Long Term Care Facilities Reform of Requirements for

Long Term Care Facilities Reform of Requirements for Participation Implementation Update Nancy L Fisher, RN, MD, MPH CMO Region VIII* and X Centers for Medicare and Medicaid [email protected] 1 * acting Final LTC Requirements of Participation These requirements have not been comprehensively updated since 1991 despite significant changes in the industry. The proposed revisions reflect advances in the theory and practice of service delivery and safety, and implement sections of the Affordable Care Act (ACA). The proposed rule received over 9,800 public comments, resulting in a number of revisions to the proposed requirements. Final rule on display in Federal Register: September 28, 2016 Effective: November 28, 2016 (with phased implementation dates)

https:// www.federalregister.gov/public-inspection/current#special-filing-centers-for-medica re-medicaid-services 2 Background The requirements for Long-Term Care (LTC) Facilities are the health and safety standards that LTC facilities must meet in order to participate in the Medicare or Medicaid Programs. The Requirements for Participation are found at 42 CFR 483 Subpart B. Additional guidance can be found in the State Operations Manual, Appendix PP 4 3

Themes of the Final LTC Rule Person-Centered Care Quality Facility Assessment, Competency-Based Approach Alignment with HHS priorities Comprehensive Review and Modernization Implementation of Legislation 5 4 Phased In Implementation Schedule Regulation will be implemented in 3 phases. Phase 1: Existing requirements, those requirements relatively straightforward to implement, and require minor changes to survey process (November 28, 2016)

Phase 2: All Phase 1 requirements, and those that providers need more time to develop, foundational elements, new survey process can assess compliance. (November 28, 2017) Phase 3: All Phase 1 and 2, those requirements that need more time to implement (personnel hiring and training, implementation of systems approaches to quality) (November 28, 2019) 6 5 Phase 1 Phase 1 (* this section is partially implemented in Phase 2 and/or 3) Resident Rights* Pharmacy Services* Freedom from Abuse Neglect and Laboratory, radiology and other diagnostic

Exploitation* services Admission, Transfer and Discharge* Dental Services* Resident Assessment Food and Nutrition* Comprehensive, Person-Centered Specialized Rehabilitation Care Planning* Administration (Facility Assessment Phase 2)* Quality of Life Quality Assurance and Performance Improvement* - QAA Committee Quality of Care* Physician Services Infection Control Program* Nursing Services* Physical Environment*

6 Phases 2 and 3 Phase Primary Implementation Phase 2 Behavioral Health Services* Quality Assurance and Performance Improvement* - QAPI Plan Infection Control Facility Assessment and Antibiotic Stewardship ** Physical Environment- smoking policies * Phase 3 Quality Assurance and Performance Improvement* Implementation of QAPI

Infection Control Infection Control Preventionist * Compliance and Ethics Physical Environment- call lights at resident bedside * Training * * This section is partially implemented in other phases. 7 483.5 Definitions & 483.10 Resident Rights 483.5 Definitions Added federal definitions: Abuse, neglect, exploitation, mistreatment, Adverse event (QAPI), Person-centered care 483.10 Resident Rights Significant existing language Participation in care plan Smaller changes (e.g., interest bearing account for funds

>$100, posting additional contact information) Almost all Phase 1 9 8 Abuse, Neglect, Exploitation & Adm., Transfer, Discharge 483.12 Freedom from Abuse, Neglect, and Exploitation Phase 1 Strengthens existing protections, in addition to review of policies and procedures. Adds language related to resident right to be free from neglect and exploitation, and expands on freedom from restraints requirement. Phase 2 Regulatory inclusion of 1150B requirements (Reporting reasonable suspicion of a crime). This is an existing requirement under the Statute. Phase 3 QAPI must be involved in review of allegations/incidences of abuse, neglect and exploitation. 483.15 Admission, Transfer, and Discharge Rights Strengthens requirements for discharge planning. Phase 1: all sections implemented except: (c)(2) Transfer/Discharge

