margaret huguet, rn long term care supervisor health ...objectives at the end of this session the...

Margaret Huguet, RN Long Term Care Supervisor Health Standards Section

Objectives At the end of this session the participant will be able

to:

Verbalize an understanding of the purpose and themes of the revised federal requirements for long term care.

Navigate through the requirements with an understanding of format and language changes.

Identify requirements within each of the 3 Implementation Phases;

42 CFR 483 Subpart B

Purpose Emergence of significant innovations in care and

quality assessment

Change in Population

Enhanced knowledge about resident safety, health outcomes, individual choice, and QAPI

Types of Changes Content & Structural

Added new requirements

Strengthened some of the regulatory language

Terminology changes

Eliminated duplicative or unnecessary provisions

Aligned requirements with current clinical practice standards

Reorganizing the regulations as appropriate

Themes in the final rule Person-Centered Care

Staffing & Competency

Quality of Life and Care

Changing Population

Implementation of Legislation

Alignment with Health & Human Services (HHS) Initiatives

Nursing Service

Food & Nutrition

Activities

Social Services

Medical Care

Medication Management

F279 - §483.21(b) Comprehensive Care Plans

(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2)and §483.10(c)(3)…

Person Centered Care

F280 - §483.10(c)(2) Comprehensive Care Plans - Resident Rights The right to:

Participate in the development and implementation of person-centered plan of care

Participate in the planning process,

Identify individuals or roles to be included in the planning process,

Request meetings

Request revisions to the person-centered plan of care.

Participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.

Receive the services and/or items included in the plan of care.

See the care plan,

Right to sign after significant changes to the plan of care.


F248 - §483.24(c) Activities. Provide an ongoing program to support residents in

their choice of activities, both facility-sponsored group and

individual activities and

independent activities,

to meet the interests of and support well-being,

encouraging independence and interaction in the community.


F360 - §483.60 Food and nutrition services.

a nourishing, palatable, well-balanced diet

that meets his or her daily nutritional and special dietary needs,

taking into consideration the preferences of each resident.


F490 – Administration §483.70(e) Facility assessment

Phase 2 Implementation

The facility must conduct and document

a FACILITY-WIDE ASSESSMENT

to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.

review and update:

as necessary,

at least annually


Facility Assessment Resident Population Facilities Resources

Number/ facility’s resident capacity

Care required

Staff competencies necessary

Physical environments, equipment, services, other…

Ethnic, cultural, religious factors…

Buildings/structures/vehicles

Equipment

Services provided

Personnel

Contracts/MOUs/…

Health information technology resources


F353 - §483.35 Nursing Services Sufficient nursing staff

with the appropriate competencies and skills sets

to assure resident safety and attain or maintain the highest practicable well-being,

as determined by resident assessments and individual plans of care and

considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e).

[As linked to Facility Assessment, §483.70(e), will be implemented beginning November 28, 2017 (Phase 2)]


F361: §483.60 (a) Staffing – Food & Nutrition Sufficient Staff

with the appropriate competencies and skills sets

to carry out the functions of the food and nutrition service,

taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility’s resident population

In accordance with the facility assessment required at §483.70(e) [As linked to Facility Assessment, §483.70(e), will be implemented beginning November 28, 2017 (Phase 2)]


F490 - Administration §483.95 Training Requirements Phase 3 Implementation A facility must:

develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a

contractual arrangement; and volunteers, consistent with their expected roles.

determine the amount and types of training necessary based on a facility assessment as specified at §483.70(e).

Training topics include: communication, resident’s rights and facility responsibilities, QAPI, Infection Control, Compliance and ethics, Behavioral health


F498 §483.95(g)(3) Required in-service training for nurse aides Phase 3 Implementation

Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.


As linked to Facility Assessment F319 – Behavioral Health Services

F353 - Nursing Services

F361 – Food and Nutrition Services

F441 - Infection prevention and control program

F490 – Administration

F498 – Proficiency of nurse aides

F520 – QAPI

QOL and QOC are overarching principles in the delivery of care to residents of nursing homes and should be applied to every service provided.

