The New Survey Process for the NAC Carol Maher, RN-BC, RAC-CT, RAC-MT, CPC
Faculty Disclosure I have no financial relationships to disclose I have no conflicts of interests to disclose I will not promote any commercial products or services 2
Requirements for Successful Completion 1.0 contact hour will be awarded for this continuing nursing education activity Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. *AAPACN d/b/a American Association of Nurse Assessment Coordination 3
Objectives State how the MDS will be used to develop the survey sample off-site Explain how motion sensors can have the effect of restraining a resident State the timeline for Baseline Care Plans Describe how the new 2017 Section N MDS items tie to the new regulations and the survey process 4
Phase 2 of New SNF Regulations Implement by November 28, 2017 Providers must be in compliance with Phase 2 regulations All States will use new computer based survey process for LTC surveys All training on new survey process needs to be completed before go live date 5
Phase 2: November 28, 2017 Implementation Date Phase 1: November 28, 2016 (Implemented) Phase 2: November 28, 2017 Phase 3: November 28, 2019 Type of Change Nursing Home Requirements for Participation F Tag numbering Interpretive Guidance (IG) Implement new survey process Requirements need more time to implement Details of Change New Regulatory Language uploaded to the Automated Survey Processing Environment (ASPEN) under current F Tags New F Tags Updated IG Begin surveying with the new survey process Requirements that need more time to implement 6
Phase 2 of LTC Regulations 1 Phase 2 includes, but is not limited to: Comprehensive Person-Centered Care Planning: Baseline Care Plans Pharmacy Services: psychotropic medications; drug regimen review and reporting Dental Services: replacing lost dentures Administration: Facility Assessment tied to sufficient and competent staff requirements 7
Phase 2 of LTC Regulations 2 Continued Phase 2 includes: Behavioral Health Services Quality Assurance and Performance Improvements: QAPI Plan Only Infection Control and Antibiotic Stewardship Physical Environment: smoking policies 8
Phase 2 of LTC Regulations 3 Continued Phase 2 includes, but is not limited to: Resident Rights and Facility Responsibilities: Required Contact Information Freedom from Abuse, Neglect, and Exploitation: 1150B Admission, Transfer, and Discharge Rights: Transfer/Discharge Documentation 9
Survey F-Tags Renumbered 10
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 lowest tag number will be 550 11
F-Tag Renumbering 12
Why is CMS Changing the Survey Process? Two different survey processes existed to review for the Requirements of Participation (Traditional and QIS) Surveyors identified opportunities to improve the efficiency and effectiveness of both survey processes The two processes appeared to identify slightly different quality of care/quality of life issues CMS set out to build on the best of both the Traditional and QIS processes to establish a single nationwide survey process 13
Goals for the New Survey Process Same survey for entire country Strengths from Traditional and QIS Traditional survey strength surveyor Could ask residents questions QIS survey strength computer based Process and pathways as investigative tools New innovative approaches Effective and efficient Resident-centered resident-specific concerns identified through observation and interviews are emphasized Balance between structure and surveyor autonomy 14
New Survey Process Each survey team member uses a tablet or laptop PC throughout the survey process to record findings that are synthesized and organized by new software Automation 15
New Survey Process Sample Selection Sample size is determined by the facility census 70% of the total sample is MDS pre-selected residents and 30% of the total sample is surveyor-selected residents. Surveyors finalize the sample based on observations, interviews, and a limited record review Maximum sample size is 35 residents 16
Off-Site Preparation Each surveyor team member independently reviews the CASPER 3 report and other facility history information Review offsite selected residents (70% chosen by their MDS data) and their indicators and the facility rates. (NAC Alert: Run the Resident Roster report in the CASPER system at least monthly. This report lists residents who are present in the facility according to the MDS assessments transmitted to QIES ASAP). 17
Information Needed on Entrance Completed new matrix (shown in later slide) Facility census number Alphabetical list of residents List of residents who smoke and designated smoking times (NAC Alert: Be sure that a care plan has been developed and updated for each resident who smokes). Updated information related to Medicare Beneficiary and Denial Notices 18
The Other 30% of the Sample The team will select 30% of the residents onsite, including vulnerable residents who are dependent on staff, new admissions within the last 30 days, complaints or facility-reported incidents or FRIs which would cover any alleged violation involving mistreatment, neglect, abuse, injuries of unknown origin, and misappropriation of property and any resident who has a significant concern but does not fall into any of the sub-groups. 19
Sample Size The sample size is based on the facility census Generally, the sample size is about 20% of the facility census In some cases, the sample size is slightly higher than the numbers included in the Traditional sample size grid but lower than the sample size for QIS One example is the cap for facilities with a census at or above 175 residents The cap for the Traditional is set at 30 and the cap for QIS is set at 40. The New LTC Survey Process has a cap of 35 residents for larger facilities 20
Surveyor Assignments Unit and mandatory facility task assignments Dining Infection Control (Antibiotic stewardship) Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Resident Council Meeting 21
Facility Entrance Skilled Nursing Facility 22
Updated Facility Matrix (Draft) 23
Day One of Survey The first day of the survey, or about eight hours, depending on when the team enters, is spent conducting observations, interviews, and a limited record review for the residents in the initial pool The survey team will be out on the units observing the residents in their assigned areas. They will focus on the 70% sample and will add additional names from their observation of vulnerable residents and new admissions 24
