LeadingAge Wisconsin204 South Hamilton StreetMadison WI 53703Tel: 608-255-7060 Fax: [emailprotected]
hosted by
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
and
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
LTCFinalRuleakaMegaRule
Pat VirnigBureau of Nursing Home Resident Care
DirectorBureau of Nursing Home Resident Care
THANK YOU!!! we have got a lot to doTHANKYOU!!!– wehavegotalottodo
beforeNovemberof2017
• 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‐InformedCare&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 PracticeClinicalStandardsOfPractice
• Use the Clinical Resource Center the facility must have a nationally recognized, evidenced based standard of practiceevidenced based standard of practice
JustCultureJ
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
StartwiththeResident
• Or… let them eat Oreos and take their own bath… or perhaps… SMOKE…
• Nursing Process
Set the Survey Up RightSettheSurveyUpRight
• 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 SurveysMDSFocusedSurveys
• 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’sThe3T’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 GuidanceUpdatedGuidance
• 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 TimelineImplementationTimeline
• 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
15
KeyChanges
• 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 PlanningComprehensivePerson‐CenteredCarePlanning
• 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 AgreementsArbitrationAgreements
• 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 RequirementsTrainingRequirements
• 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 ControlInfectionControl
• 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.InfectionControl,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 ProgramComplianceandEthicsProgram
• 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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QualityAssuranceandPerformanceImprovementQ 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 ServicesPharmacyServices
• Drug Regimen Reviewo A pharmacist must complete a monthly drug
regimen review and medical record reviewo Defined irregularities
• Unnecessary drugsUnnecessary drugso Reporting irregularitieso Responding to irregularitieso Development of policies and procedures
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Pharmacy Services, cont.PharmacyServices,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
©PathwayHealth2013
TheNEWMegaRule – RequirementsforParticipationforSkilledNursingFacilities
Objectives
• Understand the new and revised final rule for Skilled Nursing Facility Requirements for
©PathwayHealth2013 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
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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
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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
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• ACA & IMPACT Act
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• Phase 1: November 28, 2016
Phases of Implementation
• Phase 2: November 28, 2017
• Phase 3: November 28, 2019
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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
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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
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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
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Resident Representative
9
• An individual of resident choice who has access to information and participates
Resident Representative
in health care discussions• Personal representative with legal
standing in accordance with state law– Power of Attorney– Representative payee and other fiduciaries
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p p y– Legal Guardian or conservator– Health Care Surrogate– Legal representative
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• Representativeh h i h i id ’
Resident Representative
– 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
©PathwayHealth2013
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
©PathwayHealth2013
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
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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
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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
©PathwayHealth2013
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
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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
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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
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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
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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
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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 &
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– 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
©PathwayHealth2013
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
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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
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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
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• 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’
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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
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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
©PathwayHealth2013
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
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• 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
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• 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
Facility Responsibilities
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
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
the manner required by state law (F152)
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• Planning & Implementing Care– Facility must inform the resident of the
Facility Responsibilities
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
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• 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 Responsibilities
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)
©PathwayHealth201337
• Self DeterminationF ili d f ili
Facility Responsibilities
– Facility must promote and facilitate resident self determination through support of the resident choices (F242)
©PathwayHealth201338
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• Facility must provide immediate access to any resident by
Facility Responsibilities
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)
©PathwayHealth2013
illness) (F172)– His/her individual physician
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• Facility must provide immediate access to any resident by
Facility Responsibilities
– 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
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
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)
Facility Responsibilities
/ 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
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
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)
Facility Responsibilities
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
©PathwayHealth2013
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
Facility Responsibilities
(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
©PathwayHealth2013
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
Facility Responsibilities
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
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accounting principles
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• Accounting and records– Facility system must preclude any
Facility Responsibilities
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
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quarterly statements and upon request
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• Accounting and records– Facility must notify each resident that
Facility Responsibilities
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
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pfor one person the resident may lose eligibility for Medicaid or SSI
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• Accounting and records– Conveyance upon discharge, eviction, or
Facility Responsibilities
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
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individual or probate jurisdiction administering the resident’s estate
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• Accounting and records– Assurance of financial security (F161)
Facility Responsibilities
– 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
Facility Responsibilities
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
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– 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
Facility Responsibilities
– Personal clothing– Personal reading materials– Gifts purchased on behalf of resident– Flowers and plants
