FOCUS ON PHASE 2 & APPENDIX PP

Transcription

1 FOCUS ON PHASE 2 & APPENDIX PP for clients of: Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL

2 FOCUS ON PHASE 2 & APPENDIX PP Limited Copyright: September 2017, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH51 - Developed by Polaris Group Page 1 of 187

3 FOCUS ON PHASE 2 & APPENDIX PP POST TEST 1. All rules are effective Nov. 28, a. True b. False 2. Which of the following applies to Food and Beverage rules? a. Must consider preferences b. Cannot be prohibited from consuming food that are not procured by facility c. All of the above 3. Which of the following statements are correct in Pharmacy review? a. No changes in monthly regimen reviews. b. Definition of psychotropic meds has changed c. Med error rate set at 4% d. None of the above 4. The annual Facility Assessment is required Nov. 28, a. True b. False 5. Which statement below is true? a. New set of rules for Behavioral Health. b. No changes in Resident Behaviors and Facility Practices Section. c. None of the above d. Both of the above FH51 - Developed by Polaris Group Page 2 of 187

4 FOCUS ON PHASE 2 & APPENDIX PP POST TEST ANSWERS 1. All rules are effective Nov. 28, a. True b. False B 2. Which of the following applies to Food and Beverage rules? C a. Must consider preferences b. Cannot be prohibited from consuming food that are not procured by facility c. All of the above 3. Which of the following statements are correct in Pharmacy review? a. No changes in monthly regimen reviews. b. Definition of psychotropic meds has changed c. Med error rate set at 4% d. None of the above B 4. The annual Facility Assessment is required Nov. 28, a. True b. False A 5. Which statement below is true? a. New set of rules for Behavioral Health. b. No changes in Resident Behaviors and Facility Practices Section. c. None of the above d. Both of the above A FH51 - Developed by Polaris Group Page 3 of 187

5 Focus on Phase 2 & New Appendix PP 1 Person-centered Care Overview Resident is focus of control and supports resident in making choices. All Resident Rights rules support person-centered care. Right to be informed in advance of risk and benefits of proposed care/treatment; involvement in care planning - Right to review and sign care plan. Includes assessing strengths and weaknesses and supports cultural differences. Resident-driven care plan and discharge plan. 2 FH51 - Developed by Polaris Group Page 4 of 187

6 New Interpretive Guidance (IG) CMS is in the process of updating information for Appendices P and PP. Once the guidance is approved, it will be available in the SOM. States should ensure surveyors use the most recent version of the regulation. Advanced copy Appendix PP is available Certification/GuidanceforLawsAndRegulations/Download s/advance-appendix-pp-including-phase-2-.pdf 3 Implementation Grid Implementation Date Type of Change Details of Change Phase 1: November 28, 2016 (Implemented) Nursing Home Requirements for Participation New Regulatory Language was uploaded to the Automated Survey Processing Environment (ASPEN) under current F Tags New F Tags Updated IG Begin surveying with the new survey process No CMP Sanctions imposed for Phase 2 Rules for one year. Requirements that need more time to implement Phase 2: November 28, 2017 F Tag numbering Interpretive Guidance (IG) Implement new survey process Phase 3: November 28, 2019 Requirements that need more time to implement 4 FH51 - Developed by Polaris Group Page 5 of 187

7 Phase 2 of LTC Regulations Providers must be in compliance with Phase 2 regulations CMS PLANS TO DELAY IMPOSITION OF TARGET SANCTIONS (CMPs, Denial of payment, Termination) for PHASE 2 rules for one year (will still impose remedies such as directed in-service/poc. More directions will be provided All States will use new computer based survey process for LTC surveys CMS plans to freeze the Health Inspection Domain for a year on Nursing Home Compare 5 F-tag Renumbering 6 FH51 - Developed by Polaris Group Page 6 of 187

8 F-tag Renumbering The image above is the F-tag Crosswalk showing: The original regulatory grouping and the new associated grouping The original regulation number and the new associated regulation number The original F-tag and the associated new F-tag See attached List of revised F-tag 7 F-tag Renumbering, continued 8 FH51 - Developed by Polaris Group Page 7 of 187

9 Substandard Care Certain F-tags if cited at F, H, I, J, or K Scope/Severity result in Substandard Care citation. For the most part, appears same rules cause substandard care; but with different numbering system tags are spread out across more categories. 9 Moved from QoL 10 FH51 - Developed by Polaris Group Page 8 of 187

10 Moved from QoC/QoL Moved from QoC Moved from QoL Moved from POLARIS GROUP Strategic Solutions For Healthcare QoC 11 CMS has provided Video Trainings for new Appendix PP Recommend facility staff listen to every training video available assinformation.aspx?cid=0cmsltcsme_vid 12 FH51 - Developed by Polaris Group Page 9 of 187

11 Phase 2 of LTC Regulations, continued Phase 2 includes: See Quick Reference Behavioral Health Services Quality Assurance and Performance Improvements (QAPI Written Plan Only) Infection Control and Antibiotic Stewardship Physical Environment smoking policies 13 Phase 2 of LTC Regulations, continued Phase 2 includes, but is not limited to: Resident Rights and Facility Responsibilities Requirement to provide contact information for State and local advocacy organizations, Medicare and Medicaid eligibility information, Aging and Disability Resources Center and Medicaid Fraud unit Freedom from Abuse, Neglect, and Exploitation 1150B Reporting Crimes procedures Admission, Transfer, and Discharge Rights Transfer/Discharge Documentation 14 FH51 - Developed by Polaris Group Page 10 of 187

12 Phase 2 of LTC Regulations, continued Phase 2 includes, but is not limited to: Comprehensive Person-Centered Care Planning Baseline Pharmacy Services psychotropic medications (Opioids listed under GDR) and monthly medical record review of all reside. Restrictions on PRN psychotropic meds. Dental Services replacing dentures procedures Administration Facility Assessment 15 Appendix PP Overview of Sections F-tag Regulation/law Intent Definitions Guidance Key Elements of noncompliance Procedures/Critical Elements Pathways (CE)/Facility Tasks tools (from QIS surveys but with updates/new ones) Deficiency category Potential Tags for additional investigation 16 FH51 - Developed by Polaris Group Page 11 of 187

13 Appendix PP The Phase 1 rules have been required since Nov. 28, What new Appendix PP does is provide additional GUIDANCE to surveyors on Phase 1 rules and Phase 2 rules. The devil is in the detail when reading each guidance and key elements of non-compliance 17 F540 Definitions 18 FH51 - Developed by Polaris Group Page 12 of 187

14 Definitions F540 (old F150) Definitions: no change from Phase 1 edits Abuse (willful is defined; verbal, sexual, physical and mental include enabled through use of technology) Adverse Event related to QAPI - Nurse Aide Exploitation - Lic Health Prof Misappropriation of property - Neglect Mistreatment - Resident Rep Transfer/discharge - Sexual Abuse Person-centered care Resident Rights F550 *Resident Rights/Exercise of Rights F551 Right Exercised by Representative F552 Right to be informed/make treatment decisions F553 Right to Participate in Planning Care F554 Resident Self-Admin Meds-Clinically Appropriate F555 Right to Choose/Be informed of Attending Physician F557 Respect, Dignity/Right to have Personal Property F558 *Reasonable Accommodations of Needs/Preferences F559 *Choose/Be Notified of Room/Roommate Change F560 Right to Refuse Certain Transfers F561 *Self Determination Red tags are potential substandard care citations CMS Resident Council - mandatory CMS Dining - mandatory 20 FH51 - Developed by Polaris Group Page 13 of 187

15 Resident Rights F562 Immediate Access to Resident F563 Right to Receive/Deny Visitors F564 Inform of Visitation Rights/Equal Visitation Privileges F565 *Resident/Family Group and Response F566 Right to Perform Facility Services or Refuse F567 Protection/Management of Personal Funds F568 Accounting and Records of Personal Funds F569 Notice and Conveyance of Personal Funds F570 Surety Bond Security of Personal Funds F571 Limitations on Charges to Personal Funds F572 Notice of Rights and Rules F573 Right to Access/Purchase Copies of Records Red tags are potential substandard care citations Resident Rights F574 Required Notices and Contact Information F575 Required Postings F576 Right to Forms of Communication with Privacy F577 Right to Survey Results/Advocate Agency Info F578 Request/Refuse/Discontinue Treatment; Formulate Adv Directive F579 Posting/Notice of Medicare/Medicaid on Admission F580 Notify of Changes (Injury/Decline/Room, etc.) F582 Medicaid/Medicare Coverage/Liability Notice F583 Personal Privacy/Confidentiality of Records F584 *Safe/Clean/Comfortable/Homelike Environment F585 Grievances F586 Resident Contact with External Entities Red tags are potential substandard care citations 22 FH51 - Developed by Polaris Group Page 14 of 187

16 Resident Rights F Resident Rights F will address key tags Comprehensive Restructuring Moved many rules from Quality of Life (QoL) to Resident Rights Dignity, accommodations of needs, homelike environment Promoting rights and person-centered care Includes parallel facility responsibilities Rights facilitated; Include notice in Braille 23 Resident Rights F F550 (old F151, 240, 241) Resident Rights F551 (old F152) Rights of Representatives expanded guidance but no change from Nov 2016 guidance In the case of a resident who has not be adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident s rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage is valid in the jurisdiction in which it was celebrated. The resident representative has the right to exercise the resident s rights to the extent those rights are delegated to the representative. The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law. 24 FH51 - Developed by Polaris Group Page 15 of 187

