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The Rest of the Story: Other New Regulations, Surveys, and Emphasis Programs Impacting Nursing Homes

ANHA 2016 Annual Convention & ExpoPresented by:

Katrina Magdon, MPA, CAE

CMS S&C Memorandums

The Centers for Medicare and Medicaid Services (CMS) Survey and Certification on a regular basis provides memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.

These documents have a reference number that identifies which fiscal year it was issued as well as the provider group/type the document is applicable.

In addition, these documents are numbered in order of their issue date.

2016 CMS S&C Memorandums C&S Letters Issued in 2016 of interest to nursing centers are:

16-04-NH – Focus Dementia Care Survey Tools

16-05-ALL – Infection Control Pilot Project

16-11-ALL – Exit Conferences-Sharing Specific Regulatory References or Tags

16-13-NH - Payroll-Based Journal (PBJ) - Implementation of required electronic submission of Staffing Data for Long Term Care (LTC) Facilities

16-15-NH - State Operations Manual (SOM) Surveyor Guidance Revisions Related to Psychosocial Harm in Nursing Homes

16-17-NH - Affordable Care Act Section 6103: Guidance for State Consumer Oriented Websites- Update to Survey and Certification Letter 11-41-NHs

16-21-ALL - Guidance to Surveyors on Federal Requirements for Providing Services to Justice Involved Individuals

16-22-LSC - Notification of Final Rule Published: Adoption of 2012 Life Safety and Health Care Facilities Code

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2016 CMS S&C Memorandums C&S Letters Issued in 2016 of interest to nursing centers are:

16-25-NH - DRAFT Long-Term Care Facility (LTCF) Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.14, Release

16-26-NH - Fiscal Year (FY) 2016 to FY 2017 Nursing Home Action Plan

16-27-NH - Public Release of Nursing Home Enforcement Information Announcement

16-28-NH - Update Report on the National Partnership to Improve Dementia Care in Nursing Homes

16-29-LSC - Adoption of the 2012 edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC)

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

2016 CMS S&C Memorandums 16-04-NH Focus Dementia Care Survey Tools

The Centers for Medicare & Medicaid Services (CMS) completed a pilot project in 2014 to examine the process for prescribing antipsychotic medications and assess compliance with other federal requirements related to dementia care practices in nursing homes.

Expansion of Focused Dementia Care Survey Efforts: In 2015, the expansion project involved a more intensive, targeted effort to cite poor dementia care and the overutilization of antipsychotic medications, and broaden the opportunities for quality improvement among providers.

Focused Dementia Care Survey Tools: In response to feedback from stakeholders and partners of the National Partnership to Improve Dementia Care in Nursing Homes, CMS is sharing the revised survey materials that were developed for the 2014 Focused Dementia Care Survey Pilot and 2015 expansion effort. The intent is that facilities would use these tools to assess their own practices in providing resident care.

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-04.pdf

2016 CMS S&C Memorandums 16-05-ALL Infection Control Pilot Project

The Centers for Medicare & Medicaid Services (CMS) has begun a three year pilot project to improve assessment of infection control and prevention regulations in nursing homes, hospitals, and during transitions of care.

Survey details: All surveys during the pilot will be educational surveys (no citations will be issued) and will be conducted by a national contractor. New surveyor tools and processes will be developed and tested, focusing on existing regulations as well as recommended practices (such as those for antibiotic stewardship and transitions of care). Ten pilot surveys to be conducted in Fiscal Year (FY) 2016 will occur in nursing homes. Surveys in FY17 and FY18 will be conducted in nursing homes and hospitals.

Project Outcomes: New surveyor infection control tools and survey processes that can be used to optimize assessment of new infection control regulations.


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2016 CMS S&C Memorandums

16-11-ALL Exit Conferences-Sharing Specific Regulatory References or Tags The Centers for Medicare & Medicaid Services (CMS) is clarifying guidance to

surveyors regarding the procedures for conducting the exit conference in the review of compliance with Medicare or Medicaid Conditions of Participation, Conditions for Coverage, and Requirements for Participation. Review Exit Conference Procedures: Please review with surveyors the exit conference procedures for conducting the federal surveys to ensure consistency of this process across States.