Costs to participate in activities that fall
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– 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
Facility Responsibilities
– Television, radio, computer, electronics– Smoking materials, notions, novelties,
and confections
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• Facility must inform orally and in writing, the resident requesting an item
Facility Responsibilities
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 Responsibilities
– 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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( )
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• Information and Communication– Facility must provide the resident with
Facility Responsibilities
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
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
correction in effect with respect to the facility readily accessible to residents (F167)
– A notice must be posted of report availability
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• Information and Communication– Facility must post in a form and manner
accessible and understandable (F156)
Facility Responsibilities
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
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
with Advance Directives
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• Advance Directives– Inform and provide written information
Facility Responsibilities
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
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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
Facility Responsibilities
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
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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
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• Advance Directives– Facility must display in the facility
itt i f ti d id t
Facility Responsibilities
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
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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)
Facility Responsibilities
, 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
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
• 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 Responsibilities
– 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
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
rules and regulations governing resident conduct and responsibilities during the stay in the facility
66
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• Facility must provide the resident with the State developed notice of Medicaid
Facility Responsibilities
the State-developed notice of Medicaid rights and obligations
• Acknowledgement of receipt of Medicaid rights and obligations must be in writing
©PathwayHealth201367
• Facility must inform each Medicaid eligible resident in writing at the time
Facility Responsibilities
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
©PathwayHealth2013
– 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
Facility Responsibilities
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
©PathwayHealth2013
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
Facility Responsibilities
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
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• 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
Facility Responsibilities
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
©PathwayHealth2013
including the right to request an assessment of resources
71
• Facility must furnish to each resident a written description of legal rights
Facility Responsibilities
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
©PathwayHealth2013
agency Ombudsman, adult protection, community resources, and Medicaid fraud control unit
72
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• Facility must furnish to each resident a written description of legal rights i l di
Facility Responsibilities
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
©PathwayHealth2013
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
Facility Responsibilities
gindividuals and entities within and external to the facility including reasonable access to– A telephone (including TTY & TDD)– Internet if available
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
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
Facility Responsibilities
his/her verbal, written, and electronic communications– Privacy includes accommodations,
medical treatment, written and telephone communications, personal ca e isits and meetings ith famil
©PathwayHealth2013
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
Facility Responsibilities
rights regarding his/her medical records
• Facility must allow Ombudsman to examine a resident’s medical, social, and administrative records in
d h l
©PathwayHealth2013
accordance with State law
77
• Facility must provide a safe, clean, comfortable, and homelike environment
Facility Responsibilities
allowing the resident to use his or her personal belongings to the extent possible (F252)
• Facility must provide housekeeping and maintenance services necessary to
©PathwayHealth2013
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 Responsibilities
• Facility must provide closet space in each room
• Facility must provide adequate and comfortable lighting levels in all areas
• Facility must provide comfortable and
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
ensure prompt resolution of all grievances regarding resident rights
– Upon request the facility must give a copy of the policy to the resident
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• Grievance Policy must include– Residents will be notified individually or
Facility Responsibilities
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
©PathwayHealth2013
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
Facility Responsibilities
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
©PathwayHealth2013
entities with whom grievances may be filed
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– Identify a Grievance Official who is responsible for
• overseeing the grievance process receiving
Facility Responsibilities
• overseeing the grievance process, receiving and tracking grievances through their conclusion
• Leading investigations• Maintaining confidentiality• Communicating grievance decisions to
©PathwayHealth2013
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
– Identify a Grievance Official who is responsible for
• Immediately reporting all alleged violations
Facility Responsibilities
• 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
©PathwayHealth2013
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
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– Identify a Grievance Official who is responsible for
• Taking appropriate corrective action in
Facility Responsibilities
• 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
©PathwayHealth2013
less than three years• Not prohibiting or discouraging a resident
from communicating with state or advocacy agencies
85
§483.12Freedomfromabuse,neglect,and
exploitation.
Implementation Timeline
ThissectionwillbeimplementedinPhase1 withthe
followingexceptions:
(b)(4)CoordinationwithQAPIPlan—
Implemented in Phase 3
©PathwayHealth2013
ImplementedinPhase3.
(b)(5)Reportingcrimes/1150B—
ImplementedinPhase2.
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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
©PathwayHealth2013
Policy, Education, HR Forms
87
• Facility must not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion
Abuse, Neglect, & Exploitation
punishment, or involuntary seclusion (F226)
• Facility must not employ or otherwise engage individuals who F(225)– Have been found guilty of abuse,
©PathwayHealth2013
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
Abuse, Neglect, & Exploitation
– Have had a disciplinary action taken against a professional license by a state licensure body for abuse, neglect, mistreatment, or misappropriation
©PathwayHealth201389
• Facility must develop & implement written policies and procedures that
Abuse, Neglect, & Exploitation
– Prohibit abuse, neglect, exploitation, and misappropriation
– Establish policies and procedures to investigate any such allegations
– Include training for staff
©PathwayHealth2013
g– Establish coordination with QAPI
program
90
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• Facility must develop & implement written policies and procedures that
Abuse, Neglect, & Exploitation
– 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
©PathwayHealth2013
• Posting a conspicuous notice of resident rights
• Prohibiting and preventing retaliation
91
• In response to an allegation the facility must
Abuse, Neglect, & Exploitation
• 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
©PathwayHealth2013
serious bodily injury• Have evidence that alleged violations are
thoroughly investigated
92
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• In response to an allegation the facility must
Abuse, Neglect, & Exploitation
must – Prevent further violations while
investigation is in process– Report results within 5 days with
corrective actionIf ifi d t k i t ti
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– If verified, take appropriate corrective action
93
§483.15Admission,transfer,anddischarge
h
Implementation Timeline
rights.