17 Resident Rights F552 (old F154) Right to be informed expanded guidance F553 (old F154/280) Planning/Implementing Care: Key points to consider in terms of your procedures: Right to participate in person-centered plan of care includes participation in care conference Informed in advance of care, and type of professional giving care as part of communication Right to see care plan including right to sign after significant changes; not well defined but would certainly be a new problem or a change in goal Ensure documentation of how facilitates resident involvement, and if not involved, why not. Or family representative. 25 Resident Rights F F554 (old F176) Right to self administer meds expanded guidance F555 (old F163) Right to choose physician F557 (old F252) Dignity/personal property F558 (old F246) Reasonable accommodation F559 (old F175, 247) Notified of room change/roommate F560 (old F177) Right to refuse certain treatments F561 (old F242, 245) Self-determination expanded guidance 26 FH51 - Developed by Polaris Group Page 16 of 187

18 Resident Rights F562/563/564 (old F172) must have detailed written Visitation Rights; which must include when limitations are applied such as when resident/visitor has infectious disease, when facility is locked/secured, behavior such as drunkenness. Can limit or supervise, if suspicion of coercion, exploitation, abuse. Resident can limit visitations, if desired. 27 Resident Rights F565 (old F243, 244) Resident/Family Group and response F566 (old F169) Right to perform services/refuse F (old F158, 159, 161, 162) Related to fund management expanded guidance F572 (old F156) Notice of Rights and Rules F573 (old F153) Review your current procedures for access to Medical Records clarification on what you can charge Must be able to readily produce in such form and format (including in an electronic form or format when such records are maintained electronically) within 24 hours excluding weekends and holiday 28 FH51 - Developed by Polaris Group Page 17 of 187

19 Resident Rights F574 (old F156) Required Notices - expanded guidance F575 (old F156) Posting of Information F576 (old F170, 171, 174) Privacy of communications expanded guidance to include electronic such as computer. F577 (old F167/168) Most recent survey in last three years, as well as complaint surveys posted/available 29 Resident Rights F578 (old F155) Detailed discussion on Advanced Directives. Rights and facilities role to promote and ensure are respected. Role of representative If there is no Advanced Directive, must have documentation of discussion that encouraged their right to have one. Will be looked at during screening process as part of new survey task. 30 FH51 - Developed by Polaris Group Page 18 of 187

20 Resident Rights F579 (old F156) Posting/Notice of Medicare/Medicaid Even if don t accept Medicare or Medicaid F580 (old F157) Notification of Changes F584 (old F , 461) Safe/Clean/Homelike 31 Resident Rights F582 (old F156) Information and Communication: no change Notification 60 days prior to any increase in any charges not paid by Medicare/Medicaid. Also includes Proper Notices for Part A residents Improved guidance on which forms to be used and when (SNFABN/Notices and NOMNCs). This is a facility task for all surveys when new survey process rolls out. CE Pathway CMS Beneficiary Notice - mandatory 32 FH51 - Developed by Polaris Group Page 19 of 187

21 Resident Rights F583 (old 164/173) Privacy and Confidentiality F585 (old 165/166) Grievances Identify Grievance Official responsible for process. Including: Receiving and Tracking Preventing further violations while investigations are Leading investigations taking place Maintaining confidentiality Documentation Issuing official decisions to requirements the resident Meeting all applicable State Coordinating with State and Federal agencies and Federal Laws/Regulations 33 Resident Rights Phase 2 F586 (old F168) Contact with External Entities Phase 2 Requirement to provide contact information for State and local advocacy organizations, Medicare and Medicaid eligibility information, Aging and Disability Resources Center and Medicaid Fraud unit. Ensure information in admission packets and posted. Medicaid information should be posted even if facility does not accept Medicaid. 34 FH51 - Developed by Polaris Group Page 20 of 187

22 Resident Rights Phase 2 F586 (old F168) Contact with External Entities Provide contact information for State and local advocacy organizations, Medicare and Medicaid eligibility information, Aging and Disability Resources Center and Medicaid Fraud unit. Ensure information in admission packets and posted. Medicaid information should be posted even if facility does not accept Medicaid Freedom from Abuse, Neglect, and Exploitation F600 *Free from Abuse and Neglect F602 *Free from Misappropriation/Exploitation F603 *Free from Involuntary Seclusion F604 *Right to be Free from Physical Restraints F605 *Right to be Free from Chemical Restraints F606 *Not Employ/Engage Staff with Adverse Actions F607 *Develop/Implement Abuse/Neglect, etc. Policies F608 *Reporting of Reasonable Suspicion of a Crime F609 *Reporting of Alleged Violations F610 *Investigate/Prevent/Correct Alleged Violation CMS Video Training available All are potential substandard care citations 36 FH51 - Developed by Polaris Group Page 21 of 187

23 Freedom from Abuse, Neglect, Exploitation F F Freedom from abuse, neglect, exploitation Throughout guidance expanded language includes not only Abuse but neglect, misappropriation of property, and exploitation. COMBINED abuse and neglect at F600 (old F223/224) Will use CE Pathways CMS Abuse or CMS Neglect MUST READ ALL GUIDANCE again to ensure your processes are in place as the additional guidance and investigation steps may include something that would cause a change in your procedures. 37 Definitions Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all resident, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use to technology. 38 FH51 - Developed by Polaris Group Page 22 of 187

24 Definitions Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Sexual abuse is non-consensual sexual contact of any type with a resident. Willful, used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 39 Freedom from Abuse, Neglect, Exploitation F600 (old F233) Deprivation of Goods and Services by Staff Abuse also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s). Facility needs structure and processes for example, staff shortage result in residents not getting out of bed and/or no incontinent care. 40 FH51 - Developed by Polaris Group Page 23 of 187

25 Freedom from Abuse, Neglect, Exploitation F600 Right to be free from abuse even if no intent to harm; if they acted willfully and action resulted in abuse/neglect. Examples include how staff respond to residents with behavior manifestations. Even if staff are trained, if they do not react properly in an instance, the facility is still responsible. 41 Freedom from Abuse, Neglect, Exploitation F600 Definition of Sexual Abuse is better defined Can not implement no contact rules Sexual Abuse Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to: Unwanted intimate touching of any kind especially of breasts or perineal area; All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; Forced observation of masturbation and/or pornography; and Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. 42 FH51 - Developed by Polaris Group Page 24 of 187

26 Freedom from Abuse, Neglect, Exploitation F600 Generally, sexual contact is non-consensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent; or Does not want the contact to occur. 43 Freedom from Abuse, Neglect, Exploitation F600 Facility must have process to determine consent or lack of consent for residents with dementia; it cannot just be based on diagnosis. This link is to a resource on how to establish a protocol for determining consent for sexual activities in residents with dementia 44 FH51 - Developed by Polaris Group Page 25 of 187

27 Freedom from Abuse, Neglect, Exploitation F600 Clarification on Resident/Resident Abuse; Example: if resident with dementia accidentally runs into someone that is not abuse; but if they willfully shove someone and they fall; even though they have dementia and may not have understand the harm, that is abuse. May need to report to state if willful act. 45 Freedom from Abuse, Neglect, Exploitation F602/603 F602 (old F223/224) Misappropriation/Exploitation definition continues to include theft, but includes drug diversion, and persuading someone that they need to give staff something to receive good care. F603 (old F223) Involuntary seclusion no change but more guidance. 46 FH51 - Developed by Polaris Group Page 26 of 187

28 Freedom from Abuse, Neglect, Exploitation F604 F604 (old F221, 222) Physical Restraints. Least restrictive, least amount of time, and ongoing evaluation of need. Surveyors need to document the impact of inappropriate use physical restraint. Care Plan goal should include no decline/negative affect of restraint. Position change alarms added. Sounds have psychological effect, that cause resident to not rise. 47 Freedom from Abuse, Neglect, Exploitation F604 F604 Physical Restraints Examples of negative potential or actual outcomes which may result from the use of position change alarms as a physical restraint, include: Will use Physical Restraint CE Pathway CMS Loss of dignity; Decreased mobility; Bowel and bladder incontinence; Sleep disturbances due to the sound of the alarm or because the resident is afraid to move in bed thereby setting off the alarm; and Confusion, fear, agitation, anxiety, or irritation in response to the sound of the alarm as residents may mistake the alarm as a warning or as something they need to get away from. 48 FH51 - Developed by Polaris Group Page 27 of 187

29 Freedom from Abuse, Neglect, Exploitation F605 F605 (old F222) Chemical - Expanded guidance with no surprises CE Pathway CMS Unnecessary Meds. Policy should say drugs are not used as restraints; for example not used to prevent wandering only. Not a chemical restraint when Medical record has indication of medical symptom, and dose/duration are reasonable; adequate monitoring for effectiveness, and S/E - Monitor for adverse affects of medication in resident such as increased lethargy/sleeping 49 Freedom from Abuse, Neglect, Exploitation F607 F606 (old F225) Not Employ/Engage staff with Adverse Actions - no change from Nov 2016 rules F607 Policies and procedures (old F226) Still includes all 7 key components but expanded guidance for each of the 7 key components - for example see next slide. 50 FH51 - Developed by Polaris Group Page 28 of 187

