Navigating the Nov 2017 RoP Changes: New facility assessment and staff competencies Implement change sustain results! 1
Objectives 1. Discuss Phase 2 RoP regulatory changes, including the RoP revision to 483.70(e) related to conducting a Facility Assessment. 2. Review effective strategies to assist with conducting a thorough Facility Assessment and developing staff competencies necessary to provide the identified level of care. 3. Demonstrate insight into evidence-based resources and tools to assist in the development of clinical competencies. 4. Evaluate how effectively managing facility capabilities and competencies can result in improved employee and customer satisfaction. 5. Identify how to use the Facility Assessment in strategic planning and better position your facility in the marketplace. 2
Overview The Requirements of Participation (RoP) is the largest change to nursing home practice and the delivery of care since 1991 Long Term Care facilities must meet the RoP in order to participate in the Medicare or Medicaid programs Implementation of the RoP is phased in over a three year period and implements sections of the Affordable Care Act (ACA) Some of these changes may have a ripple effect which may effect more then one area 3
Themes of the Rule Person-Centered Care Assessment/Staffing, Competency-Based Approach o Know your Center, Know Your Patients, Know Your Staff Quality of Care & Quality of Life o New/Changed evidence-based practices o Care Planning Resident Goals Resident as the locus of control Changing Resident Population o Acuity o Behavioral Health Reflects dramatic cultural & technology changes over three decades 4
Time Line Phase 1 Phase 2 Phase 3 Upon the effective date of the final rule (November 28 th 2016) New Regulatory Language One year following the effective date (November 28 th 2017) New F-tags, Interpretive Guidance Changes, New Survey Process Three Years following the effective date (November 28 th 2019) 5
Phase 2 Facility Assessment Competencies QAPI Infection Control New Survey Process 6
Facility Assessment 7
Facility Assessment Timing Starts November 28, 2017 Requires a documented initial assessment and updates as needed (substantial modification to any part of the assessment) but at least annually 8
Facility Assessment Includes 1. Resident population Number of residents Resident capacity (# of residents) The care required by the resident population Types of diseases Types of conditions Physical & cognitive disabilities Overall acuity of population 9
Review Potential Capacity Options Assess Referral Source Needs Create Admission Criteria Assess Gap Between Admission Criteria and Current Skill Level Enhanced Service Offering Review your current programs and potential program growth opportunities! SWOT Analysis 10
Facility Assessment Includes 2. Staff competencies 3. Physical environment Equipment Services 4. Ethnic, cultural or religious factors Have the potential to affect the care provided by the facility, including, but not limited to, activities and food and nutrition services 11
Facility Assessment Includes 5. Facility resources Including but not limited to buildings and other physical structures and vehicles; medical and non-medical equipment 6. Provided services Physical therapy, pharmacy, and specific rehabilitation therapies 12
Facility Assessment Includes 7. Personnel Including managers, employed and contracted staff, and volunteers, as well as their education and/or training and any competencies related to resident care 8. Contracts/memorandums of understanding/agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies 13
Facility Assessment Includes 9. Health information technology resources EMR and electronically sharing information with other organizations 14
Facility Assessment Specific Requirements 1. 483.35 Nursing Services 2. 483.40 Behavioral Health (Phase 3) 3. 483.60 Food & Nutrition Services 4. 483.70 Administration Facility Assessment 483.70(e) 5. 483.80 Infection Control 6. 483.95 Training Requirements (Phase 3) 15
483.35 Nursing Services 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 wellbeing 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 483.70(e). 16
483.40 Behavioral Health Provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, includes residents with dementia These competencies and skills sets include, but are not limited to, knowledge or and appropriate training and supervision for: Care for residents with mental disorders and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to 483.70(e), including implementing non-pharmacological interventions. 17
483.60(a) Food & Nutrition The facility must employ sufficient staff with the 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 in accordance with the facility assessment required at 483.70(e) [As linked to Facility Assessment, 483.70(e), will be implemented beginning November 28, 2017 (Phase 2)] 18
