NEW Requirements for Participation for Skilled Nursing Facilities The Elements of Compliance for Phase 2 April 28, 2017 1:30pm 2:45pm Objectives Identify the new and revised regulations in the Final Rule for Phase 2 Develop a plan to implement the required elements of Phase 2 Describe guidelines for leaders to be able to operationalize the Phase 2 requirements 2 Implementation Phases Phase 1: November 28, 2016 Phase 2: November 28, 2017 Phase 3: November 28, 2019 3 1
Timeline 483.10 Resident rights The section will be implemented in Phase 1 with the following exception: (g)(4)(ii) (v) Providing contact information for State and local advocacy organizations, Medicare and Medicaid eligibility information, Aging and Disability Resources Center and Medicaid Fraud Control Unit Implemented in Phase 2. 4 Resident Rights Add contact information for: State & Local Advocacy Organizations Medicare & Medicaid Eligibility Information Aging & Disability Resource Centers Medicaid Fraud Control Unit 5 Timeline 483.12 Freedom from abuse, neglect, and exploitation. This section will be implemented in Phase 1 with the following exceptions: (b)(4) Coordination with QAPI Plan Implemented in Phase 3. (b)(5) Reporting crimes/1150b Implemented in Phase 2. 6 2
Abuse, Neglect, & Exploitation Revised Title Freedom from Abuse, Neglect & Exploitation Reporting of crimes Law Enforcement 2 hours if serious bodily injury 24 hours if not Policy, Education, HR Forms 7 Timeline 483.15 Admission, transfer, and discharge rights. This section will be implemented in Phase 1 with the following exceptions: (c)(2) Transfer/Discharge Documentation Implemented in Phase 2. 8 ADT Admission, Transfer, and Discharge Rights Transfer or discharge must be documented and include: History of present illness Reason for transfer Past medical/surgical history Exchange with receiving provider or facility Policy, education, DC documentation forms 9 3
Discharge/Transfer Information provided to the receiving entity must include at a minimum Demographics Representative information Advance directives History of present illness Reason for transfer with PCP contact information Past medical/surgical history with procedures Active diagnoses/current problem list and status Lab tests and results of pertinent lab & diagnostics Functional status 10 Discharge/Transfer Information provided to the receiving entity must include at a minimum Psycho-social assessments including cognition Social Supports Behavioral health issues Medications Allergies Immunizations Smoking status Vital signs Unique identifiers for implanted devices Comprehensive care plan goals, health concerns, assessment and plan, preferences, interventions, efforts to meet resident needs 11 Timeline 483.21 Comprehensive person centered care planning. This section will be implemented in Phase 1 with the following exceptions: (a) Baseline care plan Implemented in Phase 2 (b)(3)(iii) Trauma informed care Implemented in Phase 3. 12 4
Plan of Care Comprehensive person centered care plan Phase 2 - Baseline care plan (share with resident and/or representative) Within 48 hours of admission Initial goals based on orders Physician orders Dietary orders Therapy services Social services 13 Plan of Care Care plan must describe Service that are to be furnished to attain or maintain the resident s highest practicable physical, mental, and psychosocial well-being Any other services that would otherwise be required but are not provided due to resident exercise of rights including right to refuse treatment Specialized services or rehab from PASARR recommendations 14 Timeline 483.35 Nursing services. This section will be implemented in Phase 1 with the following exception: Specific usage of the Facility Assessment at 483.70(e) in the determination of sufficient number and competencies for staff Implemented in Phase 2 15 5
Nursing Services Sufficient Staffing (F353) Adds competency requirement for determining sufficient nursing staff based on facility assessment Capacity Census Acuity Assure resident safety Range of diagnoses Care plan content Policy, education, 16 Nursing Services Facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident needs as identified through assessments and care plans Providing care includes assessing, evaluating, planning and implementing resident care plans and responding to resident needs 17 Timeline 483.40 Behavioral health services. This section will be implemented in Phase 2 with the following exceptions: (a)(1) As related to residents with a history of trauma and/or post traumatic stress disorder Implemented in Phase 3 (b)(1), (b)(2), and (d) Comprehensive assessment and medically related social services Implemented in Phase 1 18 6