30 Freedom from Abuse, Neglect, Exploitation F607 F607 Investigation must sample of expanded guidance guidance.dures Identifying staff responsible (old F226), for continued the investigation; Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); Investigating different types of alleged violations; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation. 51 Freedom from Abuse, Neglect, Exploitation F608 Phase 2 F608 New - Procedures for reporting crimes outlined and responsibility of individuals included in training or postings. Suspicion with serious bodily injury reported within 2 hours, and others within 24 hours. Procedures must include who is covered individual, timeframe for reporting, what must be reported, for serious bodily harm which entities notified (state and local law enforcement), annual notification/training of obligation to report, includes prevention of retaliation and posting of employee rights. 52 FH51 - Developed by Polaris Group Page 29 of 187

31 Freedom from Abuse, Neglect, Exploitation F609 F609 (old F225) Report violations to State Agency or Adult Protective Services per state law immediately/no later than 2 hours if abuse or serious bodily injury no later 24 hours if not abuse or result in bodily injury. Investigation Report within 5 working days. New reference to Adult Protective Services per state law. No change in overall rule FH51 - Developed by Polaris Group Page 30 of 187

32 Freedom from Abuse, Neglect, Exploitation F610 F610 (old F225) Investigations Process/Prevention/Correction Provided additional guidance for three steps below; ask and document that resident feels safe after incident and on victims care plan. The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: Thoroughly investigate the alleged violation; Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and Take appropriate corrective action, as a result of investigation findings. 55 Steps: Freedom from Abuse, Neglect, Exploitation Phase 1 1. Review new guidance; ensure Abuse procedures and investigations meet expanded guidance. 56 FH51 - Developed by Polaris Group Page 31 of 187

33 Freedom from Abuse, Neglect, Exploitation Phase 2 F608 Reporting of Crimes Implement procedures and provide training to current employees then institute for new employees and annually. 57 Freedom from Abuse, Neglect, Exploitation Phase 3 QAPI involvement in the review and investigation of allegations of abuse, neglect or exploitation. 58 FH51 - Developed by Polaris Group Page 32 of 187

34 Admission, Transfer, & Discharge F620 Admissions Policy F621 Equal Practices Regardless of Payment Source F622 Transfer and Discharge Requirements F623 Notice Requirements Before Transfer/Discharge F624 Preparation for Safe/Orderly Transfer/Discharge F625 Notice of Bed Hold Policy Before/Upon Transfer F626 Permitting Residents to Return to Facility 59 Admissions/Transfer/Discharge Right F Reorganized with increased guidance Appendix PP F620 (old F208) Admission Policies Disclosure of specific facility characteristics/service limitations which could influence decision Will interview resident if there were any preconditions, requirements, limitations of they did not know about at admission F621 (old F207) Equal Access Rules same for all payer types 60 FH51 - Developed by Polaris Group Page 33 of 187

35 Admissions/Transfer/Discharge Right F622 F622 (old F201/202) Transfer/Discharge Procedures Definitions Transfer means expect to come back. Discharge means do not expect to come back. Facility-initiated transfer/discharge Resident objects to, did not initiate, and not in alignment with documented resident goals. Resident-Initiated Transfer/discharge must be supported in EMR that transfer/discharge aligned with resident discharge planning, and goals. Going off Part A is usually aligned with discharge plan/goals. 61 Admissions/Transfer/Discharge Right F622 Phase 1 F622 (old F201/202) - Expanded guidance about the limited circumstances facility can initiate a transfer no change In the following limited circumstances, facilities may initiate transfers or discharges: 1. The discharge or transfer is necessary for the resident s welfare and the facility cannot meet the resident s needs. 2. The resident s health has improved sufficiently so that the resident no longer needs the care and/or services of the facility. 3. The resident s clinical or behavioral status (or condition) endangers the safety of individuals in the facility. 4. The resident s clinical or behavioral status (or condition) otherwise endangers the health of individuals in the facility. 5. The resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicare or Medicaid, for his or her stay at the facility. 6. The facility ceases to operate. 62 FH51 - Developed by Polaris Group Page 34 of 187

36 Admissions/Transfer/Discharge Right F622 F622 (old F201/202) - Expanded guidance about limited circumstances facility can initiate a transfer. Can t Discharge while Appeal Pending guidance if goes to hospital, facility cannot refuse readmission if in an appeal process. 63 Admissions/Transfer/Discharge Right F622 F622 New - Conveyance of information to receiving provider - Documentation Phase 2 Applies to facility or resident initiated TRANSFERs (not discharges) See F Discharge Planning and Summary rules for document discharge Will use CE Pathway for CMS Discharge to Community or CMS Discharge to hospital Convey as soon as practicable at time/shortly after 64 FH51 - Developed by Polaris Group Page 35 of 187

37 Admissions/Transfer/Discharge Right F622 Documentation Phase 2 Contact information of physician responsible for care Resident Rep contact information Advanced Directive information Special Instructions or precautions for ongoing care such as treatments/devices, special risk (falls, elopement, aspiration) Care plan Goals 65 Admissions/Transfer/Discharge Right F622 Documentation Phase 2 All information necessary to meet needs such as: Resident status, mental, behavioral, functional, reason for transfer, recent VS Diagnosis and allergies Medications including last received Most relevant labs, other diagnostics, and recent immunization Additional info as indicated Can be satisfied on transfer form Maybe be electronic or hardcopy. 66 FH51 - Developed by Polaris Group Page 36 of 187

38 Admissions/Transfer/Discharge Right F623 F623 (old F203) Notice Before Transfer - Only required for facility initiated transfers/discharge review rule for notice content requirements Provide 30 days notice when possible; or for emergency transfers as soon as practicable NO CHANGE Share notice with resident/rep, and Ombudsman for facility initiated transfers/discharged For emergency transfers/discharges - Ombudsman Guidance suggests monthly list of transfers/types/location for Ombudsman. 67 Admissions/Transfer/Discharge Right F624 (old F204) Orientation to Transfer/Discharge expanded guidance- must provide in manner that is understood F625 (old F205) Notice of Bed-hold policy nothing new F626 (old F206) Permitting Residents to Return documentation demonstrates efforts to return; consider resident s new baseline, work with hospital to stabilize (IV to oral, or decrease psychotropic) 68 FH51 - Developed by Polaris Group Page 37 of 187

39 Steps: Admissions/Transfer/Discharge Right - Phase 1 1. Ensure notices are also provided to Ombudsman. 69 Admission, Transfer, and Discharge Phase 2 Create Transfer form for all requirements Reason for transfer Medical History as pertinent to transfer Provider in charge of care Resident Rep Contact information Advanced directives Special instructions or precautions Comprehensive care plan goals 70 FH51 - Developed by Polaris Group Page 38 of 187

40 Resident Assessments F635 Admission Physician Orders for Immediate Care F636 Comprehensive Assessments & Timing F637 Comprehensive Assessment After Significant Change F638 Quarterly Assessment at Least Every 3 Months F639 Maintain 15 Months of Resident Assessments F640 Encoding/Transmitting Resident Assessment F641 Accuracy of Assessments F642 Coordination/Certification of Assessment F644 Coordination of PASARR and Assessments F645 PASARR Screening for MD & ID F646 MD/ID Significant Change Notification 71 Resident Assessment F F636 (old F272/273/275) Expanded requirement to include resident strengths, goals, life history and preferences. Cross-reference to Behavioral Health section. Documentation of involvement - Assessment must include direct observation and communication with resident as well as communication with staff members. Discharge planning part of assessment. CMS Resident Assessment CE Pathway 72 FH51 - Developed by Polaris Group Page 39 of 187

41 Resident Assessment F F (old F274, F , F286) RAI Rules related to RAI/MDS - no changes F (old F285) Coordination with PASARR Clarifies what constitutes appropriate coordination of assessment with PASARR Level II incorporating PASARR evaluation report in assessment and care planning and notification of significant change. CE Pathway CMS PASARR 73 Resident Assessment Phase 1 Steps: 1. Document resident s involvement in assessment/rai process. 2. Ensure assessment documents and processes address resident s needs, strengths, goals, life history, and preferences. 3. Documentation of discharge planning. Review current processes. 4. Ensure PASARR updated to significant changes. 74 FH51 - Developed by Polaris Group Page 40 of 187

42 Comprehensive Resident- Centered Care Plans F655 Baseline Care Plan F656 Develop/Implement Comprehensive Care Plan F657 Care Plan Timing and Revision F658 Services Provided Meet Professional Standards F659 Qualified Persons F660 Discharge Planning Process F661 Discharge Summary 75 Comp/person-centered Care Planning F F655 New - Implement Baseline Care Plan within 48 hours Person-centered Phase 2 Baseline Care Plan to include the minimum healthcare information to properly care for resident Initial goals based on admission orders Physician orders Dietary orders Therapy Services Social Services PASARR recommendations if applicable. 76 FH51 - Developed by Polaris Group Page 41 of 187

