National Overview of CMS RoP & Quality Holly Harmon, RN, MBA, LNHA, FACHCA May 3, 2018
It s a Time of Change..
Reform of Requirements of Participation (RoP) - 3-Phase Implementation Phase 1: Upon the effective date of the final rule (Nov 28, 2016) Phase 2: 1 year following the effective date of the final rule (Nov 28, 2017) Phase 3: 3 years following the effective date of the final rule (Nov 28, 2019)
No Time for Just Sittin on the Dock of the Bay Major Phase 2 requirements with new interpretive guidance for Phases 1 and 2 New survey process with new survey forms and investigative pathways/critical element pathways Not to mention Delivery and payment system reforms rooted in person-centered care, coordination across care settings, and cross-sector accountability for outcomes This Photo by Unknown Author is licensed under CC BY-SA
What does this mean for me? A time of transition within your centers (and for surveyors too) A time to reflect, self-assess, and prioritize your efforts A marathon, not a sprint
Enforcement Delays CMS suspended the use of Remedies (CMPs, denial of payment, discretionary termination) for several Phase 2 requirements for 18 months CMS froze Survey Component of Five Star for 12 months for any survey STARTED after Nov 28 th, 2017 Updated survey component in February 2018 using only last two cycles No freeze on staffing or quality measures component 6
Survey Score in Five Star Cycle 1 Most recent standard survey + All complaint surveys in prior (1-12 months) Weighting Early Current 2018 50% 60% Cycle 2 Prior standard survey + All complaint surveys in prior (13-24 months) 33% 40% Cycle 3 Prior to cycle 2 standard survey + All complaint surveys in prior (25-36 months) 12.5% 0%
Coming Through the Fog: Managing for a Successful Survey
Mindset Model CURRENT RESULTS Key: Understand the Intent & Purpose BEHAVIORS MINDSET The Arbinger Institute: Mindset Model
The First & Last Law of Improvement Every system is perfectly designed to achieve exactly the results it gets.
New Survey Process Modeled after QIS process with elements of traditional survey Structure / Autonomy Relies on Critical Element Pathways/Investigative Pathways Computer- and software-based Updated with the reformed RoPs Emphasizes observation of care and resident interviews starting on day 1 of the survey
Managing the Survey Process Use Pathways to prepare staff and residents Self-check on compliance Practice interviews Make sure staff, residents, and families are aware of changes you have made based on the new or revised requirements Use the regulation to support your discussions with surveyors keep a copy handy and accessible!
Questions to Management Team
Questions about New Survey process Do we have the information/documents needed to give surveyors within 1 and 4 hours of entry? How are we preparing staff to be observed providing care? How are we preparing staff to be interviewed about how they do? Have we reviewed the CEPs the surveyors will use and updated our survey preparation to be c/w the CEPs? Do the administrators have a copy of the regulations, IGs and CEPs handy to ask surveyors for clarification during the survey?
Questions for Administrator
Administrator Questions Do we have all required new Policy & Procedures? Do we have a QAPI plan? Have we updated the QA committee membership? Do our policies require reporting any allegation of abuse or neglect within 2 hours to the State?
Administrator Questions Have we completed the Facility Assessment? Can we show how the FA informed Staffing QAPI plan Infection Control Plan Note: Staffing decisions must be driven by the facility assessment and come from the facility not from organization central office In-service trainings & staff competencies Admission decisions Emergency Preparedness & Plan Food services
Questions for Director of Nursing
Director of Nursing Have we completed necessary plans Infection Prevention Control Plan Have we named an infection preventionist (due Nov 2019) Do we have antibiotic stewardship program?
Director of Nursing Are the consulting pharmacist and medical director working on Drug Regimen Review How are we making sure PRN orders have correct documentation What are the plans for meeting the new behavioral health requirements? How are we checking that the PASARR has level 2 if required?
Questions for Legal
Legal Questions How are we making sure the resident representative is identified and staff are aware of the resident representative designation? Have we updated our admission agreement to be consistent with all the new resident rights? How are we informing residents and their representative of their new rights? Are we working on a compliance and ethics plan and training for staff? Have we established a grievance process and how are we training staff on the grievance process?
Questions for Food Service Management
Food Service Manager How are we meeting resident s food preferences and needs (e.g. Kosher meals)? Are we checking that new hires meet the new qualifications for dietician and food manager?
