Highlights of the New LTCSP and Regulations

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1 Highlights of the New LTCSP and Regulations New York State Department of Health Division of Nursing Homes and ICF/IID Surveillance November 15, 2017

2 November 15, Resources

3 New Long Term Care Survey Process November 15, 2017

4 November 15, ENTRANCE INFORMATION NEEDED IMMEDIATELY UPON ENTRANCE: Accurate current census-exclude bedholds Complete matrix for new admissions in the last 30 days who are still residing in the facility (copy for each surveyor) An alphabetical list of all residents A list of residents who smoke, designated smoking times, and locations

5 November 15, ENTRANCE CONFERENCE Brief Entrance Conference with the Administrator Information regarding full time DON coverage and emergency water source A copy of an updated facility floor plan, if changes have been made Name of Resident Council President

6 November 15, INFORMATION NEEDED FROM FACILITY WITHIN ONE HOUR OF ENTRANCE Dining: times and location of dining, copies of all current menus for the duration of the survey and the policy for food brought in from visitors Schedule of medication administration times Number and location of med storage rooms and med carts The actual working schedules for licensed and registered nursing staff for the survey time period

7 November 15, ONE HOUR INFORMATION (cont.) List of key personnel, location, and phone numbers. Note contract staff (e.g., rehab services) If the facility employs paid feeding assistants, provide the following: Training provided Names of staff currently assisting residents Residents who are eligible or are receiving assistance

8 November 15, INFORMATION NEEDED FROM FACILITY WITHIN FOUR HOURS OF ENTRANCE Complete matrix for all other residents Dialysis Contract(s), Agreement(s), Arrangement(s), Policy and Procedures Hospice Agreement, and Policies and Procedures for each hospice used

9 November 15, Four Hours (cont.) Infection Prevention and Control Program Standards, Policies and Procedures, and Antibiotic Stewardship Program QAA/QAPI Plan-Committee information Abuse Prohibition Policy and Procedures Facility Assessment

10 November 15, INFORMATION NEEDED BY THE END OF THE FIRST DAY OF SURVEY Electronic Health Record (EHR) information- Surveyors need to have access to the EHRs outside of the conference room Surveyors require the same access staff members have to resident s EHR s, in a read-only format Legionella Information

11 November 15, INFORMATION NEEDED FROM FACILITY WITHIN 24 HOURS OF ENTRANCE Completed Medicare/Medicaid Application (CMS-671) Completed Census and Condition Information (CMS-672) Beneficiary Notice-see page #3

12 November 15, Resident Centered CMS website-ltcsp Procedure Guide Once on the unit, surveyor will request resident roster All residents will be screened to help determine those to be included in initial pool

13 November 15, Initial Pool Approximately 8 residents/surveyor MUST INCLUDE: 70% offsite selected by software-based on MDS data 30% selected onsite by team: ovulnerable onew Admission ocomplaint ofacility Reported Incidents (FRIs) oidentified concern

14 November 15, Sample Selection: Based on facility size Combination of surveyor and software input Will not be determined until second day (earliest)

15 November 15, Screen Pool Sample

16 November 15, Day 1: Entrance Kitchen Review Resident Interview/Resident Observation/Limited record review Resident Representative Interview Dining observations Information requested during entrance conference

17 November 15, Day 2: Complete initial pool process Sample selection Begin In-depth Investigations

18 November 15, Remainder of Survey: Complete Investigations Mandatory Tasks/Triggered Tasks Potential Citation review Exit conference

19 November 15, Facility Assessment

20 November 15, The facility s resident population The facility s resources A facility-based and community-based risk assessment using an all-hazards approach

21 November 15, How is it used in the survey process? To verify if the facility conducted and documented a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies Must be reviewed annually and PRN

22 November 15, Process Recertification Survey: Request during entrance conference-review with systemic concerns Complaint Survey: Request PRN

23 November 15, Behavioral Health Services F740-F745

24 November 15, F740 Provision of Care and Services Necessary care and services are personcentered Meaningful activities are provided Environment is conducive to the resident s well-being

25 November 15, Person-centered environment includes, but is not limited to: Interdisciplinary team approach to care Qualified staff Individualized approaches Supportive environment Inclusion of the resident, their family, or resident representative

26 November 15, F741 Provision of Care and Services Address the behavioral health needs that can be met Have sufficient, competent direct care staff Demonstrate attempts to access professional behavioral health resources Seek alternative sources for services

27 November 15, F742 Treatment/Services to Correct Assessed Problem or Attain Highest Practicable Well-being

28 November 15, F743 No Assessed Diagnosis or Pattern/Development of Pattern that was Unavoidable

29 November 15, F744 Appropriate Treatment/Services for a Resident with Dementia

30 November 15, F745 Medically-related Social Services

31 November 15, Pharmacy Services F755-F761

32 November 15, Pharmacy Services Overview F756 Drug Regimen Review F757 Unnecessary Medications F758 Psychotropic Medications

33 November 15, F756 Drug Regimen Review Medication regimen review (MRR) component of the pharmaceutical services systems includes: A pharmacist s review of the resident s medication regimen and medical record Acting upon identified irregularities

34 November 15, Pharmacist must report irregularities to the: Attending physician Director of nursing Facility medical director

35 November 15, Attending physician must: Document irregularities were reviewed What action will be taken Irregularities must be documented in a separate written report

36 November 15, F756 New Requirements Each facility must develop and maintain policies and procedure, which include: Time frames for steps in the process; and steps to take when immediate action is required Policies and procedures should also address 1. Anticipated stays less than 30 days 2. Identified acute changes of condition

37 November 15, F758 Psychotropic Medications Limited to 14 days May be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order Must have a documented rationale by the attending physician or prescribing practitioner for the extended time period in the medical record, including a specific duration

38 November 15, PRN orders for antipsychotic medications only: Limited to 14 days, without exception If the attending physician or prescribing practitioner wishes to write a new order for the PRN antipsychotic, the attending physician or prescribing practitioner must first evaluate the resident

39 November 15, As part of the evaluation, the attending physician or prescribing practitioner should, at a minimum, determine and document the following in the resident s medical record: Is the antipsychotic medication still needed on a PRN basis? What is the benefit of the medication to the resident? Have the resident s expressions or indications of distress improved as a result of the PRN medication?

