WhWwhaht. SNF CMS, RoP, Survey, and Regulatory Update October /25/2017. The New and Improved Survey Process

Transcription

1 303 Cleveland Avenue SE Suite 206 Tumwater, WA Tel SNF CMS, RoP, Survey, and Regulatory Update October 2017 Elena Madrid Director of Regulatory Affairs The New and Improved Survey Process 2016 As part of the 2016/2017 NH Action Plan, CMS announced plans to strengthen the survey process, training, and standards. November 28, 2017 All states are mandated to utilize the New Survey Process. 1

2 New Survey Process Off Site Preparation Surveyors will continue to identify and review the history of the facility, including repeat deficiencies, results of last standard survey, complaints, etc. Entrance Preparation is the Key! Not limited to: Survey Book Resident Roster/Sample Matrix List of Department Heads and Contacts Exemptions/Exceptions Processes EHR Procedures Facility Map/Room List Surety Bond New Survey Process Three Parts to the New Survey Process: 1. Initial Pool Process 2. Sample Selection 3. Investigation 2

3 Initial Pool Process Sample is selected based on facility census Seventy percent of the sample is selected off site Thirty percent of the sample is selected on site by the survey team Initial Pool Process Names of New Admissions Identify Initial Pool of Residents Residents will be screened with suggested questions (not scripted) and the surveyor will be making observations of care areas, conducting rounds, and formal observations to determine if further investigation is needed or if no issues are identified Initial Pool Process Surveyors are directed to observe dining during the first full meal served once onsite. Surveyors are directed to observe/cover all dining areas and room trays and to observe enough of the meal in order adequately identify any concerns. If concerns are identified, they are directed to observe another meal 3

4 Initial Pool Process Resident representatives/family interviews and limited record review will occur after the interviews and observations are conducted. Surveyors are directed to observe dining during the first full meal served once onsite Sample Selection Surveyors are directed to select the resident sample, prioritizing based on the identified CMS considerations. Five residents will be selected for a full medication review, based on the observations, interviews, and record reviews of the surveyors, as well as MDS data. Sample Selection Include a selection of: Vulnerable residents New Admissions Residents identified via complaints Identified concerns 4

5 Investigation Surveyors will conduct investigations for all concerns that warrant further review for sampled residents. Continue observations and interviews to determine facility compliance/failed practice. Surveyors are directed to spend a majority of their time observing and interviewing, with only relevant review of records to complete the investigation New Survey Process Specific Unit/Facility Task Assignments: Dining Infection Control Resident Council Meeting Kitchen Review Medication Administration/Storage SNF Beneficiary Protection Notification Review Sufficient and Competent Nurse Staffing QAA/QAPI Resident Group Meeting Location Timing Attendance Assistance Incorporate resident rights into resident council meetings, grievance procedures, etc. 5

6 Medication Administration/Storage Medication Administration Include sample residents, if opportunity presents itself Reconcile controlled medications if observed during medication administration Observe different routes, units, and shifts Observe 25 medication opportunities Medication Storage Observe half of medication storage rooms and half of medication carts Kitchen Review Food Borne Illness Ill worker policy/procedure Dining Review Choices/Preferences Alternates, variety System for residents to express comments/concerns Special Needs Assistance (care planned) Prescribed, Therapeutic/modified diets, assistive devices, etc. Quality of Life milieu 6

7 Infection Control All surveyors will observe for IC concerns and practices. Assigned surveyor will coordinate a review of the influenza and pneumococcal vaccination systems, as well as infection prevention, control, and antibiotic stewardship program. Sufficient and Competent Nurse Staffing Review Is a mandatory task Environment Eliminate redundancy with LSC Disaster and Emergency Preparedness O2 storage Generator 7

8 What hasn t changed? Data is collected and investigated based on 3 forms of evidence: Observations Interviews Record Reviews Observations Informal/General Observations Formal Observations of Care/Services Interviews Informal/General Interviews Formal Interviews Family/Guardian Interviews Staff Interviews 8

9 Record Reviews Record reviews should be resident centered and focused on obtaining specific information to validate and clarify issues identified with a resident s provision of care and services, quality of life, and safety. Potential Citations Team makes compliance determination. Compliance decisions reviewed by team Scope and severity (S/S) Conduct exit conference and relay potential areas of deficient practice CMS S&C Memo ALL Exit Conference is a courtesy to provider Way to expedite providers planning ahead of the receipt of the Informally communicate preliminary survey team findings and an opportunity for exchange of information. Findings are subject to change 9