ThissectionwillbeimplementedinPhase1 with
thefollowingexceptions:
©PathwayHealth2013
(c)(2)Transfer/DischargeDocumentation—
ImplementedinPhase2.
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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
– 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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
– 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
©PathwayHealth2013
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
©PathwayHealth2013
• 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
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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
©PathwayHealth2013
• 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
©PathwayHealth2013
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
Preadmission Screening
mental illness or intellectual disability unless the State MH, ID or DD authority has determined prior to admission– Individual requires skilled nursing
facility services
©PathwayHealth2013
– Whether the individual requires specialized services for ID
111
• Exceptions to PASARR reviewR i f h i l
Preadmission Screening
– Returning from hospital– Admission from hospital after inpatient
acute care– Resident requires SNF services for
conditions that were treated in the
©PathwayHealth2013
hospital– If the physician certifies that SNF care is
needed less than 30 days
112
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§483.21Comprehensiveperson‐centeredcare
planning.
Implementation Timeline
planning.
ThissectionwillbeimplementedinPhase1 with
thefollowingexceptions:
‐(a)Baselinecareplan—ImplementedinPhase 2
(b)(3)(iii) Trauma informed care—
©PathwayHealth2013
‐(b)(3)(iii)Traumainformedcare—
ImplementedinPhase3.
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
©PathwayHealth2013
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
©PathwayHealth2013
• 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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
• 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
©PathwayHealth2013
– 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
©PathwayHealth2013
• 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
©PathwayHealth2013
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
©PathwayHealth2013
– 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
©PathwayHealth2013
• 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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
to his/her new living environment
126
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§483.24Qualityoflife.
‐This entire section will be implemented in
Implementation Timeline
Thisentiresectionwillbeimplementedin
Phase1
§483.25Qualityofcare.Thissectionwillbe
implementedinPhase1 withthefollowing
exception:
©PathwayHealth2013
p
‐(m)Trauma‐informedcare—Implementedin
Phase3.
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
©PathwayHealth2013
Policy, education, assessment, care plan
128
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• F 309– Pain management
Quality of Care & Life
g– Dialysis– Recognition and management of
dementia and behavior management– Non-pressure related skin ulcer/wound
Hospice
©PathwayHealth2013
– Hospice
129
• The facility must ensure– A resident is given the appropriate
treatment and services to maintain or
Quality of Care & Life
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)
©PathwayHealth2013
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,
Quality of Care & Life
yg ( g, g, g g,and oral care)
– Mobility (transfer and ambulation)– Elimination (toileting)– Dining (including meals and snacks)
Communication (Speech language
©PathwayHealth2013
– Communication (Speech, language, other functional communication systems)
131
• Activities (F248)– Facility must provide, based on the
comprehensive assessment and care
Quality of Care & Life
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
©PathwayHealth2013
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
Quality of Care & Life
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
©PathwayHealth2013
• 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
Quality of Care & Life
assessment the facility must ensure that residents receive treatment and care related to special concerns• Restraints• Bed Rails (F461)
©PathwayHealth2013134
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• Special Care Issues• Vision and hearing
Quality of Care & Life
– Facility must assist the resident in making arrangements and arranging for transportation to and from appointments
©PathwayHealth2013135
• Skin Integrity– Facility must provide care consistent
Quality of Care & Life
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
©PathwayHealth2013
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
Quality of Care & Life
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
©PathwayHealth2013
g pp g gtransportation to and from appointments
137
• Mobility (F317 & 318)– Facility must maintain range of motion
Quality of Care & Life
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
©PathwayHealth2013
/ 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
Quality of Care & Life
– 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
©PathwayHealth2013
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
Quality of Care & Life
– 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
©PathwayHealth2013
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
©PathwayHealth2013
• 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
Quality of Care and Life
– 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
©PathwayHealth2013
aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers
142
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• Accidents– Facility must ensure that resident
Quality of Care and Life
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
©PathwayHealth2013143
• Accidents– Bed Rails
Quality of Care and Life
Bed Rails • assess for risk of entrapment prior to installation
• Review risks and benefits with resident/representative and obtain informed consent
©PathwayHealth2013
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
©PathwayHealth2013145
§483.30Physicianservices.
Implementation Timeline
• Thisentiresectionwillbeimplementedin
Phase1
©PathwayHealth2013146
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• 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
©PathwayHealth2013147
• 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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
• **Is acting within the scope of practice according to State law
• Is under supervision of the physician
150
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§483.35Nursingservices.
Implementation Timeline
ThissectionwillbeimplementedinPhase1 with
thefollowingexception:
• SpecificusageoftheFacilityAssessmentat
§483 70(e) in the determination of sufficient
©PathwayHealth2013
§483.70(e)inthedeterminationofsufficient
numberandcompetenciesforstaff—
ImplementedinPhase2
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
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
• 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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• §483.40Behavioralhealthservices.