2016 CMS S&C Memorandums 16-13-ALL Payroll-Based Journal (PBJ) - Implementation of required

electronic submission of Staffing Data for Long Term Care (LTC) Facilities

Information about the requirement for LTC facilities to electronically submit staffing data through the PBJ:

Mandatory submission period began July 1, 2016.

Restate instructions on how to register and where to find instructions to submit data.

Notify stakeholders of the posting of the revised and final PBJ policy manual and related information at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html

Note, the Centers for Medicare & Medicaid Services (CMS) may use its enforcement authority for noncompliance with the requirement to submit data. The contents of this letter supports activities or actions to improve resident safety and increase quality and reliability of care for better outcomes.


2016 CMS S&C Memorandums 16-15-NH State Operations Manual (SOM) Surveyor Guidance

Revisions Related to Psychosocial Harm in Nursing Homes F329 Draft Revision: The Centers for Medicare & Medicaid Services (CMS) has revised

guidance to surveyors in Appendix PP of the SOM under F329 to enhance ease of use for surveyors and to include language related to how unnecessary use of medications may cause psychosocial harm to residents.

Psychosocial Outcome Severity Guide: CMS has revised language in the Psychosocial Outcome Severity Guide in Appendix P of the SOM.

Revisions to Selected F tags: CMS has added language to selected F tags to emphasize the risk of psychosocial harm associated with noncompliance with specific regulations.

The regulatory language remains unchanged.


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2016 CMS S&C Memorandums 16-17-NH Affordable Care Act Section 6103: Guidance for State

Consumer Oriented Websites- Update to Survey and Certification Letter 11-41-NHs Key Elements: The Centers for Medicare & Medicaid Services (CMS) provides a list of key

elements for State website development for States to qualify for Federal funding.

Financing: The costs for development of the websites and operation are allowable expenses for reimbursement through a combination of Medicaid, Medicare survey and certification, and State-only funds under standard cost- allocation procedures.

Establishment of State Websites: Effective March 23, 2010, States must maintain consumer-oriented websites providing information regarding all skilled nursing facilities and nursing facilities within in their state. State websites are expected to be completed and be accessible to consumers as soon as possible, but not later than January 1, 2018.


2016 CMS S&C Memorandums16-21-ALL Guidance to Surveyors on Federal

Requirements for Providing Services to Justice Involved Individuals Surveyor Guidance: The Centers for Medicare & Medicaid Services (CMS) are

clarifying requirements for providing services to justice involved individuals in skilled nursing facilities (SNFs), nursing facilities (NFs), hospitals, psychiatric hospitals, critical access hospitals (CAHs), and intermediate care facilities for individuals with intellectual disabilities (ICFs/IID). Specifically, this guidance seeks to assure high quality care that is consistent with essential patient rights and safety for all individuals.


2016 CMS S&C Memorandums16-22-LSC Notification of Final Rule Published:

Adoption of 2012 Life Safety and Health Care Facilities Code Fire Safety Requirements for Certain Health Care Facilities: On May

4, 2016, the Centers for Medicare & Medicaid Services (CMS) published a final rule titled “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities,” which updates the fire safety requirements for health care providers and suppliers. This regulation requires certain providers and suppliers to meet the requirements of the 2012 edition of the Life Safety Code (LSC), National Fire Protection Association (NFPA) 101 and the 2012 edition of the Health Care Facilities Code, NFPA 99.


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2016 CMS S&C Memorandums16-25-NH DRAFT Long-Term Care Facility (LTCF)

Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.14, Release The Centers for Medicare & Medicaid Services (CMS) has posted a

DRAFT version of the LTCF RAI 3.0 User’s Manual, Version 1.14 to the Nursing Home Quality Initiative web page so users can preview significant changes before they become effective October 1, 2016.


Update released August 25, 2016

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html

2016 CMS S&C Memorandums The current MDS 3.0 RAI Manual v1.14 and MDS forms,

effective October 1, 2016 is now available. This version of the MDS 3.0 RAI Manual incorporates the new Section GG: Functional Abilities and Goals, the new Part A PPS Discharge assessment, and clarifications to existing coding and transmission policy. It also addresses clarifications and scenarios concerning complex areas.