43 Comp/person-centered Care Planning F F655 Implement Baseline Care Plan within 48 hours Person-centered Phase 2 Must provide resident or rep with a summary of baseline care plan to include but not limited to: Initial Goals Summary of medications and dietary instructions Services and treatments to be administered Any updated information as necessary How this is documented is up to facility. 77 Comp/person-centered Care Planning F F656 (old F279) Care Plan guidelines, timing, revisions, and professional standards guidance offers not significant changes IDT Nurse Aide responsible for resident or primary responsibility Resident and/or family Physician involvement if not RN responsible for resident involved, must have Dietary Staff documentation with Social Worker explanation. PASARR 78 FH51 - Developed by Polaris Group Page 42 of 187

44 Comp/person-centered Care Planning F657 (old F280) Care Plan Timing and Revisions F658 (old F281) Services Provided meet Professional Standards F659 (old F282) Qualified Person 79 Comp/person-centered Care Planning What does this mean to your Care Planning processes? Must include preferences and person-centered. Must strive for less canned care plans for long term residents. Must include resident in process unless. documentation as to why not. Involve nurse aide assigned Will use CMS General CE Pathway 80 FH51 - Developed by Polaris Group Page 43 of 187

45 Comp/person-centered Care Planning F660 (old F284) Discharge Planning - Process that focuses on resident s discharge goals and prepares resident to be an active participant in post discharge care. Focus on decreasing rehospitalization. Also refers to discharge planning mandated by IMPACT where appropriate - for example, if going to another SNF, using NHC to help them chose; or picking HHA. CE Pathway CMS Discharge 81 Comp/person-centered Care Planning Discharge plan must be part of comprehensive care plan and reflect an IDT approach Resident discharge goals and preferences Preparing resident to be an active partner in post discharge care Effective transition of the resident from SNF to post SNF care Reduction of factors leading to preventable readmissions 82 FH51 - Developed by Polaris Group Page 44 of 187

46 Comp/person-centered Care Planning Post Discharge needs are identified Regular re-evaluation of residents and update to discharge plan Caregivers/support person(s) capacity and capability to perform required care. Involve resident and resident representative Addresses resident s goals of care and treatment preferences Asked and documented about interest in returning to community. 83 Comp/person-centered Care Planning Discharge Planning Process must Orientation and preparation to ensure safe and orderly transfer or discharge in a manner resident understands. Resident signed off on plan. Assist resident or their rep in selecting a post-acute care provider (e.g. SNF, HHA, IRF, or LTCH) by using data. 84 FH51 - Developed by Polaris Group Page 45 of 187

47 Discharge Planning Tips Discharge Plan Member Day of Admission Meets, greets, and educates Provides list of SNF contacts Educates and listens Resident preferred discharge location Family and community support Educate to short-term care Financial 85 Discharge Planning Tips IDT Meeting within 3 4 days Confirm discharge location preferred and resources needed Clinical checks on risks factors Develop Plan Determine educational needs Weekly IDT updates Daily Checks on status 86 FH51 - Developed by Polaris Group Page 46 of 187

48 Discharge Planning Tips 5 to 7 days before discharge to community Discharge Transition Plan Check List: initiated M Medication Written schedule to get to therapy appointments E Environment T Treatments Self-care teach back H Health Teaching Medication management O Outpatient referrals Discharge Checklist D Diet Schedule follow-up appointments Emergency numbers reviewed Home Visit possible 1 or 2 day stay at home. 87 Medication Management Triage 7 days prior to discharge home - Ask resident or representative to provide a list of all medications resident was taking by prescription or over the counter. Alert resident and/or spouse: ask for written list No spouse/resident not alert: Ask son or daughter to help with list if available. Spouse/resident easily confused: Want to confirm list. Ask son/daughter to bring in bag of pills. Ask spouse to bring in bag of all medications taken by resident. 88 FH51 - Developed by Polaris Group Page 47 of 187

49 Discharge Planning Tips Day of Discharge Final Medication Review and reconciliation Provide medications/prescriptions Equipment in place Phone numbers checked and provided Confirm appointments scheduled and transportation is arranged Completes physician F/U discharge summary and mails Resident to sign off on plan Schedule 3-day F/U phone call check 89 Discharge Planning Tips Post Discharge Two or Three day F/U call 2 week F/U call and satisfaction survey 90 FH51 - Developed by Polaris Group Page 48 of 187

50 Comp/person-centered Care Planning F661 (old F283/284) Discharge Summary Recapitulation of stay Final summary of resident s status to include items in assessment at time of discharge Reconciliation of all pre-discharge meds with the resident s post discharge meds both prescribed and over-the-counter. 91 Discharge Summary F661 Discharge Summary no real change Recapitulation of stay diagnosis, course of treatment/therapy, pertinent labs, consults. The final summary should include Assessment items listed in Assessment rules (see next slide) with resident permission; and as pertinent to receiving provider/agency. Reconciliation of all pre-discharge meds with the resident s post discharge meds both prescribed and over the counter. Post Discharge Plan as applies. 92 FH51 - Developed by Polaris Group Page 49 of 187

51 Discharge Summary for Transfers or Discharges Final summary of resident s status to include assessment items available at time of transfer/discharge that is pertinent to receiving provider or agency. Could include: Demographics Customary Routine Cognitive Communication Vision Mood/behaviors Psychological Well-being Physical Functioning Continence Disease/Diagnosis Dental/Nutritional Skin condition Activity pursuits Medications Special Treatments Discharge Planning per care plan Documentation of summary of assessments (CAAS) Documentation of participation 93 Comp/person-centered Care Planning Phase 1 1. Continue to focus on implementation of personcentered care. 2. Evaluate and strengthen Discharge Planning processes. 3. Ensure Discharge Summaries are completed. 94 FH51 - Developed by Polaris Group Page 50 of 187

52 Comp/person-centered Care Planning Phase 2 1. Develop process for baseline care planning and method to document summary provided resident/rep Phase Quality of Life F675 *Quality of Life F676 *Activities of Daily Living (ADLs)/Maintain Abilities F677 *ADL Care Provided for Dependent Residents F678 *Cardio-Pulmonary Resuscitation (CPR) F679 *Activities Meet Interest/Needs of Each Resident F680 *Qualifications of Activity Professional All are potential substandard care citations CMS Video on Quality of Life/Quality of Care 96 FH51 - Developed by Polaris Group Page 51 of 187

53 Quality of Life F F675 (old F309) Quality of life no change noted in guidance F676 (old F310/311) ADLs Maintain ADL F677 (old 312) ADL Care provision Moved from QoC F310/311/312 Added oral care Will use CMS ADL CE Pathway F678 (old F155) CPR aligns with focus on Advanced Directive rights 97 Quality of Life F F679 (old F248) Activities meets interest/need Interactions with community For residents with dementia activities to help with behavior manifestations F680 (old F249) Activities Director and Activities Qualified therapeutic recreation specialist, or licensed in that state and is eligible for certification OR 2 years experience including 1 year full time in therapeutic activity program, OR OT or OTA or completed course by state. No surprises in this section Will use CMS Activities CE Pathway 98 FH51 - Developed by Polaris Group Page 52 of 187

54 Quality of Care F684 *Quality of Care F685 *Treatment/Devices to Maintain Hearing/Vision F686 *Treatment/Svcs to Prevent/Heal Pressure Ulcers F687 *Foot Care F688 *Increase/Prevent Decrease in ROM/Mobility F689 *Free of Accident Hazards/Supervision/Devices F690 *Bowel/Bladder Incontinence, Catheter, UTI F691 *Colostomy, Urostomy, or Ileostomy Care F692 *Nutrition/Hydration Status/Maintenance F693 *Tube Feeding Management/Restore Eating Skills F694 *Parenteral/IV Fluids All potential Substandard Care citations CMS Video on Quality of Life/Quality of Care Quality of Care F695 *Respiratory/Tracheostomy care and Suctioning F696 *Prostheses F697 *Pain Management F698 *Dialysis F699 *{PHASE-3} Trauma Informed Care F700 *Bedrails All potential Substandard Care citations CMS Video on Quality of Life/Quality of Care 100 FH51 - Developed by Polaris Group Page 53 of 187

55 Quality of Care F684-F700 F684 (old F309) Quality of Care general tag for QoC citation that does not have a specific tag number (nonpressure ulcers, & palliative/hospice coordination) Some new tag numbers & new guidance F686 Skin Integrity (old F314) added language on accurate assessment of the Kennedy Terminal Ulcers (KTU) F687 (old F328) Foot care new guidance with no surprises F688 (old F317/318) Mobility - ROM and mobility 101 Quality of Care F684-F700 F689 (old F323) Free of Accidents includes reference to smoking and resident to resident altercations that are not abuse would be cited here. Reference to Position Change alarms for falls. F690 (old F315) Bowel/Bladder added guidance for bowel incontinence with details for what is included in assessment and possible interventions F697 (old F309) Pain detailed guidance 102 FH51 - Developed by Polaris Group Page 54 of 187