Questions for Building Operations
Maintenance Questions Are we working to install call system that will relay the call directly to a staff member or to a centralized staff work area from each resident s bedside? Do we have a process for completing all the checks on bed frames, mattresses, bed rails and other equipment that you can show surveyors? Do we have any plans for renovations that trigger 2 person per room maximum? NOTE: If you change provider number or build a new building, each room must have its own bathroom.
Questions for Care Plan Coordinator
Care Plan Coordinator How are we completing a baseline care plan within 48 hours? How to we share it with the resident? Are we revamping our care plans to have Measureable goals and timelines to achieve Include dietary and CNA as part of the IDT Are our goals setting us up for deficiencies?
Care Plan Coordinator Have we developed a template for a discharge plan? Do we have a plan to share it with the resident? For residents who are transferred or discharged, how are we Getting physician documentation for the reason for transfer/discharge? Making sure required information accompanies the resident?
Questions for Human Resources
Human Resources Have we identified core competencies staff need to have? Can we show how we used FA to determine core competencies? How are we assessing staff competencies? Have we checked/updated job positions to be c/w the new requirements for: Social Worker Dietician Director of Food and Nutrition Services (if not dietician on staff/contracted)
Raindrops Keep Fallin on My Head: Issues and Trends in the New Survey Process
Key Theme: Person-Centered Care Greater involvement of person and their representative Resident involvement/preferences addressed in many F-tags Supervision and choices E.g. smoking Staffing and training Staff competencies addressed in many F-tags Facilitating resident involvement and preferences Care planning process Expanded staff roles and engagement of entire IDT (CNA, food & nutrition) Person-centered approaches; e.g. language and manner resident can understand Care plan interventions and revisions Required notifications Care plan changes Transfer and discharge
Key Theme: Aligning Resources with Residents Making informed admissions decisions Do you have the staffing, competencies, resources? Using Facility Assessment to make informed decisions Staffing and competencies linked to residents needs Preparing for emergencies EP requirements and risk assessment
Key Theme: Systems Improvement/QAPI Addressing adverse events (medication related, infection related, care practice related) Transitions of care Prioritization of high-risk, high-volume, problem-prone areas and systemic concerns E.g. handwashing and hand hygiene, glucometer cleaning Role of QAA committee Identifying and monitoring issues Good faith efforts
Key Theme: Continuous Monitoring and Timely Action Data-driven approaches to monitoring and feedback Medication prescribing practices and systems E.g. unnecessary medications Infection control and antibiotic stewardship E.g. trending and analysis of infections Addressing staff competencies and training
National View: Top 10 Citations for New Survey (FY 2018) Tag # Tag Description # Citations % Providers Cited % Surveys Cited F0880 Infection Prevention & Control 1,450 9.00% 26.50% F0689 Free of Accident Hazards/Supervision/Devices 1,205 7.10% 22.00% F0656 Develop/Implement Comprehensive Care Plan 1,120 6.80% 20.50% F0812 Food Procurement, Store/Prepare/Serve Sanitary 1,015 6.30% 18.50% F0684 Quality of Care 873 5.20% 16.00% F0657 Care Plan Timing and Revision 702 4.30% 12.80% F0761 Label/Store Drugs and Biologicals 671 4.20% 12.30% F0550 Resident Rights/Exercise of Rights 609 3.80% 11.10% F0686 Treatment/Svcs to Prevent/Heal Pressure Ulcer 606 3.70% 11.10% F0677 ADL Care Provided for Dependent Residents 568 3.40% 10.40% 37
Next Top 10 Citations for New Survey (FY 2018) Tag # Tag Description # Citations % Providers Cited % Surveys Cited F0641 Accuracy of Assessments 545 3.40% 10.00% F0755 Pharmacy Srvcs/Procedures/Pharmacist/Records 531 3.30% 9.70% F0842 Resident Records - Identifiable Information 525 3.20% 9.60% F0758 Free from Unnec Psychotropic Meds/PRN Use 524 3.30% 9.60% F0658 Services Provided Meet Professional Standards 475 2.90% 8.70% F0690 Bowel/Bladder Incontinence, Catheter, UTI 464 2.80% 8.50% F0580 Notify of Changes (Injury/Decline/Room, etc.) 445 2.70% 8.10% F0584 Safe/Clean/Comfortable/Homelike Environment 432 2.60% 7.90% F0609 Reporting of Alleged Violations 411 2.40% 7.50% F0610 Investigate/Prevent/Correct Alleged Violation 354 2.10% 6.50% 38