Resident Interviews by Surveyors Surveyors will screen every resident Suggested questions, but not a specific surveyor script Must cover all care areas Includes: Rights, QOL, QOC Interviews will take about 20 minutes each Investigate further or decide there was no issue (For example, if the resident says they had an issue with their roommate, but the facility addressed the concern to their satisfaction, surveyors would not need to investigate further; conversely, they would want to investigate a concern if the resident says they have lost weight recently because of their loose dentures unaddressed by the facility). 25
Surveyor Observations Cover all care areas and probes Conduct rounds Complete formal observations (e.g., wounds or incontinence care) Investigate further or no issue identified (Surveyors may complete formal observations for wounds or incontinence care if the situation presents itself or is necessary. For example, if a resident has not been assisted to the bathroom for a long period of time or is covered in bed). 26
Family/Representative Interviews for 3 Non-interviewable Residents Non-interviewable residents (goal is to complete at least 3 representative/family interviews) Surveyors will interview representatives who are familiar with the resident s care Complete at least three during initial pool process or early enough to follow up on concerns Sampled residents if possible Investigate further or no issue 27
Limited Record Reviews Surveyors will conduct limited record review after interviews and observations are completed prior to sample selection All initial pool residents: advance directives and confirm specific information If interview not conducted: review certain care areas in record Confirm insulin, anticoagulant, and antipsychotic with a diagnosis of Alzheimer s or dementia, and PASARR (Pre-Admission Screening and Resident Review)[e.g., has appropriate diagnosis but is not receiving PASARR Level II services] 28
October 1, 2017 RAI Manual Updates Section N 29
October 1, 2017 MDS Update 30
October 1, 2017 Update 31
MDS Focus Ensure Section N entries are correct for psychotropic, anticoagulant, and antibiotic medications Remember, medications are coded in Section N according to their pharmacological classification, not how they are used/ordered For example, Trazadone is an antidepressant medication that is often ordered to help a resident to sleep. Code it as an antidepressant on the MDS Are the care plans up-to-date? 32
Section I Diagnoses Surveyors will be looking for residents with dementia who are also on an antipsychotic medication, insulin or anticoagulants. Is your Section I coding correct? Did the physician write the diagnosis within the last 60 days? Is the diagnosis active in the last 7 days? 33
PASARR Are there residents who have diagnoses of mental illness when dementia is not primary or an intellectual or developmental disability in the facility who are not identified as a Level II in the PASSAR process? If the resident does have a Level II PASSAR determination, are the PASSAR recommendations included in the resident s care plan? 34
Restraints 35
Regulation 483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing reevaluation of the need for restraints. 36
Intent The intent of this requirement is for each resident to attain and maintain his/her highest practicable wellbeing in an environment that: Prohibits the use of physical restraints for discipline or convenience; Prohibits the use of physical restraints to unnecessarily inhibit a resident s freedom of movement or activity; and Limits physical restraint use to circumstances in which the resident has medical symptoms that may warrant the use of restraints. When a physical restraint is used, the facility must: Use the least restrictive restraint for the least amount of time; and Provide ongoing re-evaluation of the need for the physical restraint. 37
Definitions Convenience is defined as the result of any action that has the effect of altering a resident s behavior such that the resident requires a lesser amount of effort or care, and is not in the resident s best interest Discipline is defined as any action taken by the facility for the purpose of punishing or penalizing residents Freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control Manual method means to hold or limit a resident s voluntary movement by using body contact as a method of physical restraint Medical symptom is defined as an indication or characteristic of a physical or psychological condition Position change alarms are alerting devices intended to monitor a resident s movement. The devices emit an audible signal when the resident moves in certain ways 38
October 1, 2017 MDS Items 39
Definition of Physical Restraint Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the resident s body; Cannot be removed easily by the resident; and Restricts the resident s freedom of movement or normal access to his/her body Removes easily means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff 40
Examples of Facility Practices that Meet the Definition of Restraint Use 1 Using bed rails that keep a resident from voluntarily getting out of bed; Placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or voluntarily getting out of bed; Placing a resident on a concave mattress so that the resident cannot independently get out of bed; Tucking in a sheet tightly so that the resident cannot get out of bed, or fastening fabric or clothing so that a resident s freedom of movement is restricted; Placing a resident in a chair, such as a beanbag or recliner, that prevents a resident from rising independently; 41
Examples of Facility Practices that Meet the Definition of Restraint Use 2 Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising; Applying leg or arm restraints, hand mitts, soft ties or vests that the resident cannot remove; Holding down a resident in response to a behavioral symptom or during the provision of care if the resident is resistive or refusing the care; Placing a resident in an enclosed framed wheeled walker, in which the resident cannot open the front gate or if the device has been altered to prevent the resident from exiting the device; and Using a position change alarm to monitor resident movement, and the resident is afraid to move to avoid setting off the alarm 42