Behavioral Health - NEW Provision of behavioral & mental health services for mental health and psychosocial illnesses Competency approach Staffing Non pharmacy interventions Adds gerontology to allowed human service fields for social service workers Policy, education, competency, care plan, partnership contracts 19 Timeline 483.45 Pharmacy services. This section will be implemented in Phase 1 with the following exceptions: (c)(2) Medical chart review Implemented in Phase 2 (e) Psychotropic drugs Implemented in Phase 2 20 Pharmacy Services Drug Regimen Review (F428) At least every month When resident is new When resident returns prior resident Transferred from hospital or another facility Monthly if on ABX or psychotic medication Any drug requested by QAA Committee Pharmacist & MD documentation guidelines Must be sent to MD, Medical Director, & DON Definition of irregularities Terminology psychotropic drugs any drug that affects brain activity associated with mental process and behavior 21 7
Timeline 483.55 Dental services. This section will be implemented in Phase 1 with the following exceptions: (a)(3) and (a)(5) Loss or damage of dentures and policy for referral Implemented in Phase 2 (b)(3) and (b)(4) Referral for dental services regarding loss or damaged dentures Implemented in Phase 2 22 Dental Services Prohibits SNF from charging a resident for lost or broken dentures when facility is responsible Must make referral promptly to fix or replace dentures within 3 business days Extenuating circumstances must be documented in the record Assist with appointments and transportation Policy, education 23 Implementation Timeline 483.60 Food and nutrition services. This section will be implemented in Phase 1 with the following exceptions: (a) As linked to Facility Assessment Implemented in Phase 2 (a)(1)(iv) Dietitians hired or contracted with prior to effective date Built in implementation date of 5 years following effective date of the final rule. (a)(2)(i) Director of food & nutrition services designated to serve prior to effective Built in implementation date of 5 years following the effective date of the final rule. (a)(2)(i) Dietitians designated to after the effective date Built in implementation date of 1 year following the effective date of the final rule. 24 8
Food & Nutrition Services F361 Staffing must employ sufficient staff with appropriate competencies and skills to carry out function of food services taking into consideration Resident assessment Plan of care Diagnoses and acuity Census Ethnic, cultural, and religious preferences 25 Timeline 483.70 Administration. This section will be implemented in Phase 1 with the following exceptions: (d)(3) Governing body responsibility of QAPI program Implemented in Phase 3. (e) Facility assessment Implemented in Phase 2. 26 Administration Facility Wide Resource Assessment (F490) To determine appropriate resources to care for residents during day to day operations and also in emergencies Update annually & with any major change in census or services Address the following: Census Capacity Types of Care Staff competencies required Cultural aspects Resources (personnel & equipment) 27 9
Intent To determine resources necessary to care for residents competently during both day to day operations and in emergencies To determine the resources you have and the resources you may need To assess and analyze the resident population and resources to competently determine the resources needed to care for residents Intent To have a record for staff and management in the future to understand the reasons for decisions that were made regarding staffing and other resources What is it? Business Plan Staffing Plan Identity of the individual skilled nursing facility Identification of resources Identifies who you are Identifies your capabilities as a provider of skilled nursing services Shows your competencies 10
Why no template from CMS? Providers should have the flexibility to create an individual assessment that is specific to each individual skilled nursing facility Providers will consult with each other and over time come up with a standard type of document Regulations & F Tags 483.35 Nursing Services F353 483.60 Nutrition Services F361 483.70 Administration F490 483.80 Infection Control F441 Elements Capacity of SNF Current average daily census Types of care offered Care required Staff competencies necessary Facility based risk assessment Community based risk assessment Training (Amount & Types) 11
Elements Physical Environment Equipment (Medical & Non-medical) Activities Buildings, physical structures Vehicles Services Provided (PT, pharmacy) Personnel Contracts, memos of understanding HIT Nursing 483.35 Nursing Services Facility Resource Assessment: Incorporate nursing staffing plan Competencies and skills Nursing Make thoughtful and informed staffing plans and decisions based on meeting resident needs, including maintaining or improving resident function and quality of life National Averages RN 0.85 hppd Total 4.15 hppd 12
Nursing Competencies and skills Based on the identification of the resident population and all of the different types of care and services provided Determine what competencies and skills are needed to care for your population Examples: Tube Feeding, Wound Vac, Wound Care Food and Nutrition 483.60 Nutrition Services Facility Resource Assessment: Incorporate dietary staffing plan Ethnic, cultural, religious preferences Infection Control 483.80 Infection Control Facility Resource Assessment Incorporate Infection Control Antibiotic Stewardship Program 13