National View: Citation Frequency CY 2017 Tag # Tag Description # Citations % Providers Cited % Surveys Cited Active Providers Total Number of Surveys = 69120 F0323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES 6,643 31.80% 9.60% F0441 INFECTION CONTROL, PREVENT SPREAD, LINENS 6,552 36.30% 9.50% F0371 FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY 5,763 33.20% 8.30% F0309 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING 5,573 26.90% 8.10% F0431 DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS 3,775 21.60% 5.50% F0279 DEVELOP COMPREHENSIVE CARE PLANS 3,745 20.00% 5.40% F0514 RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE 3,310 17.20% 4.80% F0329 DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS 3,271 18.30% 4.70% F0225 INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS 2,972 15.00% 4.30% F0226 DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES 2,839 14.70% 4.10% F0241 DIGNITY AND RESPECT OF INDIVIDUALITY 2,761 15.20% 4.00%
National View: E-tags Citations Tag # Tag Description # Citations % Providers Cited % Surveys Cited E0039 Emergency Prep Testing Requirements 300 1.90% 28.00% E0015 Subsistence needs for staff and patients 245 1.50% 22.80% E0036 Emergency Prep Training and Testing 221 1.40% 20.60% E0026 Roles under a Waiver Declared by Secretary 217 1.40% 20.20% E0024 Policies/Procedures-Volunteers and staffing 183 1.20% 17.10% E0001 Establishment of the Emergency Program (EP) 182 1.10% 17.00% E0041 Hospital CAH and LTC Emergency Power 162 1.00% 15.10% E0029 Development of Communication Plan 161 1.00% 15.00% E0013 Development of EP Policies and Procedures 151 1.00% 14.10% E0037 Emergency Prep Training Program 151 1.00% 14.10% E0035 LTC and ICF/IID sharing plan with patients 139 0.90% 13.00% E0004 Develop EP Plan, review & update annually. 127 0.80% 11.80% E0009 Local, State, Tribal Collaboration Process 123 0.80% 11.50% E0006 Plan based on all hazards risk assessment 119 0.80% 11.10% 40
Scope & Severity with New Survey 41
# of CMPs Change Per Instance vs per Diem CMP Count of Per Diem vs Per Instance CMPs (National, 2014-2017) 300 250 Per Diem CMP Per Instance CMP 200 150 100 50 0 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D 2014 2015 2016 2017 42
We all Live in a Yellow Submarine Early look: Many of the top tags nationally remain the same If you have quality problems, surveyors will look at: Staffing and training sufficient, competent QA and PI was it identified by the facility? Interview-driven Does everyone on the team know and understand the residents care needs consistent with their roles Staff responses to staffing Does the resident have a voice Resident and Resident Council interviews 43
The Seaweed is Always Greener? Variation across states and regions IJ citations and inappropriate stacking of tags Average # of deficiencies per survey Scope and severity of deficiencies Guidance and interpretations that are unclear or incorrect Appropriate use of CMPs based on CMP Tool This Photo by Unknown Author is licensed under CC BY-NC-ND 44
Other Areas of Concern Admission, Transfer, Discharge (e.g. proper notices) Abuse & Neglect Elopement
Transfer and Discharge Emphasis on discharge planning tied to resident goals If facility-initiated transfer or discharge, must issue appropriate notices All hospital transfers even scheduled Any transfer/discharge that resident/family did not initiate, even if they agree Any transfer/discharge that the resident objects to 46
Transfer and Discharge Notice Updates Must update with new information, and if significant (e.g., new location), clock resets Ombudsman to be copied on all transfer and discharge notices Discharge notice At time issued to resident Hospital Transfer notice As soon as practicable; could be a monthly list Readmission from Hospital If unable to readmit, must issue a Discharge Notice Reason must be based on status at time of readmission to the facility, not at time of hospital transfer 47
Transfer and Discharge Bed Hold The failure to pay for a bed hold or exhausted bed hold days cannot be treated as a resident-initiated discharge Must readmit to first available bed Appeal Pending Cannot discharge until hearing complete, unless there is evidence that the resident s return would endanger the health or safety of the resident or other individuals in the facility 48
CMS Initiative on Transfer & Discharge S&C 18-08 (December 22, 2017) Evaluation of State Agencies Review of intake and triage practices for discharge complaints CMS will review all deficiencies related to facility-initiated discharges State Agencies must transfer any case involving facility-initiated transfer violation to the CMS RO if: Resident placed in questionable or unsafe setting Resident remains hospitalized Where there is a pattern RO will determine whether enforcement action indicated 49
CMS FOSS Pilot (Admin Info: 18-06-NH) Areas of Focus Abuse & Neglect Admission/Transfer/Discharge Dementia Care Services Phase 1 (January April 2018) Resource and Support Surveys: Federal surveyors will accompany state surveyors on annual recertification or complaint surveys and provide instruction and guidance 50