Implementation Timeline
• ThissectionwillbeimplementedinPhase2 withthefollowing
exceptions:
– (a)(1)Asrelatedtoresidentswithahistoryoftraumaand/or
post‐traumaticstressdisorder—ImplementedinPhase3
©PathwayHealth2013
– (b)(1),(b)(2),and(d)Comprehensiveassessmentandmedically
relatedsocialservices‐‐ImplementedinPhase1
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
©PathwayHealth2013
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
©PathwayHealth2013157
• 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
©PathwayHealth2013
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
©PathwayHealth2013
and/or Medicaid provider of specialized rehab services
– Provide medically-related social services
159
§483.45Pharmacyservices.
Implementation Timeline
ThissectionwillbeimplementedinPhase1 withthe
followingexceptions:
• (c)(2)Medicalchartreview—ImplementedinPhase2
©PathwayHealth2013
• (e)Psychotropicdrugs—ImplementedinPhase2
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
©PathwayHealth2013
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
NotyetincludedatF428
©PathwayHealth2013
• 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
©PathwayHealth2013
– Hypnotic
163
• Pharmacist must report any irregularities to
Pharmacy Services
irregularities to – Attending physician– Medical Director– Director of Nursing
• Reports must be acted upon
©PathwayHealth2013
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
©PathwayHealth2013
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
©PathwayHealth2013
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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§483.50Laboratory,radiology,andother
d
Timeline Implementation
diagnosticservices.
• Thisentiresectionwillbeimplementedin
Phase1
©PathwayHealth2013167
• 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
©PathwayHealth2013
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
– Promptly notify the MD, PA, NP, or CNS of laboratory or radiology results that fall outside of clinical reference ranges in accordance with
©PathwayHealth2013
facility policies and procedures for notification or per physician order
169
§483.55Dentalservices.
Implementation Timeline
ThissectionwillbeimplementedinPhase1 withthefollowing
exceptions:
• (a)(3)and(a)(5)Lossordamageofdenturesandpolicyfor
referral—ImplementedinPhase2
©PathwayHealth2013
• (b)(3)and(b)(4)Referralfordentalservicesregardinglossor
damageddentures—ImplementedinPhase2
170
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• Prohibits SNF from charging a resident for lost or broken dentures when facility is responsible
• Must make referral promptly to fix or replace
Dental Services
• Must make referral promptly to fix or replace dentures within 3 business days
• Extenuating circ*mstances must be documented in the record
• Assist with appointments and transportation
©PathwayHealth2013
Policy, education
171
§483.60Foodandnutritionservices.
ThissectionwillbeimplementedinPhase1 withthefollowing
exceptions:
Implementation Timeline
exceptions:
• (a)AslinkedtoFacilityAssessment‐ ImplementedinPhase2
• (a)(1)(iv)Dietitianshiredorcontractedwithpriortoeffectivedate—Built
inimplementationdateof5years followingeffectivedateofthefinalrule.
• (a)(2)(i)Directoroffood&nutritionservicesdesignatedtoservepriorto
effective—Builtinimplementationdateof5years followingtheeffectivedate
of the final rule
©PathwayHealth2013
ofthefinalrule.
• (a)(2)(i)Dietitiansdesignatedtoaftertheeffectivedate—Builtin
implementationdateof1year followingtheeffectivedateofthefinalrule.
172
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• Director must be one of the following:– Certified Dietary Manager
C ifi d F d S i M
Food & Nutrition Services
– Certified Food Service Manager– Certification from national certification body– Have an AA or higher in food service management or
hospitality– Also meet any state requirements if present
• Menus & nutritional adequacy must reflect needs and preferences:
©PathwayHealth2013
and preferences:– Religious– Cultural– Ethnic
173
F361• Staffing – must employ sufficient staff with
appropriate competencies and skills to carry out
Food & Nutrition Services
pp p p yfunction of food services taking into consideration– Resident assessment– Plan of care– Diagnoses and acuity– Census
• Dietician – to be qualified must be registered by
©PathwayHealth2013
• Dietician – to be qualified must be registered by Commission on Dietetic Registration of the Academy of Nutrition and Dietetics or meets state licensure or certification requirements
174
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• Provide food & drink considering (F363)– Allergies
Food & Nutrition Services
g– Intolerances– Preferences of each resident– Ensuring adequate hydration
• Dietician may order therapeutic diets (F367)• Frequency of Meals (F368)
– Have available nourishing alternative meals & snacks
©PathwayHealth2013
– Non traditional times– Outside of scheduled meal times– Follow care plan
175
• Clinical need & extent of dining assistance for feeding assistant must be in care plan (F369)F d S f t (F371)
Food & Nutrition Services
• Food Safety (F371)– Ok from local producers– Ok for facility garden produce– Residents may consume food not procured by facility
• Policy needed for use and storage of foods brought into facility by family or visitors
©PathwayHealth2013
Policy, education, menus, preferences form, care plan
176
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• Food Safety Requirements (F371)– Facility may obtain food item from local
Food and Nutrition Services
producers, subject to applicable State and local laws or regulations
– Facility may use produce grown in facility gardens, subject to applicable safe growing and food handling
©PathwayHealth2013
practices– Residents may consume foods not
procured by the facility
177
• Facility must store, prepare, distribute and serve food in accordance with
Food and Nutrition Services
and serve food in accordance with professional standards for food service safety
• Facility must have a policy regarding use and storage of foods brought to residents from the outside to ensure
©PathwayHealth2013
residents from the outside to ensure safe and sanitary storage, handling, and consumption
178
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• Facility must provide food and drink (F364) that is palatable attractive and
Food and Nutrition Services
(F364) that is palatable, attractive, and at a safe and appetizing temperature
• Facility must provide drinks including water and other liquids consistent with resident needs and preferences and
ff d h d
©PathwayHealth2013
sufficient to maintain resident hydration (F366)
179
F 368• Facility must provide at least three
Food and Nutrition Services
meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plans of care
©PathwayHealth2013
• The 14 hour rule does not apply if the resident group agrees to waive if nourishing snack is provided – 16 then
180
