Goodbye Grace Period What will be expected from your Facility Assessment in the Coming Year Ellen Kuebrich Chief Strategy Officer, Providigm
Final Rule
Final Rule Effective Date These regulations are effective as of November 28, 2017 Phase 1 Phase 2 Phase 3 November 28, 2016 The regulations included in Phase 1 must be implemented by November 28, 2016. November 28, 2017 The regulations included in Phase 2 must be implemented by November 28, 2017. November 28, 2019 The regulations included in Phase 3 must be implemented by November 28, 2019.
Cost of Implementing Phase 2 Cost of development and documentation of comprehensive QAPI Program Estimated at 200 hours, at $40/hour Cost of completing and keeping Facility-Wide Assessment up to date Estimated at 70 hours, at $40/hour Cost of coming into compliance with Final Rule less QAPI and FA Estimated at $44.2K per facility per year EVERY YEAR EVERY YEAR EVERY YEAR https://www.gpo.gov/fdsys/pkg/fr-2016-10-04/pdf/2016-23503.pdf
This is your time. And your money. And it s a lot. 2018 Providigm, LLC 5
CMS Relief Efforts Help is on the way? $ No CMPs on Phase 2 Requirements Five Star Freeze
Relief Temporary Moratorium on: CMPs for deficiency findings on Phase 2 F-tags F655 (Baseline Care Plan) F740 (Behavioral Health Services) F741 (Sufficient/Competent Direct Care/Access Staff-Behavioral Health) F758 (Psychotropic Medications) related to PRN Limitations F838 (Facility Assessment) F881 (Antibiotic Stewardship Program) F865 (QAPI Program and Plan) related to the development of the QAPI Plan; F926 (Smoking Policies) 2018 Providigm, LLC 7
But what will happen next year? 2018 Providigm, LLC 8
Phase 2 Requirement: Facility Assessment 2018 Providigm, LLC 9
When I learned about the facility assessment, I can honestly say I was horrified. I wasn t sure how I was going to make that a meaningful document that we could build on.
The intent of the facility assessment is for the individual facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require.
How do I even start this?
Who should be involved? Facility Assessment Team At a minimum, include: The administrator, A representative of the governing body, The medical director, The director of nursing Also, consider other department heads, frontline staff, and seek input from residents and families
Sorry, this isn t something that corporate can do for you.
Facility Assessment Assessing Acuity and Diseases, Conditions, Disabilities Services Provided Determining Staffing Requirements Staff Competency Facility Resources, Equipment, Technology Emergency Preparedness Facility Assessment
QMs MDS Data Sources you may consider as you look at your facility s capabilities PBJ In-house reporting 802/672 (resident census and conditions)
Facility Assessment: Resident Population and Services Required
Facility Assessment Resident Population The facility assessment must address or include: Both the number of residents and the facility's resident capacity; The care required by the resident population that was in the facility in the last 6 months to 1 year types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; ethnic, cultural, or religious factors that may need to be considered to meet resident needs, such as activities, food preferences, and any other aspect of care identified. Consider the frequency at which you are treating each resident profile High frequency versus low frequency www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities
Let s take a look at a sample resident population
Services Required List the types of care that your resident population requires and that you provide for your resident population. List by general categories, adding specifics as needed It is not expected that you quantify each care or practice in terms of the number of residents that need that care, or enter an aggregate of all resident care plans here The intent is to identify and reflect on resources needed to provide these types of care
Example Bowel and Bladder In the past year, our resident population analysis indicated that we had: 25 stays (14%) that required a urinary toileting program 26 stays (14.5%) that required a bowel toileting program Residents that required indwelling (5), external (16), and intermittent catheterization (21) Services provided might include: Bowel/bladder toileting programs, Incontinence prevention and care, Intermittent or indwelling or other urinary catheter, Ostomy, Responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity
Facility Assessment: Staffing and Staff Competency
Staffing GUIDANCE 483.70(e) The regulation outlines that the individualized approach of the facility assessment is the foundation to determine staffing levels and competencies Therefore, the facility assessment must include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident s needs www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/advance-appendix-pp-including-phase-2-.pdf
Staff Type Who do you need in order to take care of your resident population? Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents You might refer to staffing records, your org chart, and/or to PBJ Don t forget about support staff, religious services, and volunteers
Staff Scheduling and Frequency How do you ensure that you have sufficient staff to provide these services? Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time Consider if and how the degree of fluctuation in the census and acuity levels impact staffing needs Take a look at the frequency that you are servicing each population profile And remember- this is not what you HAVE, but what you really think you NEED to adequately provide this service! The regulation provides MINIMUM staffing requirements
Example Bowel and Bladder BY STAFF TYPE Licensed Nurses providing direct care Full time DON One RN or LPN per shift 1:X LN per shift (Days, Evenings, Nights) Direct Care Staff 1:X Days 1:X Evenings 1:X Nights OR, BY HOURS PER RESIDENT DAY Total number of licensed nurse staff hours per resident per day RN hours per resident per day LPN/LVN hours per resident per day CNA hours per resident per day Then, look at Staff Assignment- how do you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments?