483.80(a) Infection Control The facility must establish and maintain an infection prevention and control program designed top provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards; [As linked to Facility Assessment, 483.70(e), will be implemented beginning November 28, 2017 (Phase 2)] 19
483.95 Training Requirements A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at 483.70(e). [ 483.95 will be implemented beginning November 28, 2019 (Phase 3)] 20
483.70(e) Facility Assessment The facility must conduct and document a facility wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Goals: To determine staffing requirements Establishing the facility QAPI Program Conducting emergency preparedness planning 21
CMS Optional Facility Assessment Tool Assist SNFs in planning for their assessment Modifiable SNFs should modify items to individualize Use of this tool is not mandated, nor does it s completion ensure regulatory compliance 22
CMS Facility Assessment Tool Intent & Purpose Purpose: to determine what resources are necessary to care for residents competently during day-to-day operations and emergencies May be used to make decisions about direct care staff needs as well as capabilities to provide services Intent: for the facility to evaluate their resident population and identify resources needed to provide person-centered care and services 23
CMS Facility Assessment Tool Consists of 3 parts: 1. Resident profile and factors that impact care & support needs 2. Services and care offered based on resident needs 3. Facility resources needed to provide competent care for residents Makes us analyze what our resources are and lac of resources to meet the needs & requests of our clientele. It triggers a pause for leadership to comprehensively look at the facility s operations and compare that to its state goals (if any), identified challenges, etc. CMS Pilot Test Comments & Feedback 24
http://qioprogram.org/facilityassessment-tool 25
Part 1: Resident Profile Numbers: licensed beds, average daily census, # persons admitted/discharged Common diseases/conditions, physical and cognitive disabilities (to help identify types of resources needed to meet the needs of residents living with these conditions or combinations of conditions) Decisions regarding caring for residents with conditions that you do not commonly see Acuity to identify potential implications regarding the intensity of care and services needed Three examples provided: Major Resource Utilization Groups (RUG)-IV categories Special treatment and conditions Assistance with activities of daily living Other Ethnic, culture, religious or other factors that may affect the care provided 26
Part 2: Services & Care Resident support and care needs based on what your resident population requires to identify and reflect on resources needed to provide these types of care Sample list provided to be modified based on your population 27
Part 3: Facility Resources Needed to Staff type Provide Competent Care Sample list provided for type of staff and other professionals/practitioners Staffing plan general approach to staffing For discussion on how to determine sufficient staffing, see attachment 2, 7.b Two examples provided Overall number of staff needed General staffing plan Individual staff assignment Staff training/education and competencies Sample lists provided (not inclusive) Policies and procedures for provision of care Working with medical practitioners Physical environment and building/plant needs Infection prevention and control program Facility-based and community - based risk assessment 28
Attachment 2: Sample Process for Conducting the Assessment 1. Plan for the assessment Designate a leader Leader prepares Team formed and included in discussions about the intent of the assessment and the process and timeline to be used Inclusive process have all voices represented in the assessment Leadership supports the work of the team check in frequently 2. Complete the assessment 29
Attachment 2: Sample Process for Conducting the Assessment 3. Synthesize and use the findings Review the findings Remember the purpose and intent make decision about needed resources, including direct care staff needs as well as their capabilities to provide services and support to residents; identify opportunities for improvement Work through the suggested questions What has changed with our population? Do we need to make any changes to staffing? How do we know if we have sufficient staffing? What training, education competency needs do we have? How can we better collaborate with medical practitioners?? Any infection control issues? Any QAA/QAPI opportunities? Doe our budget include the resources we need? 30
Attachment 2: Sample Process for Conducting the Assessment 4. Evaluate your process and plan for future assessments Be prepared to respond to surveyor questions listed in the interpretive guidance Debrief with your team: what went well, what can we do differently next time? Establish a process for updating the assessment. 31
Competencies 32