Determination of the Use of Position Change Alarms as Restraints 1 Position change alarms are any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Types of position change alarms include chair and bed sensor pads, bedside alarmed mats, alarms clipped to a resident s clothing, seatbelt alarms, and infrared beam motion detectors. Position change alarms do not include alarms intended to monitor for unsafe wandering such as door or elevator alarms. 43
Determination of the Use of Position Change Alarms as Restraints 2 While position change alarms may be implemented to monitor a resident s movements, for some residents, the use of position change alarms that are audible to the resident(s) may have the unintended consequence of inhibiting freedom of movement. For example, a resident may be afraid to move to avoid setting off the alarm and creating noise that is a nuisance to the resident(s) and staff, or is embarrassing to the resident. For this resident, a position change alarm may have the potential effect of a physical restraint. 44
Potential Negative Outcomes from Position Change Alarms Examples of negative potential or actual outcomes which may result from the use of position change alarms as a physical restraint, include: 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 45
Surveyors Will Observe 1 st Meal Dining surveyors to observe first full meal after their entrance Cover all dining rooms and room trays Observe enough to adequately identify concerns If feasible, observe initial pool residents with weight loss If concerns identified, observe another meal 46
Unnecessary Medication Survey software system selects 5 residents for full medication review. Selection process considers all psychotropic meds, insulin, anticoagulants, opioids, diuretics and antibiotics, as well as adverse consequences, such as falls, weight loss and sedation There are exclusions; for example, a resident would be excluded if they had a diagnosis of Huntington s or Schizophrenia and was receiving an antipsychotic Residents selected for full medication review include insulin, an anticoagulant, and an antipsychotic with Alzheimer s or dementia, if available Based on observation, interview, record review, and MDS Broad range of high-risk medications and adverse consequences Residents may or may not be in sample 47
Surveyor Investigations Surveyors will conduct investigations for all concerns that warrant further investigation for sampled residents (pressure ulcers, incontinence, etc.) Continuous observations, if required. Is the care plan being followed? Interview representative, if appropriate, when concerns are identified 48
Closed Record Reviews Completed during the investigation portion of survey Unexpected death (not on hospice), hospitalization (went to the hospital and did not return in last 90 days), and community discharge in last 90 days System selected or discharged resident Use Appendix PP and Critical Elements Pathways 49
Infection Control Throughout survey, all surveyors should observe for infection control Assigned surveyor coordinates a review of influenza and pneumococcal vaccinations for at least 5 residents Assigned surveyor reviews infection prevention and control, and antibiotic stewardship program One resident who is on transmission-based precautions will be reviewed The assigned surveyor will also complete a review of the infection prevention and control and antibiotic stewardship program 50
Transmission-based Precautions Coding O0100M Code O0100M only when all of the following conditions are met: The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission Precautions are over and above Standard Precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect The resident is in a room alone because of active infection and cannot have a roommate. That means the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation The resident must remain in his/her room. This requires that all services be brought to the resident (e.g., rehabilitation, activities, dining, etc.) 51
Criteria Would Not Apply 1. Urinary Tract Infections, 2. Encapsulated Pneumonia 3. Wound Infections 4. S/P MRSA with no active symptoms 5. S/P C-diff with no active symptoms 52
SNF Beneficiary Protection Notification Review A new pathway has been developed List of residents (home and in-facility) Randomly select three residents (Facility must report residents who had been discharged from Medicare A during the surveyors entrance conference) Facility completes new worksheet Review worksheet and notices 53
Kitchen Observations In addition to the brief kitchen observation upon entrance, conduct full kitchen investigation Follow Appendix PP and Facility Task Pathway to complete kitchen investigation 54
Med Carts and Medication Storage Rooms will be Examined Medication Storage Observe half of medication storage rooms and half of medication carts If issues, expand medication room/cart 55
Sufficient and Competent Staff Is a mandatory task, refer to revised Facility Task Pathway Sufficient and competent staff Throughout the survey, consider if staffing concerns can be linked to quality of life (QOL) and quality of care (QOC) concerns 56
Person-Centered Care Heart of the RAI Process Survey Focus 57
Person-Centered Care Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident s life before coming to reside in the nursing home 58
F655 483.21 Comprehensive Person-Centered Care Planning Baseline Care Plan Comprehensive Care Plan 59
Baseline Care Plan 483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must: (i) Be developed within 48 hours of a resident s admission (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: (A) Initial goals based on admission orders (B) Physician orders (C) Dietary orders (D) Therapy services (E) Social services (F) PASARR recommendation, if applicable 60
Baseline Care Plan The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary 61
Content of Baseline CP The baseline care plan must reflect the resident s stated goals and objectives, and include interventions that address his/her current needs. It must be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable Because the baseline care plan documents the interim approaches for meeting the resident s immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan Facility staff must implement the interventions to assist the resident to achieve care plan goals and objectives 62