Read more on the CMS website for MDS 3.0 RAI Manual -Centers for Medicare & Medicaid Services at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html.


16-26-NH Fiscal Year (FY) 2016 to FY 2017 Nursing Home Action PlanRelease of the Nursing Home Action Plan: The

FY 2016 to 2017 Nursing Home Action Plan is posted on the CMS website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/NHs.html


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16-27-NH Public Release of Nursing Home Enforcement Information Announcement The Centers for Medicare & Medicaid (CMS) is posting

information at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationEnforcement/Nursing-Home-Enforcement.html

which includes data on nursing home enforcement actions between 2006 and 2014. The contents of this letter supports activities or actions to improve patient or resident safety and increase quality and reliability of care for better outcomes.



16-28-NH Update Report on the National Partnership to Improve Dementia Care in Nursing Homes Update Report: The Centers for Medicare & Medicaid Services

(CMS) has released the second report that provides a brief overview of the National Partnership, summarizes activities following the release of Survey & Certification policy memorandum 14-19-NH, and outlines next steps.

The report describes the results of the Focused Dementia Care Surveys conducted in Fiscal Year (FY) 2015.


2016 CMS S&C Memorandums 16-29-LSC Adoption of the 2012 edition of the National Fire Protection

Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) Improve Dementia Care in Nursing Homes

CMS has adopted by regulation the 2012 LSC and the 2012 HCFC. The regulation effective date is July 5, 2016.

CMS will begin surveying for compliance with the 2012 LSC and HCFC on November 1, 2016.

CMS will offer an online transitional training course for existing LSC surveyors to provide an update on the new requirements. The course will be available on September 2, 2016 via the CMS Surveyor Training Website.

CMS will update the ASPEN program (i.e., the information system which tracks surveys) and CMS Fire Safety Forms (2786) prior to the November 1, 2016 survey start date.


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2016 CMS S&C Memorandums 16-31-NH Mandatory Immediate Imposition of Federal Remedies and

Assessment Factors Used to Determine the Seriousness of Deficiencies for Nursing Homes REVISED 07.29.16 to add temporary management under remedies for termination and

correct the effective date.

Revisions to Chapter 7 of the State Operations Manual (SOM): This policy memorandum provides advanced guidance relating to revisions in policies on the Immediate Imposition of Federal Remedies (previously referred to as Opportunity to Correct or No Opportunity to Correct).

CMS Regional Office (RO) must now immediately impose a CMP any time Immediate Jeopardy (IJ) is cited.

Irrespective of a state recommendation to impose or not impose a remedy, the CMS RO must immediately impose, without permitting a facility an opportunity to correct deficiencies, one or more federal remedies based on the seriousness of the deficiencies or when actual harm or Substandard Quality of Care (SQC) is identified


2016 CMS S&C Memorandums 16-33-NH Protecting Resident Privacy and Prohibiting Mental

Abuse Related to Photographs and Audio/Video Recordings by Nursing Home Staff Freedom from Abuse: Each resident has the right to be free from all types of abuse,

including mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s).

Facility and State Agency Responsibilities: This memorandum discusses the facility and State responsibilities related to the protection of residents. Specifically, at the time of the next standard survey for both the Traditional survey and QIS, the survey team will request and review facility policies and procedures that prohibit staff from taking, keeping and/or distributing photographs and recordings that demean or humiliate a resident(s).

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and- Cert-Letter-16-33.pdf

CMS Focus Surveys

MDS/Staffing Dementia CareMedication-Related Adverse EventsInfection Control

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MDS/Staffing Focus Surveys15-06-NH Nationwide Expansion of

Minimum Data Set (MDS) Focused Survey Background

Posted October 31, 2014

Effective Date: Immediately https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-06.pdf

MDS/Staffing Focus Surveys In mid-2014, CMS piloted a short-term focused survey to

assess MDS 3.0 coding practices and its relationship to resident care in nursing homes in five states – MD, PA, VA, IL and MN. Five facilities in each state was chosen – 25 facilities in pilot

CMS expanded these surveys in 2015 to be conducted nationwide.

Reported Staffing: The scope of some or all of the focused surveys will also be expanded to include an assessment of the staffing levels of nursing facilities. This assessment will aim to verify the data self-reported by the nursing home, and identify changes in staffing levels throughout the year.