56 Quality of Care F684-F700 F698 Dialysis (old F309) Old F328 several new Tags (F694 Parenteral, F695 Respiratory, F691 Colostomy, F696 Prosthesis) from F328 are now separate tags with own guidance. F699 New - Trauma Informed Care Phase 3 F700 New - Bedrails new with guidance; focus on assessment and oversight of need for, risk for entrapment, correct installation, correct bed size for resident, ongoing maintenance, and safety around side rail use. 103 CE Pathways Use for Investigations CMS Behavioral/Emotional CMS Urinary Catheter/UTI CMS Communications/sensory CMS Dialysis CMS General CMS Hospice/End of life CMS Nutrition CMS Pain CMS Physical Restraints CMS Pressure Ulcers CMS Rehab/Restorative CMS Respiratory Care CMS Hydration CMS Tube Feeding CMS Positioning/Mobility CMS Bladder/Bowel Incont CMS Accidents 104 FH51 - Developed by Polaris Group Page 55 of 187

57 Quality of Care Phase 1 1. Read through entire section of Appendix PP for Quality of Care to identify any changes needed in light of guidance to surveyors. 2. Bowel Assessments ensure assessment is detailed per guidance. 3. Add inservice and training on The Kennedy Terminal Ulcers if not already part of training. 4. Ensure risk assessments for side rails are in compliance and entrapment risk is documented, and ongoing monitoring for bed safety is documented Physician Services F710 Resident s Care Supervised by a Physician F711 Physician Visits Review Care/Notes/Order F712 Physician Visits Frequency/Timeliness/Alternate NPPs F713 Physician for Emergency Care, Available 24 Hours F714 Physician Delegation of Tasks to NPP F715 Physician Delegation to Dietitian/Therapist 106 FH51 - Developed by Polaris Group Page 56 of 187

58 Physician Services F Few Phase 1 changes F710 (old F385) Order to admit with physician s personal approval - Physician must approve an admission, however, NP or PA or CNS can now write orders for immediate care needs. F714 (old F390) Delegation to Non-Physician Practitioner (NPP) F715 (old F390) Delegation to Dietician and Therapist Delegation: Center s option whether to implement: Attending physician (only) can delegate dietary orders to qualified dietitians or other clinically qualified nutrition professional per state scope of practice. Attending physician (only) can delegate writing therapy orders by therapist within state law. Delegation to be in writing Nursing Services F725 Sufficient Nursing Staff F726 Competent Nursing Staff F727 RN 8 Hrs/7 days/wk. Full Time DON F728 Facility Hiring and Use of Nurse F729 Nurse Aide Registry Verification, Retraining F730 Nurse Aide Perform Review 12 Hr/Year In-service F731 Waiver-Licensed Nurses 24 Hr/Day and RN Coverage F732 Posted Nurse Staffing Information CMS has training video Mandatory Facility task CE Pathway CMS Sufficient Staff & Competent Staff Several tags moved from Administration 108 FH51 - Developed by Polaris Group Page 57 of 187

59 Nursing Services F FH725 (old F353) Sufficient Staffing only addresses sufficient staff The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. 109 Nursing Services F Do not need to tie to negative outcome, but can link staffing with other citations which are believed to be due, in part, to staffing. For example, ADLs not being met. Concerns found in QoC, QoL, Abuse, Resident Rights, Behavioral Health, Pharmacy, Food/Nutrition, and Person-centered care planning must investigate if due to staffing or competency. Surveyors should not defer to meeting or not meeting state Staffing Minimums if applies. 110 FH51 - Developed by Polaris Group Page 58 of 187

60 Nursing Services F F726 (old F353/498) Competent Nursing Staff Extensive changes in guidance Phase 1 A measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 111 Nursing Services F F726 (old F353/498) Competent Nursing Staff Extensive changes in guidance Phase 1 Attendance at an inservice is not enough Evaluating competency includes: Lecture/video with return demonstration for physical activities or use of a device Pre and post tests for documentation issues Reviewing adverse events for gaps in competency Competency also related to scope of practice 112 FH51 - Developed by Polaris Group Page 59 of 187

61 Nursing Services F Create list of competencies required for each staff type and a process to test and track. Staff also must be aware of current health status, and be able to explain and demonstrate how they identify changes in condition and report those changes. Linked to Facility Assessment (Phase 2 rule) F838 which must address population, care required, and competencies to provide care. 113 Validate Competency Incorporate these competencies checks into: 1. Orientation 2. Follow-up from Performance Reviews 3. Annual competency Fair 4. Incorporate into inservices when indicated 5. Consider competency when performing a root cause analysis of an adverse event, and include skill testing/inservice as part of response to event. 114 FH51 - Developed by Polaris Group Page 60 of 187

62 Nursing Services F F727 (old F354) RN Hours - no change; added 2 or more RNs sharing DON position F728 (old F494/495) Hiring and Use of Nurse Aides no change F729 (old F496) Nurse Registry Verification expanded guidance F731 (old F355) Waiver no change F732 (old F356) Posting Nurse Staffing additional guidance 115 Nursing Services F F730 (old F497) Nurse Aide Perform Review/12 hours Inservice - Extensive changes in guidance. Will cite if performance review is not conducted every 12 months OR if inservice education provided to that staff person was not based on performance review. 12 hours to be based on Individual performance reviews (in aggregate and individual) and tracked by employment date. Regarding content of inservice, go to F FH51 - Developed by Polaris Group Page 61 of 187

63 Nursing Services Only Applies to Nursing Staff Other Tags related to staffing: F741 Any Staff where there is concerns about sufficiency or competency related to behavioral health or Dementia care F801 Food and Nutrition Staff F826 Specialized Rehab Services F839 Administration for any other staff not referenced above 117 Nursing Services Phase 1 & 2 Steps: 1. Job descriptions include assuring resident safety. 2. Ensure all aides have performance reviews every 12 months. 3. Ensure process in place to identify population (diagnosis), skills needed by staff type, and skill testing developed and in place. (Tied to Phase 2 Facility Assessment) 4. Need just in time skill testing with new types of resident needs. 5. Inservices address weaknesses in performance reviews or adverse events. 118 FH51 - Developed by Polaris Group Page 62 of 187

64 Behavioral Health Services F740 Behavioral Health Services F741 Sufficient/Competent Staff-Behav Health Needs F742 *Treatment/Svc for Mental/Psychosocial Concerns F743 *No Pattern of Behavioral Difficulties Unless Unavoidable F744 *Treatment/Service for Dementia F745 *Provision of Medically Related Social Services Red tags are potential substandard care citations CMS has training video available 119 Behavioral Health F F740 New - Phase 2 - Introduction Behavioral Health Services Behavioral Health care and services encompasses treatment and supports for behavioral factors in chronic illness care, care of physical symptoms associated with stress rather than diseases, mental health conditions/substance abuse. Broad focus for treatment and service provision. Must be person-centered, meaningful activities, and environment conducive to resident s well-being; Most rules have added language for history of trauma and PTSD (Phase 3) CE Pathway for CMS Behavioral & Emotional Status 120 FH51 - Developed by Polaris Group Page 63 of 187

65 Behavioral Health F740 Key Elements of Noncompliance: Identify, address, and/or obtain necessary services for the behavioral health care needs of residents; Develop and implement person-centered care plans that include and support the behavioral health care needs, identified in the comprehensive assessment; Develop individualized interventions related to the resident s diagnosed conditions (e.g., assuring residents have access to community substance use services); Review and revise behavioral health care plans that have not been effective and/or when the resident has a change 121 in condition; Behavioral Health F740 Key Elements of Noncompliance: Learn the resident s history and prior level of functioning in order to identify appropriate goals and interventions; Identify individual resident responses to stressors and utilize person-centered interventions developed by the IDT to support each resident; or Achieve expected improvements or maintain the expected stable rate of decline based on the progression of the resident s diagnosed condition. 122 FH51 - Developed by Polaris Group Page 64 of 187

66 Behavioral Health F741 F741 New - Sufficient/competent staff for Behavioral Health Needs Phase 2 The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility s resident population. These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for: 123 Behavioral Health F741 F741 New - Sufficient/competent staff for Behavioral Health Needs Language related to trauma/ptsd care is Phase 3 Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or posttraumatic stress disorder, that have been identified in the facility assessment conducted, and as linked to history of trauma or post-traumatic stress disorder, will be implemented beginning November 28, 2019 (Phase 3). Implementing non-pharmacological interventions applies to Phase 1 & FH51 - Developed by Polaris Group Page 65 of 187

67 Behavioral Health F741 F741 New - Sufficient/competent staff for Behavioral Health Needs - Phase 2 Staff competencies include but not limited to: Communication and interpersonal skills; Promoting resident s independence; Respecting resident s rights Care for resident s environment Mental health and social services needs; Care for cognitively impaired 125 Behavioral Health F741 F741 New Sufficient/competent staff for Behavioral Health Needs - Phase 2 Must try non-drug interventions as a competency: Ensuring adequate hydration, nutrition, and pain relief Individualized sleep and dining routines Adjusting environment Assigning staff to optimize familiarity and consistency Supporting resident through meaningful activities Surveyor must identify failure to meet needs related to staffing/competency separate from Nurs Serv staffing 126 FH51 - Developed by Polaris Group Page 66 of 187