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• Facility must provide special eating equipment and utensils for residents
Food and Nutrition Services
who need them and appropriate assistance to ensure the resident can use the assistive devices when consuming meals and snacks (F369)
• In an emergency a feeding assistant
©PathwayHealth2013
• In an emergency a feeding assistant must call a supervisory nurse for help
181
• Feeding Assistant Program (F373)– Facility must base resident selection on
Food and Nutrition Services
ythe interdisciplinary team’s assessment and the resident’s latest assessment and plan of care
– Appropriateness for the program should be reflected in the care plan
©PathwayHealth2013182
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• Facility must ensure that feeding assistants provide assistance only for
d h h l d
Food and Nutrition Services
residents who have no complicated feeding problems
• Complicated feeding problems include but are not limited to– Difficulty swallowing
©PathwayHealth2013
– Recurrent lung aspirations– Tube feedings– Parenteral feedings
183
§483.65Specializedrehabilitativeservices.
Implementation Timeline
• Thisentiresectionwillbeimplementedin
Phase1.
©PathwayHealth2013184
106
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• Provision of services (F406)– Adds respiratory services to specialized rehab
Specialized & Outpatient Rehab
– Clarifies what constitutes as rehab for• Mental illness• Intellectual disability
©PathwayHealth2013185
• Provision of Services– If specialized rehab services such as but not limited
to PT ST OT RT and rehab services for mental
Specialized & Outpatient Rehab
to PT, ST, OT, RT and rehab services for mental illness and intellectual disability or services of a lesser intensity are required in the resident’s comprehensive plan of care, the facility must
• Provide the required services• Obtain the required services from an outside resource from
a MC or MA provider of specialized rehab servicesObt i itt d f h i i th lifi d
©PathwayHealth2013
• Obtain a written order of a physician or other qualified personnel
186
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§483.70Administration.
Implementation Timeline
ThissectionwillbeimplementedinPhase1 with
thefollowingexceptions:
(d)(3)GoverningbodyresponsibilityofQAPI
program—ImplementedinPhase3.
©PathwayHealth2013
p g p
(e)Facilityassessment—Implementedin
Phase2.
187
• Facility Wide Resource Assessment (F490)– To determine appropriate resources to care for
Administration
– To determine appropriate resources to care for residents during day to day operations and also in emergencies
– Update annually & with any major change in census or services
– Address the following:• Census
©PathwayHealth2013
• Capacity• Types of Care • Staff competencies required• Cultural aspects• Resources (personnel & equipment)
188
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• Facility Assessment must address or include
Resident population
Administration
– Resident population• Number of residents in facility & capacity• Care required by resident population considering
– Types of diseases, conditions, physical & cognitive disabilities, overall acuity, and other pertinent facts of the population
– Staff competencies that are necessary to care for
©PathwayHealth2013
the population– Physical environment, equipment, services, and
other physical plant considerations– Any ethnic, cultural, or religious factors that may
potentially affect the care including nutrition and activities
189
• Facility Assessment must address or include– Facility resources
Administration
Facility resources• All buildings, physical structures, vehicles• Equipment (medical and non-medical)• Therapies and pharmacy• All personnel including managers, staff (both
employed and contracted) and volunteers as well as their education and/or training and any
©PathwayHealth2013
well as their education and/or training and any competencies related to resident care
• Contracts, memos of understanding, or other agreements with third parties to provide services or equipment to facility during normal operations or emergencies
190
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• Facility Assessment must address or include– Facility resources
Administration
Facility resources• Health information technology resources, such
as systems for electronically managing patient records and electronically sharing information with other organizations
– Facility-based and community-based risk assessment utilizing a all-hazards approach
©PathwayHealth2013
assessment utilizing a all hazards approach
– https://www.fema.gov/pdf/plan/slg101.pdf– http://www.who.int/hac/techguidance/preparedness/em
ergency_preparedness_eng.pdf
191
• Clinical Records – HIPAA language added• Binding Arbitration Agreements (F525)
– Must be explained
Administration
Must be explained– Acknowledge understanding– Voluntary– Admission may not be contingent upon signing– Cannot discourage resident or anyone else from
communicating with federal, state, local health officials or ombudsman
©PathwayHealth2013
officials or ombudsman– Neutral arbitrator in convenient location
192
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• Governing body (F493)• Administrator reports to and is
Administration
paccountable to the governing body
• Governing body is responsible and accountable for the QAPI program
©PathwayHealth2013193
• Medical Records (F514)– Facility must keep confidential all PHI except
when the release is to
Administration
when the release is to• The resident or representative• Required by law• For treatment, payment, or health care operations• For public health activities, reporting of abuse,
neglect, domestic violence, health oversight activities, judicial or administrative proceedings, law
©PathwayHealth2013
enforcement purposes, organ donation purposes, to coroners, medical examiners, funeral directors, and to avert a serious threat to health and safety
194
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• Retention of medical records– The medical record must contain
• Sufficient information to identify the resident
Administration
• Sufficient information to identify the resident• Record of resident assessments• Comprehensive plan of care and services provided• Results of any preadmission screening and resident
review evaluations and determinations conducted by the state
• Physician, nurse, and other licensed professional
©PathwayHealth2013
notes• Lab, radiology, and other diagnostic services reports
195
• Any facility with more than 120 beds must employ a qualified social worker full time (F250)
Administration
(F250)• A qualified social worker is
– An individual with a minimum of a bachelor’s degree in social work or a bachelor’s degree in a human services field One year of supervised social work experience in a health care setting
©PathwayHealth2013
working directly with individuals
196
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§483.75Qualityassuranceandperformanceimprovement.
