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NursingHomeFacilityAssessmentToolandStateOperationsManualRevisionsSeptember7,20172AcronymsinthisPresentationLTC-Long-termCareRUG-ResourceUtilizationGroupsMOU-MemorandumofUnderstandingQAA-QualityAssessmentandAssuranceQAPI-QualityAssuranceandPerformanceImprovementBCP-BaselineCarePlanPRN-As-NeededIP-InfectionPreventionist3AgendaFacilityAssessmentToolJayWeinstein,CMSAngelDavis,CMSMarilynReierson,StratisHealthKellyO'Neill,StratisHealthFrequentlyAskedQuestions–StateCMSSubjectMatterExpertsOperationsManualAppendixPPRevisions4NursingHomeFacilityAssessmentToolJayWeinstein,CMSAngelDavis,CMSMarilynReierson,StratisHealth,NationalCoordinatingCenterKellyO'Neill,StratisHealth,NationalCoordinatingCenter5FacilityAssessmentTool–IntroductionJayWeinstein,NHA,HealthInsuranceSpecialist,DivisionofNursingHomes,SurveyandCertificationGroup,CMSAngelDavis,MBA,MS,BSN,RN,CenterforClinicalStandardsandQuality,QualityImprovementandInnovationGroup,DivisionofBeneficiaryHealthcareImprovementandSafety,CMSToolrequirementandintentTooloverview,developmentprocess,andpilotCloserlookatthetool–walkthrougheachsection6OptionalFacilityAssessmentToolDesignReflectFacilityAssessmentrequirementsdescribedintheregulationBesimplifiedasmuchaspossibleHelpnursingfacilityteamsinplanningfortheirassessmentModifiable–AllowateamtoconsiderandadditemsappropriatefortheirownfacilityandtoindividualizetheirassessmenttomeettheintentoftheregulationSupporttranslationofassessmentfindingsintoaplanUseofthistoolisnotmandatedbyCMS,nordoesitscompletionensureregulatorycompliance7FacilityAssessmentToolPurposeandIntentPurpose:todeterminewhatresourcesarenecessarytocareforresidentscompetentlyduringday-to-dayoperationsandemergenciesMaybeusedtomakedecisionsaboutdirectcarestaffneedsaswellascapabilitiestoprovideservicestotheresidentsinyourfacilityIntent:Forthefacilitytoevaluatetheirresidentpopulationandidentifyresourcesneededtoprovidenecessaryperson-centeredcareandservicesrequiredbyresidents8ToolDevelopmentProcessIterativeprocesswithCMSDrafttoolsharedduringapilottest(July2017)Nationalpartnerandstakeholderorganizations–representingnursinghomes,administrators,directorsofnursing,medicaldirectors,consumers,andsurveyorsNursinghomes,17homesrepresenting7states,mixofrural/urban,large/medium/small,forprofit/nonprofit,ownershipCommentsandfeedbackusedtorevisethetool9FacilityAssessmentToolOverviewIntroductionRequirement,purpose,overviewofthetool,guidelinesforconductingtheassessment,tabletocapturewhentheassessmentwascompleted/updatedandthoseinvolvedThreepartsResidentprofileandfactorsthatimpactcareandsupportneedsServicesandcareofferedbasedonresidentneedsFacilityresourcesneededtoprovidecompetentcareforresidentsTwoattachmentsReferencestothefacilityassessmentintheOctober2016ReformofrequirementsforLong-TermCare(LTC)facilitiesSampleprocessforconductingtheassessment(intendedforinternalnursinghomeuseonly)PlanfortheassessmentCompletetheassessmentSynthesizeandusetheassessmentfindingsEvaluateyourprocessandplanforfutureassessments10PilotTestCommentsandFeedbackAgreementthatitwashelpfulinprovidingdirectionfortheassessmentNearlyallagreedthetoolwasalignedwiththeregulationsandinterpretiveguidance,includedcleardescriptionsofwhatwasbeingasked,providedhelpfulexamples,andcouldbeusedtodeterminewhatresourcesarenecessarytocareforresidentsAgreementthatlistsandexamplesinthetoolwerehelpful,tohelpteamsthinkmorein-depthandnotoverlookkeyareas"Makesusanalyzewhatourresourcesareandlackofresourcestomeettheneedsandrequestsofourclientele.