Quality of Life and Care Treatment, care, and services

are provided:

consistent with the comprehensive resident assessment

in accordance with professional standards of practice

following the comprehensive person-centered care plan

that is consistent with resident’s needs and choices

Quality of Life and Care

Trauma-informed care

Behavioral health services

F319 – §483.25(m) Trauma-informed care Phase 3 Implementation

The facility must ensure that residents who are trauma survivors receive

culturally competent, trauma-informed care

in accordance with professional standards of practice and

accounting for residents’ experiences and preferences

in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Changing Population

Resources Person-centered care that reflects the principles set forth

in the SAMSHA’s

“Concept of Trauma and Guidance for a Trauma-Informed Approach,”

http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf

SAMSHA = Substance Abuse and Mental Health Services Administrations

Changing Population

F319 - §483.40 Behavioral health services. Phase 2 Implementation

Behavioral health care and services

to attain or maintain the highest practicable well-being,

encompasses a resident’s whole emotional and mental well-being,

includes, not limited to, the prevention and treatment of mental and substance use disorders.

Changing Population

F319 483.40(a) Behavioral health services. Phase 2 Implementation

The facility must have:

sufficient staff who provide direct services

appropriate competencies and skills sets

assure resident safety and attain or maintain the highest practicable well-being

considering number, acuity and diagnoses of the facility’s resident population in accordance with §483.70(e).

Changing Population

F319 – Behavioral health services Competencies and skills sets include, but are not limited

to, knowledge of and appropriate training and supervision for:

Phase 3 Implementation 483.40(a)(1) Caring for residents with

mental and psychosocial disorders, a history of trauma and/or post-traumatic stress disorder


483.40(a)(2) Implementing non-pharmacological interventions

Changing Population

F319 – Behavioral health services §483.40(b) Based on the comprehensive assessment of a

resident, the facility must ensure that—

§483.40(b)(1) A resident who displays or is diagnosed with mental disorder

or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being.

(as linked to history of trauma and/or post- traumatic stress disorder, will be implemented beginning November 28, 2019);

Changing Population

AFFORDABLE CARE ACT IMPACT ACT

F490 -Compliance and Ethics §483.85(b) General rule.


The operating organization for each facility must have in operation

a compliance and ethics program (as defined in paragraph (a) of this section)

that meets the requirements of this section.

Implementation Legislation

Compliance and Ethics Program Basic Elements:

Designation of a compliance officer and compliance committee

Development of compliance policies and procedures, including standards of conduct

Development of open lines of communication

Appropriate training and teaching

Internal monitoring and auditing

Response to detected deficiencies

Enforcement of disciplinary standards


Resources DHHS Office of the Inspector General (OIG) has

issued industry-specific guidance documents on compliance.

March 16, 2000 Federal Register (65 FR 14289)“Final Compliance Program Guidance for Nursing Facilities”

September 30, 2008 Federal Register (73FR 56832) “OIG Supplemental Compliance Program Guidance for Nursing Facilities”


QAPI

initiative


F520 – §483.75 Quality Assurance Performance Improvement Program develop, implement, and maintain

effective, comprehensive, data-driven QAPI program

focuses on indicators of the outcomes of care and quality of life

Phase 2 Implementation - (a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

Phase 3 Implementation for all other subparts of 483.75


§483.75(g) Quality Assessment and Assurance Phase 1 Implementation

(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:

(i) The director of nursing services;

(ii) The Medical Director or his/her designee;

(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role;

Quality Insights QIN-QIO: Free Assistance The Quality Improvement Organization Quality Innovation Network for

Louisiana

They offer free assistance for your performance improvement projects (PIPs), QAPI, free webinars, toolkits, individual data reports, and so much more

QAPI assistance includes how to document your PIP within the methods recommended by CMS QAPI at Glance document

To get started today, reach out to:

Julie Kueker

218-294-0458

[email protected]

CMS QAPI Resources: https://www.cms.gov/Medicare/Provider-enrollment-and-Certification/QAPI/nhqapi.html

Quality Insights: www.qualityinsights.org

mailto:[email protected]

https://www.cms.gov/Medicare/Provider-enrollment-and-Certification/QAPI/nhqapi.html







http://www.qualityinsights.org/

Reporting reasonable suspicion

of crimes


F225 - §483.12(b) Freedom from Abuse, Neglect, Exploitation

Implementation Phase 2

Develop and implement written P/P’s that:

(4) Ensure reporting of crimes occurring in federally-funded LTC facilities

in accordance with section 1150B of the Social Security Act.


(i) Annually notifying COVERED INDIVIDUALS of reporting requirements.

(A) report to the SA and one or more law enforcement …

any reasonable suspicion of a crime against any individual who

is a resident of, or is receiving care from, the facility.

(B) report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or

not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.

(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.