68 Behavioral Health F742 F742 (old F319) Treatment and Services Phase 1 -review new guidance but no significant change Language regarding Trauma Informed Care Phase 3 Based on assessment the facility must ensure that: A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; 127 Behavioral Health F742 Mental and psychosocial adjustment difficulty refers to the development of emotional and/or behavioral symptoms in response to an identifiable stressor(s) that has not been the resident s typical response to stressors in the past or an inability to adjust to stressors as evidenced by chronic emotional and/or behavioral symptoms. 128 FH51 - Developed by Polaris Group Page 67 of 187

69 Behavioral Health F742 Guidance includes definitions for and information about: Includes Trauma Informed care - Phase 3 Adjustment difficulties History of trauma PTSD Only admit residents you can care for, if admit residents with known history, but have staff skills and competency to care for them. 129 Behavioral Health F743 F743 (old 320) No pattern of behavior difficulties unless unavoidable - Phase 1 Language includes - Non-drug interventions must be taught and used, staff must know how to de-escalate behavior manifestations. Unless assessment supports after admission should not demonstrate pattern of decreased withdrawal, angry, depressive behaviors etc. Added language for history of trauma and PTSD Phase FH51 - Developed by Polaris Group Page 68 of 187

70 Behavioral Health F744 F744 New (and parts of old F309) Treatment Services for Dementia - Phase 2 A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental, and psychosocial wellbeing. CE Pathway CMS Dementia Care 131 Behavioral Health F744 Resident with dementia require specialized services and supports Facility s approach follows a systematic approach Medication use will occur only when: Determination of underlying cause of distress is made Non-drug interventions were not effective Distress worsens Deterioration must be seen as unavoidable 132 FH51 - Developed by Polaris Group Page 69 of 187

71 Behavioral Health F745 F745 (old F250) Provision of medically related Social services - Phase 1 Advocating for residents and assisting them in the assertion of their rights. Providing or arranging for needed services. Identifying and seeking ways to support resident s individual needs and dignity. Identify and promoting non-pharmacological approaches. 133 Behavioral Health New Section - Phase 2 Read guidance Identify staffing needs and competencies needed to care for resident in this population See Facility Assessment Ensure training and skill testing is documented Include training in orientation, after performance reviews, and after incident investigations. If have memory care unit, focus on staff in that unit. Address history of trauma/ptsd in assessments if applies 134 FH51 - Developed by Polaris Group Page 70 of 187

72 Behavioral Health New Section - Phase 2 Ensure best practices are in place: Person-Centered Comprehensive Assessment (history/likes/preferences) Accurate and complete diagnoses Care planning for behavior manifestations Tracking target behaviors Only initiate a medication when non-drug interventions failed Documentation shows efforts made to de-escalate resident; what works and what didn t work Changes in care plan as needed Decrease changes in primary staff caring for resident 135 Behavioral Health F741 F741 New Sufficient/competent staff for Behavioral Health Needs - Phase 2 Expect all staff including non-nursing staff assisting residents with behavioral concerns are competent in care areas Phase 3, under F949, Behavioral Health, formalized training programs must be completed and documented for all staff that support and provide care for residents that have behavioral health needs. 136 FH51 - Developed by Polaris Group Page 71 of 187

73 Comp/person-centered Care Planning Quality of Care & Life, Behavioral Health Phase 3 Trauma informed care Culturally competent In accordance with professional standards Takes into account resident s experiences and preferences to mitigate triggers. Services related to residents with history of trauma and/or post traumatic stress disorder. F659 Care Planning F699 Quality of Care F741 Behavioral Health Competent staff Pharmacy Services F755 Pharmacy Svcs/Procedures/Pharmacist/Records F756 Drug Regimen Review, Report Irregular, Act On F757 *Drug Regimen is Free from Unnecessary Drugs F758 *Free from Unnec Psychotropic Meds/PRN Use F759 *Free of Medication Error Rates of 5% or More F760 *Residents are Free of Significant Med Errors F761 Label/Store Drugs & Biologicals Red Tags are potential substandard care CMS has training video available 138 FH51 - Developed by Polaris Group Page 72 of 187

74 Pharmacy Services F F755 (old F425, 431) Pharmacy Services/procedures Added guidance about controlled drug receipt/disposal and tracking F756 (old F428) Drug Regimen Phase 2 changes Not intended to imply all adverse events are avoidable Must have procedures; with timeframes for steps in process, evaluate meds on an ongoing basis, identify irregularities, must be acted upon, and consider with acute changes in condition; and for stays less than 30 days. At a minimum must review entire medical record as part of monthly drug regimen review all residents 139 Pharmacy Services F756 F756 (old F428) Drug Regimen Phase 2 changes MRR must include review of medical record to: consider resident preferences Identify irregularities and; Identify clinically significant risks and/or actual or potential adverse consequences Must report irregularities to attending physician, DON, and Facility Medical Director Irregularities must be documented in a separate written report Attending Physician must then document Irregularities were reviewed and what action will be taken 140 FH51 - Developed by Polaris Group Page 73 of 187

75 Pharmacy Services F756 F756 (old F428) Drug Regimen Phase 2 changes Examples of Level 3, Actual harm (physical or psychosocial) that are not immediate jeopardy, include, but are not limited to: The pharmacist s MRR failed to identify the indication for continued use for opioid analgesics that had been prescribed for a resident s acute pain which had resolved. As a result of prolonged duration of use, the resident continued to be or became more lethargic and/or withdrawn. 141 Pharmacy Services F756, continued F756 (old F428) Drug Regimen Phase 2 changes Examples of Level 2, No actual harm with a potential for more than minimal harm that is not immediate jeopardy, may include, but are not limited to: The facility failed to respond to the pharmacist s notification that the resident was not receiving an over-the-counter (OTC) dietary supplement that had been prescribed. Currently, there was no change in the resident s condition, such as weight loss. 142 FH51 - Developed by Polaris Group Page 74 of 187

76 Pharmacy Services F Two Tags but ONE Guidance Phase 2 updates F757 (old F329) Drug Regimen is free of unnecessary drugs all types of meds except psychotropic medication. F758 New (some from F329, 428) Free from Unnecessary Psychotropic meds/prn use Old Anti-psychotic rules now apply to all psychotropic meds but not limited to: Refer to pharmacist for target meds: Anti-psychotic Anti-anxiety Anti-depressant Hypnotic 143 Pharmacy Services F Other potential target medications per CMS video: Opioids Central Nervous System agents Mood stabilizer Anticonvulsants Muscle relaxants Anti-cholinergic meds Antihistamines Increased confusion or over sedation could occur with these meds; so as with all meds staff must monitor for adverse consequences. 144 FH51 - Developed by Polaris Group Page 75 of 187

77 Pharmacy Services F F758 Definition of regulation Will use Unnecessary Drug/psychotropic drug CE Pathway Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that- Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; 145 Pharmacy Services F There is no change in GDR rules accept now applies to all psychotropic drugs. With regard to psychotropic medications, the regulations additionally require: Giving psychotropic medications only when necessary to treat a specific diagnosed and documented condition; Implementing GDR and other non-pharmacologic interventions for residents who receive psychotropic medications, unless contraindicated; and 146 FH51 - Developed by Polaris Group Page 76 of 187

78 Pharmacy Services F There is no change in GDR rules accept now applies to all psychotropic drugs. With regard to psychotropic medications, the regulations additionally require: Limiting the timeframe for PRN psychotropic medications, which are not antipsychotic medications, to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner. Limiting PRN psychotropic medications, which are antipsychotic medications, to 14 days and not entering a new order without first evaluating the resident. 147 Type of PRN order PRN orders for psychotropic medications excluding antipsychotics Pharmacy Services F Time Limitation Exception 14 days Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order Required Actions Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. There is no maximum in rules as to the length of duration PRN orders 14 days None If the attending physician/prescribing for practitioner wishes to write a new order for antipsychotic the PRN antipsychotic, the attending medications physician/prescribing practitioner must first only evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. This means directly examining resident, and considering the need for med, the benefit of med, has resident had a decrease in indicators of distress from the med, documenting rationale for new order. Duration of new order is not stated in rule, 148 POLARIS GROUP Strategic Solutions For suggest Healthcare 14 days. FH51 - Developed by Polaris Group Page 77 of 187

79 Pharmacy Services F F759 (old F332) Free of Medicare Error rate of 5% or more no change F760 (old F333) Residents are Free of Significant Med Errors no change F761 (old F431) Label/Storage no change CMS Unnecessary Meds CMS Medication Storage - mandatory CMS Medication Administration - mandatory 149 Pharmacy Phase 2 Steps: 1. Develop and implement detailed procedures for Monthly Medication Regimen Review per guidance. 2. Expanded definition of what is a psychotropic drug, work with Pharmacist to develop list of target meds, review each one, and ensure diagnosis, care plan, monitors for Adverse Effects, document rationale to continue or process for GDR. 150 FH51 - Developed by Polaris Group Page 78 of 187

