Mega Rule DHS PowerPoint - LeadingAge Wisconsin · 2016. 11. 28. · 11/28/2016 LTC Final Rule aka Mega Rule Pat Virnig Bureau of Nursing Home Resident Care Director Bureau of Nursing

LeadingAge Wisconsin204 South Hamilton StreetMadison WI 53703Tel: 608-255-7060 Fax: [email protected]

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Friday, December 2, 2016Sleep Inn & Suites Conference Center5872 33rd AvenueEau Claire, WI 54703715-874-2900

Tuesday, December 6, 2016Country Springs Hotel2810 Golf RoadPewaukee, WI 53187262-547-0201

Wednesday, December 7, 2016Liberty Hall Banquet& Conference Center800 Eisenhower DriveKimberly, WI 54136920-731-0164

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Handouts

presented by

The Final Rule:Requirements for Participation,

DQA Guidance, and Key Changes from an Operator's Perspective

Handouts also are available online at:www.leadingagewi.org/media/41520/megarule.pdf

11/28/2016

LTC Final Ruleaka Mega Rule

Pat VirnigBureau of Nursing Home Resident Care

DirectorBureau of Nursing Home Resident Care

THANK YOU!!! we have got a lot to doTHANK YOU!!! – we have got a lot to do

before November of 2017

• New regulations• New survey process• I hope to prove today that DQA is NOT a

barrier – We are all in this together!

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Trauma Informed Care & ACEsTrauma‐Informed Care & ACEs

• Adverse Childhood Experiences (ACEs) • https://www.cdc.gov/violenceprevention/acest

udy/• http://wichildrenstrustfund.org/Documents/REVI

SEDWisconsinACEs.August2012.pdfSEDWisconsinACEs.August2012.pdf• WI DHS Trauma-Informed Care Brochure

https://www.dhs.wisconsin.gov/publications/p0/p00202.pdf

“WWW W”“WWW – W”

• What did you know?• When did you know it?• What did you do about it?

Getting to Past Non-compliance

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Clinical Standards Of PracticeClinical Standards Of Practice

• Use the Clinical Resource Center the facility must have a nationally recognized, evidenced based standard of practiceevidenced based standard of practice

Just CultureJ

A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. While the organization has a duty and responsibility to employees (and ultimately to residents), all employees are held responsible for the quality of their choices. Just culture requires a change in f f d t t t d i d focus from errors and outcomes to system design and management of the behavioral choices of all employees. • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/• http://nursingworld.org/psjustculture

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ALWAYS

Start with the Resident

• Or… let them eat Oreos and take their own bath… or perhaps… SMOKE…

• Nursing Process

Set the Survey Up RightSet the Survey Up Right

• Shared Expectations Document• Questionnaires• Imagine this… a typical day at the NH… in

walks 5 folks with briefcases and cards!walks 5 folks with briefcases and cards!• How are we not Monday morning

quarterbacks…

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MDS Focused SurveysMDS Focused Surveys

• MDS/Staffing level focused surveys• 10 facilities selected• CMS/OIG attempt to determine if MDS filled

out correctlyout correctly• CMS S&C memo 15-06

The 3 T’sThe 3 T’s

• These are the rules

• This is how we survey to ensure the rules are met

• This is what happens when the rules are not met

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BackgroundBackground

• No comprehensive update since 1991 – despite substantial changes to service delivery

• The Reform of Requirements for Long-Term Care Facilities “Proposed Rule” was published in the p pFederal Register on July 16, 2015

• CMS received nearly 10,000 comments

OverviewOverview

• Reform of Requirements for Long-Term Care Facilities final rule or “Mega Rule”

• Published in Federal Register on October 4, 2016

• Revises regulations on a comprehensive basis

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Updated GuidanceUpdated Guidance• Phase-in approach over 3 years to allow for

changes in survey processes and to update survey guidance

• CMS will provide updated guidance to facilities, update the survey process, update , p y p , psurvey tags in accordance with the reorganization of the regulation, and provide training to surveyors on new tags

Implementation TimelineImplementation Timeline

• The Final Rule is effective November 28, 2016• Implementation is divided into 3 phases based

on complexityo Phase 1: implementation deadline is Nov. 28, 2016

Ph 2 i l t ti d dli i N 28 2017o Phase 2: implementation deadline is Nov. 28, 2017o Phase 3: implementation deadline is Nov. 28, 2019

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We are all in this together.g

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Key Changes

• Comprehensive Person-Centered Care Planning• Arbitration Agreements• Training Requirements• Infection Control• Infection Control• Compliance and Ethics Program• Quality Assurance and Performance

Improvement

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Comprehensive Person‐Centered Care PlanningComprehensive Person‐Centered Care Planning

• Requires facilities to develop and implement a baseline care plan for each resident within 48 hours of admission

• Adds a nurse aide and a member of the food and nutrition services staff to the required members of nutrition services staff to the required members of the interdisciplinary team (IDT) responsible for developing the comprehensive care plan

• Requires facilities to develop and implement a discharge planning process

Arbitration AgreementsArbitration Agreements• Final Rule prohibits the use of pre-dispute

binding arbitration agreements• LTC facilities cannot enter into agreements for

binding arbitration with a resident or their representative until after a dispute arises between the parties

• The Final Rule will not affect existing pre-dispute arbitration agreements; such existing agreements can still be enforced

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Training RequirementsTraining Requirements• Sets forth requirements of an effective training

program that facilities must develop, implement, and maintain for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers.

• Required staff training:R id t ’ i ht d f ilit ibilitio Residents’ rights and facility responsibilities

o Activities that constitute abuse and neglecto Infection controlo Compliance and ethicso QAPI training that outlines the elements and goals of the

QAPI program

Infection ControlInfection Control

• The Final Rule requires facilities to develop an Infection Prevention and Control Program (IPCP)

• The program must include at a minimum:o A system for preventing, identifying, reporting,

investigating and controlling infections and investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement

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Infection Control, cont.Infection Control, cont.• Include an Antibiotic Stewardship Program

• Antibiotic Stewardship Program must include antibiotic use protocols and system to monitor antibiotic use

• Designate at least one Infection Preventionist (IP)o IP is responsible for the IPCPo IP is responsible for the IPCPo IP’s primary professional training must be in nursing,

medical technology, microbiology, epidemiology, or other related field. Can be qualified by education, training, experience or certification.

o IP must work at the facility at least part-time

Compliance and Ethics ProgramCompliance and Ethics Program• Requires the operating organization of each facility

to have in effect a compliance and ethics program• Program must establish written compliance and

ethics standards• Must establish policies and procedures that are

capable of reducing the prospect of criminal, civil, d d i i t ti i l ti and administrative violations