ThissectionwillbeimplementedinPhase3 withthefollowing
Implementation Timeline
p g
exceptions:
• (a)(2)InitialQAPIPlanmustbeprovidedtoStateAgency
Surveyoratannualsurvey—ImplementedinPhase2
• (g)(1)QAAcommittee—Allrequirementsofthissectionwill
beimplementedinPhase1 withtheexceptionof
©PathwayHealth2013
subparagraph(iv),theadditionoftheIP,whichwillbe
implementedinPhase3
• (h)Disclosureofinformation—ImplementedinPhase1
• (i)Sanctions—ImplementedinPhase1
197
• Quality Assurance & Performance Improvement Program – requires all SNFs to:– Develop
QAPI – NEW Section
p– Implement– Maintain
• Effective, comprehensive, data driven QAPI program that focuses on:– Systems of Care
Outcomes of Care
©PathwayHealth2013
– Outcomes of Care– Quality of Life
Policy, education, QAPI program
198
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• Program Design and Scope must– Address all systems of care and
t ti
QAPI
management practices– Include clinical care, quality of life, and
resident choice– Utilize best available evidence to define
and measure indicators of quality and f ilit l th t fl t f
©PathwayHealth2013
facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of SNF
199
• Program Design and Scope must– Reflect the complexities, unique care,
d i th t th f ilit id
QAPI
and services that the facility provides• Program Feedback, data systems, and
monitoring– Facility must establish and implement
written policies and procedures for
©PathwayHealth2013
feedback, data collection systems, and monitoring, including adverse event monitoring
200
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• Program Feedback, data systems, and monitoring
QAPI
g– Policies and procedures must include
• Facility maintenance of effective systems to obtain and use feedback from staff, residents, representatives, including how much information will be used to identify problems that are high risk high volume or
©PathwayHealth2013
problems that are high risk, high volume, or problem prone and opportunities for improvement
201
• Program Feedback, data systems, and monitoring
QAPI
monitoring– Policies and procedures must include
• Facility maintenance of effective systems to identify, collect, and use data from all departments, including the facility assessment and how such
©PathwayHealth2013
the facility assessment and how such information will be used to develop and monitor performance indicators
202
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• Program Feedback, data systems, and monitoring
Policies and procedures must include
QAPI
– Policies and procedures must include• Facility development, monitoring, and
evaluation of performance indicators including methodology and frequency
• Facility adverse event monitoring, including the methods by which the facility will
©PathwayHealth2013
systematically identify, report, track, investigate, analyze and use data and information including how to develop activities to prevent adverse events
203
• Program systematic analysis and systemic action
QAPI
– Facility must take actions aimed at performance improvement and after implementing actions, measure success and track performance to ensure improvements are realized and
t i d
©PathwayHealth2013
sustained
204
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• Program systematic analysis and systemic action
Facility will develop and implement
QAPI
– Facility will develop and implement policies addressing
• How they will use a systematic approach to determine underlying causes of problems
– Root cause analysis– Reverse tracer methodology
H lth f il d ff t l i
©PathwayHealth2013
– Health care failure and effects analysis
– Develop corrective actions to prevent quality of care and life, or safety problems
205
• Program systematic analysis and systemic action
QAPI
systemic action– Facility will develop and implement
policies addressing• How the facility will monitor the
effectiveness of its performance improvement activities to ensure that i i d
©PathwayHealth2013
improvements are sustained
206
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• Program Activities– Facility must set priorities for its
f i t ti iti
QAPI
performance improvement activities that focus on high risk, high volume, problem-prone areas
– Consider the incidence, prevalence, and severity of problems in those areasAff t h lth t id t f t
©PathwayHealth2013
– Affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care
207
• Program Activities– Performance improvement activities
must track medical errors and adverse
QAPI
must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning
– Conduct distinct performance
©PathwayHealth2013
Conduct distinct performance improvement projects, at least one annually that focuses on a high risk area or problem-prone area
208
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• Governance and Leadership– Responsible and accountable for
QAPI
ensuring QAPI program is• defined, implemented and maintained
addressing identified priorities• sustained during transitions in leadership
and staffing• adequately resourced including ensuring
©PathwayHealth2013
