Highlights of the New LTCSP and Regulations New York State Department of Health Division of Nursing Homes and ICF/IID Surveillance November 15, 2017
November 15, 2017 2 Resources https://www.cms.gov/medicare/provider-enrollment-andcertification/guidanceforlawsandregulations/nursinghomes.html https://surveyortraining.cms.hhs.gov/index.aspx
New Long Term Care Survey Process November 15, 2017
November 15, 2017 4 ENTRANCE INFORMATION NEEDED IMMEDIATELY UPON ENTRANCE: Accurate current census-exclude bedholds Complete matrix for new admissions in the last 30 days who are still residing in the facility (copy for each surveyor) An alphabetical list of all residents A list of residents who smoke, designated smoking times, and locations
November 15, 2017 5 ENTRANCE CONFERENCE Brief Entrance Conference with the Administrator Information regarding full time DON coverage and emergency water source A copy of an updated facility floor plan, if changes have been made Name of Resident Council President
November 15, 2017 6 INFORMATION NEEDED FROM FACILITY WITHIN ONE HOUR OF ENTRANCE Dining: times and location of dining, copies of all current menus for the duration of the survey and the policy for food brought in from visitors Schedule of medication administration times Number and location of med storage rooms and med carts The actual working schedules for licensed and registered nursing staff for the survey time period
November 15, 2017 7 ONE HOUR INFORMATION (cont.) List of key personnel, location, and phone numbers. Note contract staff (e.g., rehab services) If the facility employs paid feeding assistants, provide the following: Training provided Names of staff currently assisting residents Residents who are eligible or are receiving assistance
November 15, 2017 8 INFORMATION NEEDED FROM FACILITY WITHIN FOUR HOURS OF ENTRANCE Complete matrix for all other residents Dialysis Contract(s), Agreement(s), Arrangement(s), Policy and Procedures Hospice Agreement, and Policies and Procedures for each hospice used
November 15, 2017 9 Four Hours (cont.) Infection Prevention and Control Program Standards, Policies and Procedures, and Antibiotic Stewardship Program QAA/QAPI Plan-Committee information Abuse Prohibition Policy and Procedures Facility Assessment
November 15, 2017 10 INFORMATION NEEDED BY THE END OF THE FIRST DAY OF SURVEY Electronic Health Record (EHR) information- Surveyors need to have access to the EHRs outside of the conference room Surveyors require the same access staff members have to resident s EHR s, in a read-only format Legionella Information
November 15, 2017 11 INFORMATION NEEDED FROM FACILITY WITHIN 24 HOURS OF ENTRANCE Completed Medicare/Medicaid Application (CMS-671) Completed Census and Condition Information (CMS-672) Beneficiary Notice-see page #3
November 15, 2017 12 Resident Centered CMS website-ltcsp Procedure Guide Once on the unit, surveyor will request resident roster All residents will be screened to help determine those to be included in initial pool
November 15, 2017 13 Initial Pool Approximately 8 residents/surveyor MUST INCLUDE: 70% offsite selected by software-based on MDS data 30% selected onsite by team: ovulnerable onew Admission ocomplaint ofacility Reported Incidents (FRIs) oidentified concern
November 15, 2017 14 Sample Selection: Based on facility size Combination of surveyor and software input Will not be determined until second day (earliest)
November 15, 2017 15 Screen Pool Sample
November 15, 2017 16 Day 1: Entrance Kitchen Review Resident Interview/Resident Observation/Limited record review Resident Representative Interview Dining observations Information requested during entrance conference
November 15, 2017 17 Day 2: Complete initial pool process Sample selection Begin In-depth Investigations