• Facility must take steps to effectively communicate the standards, policies, and procedures to entire staff, contractors, and volunteers

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Quality Assurance and Performance ImprovementQ y p

• Requires all LTC facilities to develop, implement, and maintain a comprehensive, data-driven QAPI program

• Program designed to monitor and evaluate performance of all services and programs of the facility

• Facility’s governing body is responsible and accountable for the QAPI program

• Facility must submit QAPI plan to State Agency or federal surveyor at recertification survey 1 year after effective date

Pharmacy ServicesPharmacy Services• Drug Regimen Review

o A pharmacist must complete a monthly drug regimen review and medical record review

o Defined irregularities• Unnecessary drugsUnnecessary drugs

o Reporting irregularitieso Responding to irregularitieso Development of policies and procedures

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Pharmacy Services, cont.Pharmacy Services, cont.• Use of psychotropic medications

o Antipsychoticso Antidepressantso Antianxieties

H tio Hypnotics• PRN orders limited to 14 days• Non-renewal without assessment

Questions?

DHS Program Name Here 26

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We are all in this together.g

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SOM Changes from an Operators Perspective -

Requirements for Participation

©Pathway Health 2013

The NEW MegaRule – Requirements for Participation for Skilled Nursing Facilities

Objectives

• Understand the new and revised final rule for Skilled Nursing Facility Requirements for

©Pathway Health 2013 2

g y qParticipation

• Be able to conduct a facility self assessment to determine your organizational needs for compliance

• Learn leadership strategies for implementing the new and revised regulations

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• Health and safety standards LTC must meet in order to participate in MC & MA

History & Background

p p• Requirements found at 42CFR Subpart B• No comprehensive update since 1991• Revisions reflect changes in theory and practice• Implements sections of ACA• Proposed rule was published in federal register


7/16/15• Rule: www.https://federalregister.gov/d/2016-23503

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1 Person Centered Care

Themes of the Rule

1. Person Centered Care2. Quality3. Facility Assessment 4. Alignment with HHS Priorities5. Comprehensive Review & Modernization


6. Implementation of Legislation

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• Consumers are informed, involved, and in control• Quality is overarching principle in all we do for

our residents

Summary of Provisions

• Choices are more defined• Care and DC Planning• Additional special care issues addressed• Competency based approach• Updates in standards of practice


• ACA & IMPACT Act

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• Phase 1: November 28, 2016

Phases of Implementation




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§483.10 Resident rights

Timeline for Implementation

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

f


and Medicaid eligibility information, Aging and Disability Resources Center and Medicaid Fraud Control Unit — Implemented in Phase 2.

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– Abuse– Adverse event

– Neglect– Nurse aide

Definitions

– Common area– Distinct part– Exploitation– Licensed health

professional

– Person-centered care

– Resident representative

– Sexual abuse


professional– Misappropriation– Mistreatment

– Transfer and discharge

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F150 ‐ §483.5

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• Eliminates language such asI d f il b

Resident Rights

– Interested family member– Legal representative

• Replaces it with– Resident Representative


Resident Representative

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• An individual of resident choice who has access to information and participates


in health care discussions• Personal representative with legal

standing in accordance with state law– Power of Attorney– Representative payee and other fiduciaries


p p y– Legal Guardian or conservator– Health Care Surrogate– Legal representative

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• Representativeh h i h i id ’


– has the right to exercise resident’s rights to the extent those right are delegated to the resident representative

– Resident retains right to exercise those rights not delegated to a representative and the right to revoke a delegation of


and the right to revoke a delegation of rights, except as limited by state law

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• If selected as the personal representative must be afforded

Same Sex Spouse

representative, must be afforded treatment equal to an opposite sex spouse if marriage was valid in the jurisdiction it was celebrated in


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1. Right to exercise his/her rights as resident of facility and as citizen or

id t f th U it d St t

Resident Rights

resident of the United States2. Right to be free from interference,

coercion, discrimination, and reprisal from facility in exercising those rights and to be supported by the facility in


exercising those rights3. Right to designate a representative in

accordance with state law

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4. If resident is adjudged incompetent under state law or court of competent

Resident Rights

jurisdiction the rights of the resident devolve to and are exercised by the representative appointed under state law to act on the resident’s behalf


Resident may exercise his/her rights to the extent not prohibited by court order

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• Court appointed representative exercises the resident’s rights to the

Resident Rights

exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction in accordance with state law

• Resident wishes and preferences must b d d h f h


be considered in the exercise of the rights by the representative

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• To the extent possible, the resident must be provided with the opportunity

Resident Rights

must be provided with the opportunity to participate in the care planning process

5. Any legal surrogate designated in accordance with state law may exercise the resident’s rights to the


exercise the resident s rights to the extent provided by state law if the resident has not been adjudged incompetent

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6. Planning and implementing care: resident has a right to be informed of and participate in his/her treatment

Resident Rights

and participate in his/her treatment including:– Right to be fully informed in a language

he/she can understand of total health status, including but not limited to medical condition


medical condition– Right to be informed in advance of care

to be furnished and disciplines involved

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6. Planning and implementing care– Right to be informed in advance of risks

Resident Rights

and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/she prefers

– Right to request, refuse, and/or d


discontinue treatment, to participate or refuse to participate in experimental research, and to formulate advance directives

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6. Planning and implementing care (F154)

Right to participate in the development

Resident Rights

– Right to participate in the development and implementation of his or her person centered care plan

– Right to sign his or her person centered care plan

7 Ri ht t lf d i i t di ti if


7. Right to self-administer medications if the IDT has determined that this practice is clinically appropriate (F175)

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8. Resident does not have right to receive provision of medical treatment or medical services deemed medically

Resident Rights

yunnecessary or inappropriate (F155)

9. Right to choose his/her attending physician (F163)

10.Right to respect and dignity (F221)11 Ri ht t b f f h i l


11.Right to be free from any physical or chemical restraints imposed for discipline or convenience of staff and not required to treat medical symptoms (F221) 20

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12. Right to retain and use personal possessions including furnishings, and clothing as space permits unless to do

Resident Rights

clothing as space permits, unless to do so would infringe on the rights or health and safety of other residents (F252)

13. Right to share a room with a roommate of his/her choice when practicable, when both residents live in the same facility


both residents live in the same facility and both consent (F175)

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14. Right to receive notice before the resident’s room or roommate in the facility is changed (F247)

Resident Rights

y g ( )15. Right to refuse to transfer to another

rooms if the purpose is to relocate for staff convenience (F177)

16. Self Determination (F242)


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• Notices required– State & local advocacy organizations,

State Long Term Care Ombudsman

Resident Rights

State Long-Term Care Ombudsman program

– Information regarding Medicare and Medicaid eligibility and coverage & Medicaid fraud control unit (Phase 2)Contact information for Aging &


– Contact information for Aging & Disability Resource Center

– How to file grievances or complaints about abuse, neglect, misappropriation

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• Access to Information– Right to access medical records

t i i t hi h lf (F153)

Resident Rights

pertaining to him or herself (F153)• Upon oral or written request in a readable

format requested within 24 hours excluding weekends and holidays and….