""Ittriggersapauseforleadershiptocomprehensivelylookatthefacility'soperationsandcomparethattoitsstatedgoals(ifany),identifiedchallenges,etc.
"11PilotTestCommentsandFeedbackAgreementthatAttachment2"Suggestedprocessfortheassessment,"including"synthesisanduseoffindings"washelpfulMentionthatdescribingacuitycanbechallengingSomecommentersaskedformoreinformationinthestaffingsection,othersaskedforlessSomerequestsforalgorithmsorresidentclassificationsystemstodeterminestaffingneeds,patterns,etc.
Somecommentsthatthefirstassessmentmaytakesometime,butafterthat,updatesshouldbequickerManyhelpfulcommentstostrengthenthetool12Let'sLookattheToolLinkforthetool:FacilityAssessmentTool13FacilityAssessmentTool:GuidelinesforConductingtheAssessmentUsedatafromavarietyofsourcesPlanforaninclusiveprocesstoincludepersonsthatcareaboutthisConductatthefacilitylevelReviewandupdateannuallyorwhentherearesignificantchangesUseasarecordtounderstandreasonforstaffingandresourcedecisionsUnderstandhowtheassessmentmaybeusedinthesurveyprocessSeeAttachment2forasuggestedprocessforconductingtheassessment14Part1:ResidentProfileNumbers:licensedbeds,averagedailycensus,#personsadmitted/dischargedCommondiseases/conditions,physicalandcognitivedisabilities(tohelpidentifytypesofresourcesneededtomeettheneedsofresidentslivingwiththeseconditionsorcombinationsofconditions)DecisionsregardingcaringforresidentswithconditionsthatyoudonotcommonlyseeAcuity–toidentifypotentialimplicationsregardingtheintensityofcareandservicesneededThreeexamplesprovided:MajorResourceUtilizationGroups(RUG)-IVcategoriesSpecialtreatmentandconditionsAssistancewithactivitiesofdailylivingOtherEthnic,culture,religiousorotherfactorsthatmayaffectthecareprovided15Part2:ServicesandCareResidentsupportandcareneedsbasedonwhatyourresidentpopulationrequires–toidentifyandreflectonresourcesneededtoprovidethesetypesofcareSamplelistprovided–tobemodifiedbasedonyourpopulation16Part3:FacilityResourcesNeededtoProvideCompetentCareStafftypeSamplelistprovidedfortypeofstaffandotherprofessionals/practitionersStaffingplan–generalapproachtostaffingFordiscussiononhowtodeterminesufficientstaffing,seeAttachment2,7.