Competency Defined DEFINITIONS 483.70(e) Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully. www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/advance-appendix-pp-including-phase-2-.pdf
Nursing Staff Competency GUIDANCE 483.35(a)(3)-(4),(c) Competency in skills and techniques necessary to care for residents needs includes, but is not limited to, competencies in areas such as: Person-Centered Care Communication Basic Nursing Skills Basic Restorative Services Skin and Wound Management Medication and Pain Management Infection Control Resident Rights Identification of Changes in Condition Cultural Competency
Example Bowel and Bladder Care Competencies Licensure Basic Nursing Skills Identification different types of incontinence Communication Infection Control Dignity Use of Incontinent products and monitoring Identification of resident changes in condition Person-Centered Care Perineal Care Urinary Output measurement Resident Assessment and Examination Catheterization insertion/care devices
Demonstration of Competency GUIDANCE 483.35(a)(3)-(4),(c) 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 effective November 28, 2017 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. www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/advance-appendix-pp-including-phase-2-.pdf
Demonstration of Competency GUIDANCE 483.35(a)(3)-(4),(c) Lecture with return demonstration for physical activities; A pre- and post-test for documentation issues; Demonstrated ability to use tools, devices, or equipment that were the subject of training and used to care for residents; Nursing leadership with input from the Medical Director should delineate the competencies. www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/advance-appendix-pp-including-phase-2-.pdf
Facility Assessment: Facility Resources
Facility Resources What physical resources do you need to provide care for your resident population? All buildings and/or other physical structures and vehicles; Equipment (medical and non-medical) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies All personnel Contracts with third parties to provide services or equipment to the facility during both normal operations and emergencies Health information technology resources Your operating budget www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities
Example Bowel and Bladder Physical Space Privacy Curtains Transportation? Medical Equipment and Supplies Liners/Pads/Guards/Briefs/Pullups Catheters Bladder Scanners Wipes Periwash Gloves Barrier Ointments Health IT EMR/MDS system QAPI System Data Analytics/MDS optimization Call Light System
Facility Assessment: All-Hazard Approach to Emergency Preparedness
Facility Assessment: Phase 2 (3) A facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents Explosions/ Trauma Events Chemical Events Natural Events Services Biological Provided Events All Hazards Radiological Events www.cdc.gov/phpr/documents/ahpg_final_march_2013.pdf
Hazard Vulnerability Assessments GUIDANCE 483.70(e) Hazard Vulnerability Assessments (HVAs) are systematic approaches to identifying hazards or risks that are most likely to have an impact on a healthcare facility and the surrounding community.
Hazard Vulnerability Assessment Tool www.kp.com
Review at least annually The facility must review and update this assessment annually or whenever there is/the facility plans for any change that would require a modification to any part of this assessment. It is not the intent that the organizational assessment is updated for every new person that moves into the nursing home, but rather for significant changes such as when the facility begins admitting residents that require substantially different care. However, I can tell you when I might review it again
So what do I do with this?
USE IT! The goal is to make decisions about needed resources, including direct care staff needs, as well as their capabilities to provide services to the residents in the facility.
USE IT! Resident Population Does your resident population analysis reflect the types of people you admit? Has it changed?
USE IT! Staffing types and levels Based on the staffing you said was necessary to care for your resident population, do you need to make any changes in staffing or scheduling? Consider resident and CNA input here! How well is the current staffing working? Yes, you should meet minimum standards, but if you need MORE than that, are you staffed appropriately? Look at QMs- how do you compare to the rest of the state?