CMS FOSS Pilot Phase 2 (May December 2018) Focused Comparative Surveys (i.e., look behind surveys ) Conducted w/in 30 working days of state survey end dates; Surveyors will independently investigate concerns Non-compliance identified that do not constitute SQC (or lower) will not be cited no 2567 issued (must still correct) 2567 will be issued for deficiencies at the IJ, Harm or SQC level Subsequent years RO to identify concerns unique to the region based on QMs, MDS, and QCOR data Determined in September for the coming FY 51
Abuse and Neglect 10 Separate Tags (Used to be 4) F600 Abuse & Neglect F602 Exploitation/Misappropriation F603 Involuntary Seclusion F604 - Physical Restraints F605 Chemical Restraints F606 Not Employ/engage staff with Adverse actions on license/certification F607 Development and implementation of policies and procedures F608 Reporting Reasonable suspicion of a crime to law enforcement F609 Reporting of Alleged violations to the state agency F610 Investigate/Prevent/Correct alleged violations
Facility Responsibility Determination of Findings and Potential to Foresee Abuse It has been reported that some facilities have identified that they are in compliance with F600- Free from Abuse and Neglect because that they could not foresee that abuse would occur and they have done everything to prevent abuse, such as conducted screening of potential employees, assessed residents for behavioral symptoms, monitored visitors, provided training on abuse prevention, suspended or terminated employment of the perpetrator, developed and implemented policies and procedures to prohibit abuse, and met reporting requirements. However, this interpretation would not be consistent with the regulation, which states that the resident has the right to be free from verbal, sexual, physical, and mental abuse Therefore, if the survey team has investigated and collected evidence that abuse has occurred, it is appropriate for the survey team to cite the current or past noncompliance at F600-Free from Abuse and Neglect. 53
Abuse and Neglect Willful defined as individual acted deliberately Categories of abuse defined in Appendix PP Staff-resident Resident-resident Visitor-resident Sexual Abuse Capacity to consent Photos/Social Media abuse and privacy
Abuse and Neglect Neglect - Any failure to provide what is necessary to avoid harm, pain, distress has potential to be neglect Inability to meet needs due to lack of staff or inadequate training Too busy to respond to call lights Untrained agency staff The cumulative effect of different individual failures in the provision of care and services by staff leads to an environment that promotes neglect Involuntary seclusion Secured Areas Appropriate documentation Isolation Procedures
Abuse and Neglect Physical restraints: Position change alarms to monitor a resident - if resident is afraid to move to avoid setting off the alarm Reporting Changes All abuse allegations must be reported to State Agency immediately but not later than 2 hours. All reportable incidents involving serious bodily injury must be reported immediately but not later than 2 hours (e.g., an injury of unknown source with serious injury) All other allegations that do not involve abuse or serious bodily injury must be reported immediately but not later than 24 hours.
Elopement AHCA Analysis: 85 elopement citations that received a G or higher deficiency Key Takeaways: Facility failed to do what they said they would do in P&P or Care Plan related to individuals elopement risk Failed to assess for elopement risk Door alarm or wander guard ignored or turned off, or individual in an unsecured environment without close supervision Visitors or other allowed individual to leave through a secure door Inconsistency in scope and severity assignment 57
Elopement Assess risk and revaluate Risk Assessment Tools High risk residents need special supervision, environment, and alerts Prior history, asking about going home and wandering behavior are high especially high risk 58
Elopement Alarms/monitors on residents Use of labeling on residents Routine rounding to assure residents in place Close 1:1 supervision when they leave a secure environment Frequent drilling for silver alert when resident is missing 59
Like A Bridge Over Troubled Waters
61 This Photo by Unknown Author is licensed under CC BY-NC
Success in Tomorrow s (Today s) Environment Will Require Deliberate Action
AHCA Quality Initiative 2018-2021 63
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Thank you for all that you do every day to make a difference in the lives of those you serve! 69
Contact Information Holly Harmon, RN, MBA, LNHA, FACHCA American Health Care Association Associate VP, Quality & Clinical Affairs 202-898-6317 hharmon@ahca.org