bTwoexamplesprovidedOverallnumberofstaffneededGeneralstaffingplanIndividualstaffassignmentStafftraining/educationandcompetenciesSamplelistsprovided(notinclusive)Policiesandproceduresforprovisionofcare17Part3:FacilityResourcesNeededtoProvideCompetentCareWorkingwithmedicalpractitionersPhysicalenvironmentandbuilding/plantneedsOtherContracts,MemorandumofUnderstanding(MOU)orotheragreementswiththirdpartiesHealthinformationtechnologyresourcesInfectionpreventionandcontrolprogramFacility-basedandcommunity-basedriskassessment18Attachment1:RegulatoryMentionsofFacilityAssessmentForyourreferenceNotinclusive19Attachment2:SampleProcessforConductingtheAssessmentPlanfortheassessmentDesignatealeaderLeaderpreparesTeamformedandincludedindiscussionsabouttheintentoftheassessmentandtheprocessandtimelinetobeusedInclusiveprocess–haveallvoicesrepresentedintheassessmentLeadershipsupportstheworkoftheteam–checkinfrequentlyCompletetheassessment20Attachment2:SampleProcessforConductingtheAssessmentSynthesizeandusethefindingsReviewthefindingsRememberthepurposeandintent–makedecisionaboutneededresources,includingdirectcarestaffneedsaswellastheircapabilitiestoprovideservicesandsupporttoresidents;identifyopportunitiesforimprovementWorkthroughthesuggestedquestionsWhathaschangedwithourpopulationDoweneedtomakeanychangestostaffingHowdoweknowifwehavesufficientstaffingWhattraining,educationcompetencyneedsdowehaveHowcanwebettercollaboratewithmedicalpractitionersAnyinfectioncontrolissuesAnyQualityAssessmentandAssurance(QAA)/QualityAssuranceandPerformanceImprovement(QAPI)opportunitiesDoesourbudgetincludetheresourcesweneed21Attachment2:SampleProcessforConductingtheAssessmentEvaluateyourprocessandplanforfutureassessmentsBepreparedtorespondtosurveyorquestionslistedintheinterpretiveguidanceDebriefwithyourteam:whatwentwell,whatcanwedodifferentlynexttimeEstablishaprocessforupdatingtheassessment22What'sNextNursinghomescanuseoradaptthisoptionaltoolCMS:"DuetothesignificantvariationsinthetypesofLTCfacilities,residentpopulations,andresourcesamongtheLTCfacilityfacilities,webelievethatthefacilitiesneedtheflexibilitytodeterminethebestwayforeachfacilitytocomplywiththisrequirement…andconductthatassessment,aslongasitaddressesorincludesthefactorsoritemssetforthin§483.
70(e).
"Wehavenotrequiredanyspecificmethodologyforfacilitiestouseforthefacilityassessment.
"Experienceandfeedback:Asnursinghomesconducttheirassessments,weexpecttolearnmoreaboutwhathasworkedbestforthem,andhopethisinformationwillbesharedamonghomes,andlongtermcarestakeholdergroups23FrequentlyAskedQuestions-StateOperationsManualAppendixPPRevisionsCMSSubjectMatterExperts24§483.
12FreedomfromAbuse,Neglect,andExploitationWhataretheDifferentRequirementsforReportingofSuspectedCrimesv.
AllegedViolations25§483.
12FreedomfromAbuse,Neglect,andExploitationWhatistheDefinitionofSeriousBodilyInjury"Seriousbodilyinjury"meansaninjuryinvolvingextremephysicalpain;involvingsubstantialriskofdeath;involvingprotractedlossorimpairmentofthefunctionofabodilymember,organ,ormentalfaculty;requiringmedicalinterventionsuchassurgery,hospitalization,orphysicalrehabilitation;oraninjuryresultingfromcriminalsexualabuse(Seesection2011(19)(A)oftheAct)26§483.
15Admission,Transfer,andDischargeFacility-initiatedandresident-initiatedtransfersanddischarges:"Facility-initiatedtransferordischarge":Atransferordischargewhichtheresidentobjectsto,didnotoriginatethrougharesident'sverbalorwrittenrequest,and/orisnotinalignmentwiththeresident'sstatedgoalsforcareandpreferences"Resident-initiatedtransferordischarge":Meanstheresidentor,ifappropriate,theresidentrepresentativehasprovidedverbalorwrittennoticeofintenttoleavethefacility(leavingthefacilitydoesnotincludethegeneralexpressionofadesiretoreturnhomeortheelopementofresidentswithcognitiveimpairment)27§483.
15Admission,Transfer,andDischargeSendingcopyoftransfer/dischargenoticetoombudsman:Appliestofacility-initiateddischargesForemergencyroomtransfers,maysendnoticetoombudsmanwhenpracticablesuchasinalistofresidentsonamonthlybasisNoticeoftransferordischargenotrequiredforresident-initiateddischarges28§483.