• adequately resourced, including ensuring staff time, equipment, and technical training as needed
209
• Governance and Leadership– Responsible and accountable for
QAPI
ensuring QAPI program• Identifies & prioritizes problems and
opportunities based on performance indicators, resident and staff input and services provided to residents
• Corrective action addresses gaps in systems
©PathwayHealth2013
Corrective action addresses gaps in systems and is evaluated for effectiveness
• Sets clear expectations around safety, quality, rights, choice, and respect
210
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• Committee membership must include at a minimum
QAPI
include at a minimum– Director of Nursing– Medical Director or designee– Infection Control & Prevention Officer– At least three other members of the
t ff t l t f h t b th
©PathwayHealth2013
staff, at least one of who must be the Administrator, owner, a board member, or other individual in a leadership role
211
• The committee must– Meet at least quarterly and as needed
QAPI
Meet at least quarterly and as needed– Develop & implement plans of action to
correct deficiencies– Regularly review and analyze data,
including data collected under the QAPI program and data resulting from DRR
©PathwayHealth2013
program and data resulting from DRR and act on available data to make improvements
212
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• Disclosure of information– State may not require disclosure of
QAPI
y qrecords for QA related to compliance
– Demonstration of compliance may require State or Federal surveyor access
• Systems and reports demonstrating systematic identification, reporting, i ti ti l i d ti f
©PathwayHealth2013
investigation, analysis and prevention of adverse events
213
• Disclosure of information– Demonstration of compliance may
QAPI
p yrequire State or Federal surveyor access to
• Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities
©PathwayHealth2013
performance improvement activities• Other documentation considered necessary
by a State or Federal surveyor in assessing compliance
214
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§483.80Infectioncontrol.
Implementation Timeline
ThissectionwillbeimplementedinPhase1 withthefollowing
exceptions:
• (a)AslinkedtoFacilityAssessmentat§483.70(e)—
ImplementedinPhase2
• (a)(3) Antibiotic stewardship—Implemented in Phase 2
©PathwayHealth2013
(a)(3)Antibioticstewardship ImplementedinPhase2
• (b)InfectionPreventionist (IP)—ImplementedinPhase3
• (c)IPparticipationonQAAcommittee—Implementedin
Phase3
215
• IP – Infection Preventionist• IPCP – Infection Prevention & Control Program
system to
Infection Control
– Prevent– Identify– Report– Investigate– Control infections & communicable diseases for all
• Residents
©PathwayHealth2013
Residents• Staff• Volunteers• Visitors• Others providing services
– Review and update annually216
122
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• IPCP must include written standards, policies, and procedures th t i l d (F441)
Infection Control
that include (F441)– System of surveillance designed to identify
possible communicable diseases or infections before they can spread
– When and to whom possible incidents of communicable diseases or infections should
©PathwayHealth2013
communicable diseases or infections should be reported to
– Standards and transmission based precautions to be followed to prevent the spread of infections
217
• IPCP must include written standards, policies, and procedures th t i l d
Infection Control
that include– When isolation is to be used– Circ*mstances under which the facility
must prohibit employees with communicable diseases or infected skin lesions from direct contact with residents
©PathwayHealth2013
lesions from direct contact with residents or their food
– Hand hygiene procedures to be followed by staff involved in direct resident contact
218
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• IPCP must include – Phase 2 - an antibiotic stewardship
th t i l d tibi ti
Infection Control
program that includes antibiotic use protocols and a system to monitor antibiotic use
– a system for recording incidents identified under the facility IPCP and the corrective actions taken by the facility
©PathwayHealth2013
corrective actions taken by the facility
219
• Facility must designate one individual as the Infection Preventionist (IP) for whom the IPCP at the facility is a major
Infection Control
the IPCP at the facility is a major responsibility
• The IP must– Be a nurse, medical technologist, microbiologist,
epidemiologist or other related field– work at least part time at the facility
©PathwayHealth2013
work at least part time at the facility– Is qualified by education, training, experience or
certification– Have specialized training in infection prevention
and control– Participate on the QAA committee – Phase 3 220
124
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• Annual Review– The facility will conduct an annual
i f it I f ti C t l
Infection Control
review of its Infection Control Prevention Program and update the program as necessary
©PathwayHealth2013221
§483.85Complianceandethicsprogram.