F225 - §483.12(c) Freedom from Abuse, Neglect, Exploitation Phase 1 Implementation

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are: Reported immediately, but not later than: 2 hours after allegation is made, if the events that cause the allegation

involve abuse or results in serious bodily injury,

or not later than 24 hours if the events that cause the allegation

do not involve abuse and do not result in serious bodily injury to the administrator and to State Survey Agency

TRAINING Care for

residents with

Dementia and

Abuse Prevention


Dementia and Abuse Training F498 §483.95(g) Required

in-service training for nurse aides. In-service training must—

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training

F226 - §483.95(c) Abuse, neglect, and exploitation. In addition to the freedom

from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on—

§483.95(c)(3) Dementia management and resident abuse prevention.


http://innovation.cms.gov/initiatives/rahnfr/index.html

HHS Priorities

F441 §483.80 Infection Control The facility must establish and maintain an infection

prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

HHS Priorities

F441 - §483.80 Infection Control Develop Infection Prevent and Control Program

(IPCP)

Antibiotic Stewardship Program -Phase 2 Implementation

Designate at least one Infection Preventionist (IP) - Phase 3 Implementation

Written policies and procedures for the IPCP

Education or training r/t the ICP

Integration of the ICP with the facility’s QAPI processes

HHS Priorities

Antibiotic Stewardship Program Phase 2 Implementation

includes antibiotic use protocols and

a system to monitor antibiotic use.

HHS Priorities

Infection Preventionist Phase 3 Implementation

The IP must:

have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

be qualified by education, training, experience or certification;

work at least part-time at the facility; and

have completed specialized training in infection prevention and control.

HHS Priorities

Health Associated Infections “National Action Plan to Prevent HAIs.”

http://www.hhs.gov/ash/initiatives/hai/actionplan/

HHS Priorities

F329 - §483.45(e) Psychotropic Drugs §483.45(e)(1)-(5) Phase 2 Implementation

Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are

not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

HHS Priorities

Psychotropic drugs Defined as:

any drug that affects brain activities associated with mental processes and behavior.

These drugs include, but are not limited to, drugs in the

following categories: (1) anti-psychotic, (2) antidepressant, (3) anti-anxiety, (4) hypnotic, (5) opioid analgesic, and (6) any other drug that results in effects similar to the drugs listed

above.

HHS Priorities

F329 - §483.45(e) Psychotropic Drugs Phase 2 Implementation

(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

(4) PRN orders for psychotropic drugs limited to 14 days Except , physician/prescribing practitioner believes appropriate for

the PRN order to be extended beyond 14 days, document rationale medical record and indicate the duration.

(5) PRN orders for anti-psychotic drugs

limited to 14 days cannot be renewed unless the attending physician or prescribing

practitioner evaluates the resident for the appropriateness of that medication.

HHS Priorities

Navigating Through

Red Italics = New

Regulatory Language

Navigating Through

Navigating Through

Section §483.10 Resident Rights Retaining all existing resident rights;

Additions to P/P’s may be needed;

Updated language and organization to:

Improve logical order and readability,

clarify aspects of the regulation, and

include advances such as electronic communications.

Navigating Through

Section §483.12 Freedom from Abuse, Neglect, and Exploitation Additional definitions

New Section within CFR

Strengthened existing protections

Additions needed to P/P’s

Adds language r/t right to free from neglect and exploitation

Inclusion of Reporting of reasonable suspicion of a crime in Phase 2

Will require QAPI aspect in Phase 3

Navigating Through

Comprehensive Care Plan- Baseline Care Plan Phase 2 Implementation

develop and implement within 48 hours of admission

include instructions needed to provide effective and person-centered care

Initial goals based on admission orders

Physician orders

Dietary orders

Therapy services

Social services

PASARR recommendations, if applicable

comprehensive care plans developed in 48 hrs. can take place of

Provide resident/representative with summary of baseline care plan

Navigating Through

Comprehensive Person-Centered Care Planning F279 – 483.21 (b) Care Plan must include any specialized

services the facility will provide based on PASARR recommendations

F280 - §483.21(b)(ii)(c) - Nurse aide with responsibility for the resident and §483.21(b)(ii)(d) member of food and nutrition as part of ID Team/Care planning;

F284 - §483.21(c)(1) Develop & implement discharge planning process

Navigating Through

F361 Food and nutrition services §483.60(a)(1) Qualified Dietitian or other qualified

nutrition professional

§483.60(a)(2) If not employed full time, the facility must designate a person to serve as

Director of food and nutrition services

Navigating Through

F411 – §483.55 Dental Services Dentures Phase 2 Implementation

Have policy identifying circumstances when loss or damage of dentures is the facility’s responsibility and may not charge a resident for the loss or damage

Promptly, within 3 days, refer residents with lost or damaged dentures for dental services.

If referral not done, provide documentation of what did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.