DocumentationImplemented in Phase 2. 10 9 Resident Assessment & Comp Person-Centered Care Plan 483.20 Resident Assessment Few changes to resident assessment, but strengthened PASARR section. Implemented in Phase 1. 483.21 Comprehensive Person-Centered Care Planning Most of requirements maintained- implemented in Phase 1 Baseline care planImplemented in Phase 2. (b)(3)(iii) Trauma informed careImplemented in Phase 3. 11 10

483.24 Quality of Life & 483.25 Quality of Care 483.24 Quality of Life Highest Practicable Well-Being language added to this section. No new requirements. More specifics related to CPR. ADLs moved from QoC. Implemented Phase 1. 483.25 Quality of Care Adds special care issues many of which were previously cited under F309 if there were care issues. Special Needs expanded: Foot Care, pain management, incontinence (including bowel), dialysis services, trauma-informed care, bed rails. Nutrition moved to new section of rule Medication-related provisions moved to pharmacy section All of this section implemented in Phase 1 except trauma-informed care (Phase 3). 12 11

483.30 Physician Services & 483.35 Nursing Services 483.30 Physician Services Final rule removed language in proposed rule regarding physician visit prior to transfer. Ability to delegate dietary and therapy orders (per State law). All of this section implemented in Phase 1. 483.35 Nursing Services Need both sufficient and competent staffing based on resident population. Embedded nurse aide minimum training and competency requirements. Links staffing to Facilitys Assessment (Phase 2). Otherwise, mostly existing requirements and will be implemented in Phase 1. 13 12 483.40 Behavioral Health Services

New requirement (incorporates highest practicable well-being, specialized rehabilitation, and medical social services) Prevention and treatment of mental and substance use disorders Sufficient, competent staff Resident with dementia has treatment and services needed to meet his/her needs

Implementation on non-pharmacological interventions Mostly implemented in Phase 2, except: Phase 1: Comprehensive assessment and medically-related social services. Phase 3: Residents with history of trauma/PTSD 14 13

483.45 Pharmacy Services Existing requirements (freedom from unnecessary medications and medication errors, medication storage, drug regimen review) Definition of psychotropic medication All in phase 1, except the following in phase 2: Review of medical chart as part of drug regimen review PRN usage of psychotropic medication 14 days difference between psychotropic and antipsychotic medications 15

14 Other Regulations Minor Changes 483.50 Laboratory, radiology, and other diagnostic services (phase 1): Prompt notification of findings outside clinical reference ranges Non-physician practitioners orders. 483.55 Dental services (new requirements for replacing lost dentures Phase 2). 16 15

483.60 Food and Nutrition Services Primarily Phase 1. Continues food and nutrition protections Qualified Dietary Staff sufficient and competent as linked to facility assessment (phase 2) Updated education requirements for dietitian and Director of Food and Nutrition must meet within 5 years for current employees (Diet., and Dir. F/N), or 1 year for new hires (Dir. F/N) Reasonable efforts to address religious, cultural and ethnic needs Snacks Policy regarding use and storage of foods from outside 17 16 483.70 Administration

Primarily Phase 1 Maintains Existing Requirements Facility Assessment (Phase 2): Holistic approach resident population (e.g., conditions, acuity), physical environment, cultural environment, resources, equipment, services, personnel, contracts, technology Full time social worker for 120 beds + /qualifications Emergency preparedness: Moved to new 483.73 (separate rule) Incorporates recent regulations (facility closure, hospice, payroll based journal) 18

17 483.75 Quality Assurance and Performance Improvement Phase 1 - Participation in QAA Committee and maintain existing QAA requirements Phase 2 QAPI Plan as required by Affordable Care Act Phase 3 Full Implementation of QAPI and integration of Infection Preventionist 19 18 483.80 Infection Control Current Requirements (Phase 1) Infection Control Program Linens Infection Control Preventionist with Specialized Training