80 Pharmacy Phase 2 3. Implement procedures to limit PRN usage; review each current order for PRN meds and discontinue if possible per steps in #2. 4. Ensure when reviewing care plan and target behaviors that non-drug interventions are clearly outlined and tried before any drug is considered Laboratory, Radiology, & Other Diagnostic Services F770 Laboratory Services F771 Blood Bank and Transfusion Services F772 Lab Services Not Provided On-Site F773 Lab Svcs Physician Order/Notify of Results F774 Assist with Transport Arrangements to Lab Svcs F775 Lab Reports in Record-Lab Name/Address F776 Radiology/Other Diagnostic Services F777 Radiology/Diag. Svcs Ordered/Notify Results F778 Assist with Transport Arrangements to Radiology F779 X-Ray/Diagnostic Report in Record-Sign/Dated 152 FH51 - Developed by Polaris Group Page 79 of 187

81 Laboratory, Radiology, and Other Diagnostic Services F Phase 1 F770/771/772/773 (old F502, 503, 504, 505) provide or arrange for timely services. Will investigate further if provide transfusions. F774 (old F506) Assist with transportation F775 (old F507) Lab reports/in record complete info F776/777/778 (old F508, 509, 510, 511, 512) Radiology Services & transportation F779 (old F513) Documented as Reported/dated/signed in records for radiology and diagnostics No significant changes, read expanded guidance to confirm Dental Services F790 Routine/Emergency Dental Services in SNFs F791 Routine/Emergency Dental Services in NFs CMS Dental CE Pathway 154 FH51 - Developed by Polaris Group Page 80 of 187

82 Dental Services F Phase 2 Expanded guidance F790 (old F411) Routine/Emergency Dental in SNFs Prohibit charging Medicare resident for the loss or damage of dentures in accordance with policy of when becomes facility s responsibility. Must create written policy when facility is responsible Within 3 business days refer residents for dental services/transportation or documentation why not. Must document how resident eats/drinks without dentures, if referral is delayed. 155 Dental Services F Phase 2 F791 (old F412) Routine/Emergency Dental in NFs Same set of regulations as for F790 Procedures for when and if they would be responsible for denture replacements Added guidance on helping with resources for payment for services including for Medicaid residents 156 FH51 - Developed by Polaris Group Page 81 of 187

83 Food and Nutrition Services F800 Provided Diet Meets Needs of Each Resident F801 Qualified Dietary Staff F802 Sufficient Dietary Support Personnel F803 Menus Meet Res Needs/Prep in Advance/Followed F804 Nutritive Value/Appear Palatable/Prefer Temp F805 Food in Form to Meet Individual Needs F806 Resident Allergies, Preferences and Substitutes F807 Drinks Avail to Meet Needs/Preferences/Hydration CMS Kitchen-Mandatory Food and Nutrition Services F808 Therapeutic Diet Prescribed by Physician F809 Frequency of Meals/Snacks at Bedtime F810 Assistive Devices Eating Equipment/Utensils F811 Feeding Asst Training/Supervision/Resident F812 Food Procurement, Store/Prepare/Serve Sanitary F813 Personal Food Policy F814 Dispose Garbage & Refuse Properly 158 FH51 - Developed by Polaris Group Page 82 of 187

84 Food and Nutrition F F800 (old F360) Food and Nutrition Services expanded guidance The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. INTENT To ensure that facility staff support the nutritional wellbeing of the residents while respecting an individual s right to make choices about his or her diet. Must consider preferences both food and fluids Ongoing communication Make reasonable efforts 159 Food and Nutrition F802 F801 (old F361) Staffing qualifications refer to guidance F802 (old 362) Sufficient Staffing Phase 2 related to Staffing/Competency/Facility Assessment Staffing The facility must employ sufficient staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility s resident population. 160 FH51 - Developed by Polaris Group Page 83 of 187

85 Food and Nutrition F802 F802 (old 362) Sufficient Staffing - Surveyor guidance Through observations and interviews, determine if there are sufficient support personnel to safely and effectively carry out the meal preparation and other food and nutrition services as defined by facility management. Observe and interview residents to determine if their needs and preferences are met, if the food is palatable, attractive, served at the proper temperatures and at appropriate times? If concerns are identified, determine if they may be related to insufficient or inadequately trained personnel. 161 Food and Nutrition F F803 (old F363) Menus and Nutritional Adequacy expanded guidance F804 (old F364) Food and Drinks - Nutritive Value/appearance/temp F805 (old F365) Meets individual needs F806 (old F366) Allergies/preferences/substitutes F807 (old F366) Drinks to meet needs/preferences F808 (old F367) Therapeutic Diet F810 (old F369) Assistive Devices Per resident s preference throughout all these rules as well as reference to Food and Drink, not just food 162 FH51 - Developed by Polaris Group Page 84 of 187

86 Food and Nutrition F809 F809 (old 368) Frequency of meals and snacks at bedtime expanded guidance There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care. 163 Food and Nutrition F F811 (old F373) Feeding Assistant no change F812 (old F371) Food Procurement expanded guidance May procure food from local producers and may use food grown in facility garden. Residents may not be prohibited from consuming food that are not procured by facility. F814 (old F372) Dispose Garbage no change 164 FH51 - Developed by Polaris Group Page 85 of 187

87 Food and Nutrition F812 Potluck Events Are generally events where families, volunteers or other non-facility staff may organize to provide enjoyment to nursing home residents and support a personcentered homelike environment. These are different from a facility s special event. Regarding food brought into a nursing home prepared by others, please remember the nursing home is responsible for: Storing visitor food in such a way to clearly distinguish it from food used by or prepared by the facility. Ensuring safe food handling once the food is brought to the facility, including safe reheating and hot/cold holding, and handling of leftovers. 165 Food and Nutrition F813 F813 (old F371) Personal Food policy Food Safety Requirements. The facility must - Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Guidance: The facility must have a policy regarding food brought to residents by family or other visitors. The policy must also include ensuring facility staff assists the resident in accessing and consuming the food, if the resident is not able to do so on his or her own. The facility also is responsible for storing food brought in by family or visitors in a way that is either separate or easily distinguishable from facility food. 166 FH51 - Developed by Polaris Group Page 86 of 187

88 Food and Nutrition F813, continued F813 (old F371) Personal Food policy Guidance, continued The facility has a responsibility to help family and visitors understand safe food handling practices (such as safe cooling/reheating processes, hot/cold handling temperatures, preventing cross-contamination, hand hygiene, etc.) If the facility is assisting family or visitors with reheating or other preparation activities, facility staff must use safe handling practices. 167 Food and Nutrition Phase 1 1. F813 - Procedures for allowing residents to have foods of their choice brought in, and how to store it. 2. Review guidance for F812 Food Procurement to ensure procedures are in compliance 3. Ensure resident can eat meals/snacks at times desired within reason. 168 FH51 - Developed by Polaris Group Page 87 of 187

89 Food and Nutrition Phase 2 1. Staffing and competencies based on Annual Facility Assessment Make a list of competencies needed by staff. Perform skill testing at hire and annually Performance review Specialized Rehabilitative Services F825 Provide/Obtain Specialized Rehab Services F826 Rehab Services Physician Order/Qualified Person 170 FH51 - Developed by Polaris Group Page 88 of 187

90 Specialized Rehab F Expanded Guidance F825 (old F406) Provide/obtain Rehab Services F826 (old F407) Rehab Orders by physician/qualified person Adding respiratory services must provide or obtain. Clarify what constitutes services for residents with Mental Illness and Intellectual Disabilities Administration F835 Administration F836 License/Comply w/fed/state/local Law/Prof Std F837 Governing Body F838 Facility Assessment F839 Staff Qualifications F840 Use of Outside Resources F841 Responsibilities of Medical Director F842 Resident Records Identifiable Information F843 Transfer Agreement F844 Disclosure of Ownership Requirements Red tags are potential Substandard Care citations CMS Training video for Facility Assessment 172 FH51 - Developed by Polaris Group Page 89 of 187

91 Administration F845 Facility closure-administrator F846 Facility closure F849 Hospice Services F850 *Qualifications of Social Worker>120 Beds F851 Payroll Based Journal Red tags are potential Substandard Care citations CMS Video on Facility Assessment 173 Administration F F835 (old F490) Administration F836 (old F492, 492) License/comply F837 (old F493) Governing Body responsible for QAPI Phase 3 F839 (old F499) Staff Qualifications - only cite this tag if related to personnel not covered by other staffing rules in Nursing Serv, Behavior Serv, Nutrition/dietary serv/specialized rehab. F840 (old F500) Outside resources 174 FH51 - Developed by Polaris Group Page 90 of 187

92 Administration F F841 (old F501) Medical Director expanded guidance If the medical director is also an attending physician, there should be a process to ensure there are no concerns with the individual s performance as a physician (i.e., otherwise the medical director is monitoring his/her own performance). If there are concerns regarding his/her performance, the facility s administration should have a process for how to address these situations. 175 Administration F F841 (old F501) Medical Director expanded guidance Medical director responsibilities must include their participation in: Administrative decisions including recommending, developing and approving facility policies related to resident care. Resident care includes resident s physical, mental and psychosocial well-being; Issues related to the coordination of medical care identified through the facility s quality assessment and assurance committee and other activities related to the coordination of care; Organizing and coordinating physician services and services provided by other professionals as they relate to resident care; Participate in the Quality Assessment and Assurance (QAA) committee or assign a designee to represent him/her. (Refer to F865) 176 FH51 - Developed by Polaris Group Page 91 of 187