• After receipt for inspection, the opportunity to purchase a copy or portions of upon


p py p prequest and 2 working days advance notice to facility

• Charges may include, labor for copying, supplies for creating copies, postage if mailed

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• Right to examine the results of the most recent survey of the facility

Resident Rights

most recent survey of the facility conducted by the Federal or State surveyors and any plan of correction in effect with respect to the facility (F167)

• Right to receive information from agencies acting as client advocates


agencies acting as client advocates, and be afforded the opportunity to contact these agencies (F168)

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• Right to personal privacy and confidentiality of his/her own personal

Resident Rights

y pand medical records (F164)

• Right to privacy in his/her verbal, written, and electronic communication, including right to send and promptly receive unopened mail and other


receive unopened mail and other letters, packages and other materials delivered to the facility for the resident (F170)

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• Right to privacy includes accommodations, medical treatment, written and telephone communications

Resident Rights

written and telephone communications, personal care, visits, and meetings of family and resident groups, but does not require facility to provide a private room for each resident (F164)Ri ht t d fid ti l


• Right to a secure and confidential medical record (F164)

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• Communication– Right to have reasonable access to the

f t l h i l di TTY d

Resident Rights

use of a telephone including TTY and TDD services (F174)

– Right to a place where calls can be made without being overheard

– Right to retain and use a cell phone at id t’


resident’s own expense

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• Communication– Right to have reasonable access to and

Rights

gprivacy in the use of electronic communications such as email and video if the facility has access (F170)

• At the resident’s expense if additional costs are incurred by the facility to provide such access


access– Right to access stationary, postage, and

writing implements at resident expense

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• Right to an environment that is safe, clean comfortable and homelike

Resident Rights

clean, comfortable, and homelike environment (F252)

• Right to receive treatment and supports for safe daily living


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• Right to voice grievances to the facility or other agency or entity without

Resident Rights

reprisal and without fear of discrimination (F165)– Includes those with respect to care and

treatment which has been furnished as well as that which has not been


furnished• Right to prompt efforts by the facility to

resolve grievances (F166)

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• Included in Resident Rights

Facility Responsibilities -NEW

• Protects resident rights• Enhances quality of life• Brings responsibilities together that are dispersed

throughout the SOM• Parallels many resident rights provisions

E d i it ti i ht


• Expands visitation rights

Policy, Education, Update Resident and Employee Handbook

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• Facility must ensure that resident can exercise his/her rights without interference, coercion discrimination or reprisal from

Facility Responsibilities

coercion, discrimination, or reprisal from the facility (F151)

• Facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source (F240)

• Facility must establish and maintain


• Facility must establish and maintain identical policies and practices regarding transfer, discharge, and provision of services regardless of pay source (F207)

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• Facility must treat the decisions of the representative as the decisions of the


representative as the decisions of the resident to the extent required by the court or as delegated by the resident (F152)

• Facility shall not extend the representative’s right to make decisions


representative’s right to make decisions on the resident’s behalf beyond the extent required by the court or delegated by the resident (F152)

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• If the facility has reason to believe that a representative is making decisions or


a representative is making decisions or taking actions that are not in the best interest of the resident, the facility may report such concerns as permitted and shall report such concerns when and in the manner required by state law


the manner required by state law (F152)

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• Planning & Implementing Care– Facility must inform the resident of the


right to participate in his/her treatment and shall support the resident in this right (F155)

– The planning process must• Include resident and/or representative


• Include an assessment of the resident’s strengths and needs

• Incorporate resident personal and cultural preferences in developing goals of care

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• Attending physician– Facility must ensure that each resident


Facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his/her care (F163)


• Self DeterminationF ili d f ili


– Facility must promote and facilitate resident self determination through support of the resident choices (F242)


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• Facility must provide immediate access to any resident by


to any resident by– Any representative of the Secretary,

State, Office of the State Long Term Care Ombudsman, protection and advocacy systems (including mental illness) (F172)


illness) (F172)– His/her individual physician

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• Facility must provide immediate access to any resident by


– Resident representative (F172)• Immediate family member or other relatives

subject to the resident right to deny or withdraw consent at any time

• Others who are visiting with consent of resident subject to reasonable clinical and


resident, subject to reasonable clinical and safety restrictions

• Individuals that provide health, social, legal, or other services to the resident

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• Facility must have written policies and procedures regarding the visitation


procedures regarding the visitationrights of the residents, including those setting forth any clinically necessary or reasonable restrictions or limitation that the facility may need to place on such rights and the reasons for the


such rights and the reasons for the clinical or safety restriction or limitation (F172)

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• Facility must inform each resident and/or representative (F172)


/ p ( )– Of his/her visitation rights, including any clinical or

safety restrictions or limitations– Of the right to receive visitors he/she designates

including spouse (same-sex) or partner, family member, friend

– That facility may not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national


visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability

– Ensure all visitors enjoy full and equal visitation privileges

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• Facility must provide a resident or family group with private space (F243)

d


and– Staff and visitors may attend meetings only at

the group’s invitation– Facility must provide a designated staff person

who is approved by the family or resident group and facility who is responsible for


g p y pproviding assistance and responding to written requests from the groups

– Facility must consider and act upon grievances and recommendations of groups regarding care and life in the facility

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• Facility must not require a resident to perform services for the facility, the

id if h / h h (F169)


resident may if he/she chooses (F169) when– Facility has documented the resident’s need or

desire for work in the care plan– Plan specifies the nature of the services

performed and whether the services are paid


performed and whether the services are paid or voluntary

– Compensation for paid services is at or above prevailing rates

– Resident agrees to the work arrangement in the plan of care 44

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• Facility must not require residents to deposit personal funds with the facility (F158) if h id h


(F158), if the resident chooses to – Upon written authorization of the resident, the

facility must safeguard, manage, and account for personal funds of the resident

– Deposits in excess of $100 must be deposited into an interest bearing account that is separate from

ti t th t dit ll i t t


any operating accounts, that credits all interest earned to the resident account.

