ProfEdOnDemand Compass Helping You Find True North in Healthcare Compliance
Helping You Find True North in Healthcare Compliance
Phase II of New Nursing Home Regulations Goes Into Effect
Is Your Facility Ready for Its Next Inspection Under the New Rules?
The Centers for Medicare & Medicaid Services’ 2016 and 2017 updates to its State Operations Manual Appendix PP, “Guidance to Surveyors for Long Term Care Facilities,” are the most extensive regulatory update for nursing homes in 25 years. Last year, CMS began a three-phase update to its current LTC regulations. These changes are designed to modernize LTC and help LTC organizations comply with other healthcare regulations, like the Affordable Care Act (ACA).
Volume 1, Issue 3
In This Issue
Phase II of New Nursing Home Regulations Goes Into Effect
The first phase of changes took effect in November 2016. Phase I, the most far-reaching of the three phases, made changes to staffing requirements, care plans and resident rights, among other areas. Phase I began a three-year process of modernizing the regulation structure.
While the changes required by Phase I are well underway, Phase II just took effect on November 28, 2017, and Phase III will take effect on November 28, 2019. Phase III includes additional changes to Quality Assurance and Performance Improvement (QAPI) plans, changes to hiring and training requirements, and changes to quality monitoring systems that require extra time to implement.
Phase II features five areas of focus: 1) Behavioral Health Services; 2) Quality Assurance and Performance Improvement (QAPI) Plan; 3) Infection Control via Facility Assessment and Antibiotic Stewardship; 4) Compliance and Ethics; and 5) Physical Environment, including Smoking Policies. These changes range from very broad and comprehensive (facility assessments) to very specific and narrow (smoking regulations).
Is your nursing home ready? Understanding these often-dense rules is necessary in order to help your organization maintain compliance and avoid costly penalties.
Resident Rights: Most of the changes to resident rights took effect in Phase I. The only piece that takes effect with Phase II mandates that facilities provide written and oral information regarding certain services. Facilities must provide contact information for state and local advocacy organizations and for fraud control units, as well as Medicare and Medicaid eligibility information.
Reporting Crimes: Freedom From Abuse, Neglect and Exploitation: Phase II includes new requirements for reporting allegations of abuse, neglect and exploitation. This includes corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms, according to CMS. These allegations must be reported within 24 hours of the suspected neglect or exploitation, but if the incident involves bodily harm to the resident, CMS requires that it be reported “immediately.”
Transfer and Discharge Documentation: This update, designed to protect a resident’s legal rights, requires facilities to provide more thorough documentation during a discharge, including a discharge summary and advance directive information. Physician documentation in the medical record must include the reason for the transfer. In addition to these documentation guidelines, facilities must provide the resident with written notice of their transfer, and if the resident appeals a transfer, facilities cannot transfer an individual while an appeal is pending unless failure to discharge or transfer would endanger the resident’s health or safety.
Baseline Care Plan: All facilities must develop a “Baseline Care Plan” within 48 hours of admission that includes all necessary instructions for providing effective and person-centered care. This includes, but is not limited to: Initial goals of care based on admission order; physician and dietary orders; therapy and social services; and pre-admission screening and resident review (PASARR) recommendations, if applicable. Facilities are now required to provide the resident (or the resident’s representative) with a summary of the baseline care plan within 48 hours.
Nursing Services: This rule changes the staffing requirements for nursing services, following the new guidelines for facility assessment that took effect in Phase I. CMS gave facilities a year to hire enough nursing and professional staff to meet the guidelines outlined in the new facility-wide assessment from Phase I. The number and type of staff required for each facility depends on the number of residents, the residents’ acuity, the range of diagnoses, resident assessments, and care plan content. The important change is that staff competencies and skills are now criteria in determining the minimum number of required staff.
Medical Chart Review: Even before Phase II, facilities were required to have a pharmacist provide a drug regimen review (DRR) once a month. Now, this monthly review must also include a review of each resident’s medical chart.
Dental Services: With this amendment, CMS clarified an ambiguity in its original rule by defining “promptly” as “within three days.” Facilities must now have a policy and protocol for identifying when dentures were lost or damaged and when the lost or damaged dentures are the facility’s responsibility. Facilities must also refer residents with lost or damaged dentures for dental services within three days. If the referral does not occur within three days, the facility must document the extenuating circumstances and how the facility will ensure that the resident can still eat and drink. Finally, facilities must also assist residents in making appointments and arranging appointments for dental services, when necessary.
Dietary and Nutrition Changes: Like Nursing Services, this rule provided a one-year grace period for facilities to hire additional dietary and nutrition staff to meet the new facility inspection guidelines from Phase I. The most obvious change is that residents’ preferences must now be taken into consideration when designing meals. This rule also provides specific details on who can and cannot serve as a dietician for a facility, based on the facility’s resident population. Importantly, for dieticians appointed before November 28, 2016, the requirements must be met with five years of November 28, 2016. For dietician designees made after November 28, 2016, the requirements must be met by November 28, 2017.
Facility Assessment: The new facility assessment requirement is the biggest change in Phase II. In short, each facility must conduct a facility- wide assessment to determine what resources are needed daily and during emergency situations. This assessment must be reviewed annually and updated as necessary. Multiple specific requirements are included in the facility assessment, but the general requirements of the assessment cover: the facility’s resident population, the facility’s resources, and a facility- and community-based risk assessment utilizing an all-hazards approach.
Quality Assurance and Performance Improvement: Facilities were already required to maintain a Quality Assurance and Performance Improvement (QAPI) plan. However, facilities must now submit their QAPI plan during the first standard survey after November 28, 2017. Facilities must also provide the plan at any subsequent standard survey upon request, as well as evidence of ongoing implementation.
Antibiotic Stewardship: To mitigate the risk of infection and drug-resistant “superbugs,” CMS now requires each facility to create an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. The new facility assessment guidelines also include a specific section on antibiotic use and infection control, and each facility must have a system in place for controlling infections.
Smoking Policies: The final update of Phase II might seem obvious, but it’s important for avoiding costly penalties. Every facility must establish policies regarding smoking and smoking areas that accommodate non-smoking residents. While local and state laws vary, every facility is responsible for instituting a smoking policy for residents and staff that complies with all federal, state and local laws.
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