15Admission,Transfer,andDischargeIsaresident'stransferordischargefacility-orresident-initiatedForatransferordischargetobeconsideredresident-initiated:"Themedicalrecordshouldcontaindocumentationorevidenceoftheresident'sorresidentrepresentative'sverbalorwrittennoticeofintenttoleavethefacility,adischargecareplan,anddocumenteddiscussionswiththeresidentor,ifappropriate,his/herrepresentative,containingdetailsofdischargeplanningandarrangementsforpost-dischargecare.
"(F623guidance)29§483.
21ComprehensiveResidentCenteredCarePlansHowcanprovidersmeetthe48hourrequirementifadmissionoccursontheweekendTheregulationsdonotspecifyhowtocreatetheBaselineCarePlan(BCP);FacilitieswillhavetodeviseaprocessthatensuresnewadmissionshavetheirBCPdonewithintherequired48hours.
ItmaybenecessaryforBCPtobedevelopedoverthecourseofseveralshiftsE.
G.
,Newadmissionat11:40pmonFriday–BCPcompleteby11:40pmonSunday.
30§483.
21ComprehensiveResidentCenteredCarePlansWhatmustbeincludedintheBCP483.
21(a)states,"…TheBCPmust—(ii)Includetheminimumhealthcareinformationnecessarytoproperlycareforaresidentincluding,butnotlimitedto–(A)Initialgoalsbasedonadmissionorders(B)Physicianorders(C)Dietaryorders(D)Therapyservices(E)Socialservices(F)PASARRrecommendation,ifapplicable"Itisexpectedthattheadmissionorderswillbeused,alongwithinformationgatheredbytheadmittingnurse,whichwillincludeinputfromtheresidentorrepresentative.
31§483.
21ComprehensiveResidentCenteredCarePlansCantheBCPbewrittenbeforeadmission,orbeforetalkingtotheresidentItmaybepossibletobegindevelopmentofpartsoftheBCPbeforetheactualadmissionbasedoninformationreceivedfromthetransferringprovider,however,theinformationmustbeverifiedbytheadmissionordersandadmittingnurse'sobservationandinterviewoftheresident32§483.
21ComprehensiveResidentCenteredCarePlansIsaverbalsummaryoftheBCPacceptableTheguidanceatF655states,"Thefacilitymustprovidetheresidentandtherepresentative,ifapplicable,withawrittensummaryofthebaselinecareplan…"33§483.
45PharmacyServicesTwoseparaterequirementsforAs-Needed(PRN)ordersfor:PsychotropicmedicationsAnti-psychoticmedicationsPsychotropicmedicationsinclude,butarenotlimitedto,medicationsinthefollowingcategories:AntipsychoticAnti-depressantAnti-anxietyHypnotic34§483.
45PharmacyServicesFrominterpretiveguidanceatF757/F758:TypeofPRNOrderTimeLimitationExceptionRequiredActionsPRNordersforpsychotropicmedications,excludingantipsychotics14daysOrdermaybeextendedbeyond14daysiftheattendingphysicianorprescribingpractitionerbelievesitisappropriatetoextendtheorder.
Attendingphysicianorprescribingpractitionershoulddocumenttherationalefortheextendedtimeperiodinthemedicalrecordandindicateaspecificduration.
PRNordersforantipsychoticmedicationsonly14daysNoneIftheattendingphysicianorprescribingpractitionerwishestowriteaneworderforthePRNantipsychotic,theattendingphysicianorprescribingpractitionermustfirstevaluatetheresidenttodetermineiftheneworderforthePRNantipsychoticisappropriate.
35§483.
45PharmacyServicesEvaluationofresidentbeforewritinganewPRNorderforantipsychoticmedication:Theattendingphysicianorprescribingpractitionermustdirectlyexaminetheresidentandassesstheresident'scurrentconditionandprogresstodetermineifthePRNantipsychoticmedicationisstillneededTheattendingphysicianorprescribingpractitionershould,ataminimum,determineanddocumentthefollowingintheresident'smedicalrecord:IstheantipsychoticmedicationstillneededonaPRNbasisWhatisthebenefitofthemedicationtotheresidentHavetheresident'sexpressionsorindicationsofdistressimprovedasaresultofthePRNmedication36§483.
