(4) F655 Baseline Care Plan (a)(1)-(3) Comprehensive Resident Centered Care Plans No Associated Tag F656 Develop/Implement Comprehensive Care Plan (b)(1) Comprehensive Resident Centered Care Plans F (b)(1) F657 Care Plan Timing and Revision (b)(2)(i)-(iii) Comprehensive Resident Centered Care Plans F (b)(2)(i)-(iii) F658 Services Provided Meet Professional Standards (b)(3)(i) Comprehensive Resident Centered Care Plans F (b)(3)(i) F659 Qualified Persons (b)(3)(ii)(iii) Comprehensive Resident Centered Care Plans (b)(iii) - Will not be in ASPEN until F (b)(3)(ii) F660 Discharge Planning Process (c)(1)(i)-(ix) Comprehensive Resident Centered Care Plans F (c)(1)(i)-(ix) 4