Staff Competencies Primary areas: 1. Physical & Cognitive Systems Assessments 2. Technical procedures using evidenced based tools 3. Use of medical equipment/supplies for treatment 33
Intent & Purpose Centers need to ensure all staff have the skills and competencies they need to provide effective, person-centered care 34
Definition: Staff Competency Competencies: An expected level of performance that integrates knowledge, skills, abilities and judgement. Competent staff are more likely to engage residents & families in a knowledgeable, honest manner! ANA 2008 35
Guiding Principles Based on your Facility Assessment Tie your competencies to your mission Review current Policies & Procedures Develop missing Policies & Procedures Create a competency from the procedures (stepby-step) in your policies Develop a process for administering initial and ongoing competencies (i.e., upon hire, annually, etc.) 36
Competency Process Staff Self-Assessments Preceptor Programs Utilize outside resources (i.e., hospitals, colleges, You Tube, etc.) Don t forget agency staff! 37
Reviewing Your Competency Process What competencies do you assess? Are they core & job specific? How often, what methods are used & who assesses? How do you document? What s working well and what isn t? How do you promote accountability for competencies? Does your process incorporate cultural competency & person centered care? 38
Methods for Evaluating Competencies Self assessment Observation of daily practices Peer review Return demonstration Interactive scenarios or role play Competency fair Checklists (procedures) Pre and Post tests 39
Preceptor Programs Guiding Principles: Avoid temptation - Don t rush it! Ensure Staff Development staff & Preceptors are competent Use hands on demonstrations / Simulation Labs Make an effort to use 1 consistent preceptor throughout orientation 40
Helpful Hints Link competencies to resident population, acuity and diagnosis Build on experience, certification and education Ensure competencies are job and team specific Involve key people and ask for input Competency Assessment/Verification Remember contract staff 41
Ready, Set, Go! Complete facility assessment Specific competency Review current procedures and education Revise or develop list of competencies & review annually Who is accountable to verify competencies Action Plan Monitor & report quarterly Record in personnel file 42
Webinars Video links (Nursing Schools) / You Tube Hospital Resources Procedural manuals Sim Labs Look for current evidence based resources! 43
Develop Your Competencies 44
Staff Capacity 45
Definition: Staff Capacity Your organization s ability to ensure sufficient staffing levels to carry out its work processes and successfully deliver health care services to patients, including the ability to meet seasonal or varying demand levels. 46
Sufficient Staffing Nursing Five Star Calculation Methodology Actual Staffing Hours Per Patient Day (PPD) Expected Staffing Hours PPD Adjusted Staffing Hours PPD Adjusted Hours= (Actual or Reported Hours/Expected Hours) * National Ave Hrs 47
CMS 671 48
CMS 672 49
Actual Staffing Hours PPD Hours reported on 671 / 14 days / Census on 672 = Actual Staffing Hours PPD (HRD) 1. RN Hours PPD (F39 DNS; F40 Admin Duties; F41 RN) 2. Total Nursing Hours PPD: RN (F39, F40, F41) + LPN (F42) + Nurse Aide (F43, F44, F45) 50
Expected Hours RUGs for each resident are calculated on the last business day of each quarter using the most recent MDS o Target Date is 7 days prior to most recent standard survey o Uses RUG Data for the quarter containing that target date o Utilization of STRIVE CMS 1995 & 1997 (RUG III) results for staffing thresholds Utilizes percentile ranking compared to nation Higher acuity is expected to have higher staffing levels Expected Hrs = Sum of nsg time connected to each Resident s RUG / # of rdnts included 51
STRIVE Estimates Five-Star Quality Rating System: Technical Users Guide https://www.cms.gov/medicare/provider-enrollment-and- Certification/CertificationandComplianc/Downloads/usersguide.pdf 52
Adjusted Staffing Hours PPD Case Mix Adjusted based on RUG Categories Hours Adjusted = (Hours Reported/Hours Expected) * Hours National Average 671 RUGs/STRIVE CMS Staffing Data File (calculations updated monthly) https://www.cms.gov/medicare/provider-enrollment-andcertification/certificationandcomplianc/fsqrs.html 53
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Just a few positive outcomes from the Facility Assessment/Competencies 1. Improved resident & employee satisfaction 2. Improved staff retention & recruitment 3. Improved census 4. Potential new program development 5. Decreased re-admissions / ED visits 6. Improved communication with community partners (i.e., hospitals, schools of nursing, etc.) 7. Improved Five Star Rating 56
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Thank you for joining us today! Questions? Sarah Ragone, MSPT, RAC-CT VP of Clinical Reimbursement/Education & Training Coretactics, Inc. sarah.ragone@core-tactics.com 58