– A personal fund that does not exceed $100 may be placed in non-interest bearing, interest bearing, or petty cash account

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• Accounting and records (F159)– Facility must establish and maintain a


system that assures a full, complete, and separate accounting of each resident’s personal funds entrusted to the facility on the resident’s behalf

– Must be according to generally accepted ti i i l


accounting principles

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• Accounting and records– Facility system must preclude any


commingling of resident funds with facility funds or with the funds of any person other than the resident

– Individual financial record must be available to the resident through


quarterly statements and upon request

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• Accounting and records– Facility must notify each resident that


receives Medicaid benefits • When the account reaches $200 less than

the SSI resource limit for one person• That if the amount in the account in addition

to the value of the resident’s other nonexempt resources reaches the SSI limit


pfor one person the resident may lose eligibility for Medicaid or SSI

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• Accounting and records– Conveyance upon discharge, eviction, or


y p g , ,death of a resident with a personal fund with the facility, facility must convey within 30 days the resident’s funds and a final accounting of those funds to the resident, or in the case of death, the

d d l b d


individual or probate jurisdiction administering the resident’s estate

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• Accounting and records– Assurance of financial security (F161)


– Facility must purchase a surety bond or otherwise provide assurance satisfactory to the Secretary to assure the security of all personal funds of residents deposited with the facility


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• Accounting and records– Facility must not impose a charge

h l f d f d


against the personal funds of a resident for any item or service for which payment is made under Medicare or Medicaid (except for applicable deductibles or co-insurance) (F162)F ilit h id t f


– Facility may charge a resident for requested services that are more expensive or in excess of covered services

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• Facility may charge for– Cosmetics and grooming items


– Personal clothing– Personal reading materials– Gifts purchased on behalf of resident– Flowers and plants

Costs to participate in activities that fall


– Costs to participate in activities that fall outside the scope of the activity program

– Private duty nurses or aides52

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• Facility may charge for– Telephone, including cell phone


– Television, radio, computer, electronics– Smoking materials, notions, novelties,

and confections


• Facility must inform orally and in writing, the resident requesting an item


g, q gor service, for which a charge will be made that there will be a charge for the item and what the charge will be


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• Information and CommunicationFacility must ensure that information is


– Facility must ensure that information is provided to each resident in a form and manner that the resident can access and understand, including an alternative format or in a language the resident can understand (F156)


( )

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• Information and Communication– Facility must provide the resident with


access to medical records pertaining to him or herself upon oral or written request in the form or format requested by the individual including electronic format, or a hard copy or other form agreed to by the facility and resident


agreed to by the facility and resident within 24 hours excluding weekends and holidays (F153)

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• Information and Communication– Facility must make reports with respect


to any surveys, certification, and complaint investigations conducted by Federal or State surveyors during the 3 preceding years available for reviewupon request and any plans of correction in effect with respect to the


correction in effect with respect to the facility readily accessible to residents (F167)

– A notice must be posted of report availability 57

• Information and Communication– Facility must post in a form and manner

accessible and understandable (F156)


accessible and understandable (F156)• List of names, addresses (mailing & email),

and telephone numbers of all pertinent agencies and advocacy groups such as State survey & certification agency, State licensure office, adult protective services where state law provide for jurisdiction in


where state law provide for jurisdiction in LTC facilities, Office of Ombudsman, protection & advocacy network, home and community based service programs, and Medicaid fraud control unit

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• Information and Communication– Facility must post in a form and manner

accessible and understandable


accessible and understandable • A statement that the resident may file a

complaint with the State survey and certification agency concerning resident abuse, neglect, misappropriation of resident property in the facility, and non-compliance with Advance Directives


with Advance Directives

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• Advance Directives– Inform and provide written information


pto all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive (F155)

– Provide a written description of the


facility policies to implement advance directives and applicable State law

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• Advance Directives– Facilities are permitted to contract with

th titi t f i h thi i f ti


other entities to furnish this information but are still legally responsible for ensuring that the requirements are met

– Facility may give advance directive information to the representative if the resident is incapacitated upon admission


resident is incapacitated upon admission– If the resident does become able to

receive the information the facility must have measures in place to follow up

61

• Advance Directives– Facility must display in the facility

itt i f ti d id t


written information and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered


refunds for previous payments covered by such benefits

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Notification of Changes– Facility must immediately inform the

resident, consult with the physician, (F157)


, p y , ( )and notify representative when there is

• An accident involving the resident which results in injury and has the potential for requiring physician intervention

• A significant change in the resident’s physical, mental, or psychosocial status


mental, or psychosocial status• A need to alter treatment significantly – due to

adverse consequences or new form of treatment• A decision to transfer or discharge the resident

from the facility63

• Notification of Changes– When making notification facility must

th t ll ti t i f ti i


ensure that all pertinent information is provided upon request to the physician

– Facility must promptly notify the resident and/or representative if there is

• A change in room or roommate assignmentA h i id t i ht


• A change in resident rights– Facility must record and periodically

update the address, email, and phone number of the representative

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• Admission to a composite distinct part (F208)

l d l d


– Facility must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part and also the policies that apply to room changes between its different locations


changes between its different locations

65

F156• Facility must provide a notice of rights

nd e i e to the e ident p io to o


and services to the resident prior to or upon admission and during the resident’s stay

• Facility must inform the resident orally and in writing of his/her rights and all


rules and regulations governing resident conduct and responsibilities during the stay in the facility

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• Facility must provide the resident with the State developed notice of Medicaid


the State-developed notice of Medicaid rights and obligations

• Acknowledgement of receipt of Medicaid rights and obligations must be in writing


• Facility must inform each Medicaid eligible resident in writing at the time


eligible resident, in writing, at the time of admission to the SNF and when the resident becomes eligible for MA of– Items and services that are included in

nursing facility servicesOther items and services that the facility


– Other items and services that the facility offers and for which the resident may be charged and the amount

68

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• Facility must inform each Medicaid eligible resident, in writing, at the time


of admission to the SNF, when the resident becomes eligible for MA, and periodically of– Items and services that change under

Medicare and Medicaid (as soon as


reasonably possible)– Items and/or services that facility offers

(Must give 60 day notice in writing)