MDS/Staffing Focus Surveys Federal regulations for the Resident Assessment Instrument

(RAI), including the MDS 3.0 and the Care Area Assessments (CAAs), are found at 42 CFR 483.20, and the guidance is found in Appendix PP of the State Operations Manual (SOM) at F-Tags F272 through F287

States will be expected to allocate two surveyors for each survey, requiring an estimated 2 days on average. Surveyors will also need to complete and submit post-survey information to CMS or its contractor (e.g., questionnaire about the process and findings).

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MDS/Staffing Focus Surveys CMS will work with States to determine how many

surveys should be conducted, and when they should take place throughout the year.

CMS will also collaborate with States to identify the specific facilities to be surveyed, and is developing both the survey protocol and tool for the States’ to use. Record review, augmented by resident observations and staff and/or resident interviews, will be used by the surveyors to validate MDS 3.0 coding and staffing levels.

Additionally, while on-site, the surveyors will ask a series of questions regarding staffing and MDS related practices of the facility staff, leadership, and others as appropriate.

MDS/Staffing Focus Surveys

The MDS 3.0 inaccuracies and insufficient staffing noted during the survey will result in relevant citations, including those related to quality of care and/or life, or nursing services.

If patterns of inaccuracies are noted, the case will be referred to the CMS RO and CO for follow-up. In the event that care concerns are identified during on-site reviews, the concerns may be cited or referred to the SA as a complaint for further review.

MDS/Staffing Focus Surveys - Results

The pilot results included "relatively high levels of compliance" regarding RN coordination and assessment timing requirements.

"Room for improvement" was found in MDS 3.0/medical record agreement in 4 of the 7 clinical conditions reviewed:Severity of injury associated with falls – 25%

Pressure ulcer status – 18%

Restraint use - 17 %

Late loss activities of daily living (ADL) status – 15%

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MDS/Staffing Focus Surveys - Results Staffing Deficiencies - Posting Nurse Staffing Information

Focus has been on posting of nurse staffing information

Requirements located at F356 – §483.30(e)

(e) Nurse staffing information—

(1) Data requirements. The facility must post the following information on a daily basis:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).

(C) Certified nurse aides.

(iv) Resident census.

MDS/Staffing Focus Surveys - Results Staffing Deficiencies - Posting Nurse Staffing Information

Requirements located at F356 – §483.30(e)

(e) Nurse staffing information—

(2) Posting requirements.

(i) The facility must post the nurse staffing data specified in paragraph (e)(1) of this section on a daily basis at the beginning of each shift.

(ii) Data must be posted as follows:

(A) Clear and readable format.

(B) In a prominent place readily accessible to residents and visitors.

(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

MDS/Staffing Focus Surveys - Tips Implement a system to ensure MDS assessments are completed and

submitted timely, consistent with regular required assessment schedules (e.g., admission, quarterly, annually) and those required due to a significant change of condition (either improvement or decline). An effective system is particularly important when there is turnover of the MDS Coordinator or Assessment Coordinator.

Know the scope of practice for an LPN/LVN in your state and ensure appropriate supervision is provided and reflected in documentation. Monitor LPN/LVN notes in the medical records to ensure accurate words are used (e.g., LPNs/LVNs are not “assessing” the resident’s condition).

An accurate MDS assessment requires collecting information from multiple sources. Implement a system to ensure documentation about a resident is accurate and consistent in all places including ADL records, care plan, interdisciplinary notes, assessments, physician orders, etc.

Ensure the Care Area Assessment (CAA) process is effectively used to provide a link between the MDS and care planning and involves the resident, family and other representatives as appropriate.

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MDS/Staffing Focus Surveys – Entrance Conference

Immediately Upon EntranceResident Census Sheet

Computer Access to EMR and MDS data

Facility Floor Plan

Facility Transfer Records for last 90 days

Name of Wound Care Nurse – Who coordinates wound care? How is it tracked?