USE IT! Staff Competencies Don t forget behavioral health Look at infection control it s pervasive CNA training Are people s job descriptions appropriate? Are these competencies reviewed annually in our review process? Are there any opportunities to more closely collaborate with medical professionals to enhance care?
USE IT! Physical Resources Do we have the space to provide the care we are advertising? Do we have the RIGHT equipment and supplies? Have we educated ourselves on innovations in these areas? Lean on your vendors. Have we talked with our medical suppliers about what will happen in an emergency? Are there IT solutions that you need to more adequately assess and care for the population that you serve?
USE IT! QAPI If there are any areas where you don t feel you have the appropriate services, staff, competencies, physical resources, utilize QAPI If you make a change, measure its success Are adjustments needed in your budget?
Look at what you said you needed. And if you don t have what you need to take care of your residents Create an action plan This could mean looking at who we admit This could mean adjusting resources But, if you have the capabilities to take care of your residents, you will see: Better outcomes Happier residents Happier staff AND THIS IS WHY YOU ARE LOOKING AT THIS NOW INSTEAD OF WHEN THE GRACE PERIOD ENDS 2018 Providigm, LLC 47
What will happen in Survey? Perception vs. Reality
Linking Administration to Quality: Facility Assessment Related F-Tags in surveyor guidance Tag F607 F622 F626 F656 F689 F695 F715 F725 F726 F741 F742 F801 F802 F803 F837 F838 F841 F865 F866 F867 F880 F940 F943 F947 F949 Description Policies to Prohibit and Prevent Abuse, Neglect, Exploitation Transfer & Discharge Permitting Residents to Return to Facility Comprehensive Care Plans Accidents Respiratory Care Dietary Order Delegation Nursing Services - Sufficient Staff Nursing Services - Staff Competencies Sufficient Staff - Mental & Psychosocial Disorders Comprehensive Assessment Staffing - Food & Nutrition Services Staffing - Food & Nutrition Services - Support Staff Menus & Nutritional Adequacy Governing Body Facility Assessment Medical Director QAPI Program Program Feedback, Data Systems, and Monitoring Program Systemic Analysis and Systemic Action Infection Control Training Requirements Training to Prevent Abuse, Neglect, and Exploitation Required In-service Training for Nurse Aides Behavioral Health
Survey Procedures PROCEDURES 483.70(e) If systemic care concerns are identified that are related to the facility s planning, review the facility assessment to determine if these concerns were considered as part of the facility s assessment process. For example, if a facility recently started accepting bariatric residents, and concerns are identified related to providing bariatric services, did facility staff update its assessment before accepting residents with these needs to identify the necessary equipment, staffing, etc., needed to provide care that is effective and safe for the residents and staff? www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/advance-appendix-pp-including-phase-2-.pdf
Survey Questions Questions surveyors should consider include, but are not limited to, the following: Who was involved in conducting the facility assessment? How did the facility determine what equipment, supplies, and physical environment would be required to meet all resident needs? How did the facility develop its emergency plan? If a deficient practice is systemic and is observed at another tag, was this related to an incomplete facility assessment? How? www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/advance-appendix-pp-including-phase-2-.pdf
The Facility Assessment and Responsibility
Administration F-Tags
Governing Body DEFINITIONS 483.70(d) Governing body refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility. www.cms.gov/medicare/provider-enrollment-and- Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf
Administration F835 PROCEDURES 483.70 Cite this tag if the actions, inactions, or decisions in administering the facility contributed to deficient practice(s). The facility s administration is not limited to the administrator and may also include the facility s governing body, management company, and/or others identified by the facility as part of the facility administration. www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/advance-appendix-pp-including-phase-2-.pdf
System Failure Negative Survey Outcome Competency and Staffing Facility Assessment QAPI Plan Administration Governing Body
Yikes. So, what now? Get started Yes, get something completed before survey. But don t treat this as a homework assignment that you have to do. This is a real opportunity for you to streamline your business and improve care. Get the right people involved Take a critical look at the way you are running your business and who you care for Be honest about changes that may need to happen for you to improve
Contact Ellen Kuebrich CSMO 720.203.1174 ekuebrich@providigm.com twitter.com/providigm facebook.com/providigm www.providigm.com 2018 Providigm, LLC