93 Administration F F842 (old F164, 514, 515, 516) Medical Records F843 (old F519) Transfer Agreement F844 (old F522) Disclosure of Ownership F850 (old F251) Social Services qualifications added background in gerontology F851 (old F527) Payroll Based Journal updated to this requirement to be in compliance with new rule F845 & F846 (old F523, 524) Facility Closure expanded guidance 177 Administration F F849 (old F526) Hospice Extensive expansion of guidance must read Written agreement Provision of services - must assist to get services NH responsibilities, collaboration, reporting abuse etc. 178 FH51 - Developed by Polaris Group Page 92 of 187

94 Administration F , continued F849 (old F526) Hospice Extensive expansion of guidance must read Based on the shared communication between the hospice and the nursing home, the coordinated plan(s) of care should reflect the identification of: Diagnoses; A common problem list; Palliative interventions; Palliative goals/objectives; Responsible discipline(s); Responsible provider(s); and Resident/designated representative choices regarding care and goals. 179 Arbitration Rules are still pending CMS is to public final rules shortly - Below is some of proposed rules The prohibition on pre-dispute binding arbitration agreements is removed. If signing the agreement for binding arbitration is a condition of admission into the facility, the language of the agreement must be in plain writing and in the admissions contract. The resident must acknowledge that he or she understands the agreement. No language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials. The facility must post a notice regarding its use of binding arbitration in an area that is visible to both residents and visitors. 180 FH51 - Developed by Polaris Group Page 93 of 187

95 Administration Phase 1 Steps: Compare new rules to P/P for facility closure, administrator duties, Social Services (add Gerontology). Review guidance for Medical Director and share with MD. Review rules on Hospice Arrangements and update contract/procedures as needed. Await final rules regarding binding arbitration. 181 Administration F838 Phase 2 F838 New Facility Assessment Updated Annually and upon need (such as admitting resident with new care needs not formally considered in Facility Assessment) Who is involved: Administrator Governing Body DON Medical Director Department Heads Consider how to involve residents/families/staff 182 FH51 - Developed by Polaris Group Page 94 of 187

96 Administration F838 Phase 2 F838 New Facility Assessment Center-wide assessment to determine resources needed to care for residents day-to-day and in an emergency. Facility Assessment Includes: Resident Population/Profile Care and Services Needed Resources Needed to provide services Includes a facility-based and community-based risk assessment ongoing and for emergencies See Appendix Z for Emergency Preparedness rules 183 Administration F838 Phase 2 Resident Population & Services The facility s resident population, including, but not limited to, Both the number of residents and the facility s resident capacity; The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; The staff competencies that are necessary to provide the level and types of care needed for resident population; The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food/nutrition services. Includes technical support and individual communication devices Operational budget for supplies/equipment 184 FH51 - Developed by Polaris Group Page 95 of 187

97 Administration F838 Phase 2 Resources The facility s resources, including but not limited to, All buildings and/or other physical structures and vehicles; Equipment (medical and non-medical); Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; The methods to ensure meeting needs and competent skills Including volunteers 185 Resources Administration F838 Phase 2 The facility s resources, including but not limited to, Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. The methods to ensure meeting needs and competent skills Including volunteers 186 FH51 - Developed by Polaris Group Page 96 of 187

98 Emergency Plan Integrated Facility and Community Based Risk Assessment for ongoing and in emergency all hazards approach Your emergency plan (Appendix Z effective Nov. 15, 2017) linked to Facility Assessment as what would be done under certain emergencies/disasters. E-tags will be completed with Life Safety inspection in most states but could be completed with annual survey States choice. No F-tags for disaster planning Certification/SurveyCertificationGenInfo/Downloads/Surveyand-Cert-Letter pdf 187 Emergency Plan Integrated Facility and Community Based Risk Assessment for ongoing and in emergency all hazards approach 188 FH51 - Developed by Polaris Group Page 97 of 187

99 Administration F838 Phase 2 Key Elements of Non-compliance To cite deficient practice at F838, the surveyor s investigation will generally show that the facility failed to do any one of the following: Annually and as necessary, conduct, document, review and update a facility-wide assessment; or Address or include in the facility assessment the minimum requirements 189 Administration F838 Phase 2 F838 New - Facility Assessment - Phase 2 CMS Link to Facility Assessment Tool Example optional to use Annual Survey - will ask for Facility Assessment upon arrival - Entrance Will not review it line-by-line but as indicated by citations; will look to see how Facility Assessment addressed it Review of Facility Assessment is part of a root cause analysis for a care issue says CMS. Complaint Surveys only if indicated 190 FH51 - Developed by Polaris Group Page 98 of 187

100 See attached example Facility Assessment tool FH51 - Developed by Polaris Group Page 99 of 187

101 Use MDS Data Use Characteristics from CMS FH51 - Developed by Polaris Group Page 100 of 187

102 FH51 - Developed by Polaris Group Page 101 of 187

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105 201 Administration F838 Phase 2 Get Started - Number of residents Acuity population (typical Diseases) Use MDS Data Use Characteristics from CMS-672 Common diagnosis Should drive staffing levels, staff assignments Ethnic/cultural, religious, activities 202 FH51 - Developed by Polaris Group Page 104 of 187

106 Administration F838 Phase 2 Annual Facility Assessment Equipment/devices/food preferences needed (per person-centered care plans) Adaptive devices, wheelchairs, rise alarms, communication devises, translators, for example Staff competencies needed by staff type for type of residents Generic list for basic care provided all types of residents Then list by common diseases admitted (Diabetes, Cardiac, Rehab, Dementia, Parkinson s, etc.) Health Information Technology managing and sharing with other providers 203 Administration F838 Phase 2 Annual Facility Assessment Physical environment dining, rehab, activities Vehicles Contracted providers - How oversight to ensure services meet needs; contract should address both ongoing and in emergencies Applies to interim staff and volunteers staff Similar to strategic planning and operational budgets Must create process and document process. Must be a living document with updates as needed. 204 FH51 - Developed by Polaris Group Page 105 of 187

107 Administration Phase 3 F837 - Governing body responsibility for QAPI Program Quality Assurance & Performance Improvement F865 QAPI Program/Plan, Disclosure/Good Faith Attempt F866 {PHASE 3} QAPI/QAA Data Collection and Monitoring F867 QAPI/QAA Improvement Activities F868 QAA Committee CMS has video training available Surveyors will use CE Pathway CMS QAA/QAPI Review - mandatory 206 FH51 - Developed by Polaris Group Page 106 of 187

108 Quality Assurance & Performance Improvement F All new tags are old F520 F865 New - QAPI Program/Plan/disclosure/good faith effort Plan required for Phase 2 Will ask for plan during entrance F866 QAPI/QAA Data collection and monitoring Phase 3 F867 QAPI/QAA Improvement Activities - Phase 2 F868 QAA Committee - Phase Quality Assurance & Performance Improvement F QAPI/QAA Implementation QAPI Plan effective Nov. 28, 2017 QAA Committee effective Nov. 28, 2016 Infection Preventionist Nov. 28, 2019 Analysis of QAPI Data Nov. 28, 2019 Language related to implementation of QAPI Program is Nov. 28, 2019 Disclosure of Information/Sanctions Nov. 28, 2016 Expanded guidelines for QAPI/QAA Nov. 28, FH51 - Developed by Polaris Group Page 107 of 187

109 Quality Assurance & Performance Improvement F Nov. 28, 2016 Phase 1 F520 QAA Rules related to Disclosure of Information/Sanctions Nov. 28, 2017 Phase 2 F865 QAPI Plan will as for copy at Entrance Nov. 28, 2019 Phase 3 F868 QAPI Program implementation F866 QAPI Feedback Data and Monitoring F867 QAA Activities expanded guidance F868 QAA Committee 209 Quality Assurance & Performance Improvement F865 F865 New QAPI Program/Plan/disclosure/good faith effort What goes in affect Nov. 28, 2017 Phase 2 Quality Assurance and Performance Improvement (QAPI) program The facility must present QAPI Plan during survey Disclosure of Information No change in requirements - Phase 1 Sanctions no change in requirements Phase 1 Language on QAPI Program requirements are Phase FH51 - Developed by Polaris Group Page 108 of 187

110 Quality Assurance & Performance Improvement F865 A QAPI plan is the 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. The plan describes how the facility will conduct its required QAPI and QAA committee functions. The facility is required to develop a QAPI plan and present its plan to federal and state surveyors at each annual recertification survey and upon request during any other survey, and to CMS upon request. 211 Quality Assurance & Performance Improvement PLAN Phase 2 The Plan must address the QAA Committee requirements Quarterly Meeting, Members, etc. (no change in these requirements) & requirement to take corrective action for identified care concerns- integrate more detail for items below: How you identify Issues data used (suggest Plan Grid) How collecting and when analyze How analyze Root Cause Analysis tools, PDCA, etc. How monitor that improvement efforts worked 212 FH51 - Developed by Polaris Group Page 109 of 187

111 FH51 - Developed by Polaris Group Page 110 of 187

112 215 Quality Assurance & Performance Improvement F866 F866 QAPI/QAA Data collection & monitoring Phase 3 A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at minimum, the following: Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problemprone, and opportunities for improvement. Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation. 216 FH51 - Developed by Polaris Group Page 111 of 187