40 November 15, Infection Control

41 November 15, F880: Infection Prevention and Control ( Old F441 ) F881: Antibiotic Stewardship Program(New) F882: Infection Preventionist Qualifications/Role (New) Phase 3 F883: Influenza and Pneumococcal Immunizations ( Old F334 )

42 November 15, F880 Infection Prevention and Control System for identifying and reporting of infections and communicable diseases The Infection Prevention and Control Program (IPCP) applies to residents, staff, volunteers, visitors, and contractors Based upon the Facility Assessment and national standards

43 November 15, F881 Antibiotic Stewardship Part of the Infection Prevention and Control Program (IPCP) Antibiotic use protocols System to monitor antibiotic use and resistance

44 November 15, F883 Resident self reported influenza and Pneumococcal Polysaccharide Vaccine (PPSV) are acceptable Flu-not date specific when available Most recent ACIP guidelines recommend both PCV13 and PPSV23

45 November 15, Admission, Transfer, and Discharge (F620-F626)

46 November 15, F620 Admissions Policy Facility must develop an admissions policy Must provide notice regarding special characteristics/limitations of facility Must disclose locations which make up distinct parts of facility Must include policy for room changes Must NOT ask residents to waive facility responsibility for loss of personal items

47 November 15, F622 Transfer and Discharge Requirements Facility may not D/C resident while appeal is pending Facility initiated D/C or transfer- MD must document 1. Reason for move 2. What needs cannot be met 3. Attempts to meet those needs 4. Service available at receiving facility which can meet needs

48 November 15, F622 (cont.) Documentation to receiving facility must include: 1. Contact information for provider 2. Contact information for resident s representative 3. Advance Directive information 4. Special care instructions 5. Comprehensive care plan goals 6. Any additional information (including discharge summary) to ensure a safe transition

49 November 15, F623 Notice to Ombudsman Facility initiated discharges or transfers 30 days in advance, or as soon as possible Emergency transfers-may send a monthly list Provides additional protection for the resident

50 November 15, F626 Permitting Residents to return Decision must not be based on resident s condition at time of transfer Facilities should work with hospital to determine if resident s current needs can be met

51 November 15, Quality Assurance and Performance Improvement F865-F868

52 November 15, F865 QAPI Plan Annually and prn as requested Program must be defined, implemented and maintained Adequately resourced

53 November 15, Good Faith Attempts by committee Key Points: If a facility has identified and is making a good faith attempt to correct same issue identified by the survey team, on the current survey, the facility should not be cited at QAA (F865), but may still be cited at relevant tag

54 November 15, Protection from disclosure is generally afforded documents generated by the QAA committee, such as minutes, internal papers, or conclusions. However, if those documents contain the evidence necessary to determine compliance with QAPI/QAA regulations, the facility must allow the surveyor to review and copy them. The key point is that the facility must provide satisfactory evidence that it has, through its QAA committee, identified its own high risk, high volume, and problem-prone quality deficiencies, and are making a good faith attempt to correct them.

55 November 15, Facility Refusal to Provide Evidence of Compliance Refusal by a facility to produce evidence of compliance with QAA will lead to citation of noncompliance with F865, requiring a plan of correction, and possible imposition of enforcement remedies up to and including termination of the facility s provider agreement. In the event of a facility refusal to produce evidence of compliance, the team coordinator should contact their State Agency supervisor.

56 November 15, F868 QAA Committee A facility must maintain a quality assessment and assurance committee consisting at a minimum of: The Director of Nursing Services The Medical Director or his/her designee At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role The committee must: Meet at least quarterly

57 November 15, Nursing Services

58 November 15, F726 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 required at (e).

59 November 15, Competency A measurable pattern of: Knowledge Skills Abilities Behaviors Other characteristics that an individual needs to perform work roles or occupational functions successfully.

60 November 15, Competency in skills and techniques necessary to care for residents needs includes but is not limited to competencies in areas such as; Resident Rights Person centered care Communication Basic nursing skills Basic restorative services Skin and wound care Medication management Pain management Infection control Identification of changes in condition Cultural competency

61 November 15, Demonstration of Competency Competency may not be demonstrated simply by documenting that staff attended a training, listened to a lecture, or watched a video. A staff s ability to use and integrate the knowledge and skills that were the subject of the training, lecture or video must be assessed and evaluated by staff already determined to be competent in these skill areas.

62 November 15, Examples for evaluating competencies may include but are not limited to: Lecture with return demonstration A pre-and post-test

63 November 15, Questions? Please submit to:

64 November 15, Resources

65 November 15, Thank you!

Overview of the New Long-Term Care Survey Process FOR LONG-TERM CARE (LTC) PROVIDERS

Overview of the New Long-Term Care Survey Process FOR LONG-TERM CARE (LTC) PROVIDERS Navigation To Start the training, please press Function + F5 To advance through each slide use the icon located at the