When to review & revise? Initial Development As necessary If you plan for or have a change that would require a substantial modification to any part of the assessment Annually Third Parties Contracts Memos of Understanding Those providing services or equipment Day to Day Operations Emergencies Ex. Therapy, Food Service, Radiology, Medical Director, Staffing Agencies Health Information Technology What types of systems do you use to manage health information Electronic health records Other electronic systems Interoperability If you share information electronically with another entity what safeguards are in place for HIPAA 14
Physical Plant The facility resource assessment must address all buildings, structures, and vehicles used for operations Including non-resident areas Preventive maintenance plan Would cover equipment Inventory of equipment Number of lifts, stands, bladder scanners, items used for patient care Risk Assessments All Hazards Approach Work toward hazard prevention while preparing for unexpected emergencies and unforeseen situations that inevitably occur Identify hazards Identify Vulnerabilities Determine potential impact Hazards Hazards that may cause: Injury Property Damage Business Disruption Environmental Impact Plan should identify threats or hazards, opportunities for prevention, and risk mitigation 15
Scenarios for Emergency Planning Resources needed to respond to an emergency How to continue business operations in an emergency Communication planning during and after an emergency IT Recovery Plan Employee Assistance Incident Management Community Risk Assessment Identify the knowledge and skill of your community and of yourself as a provider in the community Know your consumers and local residents Know your facility, your capabilities and your capacities Consumer Knowledge & Skill Communication access/barriers Knowledge of preventive care Experience with health systems Beliefs about health outcomes Cultural norms, healing practices Skill in accessing services Age of community members Education and training of consumers Living conditions / homeless Poverty basic needs not met Physical access barriers 16
Provider Knowledge & Skill Knowledge of local culture Respect shown to consumers Beliefs about what consumers value History / reputation in community Availability of continuum of care Education, competency, skills of staff Human resources Convenience Insurance contracts who can you take Community Involvement Implementation Timeline 483.75 Quality assurance and performance improvement. This section will be implemented in Phase 3 with the following exceptions: (a)(2) Initial QAPI Plan must be provided to State Agency Surveyor at annual survey Implemented in Phase 2 (g)(1) QAA committee All requirements of this section will be implemented in Phase 1 with the exception of subparagraph (iv), the addition of the IP, which will be implemented in Phase 3 (h) Disclosure of information Implemented in Phase 1 (i)sanctions Implemented in Phase 1 50 QAPI NEW Section Quality Assurance & Performance Improvement Program requires all SNFs to: Develop Implement Maintain Effective, comprehensive, data driven QAPI program that focuses on: Systems of Care Outcomes of Care Quality of Life Policy, education, QAPI program 51 17
QAPI Program Design and Scope Program Feedback, data systems, and monitoring Program systematic analysis and systemic action 52 Timeline 483.80 Infection control. This section will be implemented in Phase 1 with the following exceptions: (a) As linked to Facility Assessment at 483.70(e) Implemented in Phase 2 (a)(3) Antibiotic stewardship Implemented in Phase 2 (b) Infection Preventionist (IP) Implemented in Phase 3 (c) IP participation on QAA committee Implemented in Phase 3 53 Infection Control IPCP must include Phase 2 - an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use a system for recording incidents identified under the facility IPCP and the corrective actions taken by the facility 54 18
Implementation Timeline 483.90 Physical environment. This section will be implemented in Phase 1 with the following exceptions: (f)(1) Call system from each resident s bedside Implemented in Phase 3 (h)(5) Policies regarding smoking Implemented in Phase 2 55 Physical Environment Establish policies regarding smoking in accordance with federal, state, and local laws and regulations, must include Smoking Tobacco cessation Smoking areas Safety Policy, education, admission agreement 56 Leadership Strategies Start early on Phase 2 Tap into resources available Break the facility plan into sections Review and revise policies as needed Utilize a checklist to keep track of collected information Check for state requirements Network with peers for ideas 19
Resources/References www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey -and-cert-letter-17-07.pdf www.federalregister.gov/articles/2015/07/16/2015-17207/medicare-and-medicaid-programs-reform-ofrequirements-for-long-term-care-facilities www.cms.gov/medicare/provider-enrollment-and- Certification/QAPI/qapidefinition.html https://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/2017Downloads/R168SOM A.pdf 58 Thank you! Leah Killian-Smith, BA, NHA, RHIA Director of Quality Assurance & Government Services Pathway Health, Inc. Leah.smith@pathwayhealth.com 651-407-8699 59 20