69

• If a resident dies or is hospitalized or is transferred and does not return, facility must refund any deposit or any charges


must refund any deposit or any charges already paid less the facility per diem rate, regardless of any minimum stay or discharge notice requirements (F160)

f


• Facility must refund money due within 30 days of discharge

70

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• Facility must furnish to each resident a written description of legal rights


written description of legal rights including– Manner of protection of personal funds– Requirements and procedures for

establishing eligibility for Medicaid i l di h i h


including the right to request an assessment of resources

71

• Facility must furnish to each resident a written description of legal rights


including– A list of names, addresses (mailing and

email) and telephone numbers of State regulatory and informational agencies, advocacy groups such as State licensure

O b d d lt t ti


agency Ombudsman, adult protection, community resources, and Medicaid fraud control unit

72

50

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• Facility must furnish to each resident a written description of legal rights i l di


including– A statement that the resident may file a

complaint with the State survey and certification agency concerning any suspected violation of regulations, including but not limited to abuse


including but not limited to abuse, neglect, misappropriation, and non-compliance with advance directive or return to community requirements

73

• Facility must protect and facilitate that resident’s right to communicate with


gindividuals and entities within and external to the facility including reasonable access to– A telephone (including TTY & TDD)– Internet if available


Internet if available– Stationary, postage, writing implements,

and ability to send mail

74

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• Facility must protect the resident’s right to personal privacy, including privacy in


p p y, g p yhis/her verbal, written, and electronic communications– Including the right to send and promptly

receive mail that is unopened both from a postal service and by other means


p y

75

• Facility must protect the resident’s right to personal privacy, including privacy in hi /h b l itt d l t i


his/her verbal, written, and electronic communications– Privacy includes accommodations,

medical treatment, written and telephone communications, personal ca e isits and meetings ith famil


care, visits, and meetings with family and resident groups, but does not require facility to provide private room for each resident

76

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• Facility must comply with resident rights regarding his/her medical


rights regarding his/her medical records

• Facility must allow Ombudsman to examine a resident’s medical, social, and administrative records in

d h l


accordance with State law

77

• Facility must provide a safe, clean, comfortable, and homelike environment


allowing the resident to use his or her personal belongings to the extent possible (F252)

• Facility must provide housekeeping and maintenance services necessary to


ymaintain a safe, orderly, and comfortable interior (F253)

78

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• Facility must provide clean bed and bath linens that are in good condition


• Facility must provide closet space in each room

• Facility must provide adequate and comfortable lighting levels in all areas

• Facility must provide comfortable and


Facility must provide comfortable and safe temperature levels (if initially certified after 10/1/90 must maintain a temperature range of 71-81°F)

79

• Grievances (F165 & F166) – Facility must make information on how to file a

i l i il bl h


grievance or complaint available to the resident

– Facility must make prompt efforts to resolve grievances including those with respect to the behavior of other residents

– Facility must establish a grievance policy to


ensure prompt resolution of all grievances regarding resident rights

– Upon request the facility must give a copy of the policy to the resident

80

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• Grievance Policy must include– Residents will be notified individually or


through postings in prominent locations throughout the facility of the right to files grievances verbally or in writing

– Right to file grievances anonymously– Contact information of the grievance


official with whom a grievance can be filed including name, business address, email, phone number

81

• Grievance Policy must include– A reasonable expected time frame for


A reasonable expected time frame for completing the review of the grievance

– The right to obtain a written decision regarding his/her grievance

– Contact information of independent entities with whom grievances may be


entities with whom grievances may be filed

82

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– Identify a Grievance Official who is responsible for

• overseeing the grievance process receiving


• overseeing the grievance process, receiving and tracking grievances through their conclusion

• Leading investigations• Maintaining confidentiality• Communicating grievance decisions to


resident and coordinating with agencies• Taking immediate action to prevent further

potential violations of any resident right while the alleged violation is being investigated.

83


• Immediately reporting all alleged violations


• Immediately reporting all alleged violations involving neglect, abuse, injuries of unknown origin, and/or misappropriation to the Administrator and a required by State law

• Ensure that all grievance decisions include the date received a summary statement of


the date received, a summary statement of the resident grievance, steps taken to investigate, summary of findings, a statement of confirmed or not, any action taken as a result of the grievance, date written decision was issued 84

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• Taking appropriate corrective action in


• Taking appropriate corrective action in accordance with State law if the alleged violation is confirmed by the facility or an outside entity having jurisdiction

• Maintaining evidence demonstrating the results of all grievances for a period of no less than three years


less than three years• Not prohibiting or discouraging a resident

from communicating with state or advocacy agencies

85

§483.12 Freedom from abuse, neglect, and exploitation.

Implementation Timeline

This section will be implemented in Phase 1 with the following exceptions:

(b)(4) Coordination with QAPI Plan—Implemented in Phase 3


Implemented in Phase 3.(b)(5) Reporting crimes/1150B—Implemented in Phase 2.

86

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• Revised Title – “Freedom from Abuse, Neglect & Exploitation”S f h l d d l h

Abuse, Neglect, & Exploitation

• Specifies that you cannot employ individuals who have discipline on license by state licensure body– Abuse– Neglect– Mistreatment– Misappropriation


Policy, Education, HR Forms

87

• Facility must not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion


punishment, or involuntary seclusion (F226)

• Facility must not employ or otherwise engage individuals who F(225)– Have been found guilty of abuse,


neglect, misappropriation, or mistreatment by a court of law

– Findings on the CNA registry concerning abuse, neglect, mistreatment, or misappropriation 88

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• Facility must not employ or otherwise engage individuals who

H h d di i li ti t k


– Have had a disciplinary action taken against a professional license by a state licensure body for abuse, neglect, mistreatment, or misappropriation


• Facility must develop & implement written policies and procedures that


– Prohibit abuse, neglect, exploitation, and misappropriation

– Establish policies and procedures to investigate any such allegations

– Include training for staff


g– Establish coordination with QAPI

program

90

59

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• Facility must develop & implement written policies and procedures that


– Ensure reporting of crimes in federally funded facilities

• Policy must include annually notification of covered individuals of obligation to comply with, Posting a conspicuous notice of resident


• Posting a conspicuous notice of resident rights

• Prohibiting and preventing retaliation

91

• In response to an allegation the facility must


• Ensure all alleged violations are reported immediately to Administrator and other officials

– No later than 2 hours after allegation if events causes serious bodily injury

– No later than 24 hours if events did not result in serious bodily injury


serious bodily injury• Have evidence that alleged violations are

thoroughly investigated

92

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• In response to an allegation the facility must


must – Prevent further violations while

investigation is in process– Report results within 5 days with

corrective actionIf ifi d t k i t ti


– If verified, take appropriate corrective action

93

§483.15 Admission, transfer, and discharge h


rights.



(c)(2) Transfer/Discharge Documentation—Implemented in Phase 2.