Navigating Through

F428 483.45 c - Drug Regimen Review Reviewed every month

include a review of the resident’s medical chart (phase 2)

Pharmacist must report any irregularities to the attending physician, medical director, and director of nursing, and these must be acted upon.

Develop and maintain P/Ps for monthly drug regimen review Time frames for different steps in the process and steps the

pharmacist must take when identifying and irregularity that requires urgent action to protect resident

F323 483.25(n) – Accidents Bed Rails Attempt appropriate alternatives prior to installing a

side or bed rail

Ensure correct installation, use, and maintenance of bed (1) Assess risk of entrapment prior to installation

(2) Review risks and benefits with resident or RP obtain informed consent prior to installation.

(3) Ensure bed’s dimensions are appropriate for the resident’s size and weight.

Navigating Through

F461 –§483.90(c)(3) Physical Environment - Bed Rails Conduct regular inspection of all bed frames,

mattresses, and bed rails, if any, as part of a regular maintenance program

When bed rails and mattresses are used and purchased separately from the bed frame, ensure bed rails, mattress, and bed frame are compatible.

Navigating Through

F465 – 483.90(h)(5) Other Environmental Conditions Establish policies, in accordance with applicable

Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents.

Navigating Through

Terminology changes Examples Examples

F314

Pressure Sores

Pressure Ulcers

F315

Urinary Incontinence

Incontinence (both fecal and urinary)

F317 & F318

Range of Motion

Mobility

F322 483.25 (g) Naso-Gastric Tubes

Assisted nutrition and hydration

F325 Nutrition

Assisted nutrition and hydration

F360 Dietary Services

Food and nutrition services

Navigating Through

New Tags F525 §483.70(n)(1)(2)

Binding arbitration agreements

F526 §483.70(o)(1)-(4)

Hospice services

F527 §483.70(q)(1)-(5)

Mandatory submission of staffing information based on payroll data in a uniform format.

Navigating Through

Implementation Dates

Phase 1 must be implemented by November 28, 2016.



Phase 1 Implementation Existing requirements, those requirements relatively

straightforward to implement, and require minor changes to survey process.

New regulatory language added to the existing F-tags

CFR numbering changes

Phase 2 Implementation F-tag renumbering

additional effective regulations

additional interpretive guidance.

Phase 2 Implementation F156 - Information and

Communication

F202 –Transfer & Discharge Documentation

F225 – P/Ps for Reporting of Crimes

F279 - Baseline Care Plans

F309 - Dementia

F319 Behavioral health services

F328 - Prostheses

F329 - Psychotropic drugs

F353 & F361 as it r/t’s Facility Assessment

Phase 2 Implementation F411 - Dentures

F428 – DRR – Pharmacist review of medical chart

F441 - Antibiotic Stewardship Program

F490 - Facility assessment

F520 - QAPI to SSA

Phase 3 Implementation F226 Abuse P/Ps – QAPI

aspect

F282 Care Plans – be culturally competent and trauma-informed

F319 Trauma-informed care

F441 -Infection Preventionist & QAPI team member

F463 - Resident Call System – each resident’s bedside

F490 - Compliance and ethics program

F490 - Training Requirements

F493 - Governing body – responsible/accountable for QAPI program

F498 - In-service training for NA’s – address areas of weakness identified in the facility assessment

F520 – QAPI

Quality Indicator Survey/ Traditional Survey

New Survey Process Quality Indicator Survey

+

Traditional Survey Process

+

Revised Regulations

Louisiana Top 10 Deficiencies 1. F282 – Follow Plan of

Care

2. F441 – Infection Control

3. F323 – Accidents/ Supervision

4. F371 – Food Store/Prepare/Serve

5. F157 – Notification of Change

6. F278 – Accuracy of Assessment

7. F280 – Revise Care Plan

8. F309 – Highest Practical Well Being

9. F431 – Drug Storage

10. F253 - Housekeeping

Top tags cited at Harm Level F157 – Notification of

Change

F223 - Abuse

F282 – Follow Plan of Care

F309 – Highest Practicable Well-being

F314 – Pressure Ulcers

F315 – Weight Loss

F323 – Accidents Supervision

F325 – Weight Loss

F327 – Sufficient Fluids

F353 – Nurse Staffing

F490 - Administration

F502 – Laboratory Services

F520 - QAA

Tags Cited at Immediate Jeopardy Health Survey LSC Survey

F323 – Accident / Supervision

F490 – Administration

K343 – Fire Alarm System – Notification

K353 – Sprinkler System – Maintenance and Testing

K915 – Electrical Systems

margaret huguet, rn long term care supervisor health ...objectives at the end of this session the...

Documents