November 15, 2017 18 Remainder of Survey: Complete Investigations Mandatory Tasks/Triggered Tasks Potential Citation review Exit conference
November 15, 2017 19 Facility Assessment
November 15, 2017 20 The facility s resident population The facility s resources A facility-based and community-based risk assessment using an all-hazards approach
November 15, 2017 21 How is it used in the survey process? To verify if the facility conducted and documented a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies Must be reviewed annually and PRN
November 15, 2017 22 Process Recertification Survey: Request during entrance conference-review with systemic concerns Complaint Survey: Request PRN
November 15, 2017 23 Behavioral Health Services F740-F745
November 15, 2017 24 F740 Provision of Care and Services Necessary care and services are personcentered Meaningful activities are provided Environment is conducive to the resident s well-being
November 15, 2017 25 Person-centered environment includes, but is not limited to: Interdisciplinary team approach to care Qualified staff Individualized approaches Supportive environment Inclusion of the resident, their family, or resident representative
November 15, 2017 26 F741 Provision of Care and Services Address the behavioral health needs that can be met Have sufficient, competent direct care staff Demonstrate attempts to access professional behavioral health resources Seek alternative sources for services
November 15, 2017 27 1 F742 Treatment/Services to Correct Assessed Problem or Attain Highest Practicable Well-being
November 15, 2017 28 F743 No Assessed Diagnosis or Pattern/Development of Pattern that was Unavoidable
November 15, 2017 29 F744 Appropriate Treatment/Services for a Resident with Dementia
November 15, 2017 30 F745 Medically-related Social Services
November 15, 2017 31 Pharmacy Services F755-F761
November 15, 2017 32 483.45 Pharmacy Services Overview F756 Drug Regimen Review F757 Unnecessary Medications F758 Psychotropic Medications
November 15, 2017 33 F756 Drug Regimen Review Medication regimen review (MRR) component of the pharmaceutical services systems includes: A pharmacist s review of the resident s medication regimen and medical record Acting upon identified irregularities
November 15, 2017 34 Pharmacist must report irregularities to the: Attending physician Director of nursing Facility medical director
November 15, 2017 35 Attending physician must: Document irregularities were reviewed What action will be taken Irregularities must be documented in a separate written report
November 15, 2017 36 F756 New Requirements Each facility must develop and maintain policies and procedure, which include: Time frames for steps in the process; and steps to take when immediate action is required Policies and procedures should also address 1. Anticipated stays less than 30 days 2. Identified acute changes of condition
November 15, 2017 37 F758 Psychotropic Medications Limited to 14 days May be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order Must have a documented rationale by the attending physician or prescribing practitioner for the extended time period in the medical record, including a specific duration
November 15, 2017 38 PRN orders for antipsychotic medications only: Limited to 14 days, without exception If the attending physician or prescribing practitioner wishes to write a new order for the PRN antipsychotic, the attending physician or prescribing practitioner must first evaluate the resident
November 15, 2017 39 As part of the evaluation, the attending physician or prescribing practitioner should, at a minimum, determine and document the following in the resident s medical record: Is the antipsychotic medication still needed on a PRN basis? What is the benefit of the medication to the resident? Have the resident s expressions or indications of distress improved as a result of the PRN medication?