94

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• Admission, Transfer, and Discharge Rights• Transfer or discharge must be documented and

Admission, Transfer, Discharge

• 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

95

• Facility must establish and implement an admissions policy (F208)

• Facility must not request or require residents or

Admissions

• Facility must not request or require residents or potential residents to waive their rights under Medicare and Medicaid

• Facility must not require oral or written assurance that residents or potential residents are not eligible for or will not apply for Medicare or Medicaid


Medicaid• Facility must not request or require residents or

potential residents to waive potential liability for losses of personal property

96

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• Facility must not request or require a third party guarantee of payment to the facility

Admissions

party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in facility

• Facility may ask representative to sign the admission agreement if they have legal access to resident resources without


access to resident resources, without incurring personal financial responsibility, to provide payment from the resident resources

97

• Facility must establish, maintain, and implement identical policies for transfer, discharge and the provision of services

Policies

discharge, and the provision of services for all individuals regardless of payment

• Facility may charge any amount for services furnished to non-Medicaid residents unless otherwise limited by state law


law• The State is not required to offer

additional services other than what is provided in the State plan

98

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• Facility must permit each resident to remain in the facility and not transfer or discharge (F201)them unless

Discharge/Transfer

them unless– The transfer or discharge is necessary for the

resident’s welfare and the resident needs cannot be met in facility

– The transfer or discharge is appropriate because the resident’s health has improved sufficiently so that the resident no longer needs the services


gprovided by the facility

– The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident

99

• Facility must permit each resident to remain in the facility and not transfer or discharge them unless

Discharge/Transfer

unless– The health of individuals in the facility would

otherwise be endangered– The resident has failed, after appropriate and

reasonable notice to pay for a stay at the facility, non-payment does not apply unless the resident has not submitted the necessary paperwork for


has not submitted the necessary paperwork for 3rd party payment

– The facility ceases to operate

100

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• Facility must document the discharge or transfer in the resident medical record (F202)

Discharge/Transfer

in the resident medical record (F202)• Documentation must include

– Basis for transfer– Specific needs that cannot be met and the

attempts to meet the resident needs and the service available at the receiving facility to meet the need


e eed• Documentation must be made by

– The physician – The staff processing the discharge

101

• Information provided to the receiving entity must include at a minimum

D hi

Discharge/Transfer

– 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

102

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• Information provided to the receiving entity must include at a minimum– Psycho-social assessments including cognition

Discharge/Transfer

– Social Supports– Behavioral health issues– Medications– Allergies– Immunizations– Smoking status


g– Vital signs– Unique identifiers for implanted devices– Comprehensive care plan goals, health concerns,

assessment and plan, preferences, interventions, efforts to meet resident needs

103

• Notice of involuntary transfer or discharge – Facility must notify resident/representative in

Involuntary DC

– Facility must notify resident/representative in writing

– Record the reasons in the clinical record– Provide 30 days notice unless

• the safety of the individuals in the facility is endangered (then as soon as practicable)

• If the resident health status improves sufficiently to allow f di h


for sooner discharge • Immediate transfer or discharge is required by resident’s

urgent medical needs• Resident has been there less than 30 days

104

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• Contents of discharge notice– Reason for discharge/transfer

Involuntary DC

– Reason for discharge/transfer– Effective date of discharge/transfer– Location resident will be discharged to– Resident right to appeal notice language– Ombudsman contact information– State contact information

F ID d MH id h i d


– For ID and MH residents the protection and advocacy agency contact information

105

• Changes to the notice– If the information in the notice changes prior to

Involuntary DC

effecting the transfer/discharge of the resident, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available

• Orientation for transfer or discharge (F204)– Facility must provide and document sufficient

preparation and orientation to residents to ensure


preparation and orientation to residents to ensure safe and orderly transfer or discharge

– Provision of information must be in a format the resident can understand

106

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• Notice in advance of facility closure (F203)

Facility Closure

(F203)– Administrator must provide written notification

prior to the impending closure to• State survey agency• Office of Ombudsman• Residents of facility

R t ti


• Representatives• Other responsible parties

– Must include plan for the transfer and adequate relocation of the residents

107

• Notice of bed-hold and readmission (F205)

Bed Hold

(F205)– Must be given before hospitalization or leave– Duration of the state bed hold policy during

which the resident is permitted to return and resume residence in the facility

– The reserve bed payment policy in the state


plan– Policy regarding bed hold must be given to

resident

108

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• Comprehensive Assessment using RAI/MDS (F272)

Discharge Planning

– Facility must make a comprehensive assessment of a residents

• Needs• Strengths• Goals


• Life history• Preferences

109

• Coordination (F285)– Facility must coordinate assessments with the

Preadmission Screening

PASARR (preadmission screening and resident review) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort

– Facility must incorporate recommendations from PASARR level II determination and the PASARR evaluation report into a resident’s assessment, care


evaluation report into a resident s assessment, care planning, and transitions of care

– Refer all level II residents to PASARR for review when significant change occurs

110

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• A facility may not admit a resident with mental illness or intellectual disability


mental illness or intellectual disability unless the State MH, ID or DD authority has determined prior to admission– Individual requires skilled nursing

facility services


– Whether the individual requires specialized services for ID

111

• Exceptions to PASARR reviewR i f h i l


– Returning from hospital– Admission from hospital after inpatient

acute care– Resident requires SNF services for

conditions that were treated in the


hospital– If the physician certifies that SNF care is

needed less than 30 days

112

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§483.21 Comprehensive person‐centered care planning.


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—


‐(b)(3)(iii) Trauma informed care—Implemented in Phase 3.