Intent Completion and implementation of the baseline care plan within 48 hours of a resident s admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. 63
Guidance to Surveyors Nursing homes are required to develop a baseline care plan within the first 48 hours of admission which provides instructions for the provision of effective and person-centered care to each resident. This means that the baseline care plan should strike a balance between conditions and risks affecting the resident s health and safety, and what is important to him or her, within the limitations of the baseline care plan timeframe. 64
Baseline Care Plan Summary 483.21(a)(3) The facility must provide the resident and the representative, if applicable with a written summary of the baseline care plan by completion of the comprehensive care plan. The summary must be in a language and conveyed in a manner the resident and/or representative can understand. Summary must include: o Initial goals for the resident; o A list of current medications and dietary instructions, and o Services and treatments to be administered by the facility and personnel acting on behalf of the facility; The format and location of the summary is at the facility s discretion, however, the medical record must contain evidence that summary was given to the resident and resident representative, if applicable. Facility may choose to provide a copy of the baseline care plan itself as the summary, if it meets all of the summary requirements 65
What Might the Summary Look Like? Summaries have become common at discharge from the hospital, or after visits to an Urgent Care or physician s office Must be in plain language not medical terminology 66
Preparation Talk to your facility s software vendor. Are they planning to develop a template to pull the physician orders, diet orders and medications into a summary format? Build a simple template: Physician s orders Medications: list of and what to watch for Treatments Resident goals 67
Involve the Resident/Representative Ask the resident about their goals for their care What is their discharge plan? What is important to them while receiving care during this stay? What would they like us to know about them? 68
Care Plan vs. Summary The actual baseline care plan (due with 48 hours) may be in a format other than a summary format The resident should be given a summary or the actual baseline care plan if the actual care plan is in a format that is easily understandable to the resident/representative 69
F657 Comprehensive Care Plans 483.21(b) Comprehensive Care Plans 483.21(b)(2) A comprehensive care plan must be (i) Developed within 7 days after completion of the comprehensive assessment (ii) Prepared by an IDT, that includes but is not limited to: A. The attending physician B. A registered nurse with responsibility for the resident C. A nurse aide with responsibility for the resident D. A member of food and nutrition services staff E. To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident s care plan F. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments 70
Interdisciplinary Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary team (IDT) meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) is at the discretion of the facility. In instances where an IDT member participates in care plan development, review or revision via written communication, the written communication in the medical record must reflect involvement of the resident and resident representative, if applicable, and other members of the IDT, as appropriate. 71
Resident s Rights in Care Planning Each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review and revision of his/her care plan. Residents also have the right to refuse treatment. 72
Notices of Care Plan Conferences The facility must provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. Resident and resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing. 73
Documentation When Resident Not Capable Facilities are expected to facilitate the residents and if applicable, the resident representatives participation in the care planning process. There are limited circumstances in which the inclusion of the resident and/or resident representative may not be practicable (or feasible). An example may be the case of a severely cognitively impaired resident who is unable to understand or participate in care plan development, and the resident s representative does not respond to facility attempts to make contact. If the facility determines that the inclusion of the resident and/or resident representative is not practicable, documentation of the reasons, including the steps the facility took to include the resident and/or resident representative, must be included in the medical record. 74
Surveyor Probes Related to Care Plans Was a comprehensive plan of care developed within seven days of completion of the resident s comprehensive assessment? Is there evidence of participation in the care planning process by required IDT members? Ask required members of the IDT how they participate in the development, review and revision of care plans. Based on the resident s goals and needs, were other appropriate staff or professionals expertise utilized to develop a plan to improve the resident s functional abilities? Ask the resident and resident representative, if applicable if he or she actively participates in the care planning process? If not, what have been the barriers to participation? Ask the resident and if applicable, the resident representative if he or she has requested the participation of additional individuals care planning process. If so, was the request respected? 75
Successfully Completing the RAI Process Will Lead to: Resident-Centered Care Better resident outcomes Happier residents, families and staff. (When the residents participate in care planning and know that their voices have been heard, the residents are happier. When residents are happy, families are happy. When residents and families are happy, the staff is happy.) 76
You and Your Work are Very Important! 77
Questions? 78