November 15, 2017 40 Infection Control
November 15, 2017 41 F880: Infection Prevention and Control ( Old F441 ) F881: Antibiotic Stewardship Program(New) F882: Infection Preventionist Qualifications/Role (New) Phase 3 F883: Influenza and Pneumococcal Immunizations ( Old F334 )
November 15, 2017 42 F880 Infection Prevention and Control System for identifying and reporting of infections and communicable diseases The Infection Prevention and Control Program (IPCP) applies to residents, staff, volunteers, visitors, and contractors Based upon the Facility Assessment and national standards
November 15, 2017 43 F881 Antibiotic Stewardship Part of the Infection Prevention and Control Program (IPCP) Antibiotic use protocols System to monitor antibiotic use and resistance
November 15, 2017 44 F883 Resident self reported influenza and Pneumococcal Polysaccharide Vaccine (PPSV) are acceptable Flu-not date specific when available Most recent ACIP guidelines recommend both PCV13 and PPSV23
November 15, 2017 45 Admission, Transfer, and Discharge (F620-F626)
November 15, 2017 46 F620 Admissions Policy Facility must develop an admissions policy Must provide notice regarding special characteristics/limitations of facility Must disclose locations which make up distinct parts of facility Must include policy for room changes Must NOT ask residents to waive facility responsibility for loss of personal items
November 15, 2017 47 F622 Transfer and Discharge Requirements Facility may not D/C resident while appeal is pending Facility initiated D/C or transfer- MD must document 1. Reason for move 2. What needs cannot be met 3. Attempts to meet those needs 4. Service available at receiving facility which can meet needs
November 15, 2017 48 F622 (cont.) Documentation to receiving facility must include: 1. Contact information for provider 2. Contact information for resident s representative 3. Advance Directive information 4. Special care instructions 5. Comprehensive care plan goals 6. Any additional information (including discharge summary) to ensure a safe transition
November 15, 2017 49 F623 Notice to Ombudsman Facility initiated discharges or transfers 30 days in advance, or as soon as possible Emergency transfers-may send a monthly list Provides additional protection for the resident
November 15, 2017 50 F626 Permitting Residents to return Decision must not be based on resident s condition at time of transfer Facilities should work with hospital to determine if resident s current needs can be met
November 15, 2017 51 Quality Assurance and Performance Improvement F865-F868
November 15, 2017 52 F865 QAPI Plan Annually and prn as requested Program must be defined, implemented and maintained Adequately resourced
November 15, 2017 53 Good Faith Attempts by committee Key Points: If a facility has identified and is making a good faith attempt to correct same issue identified by the survey team, on the current survey, the facility should not be cited at QAA (F865), but may still be cited at relevant tag
November 15, 2017 54 Protection from disclosure is generally afforded documents generated by the QAA committee, such as minutes, internal papers, or conclusions. However, if those documents contain the evidence necessary to determine compliance with QAPI/QAA regulations, the facility must allow the surveyor to review and copy them. The key point is that the facility must provide satisfactory evidence that it has, through its QAA committee, identified its own high risk, high volume, and problem-prone quality deficiencies, and are making a good faith attempt to correct them.
November 15, 2017 55 Facility Refusal to Provide Evidence of Compliance Refusal by a facility to produce evidence of compliance with QAA will lead to citation of noncompliance with F865, requiring a plan of correction, and possible imposition of enforcement remedies up to and including termination of the facility s provider agreement. In the event of a facility refusal to produce evidence of compliance, the team coordinator should contact their State Agency supervisor.
November 15, 2017 56 F868 QAA Committee A facility must maintain a quality assessment and assurance committee consisting at a minimum of: The Director of Nursing Services The Medical Director or his/her designee At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role The committee must: Meet at least quarterly
November 15, 2017 57 Nursing Services
November 15, 2017 58 F726 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 well-being 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).
November 15, 2017 59 Competency A measurable pattern of: Knowledge Skills Abilities Behaviors Other characteristics that an individual needs to perform work roles or occupational functions successfully.
November 15, 2017 60 Competency in skills and techniques necessary to care for residents needs includes but is not limited to competencies in areas such as; Resident Rights Person centered care Communication Basic nursing skills Basic restorative services Skin and wound care Medication management Pain management Infection control Identification of changes in condition Cultural competency
November 15, 2017 61 Demonstration of Competency Competency may not be demonstrated simply by documenting that staff attended a training, listened to a lecture, or watched a video. A staff s ability to use and integrate the knowledge and skills that were the subject of the training, lecture or video must be assessed and evaluated by staff already determined to be competent in these skill areas.
November 15, 2017 62 Examples for evaluating competencies may include but are not limited to: Lecture with return demonstration A pre-and post-test
November 15, 2017 63 Questions? Please submit to: NHROP@health.ny.gov
November 15, 2017 64 Resources https://www.cms.gov/medicare/provider-enrollment-andcertification/guidanceforlawsandregulations/nursinghomes.html https://surveyortraining.cms.hhs.gov/index.aspx
November 15, 2017 65 Thank you!