10 CMS S&C Memo ALL If a provider directly asks the F Tag or regulatory reference, surveyors should generally provide this information, but must always caution the facility that it is preliminary. If facility does not ask, the surveyors can use their own judgement Should describe the general area noncompliance. Under no circumstances are surveyors to share the S/S unless identified as an IJ Both can change Phase 2 Requirements of Participation Behavioral Health Services Infection Control and Antibiotic Stewardship Resident Rights and Facility Responsibilities regarding Contact Information Abuse, Neglect, and Exploitation 1150B Transfer/Discharge Documentation Phase 2 Requirements of Participation Comprehensive Person Centered Care Planning Pharmacy Services Dental Services Administration Facility Assessment Quality Assurance & Performance Improvement (QAPI Plan Only) 10

11 Freedom from Abuse, Neglect, and Exploitation Need to know the different requirements for reporting of suspected crimes versus allegations of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property Admission, Transfer, and Discharge Facility initiated transfer or discharge : A transfer or discharge which the resident objects to, did not originate through a resident s verbal or written request, and/or is not in alignment with the resident s states goals for care and preferences Resident initiated transfer or discharge : Means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment) Admission, Transfer, and Discharge Sending copy of transfer/discharge notice to ombudsman: Applies to facility initiated discharges For emergency room transfer, may send notice to ombudsman when practicable such as in a list of residents on a monthly basis Notice of transfer or discharge is not required for resident initiated discharges 11

12 F Tag Renumbering Facility Assessment Purpose: to determine what resources are necessary to car for residents competently during day today operations and emergencies May be used to make decisions about direct care staff needs as well as capabilities to provide services to the residents in your facility. assessment tool September 16, 2016, CMS published the Emergency Preparedness final rule to establish consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid. Skilled nursing facilities are only one of the 17 health care settings. 12

13 Implementation Date: November 15, 2017 There are four overall provisions required of each facility s Emergency Preparedness Program. 1. Risk Assessment and Planning Each facility must develop an emergency plan based on a risk (flood, tornadoes, wind storm, fire, etc.) assessment. Each facility must perform a risk assessment using an all hazards approach, focusing on the capacities and capabilities of each facility. The facility must update the emergency plan at least annually. What is an all hazards approach? An all hazards approach is defined by CMS as an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including internal emergencies and a man made emergency (or both) or natural disaster. 13

14 2. Policies and Procedures Every facility must develop and implement policies and procedures based on the emergency plan and risk assessment. Policies and procedures must address a range of issues that could affect the facility, including the need for food, water, shelter, medications, evacuation plans, and means of tracking residents and staff. The facility must review and update these policies and procedures annually. 3. Communication Plan Facilities must develop a communication plan that complies with both Federal and State requirements. Each facility must have a plan to coordinate resident care within the facility, across health care providers, and with state and local public health departments and emergency management systems. This plan must be reviewed and updated annually. 4. Training and Testing Program Each facility must develop and maintain training and testing programs for all personnel, including initial training in policies and procedures. The facility and staff must demonstrate knowledge of emergency procedures and provide training at least annually. The facility MUST conduct drills and exercises to test the emergency plan. 14

15 Additional requirements vary per provider type. For example, long term care facilities must share information from the emergency plan with residents and family members/representatives. Facilities are expected to meet all training and testing requirements by the implementation date. This means facilities are expected to have completed the following by November 15, 2017: All of the staff training requirements. Participation in a full scale exercise that is communitybased or when a community based exercise is not accessible, an individual, facility based exercise. Conduct an additional exercise that may include, but is not limited to the following: A second full scale exercise that is individual, facility based. A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. CMS uses the following training and testing program definitions: Facility Based: CMS considers the term to mean that the emergency preparedness program is specific to the facility. Facility based includes, but is not limited to, hazards specific to a facility based on the geographic location, resident population, facility type, and potential surround community assets. Full Scale Exercise: Is a multi agency, multi jurisdictional, multi discipline exercise involving functional and/or boots on the ground response (for example firefighters decontaminating mock victims). Table Top Exercise: Is a group discussion as defined above and involves key personnel discussing simulated scenarios in an informal setting. A table top exercise can be used to assess plans, policies, and procedures. 15

16 Enforcement CMP Revised Analytic Tool July 2017 Past Non Compliance CMS Guidance Phase 2 RoP Nursing Assistant Training Programs waivers DOH Nursing Home Administrator Investigations RCS Management Department Changes Regional Management Structure Field Managers Questions/Answers/Discussion 16

17 My Contact Information: Elena Madrid, RN BSN Director of Regulatory Affairs Washington Health Care Association T: , ext. 105 P: , ext