(Phase 3) Antibiotic Stewardship (Phase 2) Flu and Pneumonia Vaccines 20 19 483.85 Compliance and Ethics Program Phase 3 Implementation Program must be reasonably capable of reducing the prospect of criminal, civil and administrative violations under the Act and promoting quality of care and include: Appointing a C&E representative for facility and organization

Enforcing operating standards Responding to violations Reviewing annually 21 20 483.90 Physical Environment Primarily Phase 1 Maintains many existing protections:

Two residents to a room for new construction/reconstruction Resident call next to the bed Phase 3 Smoking policies Phase 2 22 21 483.95 Training Requirements Training requirements for all staff, contractors, volunteers in Phase 3 except... Incorporates training requirements previously found elsewhere (required training for nurse aides, prohibition of abuse and neglect) Phase 1 Adds in requirements from Affordable Care Act dementia care training Phase 1 23

22 How are we going to implement? 24 Implementation Timeline Implementatio n Date Phase 1: November 2016 Type of Change Details of Change Effective date of new

LTC Requirements for Participation New Regulatory Language under current F Tags New F Tag numbers Interpretive Guidance (IG) Changes Begin surveying with the new survey process Phase 2: November 2017

Appendix PP of State Operations Manual Implement new survey process 24 What Exactly Does This Mean? For example: 42 CFR 483.999 The facility must provide purple attire for all residents to wear on Sundays. (Disclaimer: This is not a real requirement.) 26

25 Expected Impact Phase 1 F156 (Closest fit in terms of regulatory intent.) 483.10(b)(1) -- The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility 483.999 The facility must provide purple attire for all residents to wear on Sundays. ************************************* Interpretive Guidance/Survey Process doesnt change 27 26

Expected Impact Phase 2 F980 (Formerly F156) 483.10(g)(16)(i) -- The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. ************************************* F981 (NEW) 483.999 The facility must provide purple attire for all residents to wear on Sundays. Interpretive Guidance/Survey Process may change 28 27 New Survey Process Background

Quality Indicator Survey (QIS) and Traditional Survey operating simultaneously for ~10 years (S & C memorandum 15-40-NH) Regulatory Changes Quality Indicator Survey Maintaining two survey processes:

Positives/negatives to each process Consistency issues Efficiency issues Traditional Data/ Study/ Test New Survey Process 28

New Survey Protocol New Survey Process starting in Phase 2 - November 28, 2017 Incorporates New Requirements and interpretive guidance (SOM App. PP) New F-tags Coding System- F540 + Computer-based

Two parts: 1. Sample Selection o Off-site o Onsite 2. Investigation o Interviews, observations, record reviews 29 Roll Out Phase 1: Recorded Webinar highlighting Phase 1 changes (S&C 17-03-NH) Tools (S&C 17-07-NH) Revised F-Tags, Advance Copy Appendix PP, Job Aide

Phase 2: Webinars and National Provider Calls New Tags, Interpretive Guidance, Survey Process Summer 2017 31 30 Survey and Certification Resources Policy Memos to Regions and States: https:// www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-Sta tes-and-Regions.html 16-13-NH: Electronic Staffing Data Submission PBJ 16-15-NH: State Operations Manual (SOM) revisions to guidance for surveyors to help identify psychosocial harm 16-27-NH: Release of Nursing Home Enforcement Data 16-28-NH: Update Report on National Partnership to Improve Dementia Care in Nursing Homes

16-31-NH: Mandatory Immediate Imposition of Federal Remedies and Assessment Factors Used to Determine the Seriousness of Deficiencies for Nursing Homes 16-33-NH: Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings by Nursing Home Staff 17-03-NH: Save the Date: Training for Phase 1 Implementation of New Nursing Home Regulations 17-07-NH: Advance Copy - Revisions to State Operations Manual (SOM), Appendix PP-Revised Regulations and Tags Questions: [email protected] 31 Thank You Thank you Page 32 32

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