Overview of New Federal Nursing Facility Regulations * Alison Hirschel (Grand Blanc) Director & Managing Attorney, Michigan Elder Justice Initiative Salli Pung (Rochester Hills) State Long Term Care Ombudsman May, 2017 *This presentation relies heavily on materials prepared by The National Consumer Voice for Quality Long Term Care, Justice in Aging, the Center for Medicare Advocacy, and the Centers for Medicare & Medicaid Services. What s happened? Last fall, CMS published 700+ pages of new nursing facility regs & comments. First revision since the original regs. were promulgated in 1991. Apply nationwide to any nursing facility that accepts Medicare and/or Medicaid. When are the new regs effective? New regs will go into effect in 3 phases:, 11/28/17, and 11/28/19 2016 changes: easier to implement / minor changes in the survey process. 2017 changes include: new F-tag numbering, new interpretive guidelines, and changes to survey process. 1
Why change the regs? After 25+ years & industry changes, time to update regs Reflect updated theories on service delivery and safety Goal of organizing and grouping regs in more effective ways Include ACA provisions CMS goals in new regs? Person-centered care Quality Facility Assessments Alignment with CMS initiatives Decrease unnecessary hospitalizations Decrease h/c acquired infections Improve behavioral health care Reduce unnecessary psychotropic drugs Good news for residents in preamble Our primary concern is to protect the health and safety of residents. Quality of Care and Quality of Life are two separate and overarching principles in the delivery of care to residents of LTC facilities. [W]e proposed to retain all existing resident s rights. [W]e do not intend in this update to diminish resident rights or protections. Rather, we want to ensure that those rights and protections encompass advancements, such as in the area of telecommunications,.... 2
More good news for residents in preamble to regs It is not our intent to reduce a resident s access to information. Person-centered care is a focus of these requirements These requirements are intended to decrease, and hopefully eliminate, inappropriate psychotropic drug use and the use of medications for reasons other than the resident s benefit. Changes in ADMISSIONS Can t require or request resident to waive any rights (including right to Medicaid & Medicare, facility responsibility for resident s property, & all rights under federal, state & local law.) Can t require or request third party guarantee of payment or hold resident s agent personally liable. Can require/request resident s agent to pay facility from resident s funds. Pre-dispute arbitration agreements barred BUT AHCA sued, court ordered temporary injunction, future unclear. Must notify of any service limitations/special characteristics Changes in CARE PLANNING Emphasis on preferences, goals, life history. PERSON-CENTERED! Baseline care plan w/in 48 hours of admission (11/28/17) Care planning team must now include nurse aide with responsibility for resident and food & nutrition staff Must facilitate participation of resident & resident s representative; provide written explanation if facility determines including either is not practicable. Must offer culturally competent & trauma informed care. (11/28/19) 3
Quality of Life VISITATION Right to receive visitors 24/7 Facility must have written policy & inform resident of rights, policy, any restrictions, and reason for restrictions. Resident representative -- immediate & unrestricted access. Non-family visitors subject to reasonable clinical and safety restrictions (e.g., limiting visits to prevent spread of disease or denying or limiting access to visitors who have abused residents, committed criminal acts, or are drunk/disruptive.) Same sex and domestic partners must be treated the same as other spouses. Quality of Life RESIDENT & FAMILY COUNCILS Resident decides if family member can participate in family council. Residents can participate in family councils. Facility must notify resident and family members/resident reps about upcoming meetings Facility must assign and councils must approve staff liaison Facility must act promptly on grievances and recs. made by councils, explain rationale for response. Resident Rights GRIEVANCES Residents should be free of actual /fear of discrimination/reprisal. Grievances can be oral, written, and anonymous. Must have grievance official to manage & resolve grievances from beginning to end Decisions on grievances must be in writing including date received, summary of grievance, steps taken to investigate, summary of findings, whether substantiated, any corrective action, & date of written decision. 4
RETURNING FROM THE HOSPITAL Notice re bed hold in advance of hospital stay (at admission?) and at time of transfer to hospital. Right to return even after bed hold expires or if no bed hold to previous room if available. If refuse to readmit, resident can request a transfer/discharge hearing. INVOLUNTARY DISCHARGE Notice of involuntary discharge must be sent to the State Ombudsman Office Discharge for safety only if due to clinical or behavioral status. No d/c for non-payment if resident has submitted paperwork for 3 rd party payment (already in Mich. law) If information in d/c notice changes, must advise resident. If facility alleges it cannot meet resident s needs, must specify what need, how it attempted to meet need, services at new facility to meet needs (11/28/17). Quality of Care NURSING SERVICES No minimum staffing standard. Facility must conduct at least yearly assessment of resident population & staff skills to determine staffing and training needs. More focus on staff minimum competencies and skills In-service training now required on dementia management and resident abuse prevention. Training required for all staff including contract employees and volunteers. 5
MEDICATION Moved from Quality of Care to Pharmacy Protections regarding antipsychotropic drugs now expanded to include all psychotropic drugs (including anti-depressants, antianxiety drugs, and hypnotics). (11/28/17) Psychotropics should be given only if necessary to treat a specific condition as documented in record and subject to gradual dose reduction and behavioral intervention. (11/28/17) Physicians must report pharmacy irregularities to medical director & document he/she reviewed pharmacist s report and action taken. Facilities must have policies/procedures for drug regimen review. MORE COMPREHENSIVE CARE Specialized rehab requirements now must include respiratory therapy. Does that include ventilators? CMS response: scope of reg. is broad and nursing facility is obligated to meet residents needs. Doctor may delegate task of writing respiratory therapy orders to qualified therapist. Treatments must now also include pain management, dialysis, and behavioral health services. So much more to learn This overview just touched highlights Will be learning more about new survey procedures, renumbered F- Tags, and 2 nd and 3 rd wave requirements. Many resources available to help understand what s new, what s different, and where all the requirements are. 6
Thank you! Questions?? Alison Hirschel hirschel@meji.org 517-827-8023 Salli Pung spung@meji.org 517-827-8025 7