113

F279• Baseline care plan within 48 hours - Phase 2• Specialized services or rehab follow through from

Person Centered Care Planning

• Specialized services or rehab follow through from PASARR recommendations

• IDT – must include a nursing assistant and a member of the nutrition services department to develop care plan

• Care plan must include dc planning, resident goals treatment preferences


goals, treatment preferences• DC Summary – Medication Reconciliation• Post DC Plan of Care

Policy, education, care plan, dc documents114

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• Comprehensive person centered care plan

Plan of Care

• 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

115

• Care plan must describe– Service that are to be furnished to

Plan of Care

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

id t i f i ht i l di


resident exercise of rights including right to refuse treatment

– Specialized services or rehab from PASARR recommendations

116

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• Care plan must describe in consultation with the resident and the

Plan of Care

with the resident and the representative– Goals for admission & desired outcomes– Preferences and potential for future DC

• Facility must document whether the id t’ d i t t t th it


resident’s desire to return to the community was assessed and any referrals to community resources

• DC plan in care plan

117

• Comprehensive care plan must be– Developed within 7 days after

l ti f h i

Plan of Care

completion of comprehensive assessment

– Prepared by the IDT• Attending Physician• RN

N id


• Nurse aide• Nutrition services• Resident/representative if practicable

118

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• The services provided or arranged by the facility must

Plan of Care

the facility must– Be provided by qualified persons in

accordance with each resident’s written plan of care

– Meet professional standards of quality


– Phase 3 - Be culturally-competent and trauma-informed www.samhsa.gov

119

• Discharge Planning– Facility must develop and implement an

Discharge Planning

y p peffective discharge process that focuses on

• the resident’s discharge goals• preparing residents to be active partners in

post-discharge care


• effective transition from SNF to post-SNF • reduction of factors leading to preventable

readmissions

120

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• The discharge planning process must

Discharge Planning

– Ensure the discharge needs are identified & result in the development of a discharge plan

– Include regular re-evaluation during stay for any needed changes to the


y y gdischarge plan

– Involve the IDT in the process of developing the discharge plan

121

• The discharge planning process must

Discharge Planning

– Consider the resident or caregiver support persons capacity and capability to perform required care upon discharge

– Involve the resident and/or representative


– Inform the resident/representative of the final plan

– Address the resident’s goals of care and treatment preferences

122

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• Facility must assist residents and/or representatives in selecting a post

Discharge Planning

representatives in selecting a post-acute care provider by using data that includes standardized patient assessment data, data on quality measures, and data on resource useh d b l d


• The data must be relevant and applicable to the resident’s goals of care and treatment preferences

123

• Facility must document an evaluation of the resident’s discharge needs and di h l

Discharge Planning

discharge plan• Facility must discuss the results of the

evaluation with the resident/representative

• Facility must incorporate all relevant i f ti i t th di h l t


information into the discharge plan to facilitate its implementation and avoid unnecessary delays in the resident’s discharge or transfer

124

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• Diagnoses• Course of illness/treatment or therapy

Discharge Summary

• Course of illness/treatment or therapy• Pertinent lab, radiology and

consultation reports• Final summary of the resident’s status

available for release to authorized


persons and agencies with consent of resident and/or representative

125

• Reconciliation of all pre-discharge medications with the post-discharge

di ti i l di OTC

Discharge Summary

medications including OTC• A post discharge plan of care that is

developed with the participation of the resident and with consent the family which will assist the resident to adjust


to his/her new living environment

126

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§483.24 Quality of life. ‐This entire section will be implemented in


This entire section will be implemented in Phase 1§483.25 Quality of care. This section will be implemented in Phase 1 with the following exception:


p‐(m) Trauma‐informed care—Implemented in Phase 3.

127

• Clarifies ADL abilities• Minimum requirements for Activity Director

qualifications

Quality of Care & Life

qualifications• Assisted nutrition and hydration – new name• Pain management• Moves unnecessary meds, medication errors,

immunizations to pharmacy services


Policy, education, assessment, care plan

128

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• F 309– Pain management


g– Dialysis– Recognition and management of

dementia and behavior management– Non-pressure related skin ulcer/wound

Hospice


– Hospice

129

• The facility must ensure– A resident is given the appropriate

treatment and services to maintain or


treatment and services to maintain or improve his/her ability in ADLs (F310)

– A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, personal & oral hygiene (F311)


personal & oral hygiene (F311)– That personnel provide basic life support

including CPR subject to the resident’s advance directives (F155)

130

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• Activities of daily living– Hygiene (bathing, dressing, grooming,


yg ( g, g, g g,and oral care)

– Mobility (transfer and ambulation)– Elimination (toileting)– Dining (including meals and snacks)

Communication (Speech language


– Communication (Speech, language, other functional communication systems)

131

• Activities (F248)– Facility must provide, based on the

comprehensive assessment and care


pplan and the preferences of each resident an ongoing program to support residents in their choice of activities both facility sponsored group, individual, and independent activities d d h f d


designed to meet the interests of and support the physical, mental, and psychosocial well being of each resident, encouraging both independence and interaction in the community 132

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• Activities– The program must be directed by a qualified

professional who is a qualified therapeutic


p q precreation specialist or an activities professional who

• Is licensed or registered by the state in which practicing

• Is eligible for certification as a therapeutic specialist or as an activities professionalHas two years of experience in a social or


• Has two years of experience in a social or recreational program within the last 5 years, 1 of which was full time in an activity program

• Is an OT or OTA• Has completed a training course approved by the

state 133

• Special Treatments and Procedures– Based on the comprehensive

t th f ilit t th t


assessment the facility must ensure that residents receive treatment and care related to special concerns• Restraints• Bed Rails (F461)


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• Special Care Issues• Vision and hearing


– Facility must assist the resident in making arrangements and arranging for transportation to and from appointments


• Skin Integrity– Facility must provide care consistent


Facility must provide care consistent with professional standards of practice to prevent pressure injuries unless unavoidable

– For residents with pressure injuries they receive treatment and services to


promote healing, prevent infection, and prevent new pressure injuries from developing

136

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• Foot Care (F328)– Facility must provide foot care and


Facility must provide foot care and treatment including preventing complications from the resident’s medical condition

– Facility must assist the residents with making appointments and arranging for


g pp g gtransportation to and from appointments

137

• Mobility (F317 & 318)– Facility must maintain range of motion


Facility must maintain range of motion unless clinical condition demonstrates that a reduction is unavoidable

– Facility must provide appropriate treatment and services if limited range of motion/limited mobility to increase


/ yrange/mobility and to prevent further decrease in range of motion/mobility

138

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• Urinary Incontinence (F315)F ili h id h


– Facility must ensure that a resident who is continent on admission receives services and assistance to maintain continence unless the resident’s condition becomes such that continence is not possible to maintain


is not possible to maintain– Assess for removal of a catheter as soon

as possible unless clinically necessary

139

• Fecal Incontinence (F315)B d h h i


– Based on the comprehensive assessment facility must ensure the resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible


bowel function as possible

140

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• “Assisted nutrition and hydration”(F322)

Quality of Care and Life

( )– NG tubes– G tubes– Enteral fluids– Facility must ensure that a resident

M i t i t bl t f


• Maintain acceptable parameters of nutritional status such as usual body weight, protein levels, unless the condition demonstrates that it is not possible or resident preferences indicate otherwise

141

• “Assisted nutrition and hydration”Facility must ensure that a resident


– Facility must ensure that a resident• who is fed by enteral means receives

treatment and services to restore oral eating skills

• and to prevent complications of enteral feeding including but not limited to


aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers

142

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• Accidents– Facility must ensure that resident


yenvironment remains as free of accident hazards as is possible

– Facility must ensure that each resident receives adequate supervision and assistive devices to prevent accidents


• Accidents– Bed Rails


Bed Rails • assess for risk of entrapment prior to installation

• Review risks and benefits with resident/representative and obtain informed consent


informed consent• Ensure bed dimensions are appropriate for resident’s size and weight

144

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• Respiratory Care– Respiratory care including tracheostomy

Quality of Care

Respiratory care including tracheostomy care and tracheal suctioning have been added to specialized services

• Prostheses– Provide rehab services if needed


§483.30 Physician services.