60FoodandNutritionServicesQualifiedDieticianAqualifieddietitianorotherclinicallyqualifiednutritionprofessionalisonewho—Holdsabachelor'sorhigherdegree;Completedatleast900hoursofsuperviseddieteticspractice;IslicensedorcertifiedasadietitianornutritionprofessionalbytheState;andMeetstherequirementsofeducationandexperienceof§483.
60(a)(1)(i)and(ii).
Note:IfyouwerehiredbeforeNov28,2016,youhave5yearstomeettheserequirements.
37§483.
60FoodandNutritionServices483.
60(a)(2)Ifaqualifieddietitianorotherclinicallyqualifiednutritionprofessionalisnotemployedfull-time,thefacilitymustdesignateapersontoserveasthedirectoroffoodandnutritionservicesDesignatedpersonsinclude:Acertifieddietarymanager(or)Acertifiedfoodservicemanager(or)Someonewhohassimilarnationalcertificationforfoodservicemanagementandsafetyfromanationalcertifyingbody(or)Someonewhohasanassociate'sorhigherdegreeinfoodservicemanagementorinhospitality,ifthecoursestudyincludesfoodservicesorrestaurantmanagement,fromanaccreditedinstitutionofhigherlearning.
Note:Thesedesigneesmustreceivefrequentscheduledconsultationsfromaqualifieddietitianorotherqualifiednutritionalprofessional.
38§483.
75QAPIWhatneedstobeinplacenowAQAAcommitteewhich–Iscomposedof:DirectorofNurses;MedicalDirector(ordesignee);and3otherstaff,oneofwhichmustbeAdministrator,owner,boardmemberorotherindividualinleadershiprole.
InfectionControl&PreventionOfficer-effective11/28/19Meetsatleastquarterlyandasneededto:IdentifywhichQAAactivitiesarenecessary,andDevelop&implementappropriateplansofactiontocorrectidentifiedqualitydeficiencies.
39§483.
75QAPIWhatchangeswillgointoeffectonNovember28,2017PresentQAPIplantostateorfederalsurveyors-AQAPIPlandescribestheprocessforconductingQAPI/QAAactivitiessuchasidentifyingandcorrectingqualitydeficienciesandopportunitiesforimprovementTheQAPIplanshouldbetailoredtoreflectthespecificunits,programs,departments,anduniquepopulationeachfacilityservices40§483.
75QAPIWillCMSprovideatemplatefortheQAPIPlanQAPIWrittenPlanHow-toGuide,developedbyLakeSuperiorQualityInnovationNetworkforparticipantsintheNationalNursingHomeQualityCareCollaborativeVisittheNursingHomeQAPIWebsiteforadditionaltoolsandresources41§483.
80InfectionControlIsdocumentationoftheinformationwehaveprovidedandcorrespondenceregardingourantibioticstewardshippoliciesandthepractitioner'scontinueduseofantibioticswithoutavalidcauseenoughforustoproveduediligenceonthepartofthefacilityF881,AntibioticStewardshipProgramF757,UnnecessaryDrugs42§483.
80InfectionControlDoestheantibioticstewardshipprogramapplyonlytotheuseofantibioticsorwouldsuchaprogramalsoapplytotheuseofantifungalsandantivirals,whichwouldbeincludedunderthebroadertitleofan"antimicrobialstewardshipprogram"Doestheprogramapplytoallformulationsofantibiotics(e.
g.
,ophthalmicantibiotics,topicalantibiotics)AntibioticsAllformulations43§483.
80InfectionControlDoesanInfectionPreventionist(IP)havetobecertifiedandbywhatdateisthisrequiredTheroleandqualificationsoftheIPareeffectiveNovember28,2019TheIPmustbequalifiedbyeducation,training,experienceorcertification44Question&AnswerSession45ResourcesVisittheCMSSurveyandCertification–NursingHomeswebpageContactusatNHSurveyDevelopment@cms.
hhs.
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