Implementation Timeline
• Thisentiresectionwillbeimplementedin
Phase3
©PathwayHealth2013222
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• Requires the operating organization for each facility to have a program that has:
Compliance & Ethics -NEW
– Established written compliance & ethics standards
– Polices and procedures capable of reducing the prospect of violations:
• Criminal• Civil
©PathwayHealth2013
• Administrative violations
Policy, program, education
223
• Minimum requirements– Established written policies and
d
Compliance & Ethics -NEW
procedures– Contact person for reporting– Alternate method of reporting
anonymously – Disciplinary standards that set out
©PathwayHealth2013
consequences for violations– Assignment of overseers of compliance
224
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• Minimum requirements– Sufficient resources and authority to overseer
Due care not to delegate substantial
Compliance & Ethics -NEW
– Due care not to delegate substantial discretionary authority to individuals who the operating organization knew or should have known may have had the propensity to engage in a violation
– Facility must communicate program to staff, individuals providing services under a
©PathwayHealth2013
individuals providing services under a contractual arrangement and volunteers, training is mandatory
225
• Minimum requirementsTake reasonable steps to achieve
Compliance & Ethics -NEW
– Take reasonable steps to achieve compliance by monitoring & auditing
– Consistent enforcement of the program– After a violation is detected ensure all
reasonable steps are tend to respond appropriately to the violation and
©PathwayHealth2013
appropriately to the violation and prevent further similar violations
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• For 5 or more facilities– Mandatory annual training on the
Compliance & Ethics -NEW
Mandatory annual training on the program
– Designated compliance officer for whom the program is a responsibility and must report to governing body
– Have designated compliance liaisons at
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Have designated compliance liaisons at each facility
– Annual review of program and revision if necessary
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§483.90Physicalenvironment.
Implementation Timeline
ThissectionwillbeimplementedinPhase1 withthefollowing
exceptions:
• (f)(1)Callsystemfromeachresident’sbedside—Implemented
inPhase3
• (h)(5) Policies regarding smoking—Implemented in Phase 2
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(h)(5)Policiesregardingsmoking ImplementedinPhase2
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• New certification/building going forward– Two residents or less per room– Each resident room must have a bathroom with:
Physical Environment
• Toilet• Sink
• Establish policies regarding smoking in accordance with federal, state, and local laws and regulations, must include– Smoking
T b i
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– Tobacco cessation– Smoking areas– Safety
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• Facility must conduct regular inspection of all bed frames mattresses and bed
Physical Environment
of all bed frames, mattresses, and bed rails as a part of a preventive maintenance program to identify possible areas of entrapment
• Facility must ensure all components are bl
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compatible• Call light availability at the bedside
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§483.95Trainingrequirements.
Implementation Timeline
ThisentiresectionwillbeimplementedinPhase3 withthe
followingexceptions:
• (c)Abuse,neglect,andexploitationtraining—Implementedin
Phase1
• (g)(1)Regardingin‐servicetraining,(g)2)dementia
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management&abusepreventiontraining,(g)(4)careofthe
cognitivelyimpaired—ImplementedinPhase1
• (h)Trainingoffeedingassistants—ImplementedinPhase1
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• Training program for:New and existing staff
Training Requirements
– New and existing staff– Contracted staff– Volunteers
• Facility determines the amount and
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types of training necessary
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• Topics must include:– Communication– Resident Rights / Facility Responsibilities
Training Requirements - NEW
– Resident Rights / Facility Responsibilities– Abuse, Neglect, and Exploitation– QAPI– Infection Control– Compliance & Ethics– In-service training for nursing assistants
D ti & b t f 12 h
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• Dementia & abuse part of 12 hours
– Behavioral Health
Policy, education, programs
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Question & Answer
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• www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf
Resources/References
ds/Survey and Cert Letter 17 07.pdf• www.federalregister.gov/articles/2015/07/16/201
5-17207/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilitieswww.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-
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/ / / yIOMs-Items/CMS1201984.html
• www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapidefinition.html
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• http://www.samhsa.gov/nctic(substance abuse and mental health
Resources/References
(services administration)
• https://surveyortraining.cms.hhs.gov/index.aspx
• https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National
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Education/Outreach/NPC/National-Provider-Calls-and-Events.html
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Resources for changes to the SNF Requirements of Participation and State Operations Manual Appendix PP
State Operations Manual Draft:
www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-17-07.pdf
FDA Bed Rail Safety:
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/BedRailSafety/default.htm
Checklist for Care and Services for a Resident with Dementia:
www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QIS-Dementia-Care-Checklist.pdf
CMS Medicare Beneficiary Resident Rights:
www.medicare.gov/what-medicare-covers/part-a/rights-in-snf.html
Resident Assessment Instrument manual (MDS 3.0):
www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html
National Nursing Home Quality Improvement Campaign for Person Centered Care:
www.nhqualitycampaign.org/goalDetail.aspx?g=pcc
Nursing Skills and Competency Tools:
www.ebscohost.com/promoMaterials/NPS_Neurological_Assessment.pdf
Substance Abuse and Mental Health Services Administration:
http://www.samhsa.gov/
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Compliance Programs:
www.ahcancal.org/facility_operations/integrity/Pages/Compliance-Programs.aspx
CMS S&C Memo re: Safe Smoking in Nursing Homes:
www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter12_04.pdf
National Fire Protection Association:
http://www.nfpa.org/
CMS website for QAPI:
www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/nhqapi.html
CDC website for Antibiotic Stewardship:
http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
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