• This entire section will be implemented in Phase 1


87

11/28/2016

• Delegation of Orders– Dieticians

• Delegation of Orders– Dieticians

Physician Services

– Therapists– NP, PA, CNS

State practice laws Policy, education

– Therapists– NP, PA, CNS

State practice laws Policy, education


• Physician Visits• The physician must

Physician Services

– Review the resident’s total program of care including medications and treatments at each visit

– Write sign and date progress notes at each visit

– Sign and date all orders except for flu and


Sign and date all orders except for flu and pneumovax which can be administered per physician approved policy after assessment for contraindications

148

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• Physician Visit Frequency– The resident must be seen every 30 days for

Physician Services

The resident must be seen every 30 days for the first 90 days after admission and then every 60 days thereafter

– Timely if done no later than 10 days after visit is required

– Visits may be alternated by physician and NP, PA or CNS


PA, or CNS– Facility must provide availability of physician

coverage 24 hours per day

149

• *Delegation of TasksPh i i d l h k f

Physician Services

– Physician may delegate the task of writing dietary orders to a qualified dietician or other qualified nutritional professional and therapy orders to a therapist who

• **Is acting within the scope of practice


• **Is acting within the scope of practice according to State law

• Is under supervision of the physician

150

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§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


§483.70(e) in the determination of sufficient number and competencies for staff —Implemented in Phase 2

151

• Sufficient Staffing (F353)• Adds competency requirement for determining

Nursing Services

dds co pete cy equ e e t o dete gsufficient nursing staff based on facility assessment– Capacity– Census– Acuity– Assure resident safety


Assure resident safety – Range of diagnoses– Care plan content

Policy, education, 152

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• Facility must ensure that licensed nurses have the specific competencies

Nursing Services

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, l l d l


evaluating, planning and implementing resident care plans and responding to resident needs

153

• Hiring and Use of Nurse Aides (F494)

Facility may not use an use an individual

Nursing Services

– Facility may not use an use an individual working in the facility as a nurse aide for more than 4 months, on a full time basis unless

• The individual has completed a CNA training program


• A facility may not use a temporary, per diem, leased, or any basis other than permanent who does not meet requirements

• Facility must seek information from every State registry that may include information

154

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• §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

155

• Provision of behavioral & mental health services for mental health and psychosocial

Behavioral Health - NEW

services for mental health and psychosocial illnesses

• Competency approach• Staffing• Non pharmacy interventions• Adds gerontology to allowed human service fields

f


for social service workers

Policy, education, competency, care plan, partnership contracts

156

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• Facility must have sufficient direct care/direct access staff with

Behavioral Health

/appropriate competencies and skills to provide nursing and related services

• Staffing must be based on the facility assessment


• Behavioral health competencies– Caring for residents with mental illness and

psychosocial disorders as well as residents

Behavioral Health

psychosocial disorders, as well as residents with a history of trauma or PTSD and implementing non-pharmacy interventions

– Based on comprehensive assessment ensure that

• A resident receives appropriate care and i


services• A resident who does not have a diagnosis of

mental health or history of trauma does not display a pattern of decreased social interaction or behaviors unless unavoidable

158

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• If rehab services for mental illness and intellectual disability are required the f ilit t

Behavioral Health

facility must– Provide the required services including

specialized rehab– Obtain the required services from an

outside resource from a Medicare d/ M di id id f i li d


and/or Medicaid provider of specialized rehab services

– Provide medically-related social services

159

§483.45 Pharmacy services.



• (c)(2) Medical chart review—Implemented in Phase 2


• (e) Psychotropic drugs—Implemented in Phase 2

160

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• Re-designation of requirements – relocates to pharmacy services

Pharmacy Services

to pharmacy services– Unnecessary drugs– Antipsychotic drugs– Medication errors– Influenza– Pneumovax


Policy, education, pharmacy consultant agreement, forms/assessments

161

• Drug Regimen Review (F428)– At least every month– When resident is “new”

Pharmacy Services

– 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

Not yet included at F 428


• 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

162

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• A psychotropic drug is any drug that ff t b i ti iti i t d ith

Pharmacy Services

affects brain activities associated with mental processes and behavior– Anti-psychotic– Anti-depressant– Anti-anxiety


– Hypnotic

163

• Pharmacist must report any irregularities to

Pharmacy Services

irregularities to – Attending physician– Medical Director– Director of Nursing

• Reports must be acted upon


p p• Irregularities include any drug that

meets the criteria for unnecessary drug

164

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• Irregularities noted by pharmacist during the review must be documented

t itt t i l di

Pharmacy Services

on a separate written report including– Resident name– Relevant drug– Irregularities identified

• Physician must document


y– Irregularity that was reviewed and action

taken, if no changes rationale must be documented

165

F 329 Phase 2• Facility must ensure that

R id t d t i PRN

Pharmacy Services

– Residents do not receive PRN psychotropic drugs unless that medication is necessary to treat a specific diagnosed condition

– PRN orders are limited to 14 days and cannot be continued beyond that time


cannot be continued beyond that time unless the PCP documents the rationale for this continuation in the record

– PRN orders for antipsychotics extended after PCP evaluation of the resident 166

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§483.50 Laboratory, radiology, and other d

Timeline Implementation

diagnostic services.

• This entire section will be implemented in Phase 1


• NEW Section• Ordering Services may be done by:

Lab, Radiology, & Other Diagnostic Services

– Physician Assistant– Nurse Practitioner– Clinical Nurse Specialist

• Ordering clinician must be notified of abnormal labs when they fall outside clinical reference ranges, in accordance with policy or per provider


a ges, acco da ce t po cy o pe p o deorders

Policy, education, contracted provider agreements

168

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• The facility must– Provide or obtain lab or radiology services only

Lab, Radiology, & Other Diagnostic Services

when ordered by an MD, PA, NP or CNS in accordance with State and scope of practice laws