Name of Individual responsible for staffing

MDS/Staffing Focus Surveys – Entrance Conference Within 1 hour of Entrance Conference

List of key personnel – including locations and extensions

Computer access

All facility policies and procedures related to RAI and MDS

All Facility policies and procedures related to staffing and scheduling

Within 24 hours of Entrance Conference CMS 671

Upon Request Make staff members and other policies and procedures

available

Dementia Care Focus Survey In 2014, CMS invited States to participate in the pilot of a

Focused Dementia Care Survey to test new surveyor worksheets and processes, focused on dementia care in nursing homes. The focused survey examined the process for prescribing antipsychotic medication and assessed compliance with other federal requirements related to dementia care practices in nursing homes. The pilot was initiated to gain new insights about surveyor knowledge and skills and ways that the current survey process may be streamlined to more efficiently and accurately identify and cite deficient practice, as well as to recognize successful dementia care programs.

The states where the pilot surveys were conducted: IL, MN, NY, CA, and LA.

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Dementia Care Focus Survey There were five nursing centers in five states that were

surveyed for this pilot: one that was considered by the state a “best-practice” center and four others. The “best practice” centers received no deficiency citations, even if surveyors identified potential deficiencies.

Of the 20 centers that were surveyed, 16 were cited at either F309 (Care of a Resident with Dementia) or F329 (Unnecessary Use of Medications).

11 of the 20 centers were cited at both tags (F309 and F329).

Of the 68 total deficiency citations, 4 were at a G or harm level (three in CA and one in IL).

Dementia Care Focus Survey Next Steps

The dementia care focused survey process was revised and a new streamlined version will be used in both traditional and QIS States.

The streamlined version will also be used during complaint surveys

CMS Expansion Project

States were invited to conduct dementia-focused surveys in FY 2015 on a voluntary basis using the revised survey tools. Six States participated in this effort (CA, IL, MS, MO, NE and TX).

The expansion project involved a more intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications.

CMS provided criteria for determining specific facilities to be surveyed in those volunteer states.

CMS has initiated a comprehensive survey effort in Texas. A CMS subject matter expert will accompany each survey team on its initial survey.

All deficient practices noted during the surveys will result in relevant citations.

Dementia Care Focus Survey

In general, 2 surveyors will be able to complete the focused survey of 5 residents in 2-3 days for a medium sized (e.g., 120-150 bed) facility. For larger facilities (e.g., over 150 beds), or facilities with a history of deficiency citations at F309 that relate to dementia care, state agency directors or managers may elect to expand the sample up to 10 residents.

In addition to staff who are on site (e.g., CNAs, nurses, activities professionals, dementia unit director), surveyors will interview physicians, nurse practitioners, physician’s assistants, pharmacists, LTC ombudsmen and family members as part of the survey.

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Dementia Care Focus Survey Worksheet

18 page Focused Dementia Care Surveyor Worksheet

7 pages for Facilities

Part 1 – Nursing Home Characteristics

Part 2 – Dementia Care – Policies, Leadership, Training, Documentation

Part 3 – Quality Assessment and Assurance (QAA)

11 pages for Surveyors

Part 4 – Dementia Care & Related Practices Comprehensive Evaluation of Each Resident on Admission by the Interdisciplinary Team

Recognition, Assessment and Cause Identification of Behavioral Manifestations of Dementia

Care Planning

Individualized Approaches and Treatment: Care Plan Implementation and Staffing

Monitoring, Follow-Up and Oversight

Dementia Care Focus Survey Upon completion of the pilot and 2015 expansion effort, CMS

revised the survey materials and tools based on surveyor feedback and data analysis. In response to feedback from stakeholders and partners of the National Partnership to Improve Dementia Care, CMS shared these revised materials. The intent is that facilities can use these tools to assess their own practices in providing resident care.

Review the dementia care-focused surveyor checklist (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-16-04.html?DLPage=1&DLEntries=10&DLSort=3&DLSortDir=descending) that CMS recently posted.

Infection Control Focus Survey CMS has begun a three year pilot project to improve

assessment of infection control and prevention regulations in nursing homes, hospitals, and during transitions of care.

There is a clear need to assess the continuum of infection prevention efforts between hospitals and nursing homes in order to prevent transmission of infections in both settings.

All surveys during the pilot will be educational surveys (no citations will be issued) and will be conducted by a national contractor. If Immediate Jeopardy exists referrals will be made to the Regional

Office

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Infection Control Focus Survey New surveyor tools and processes will be developed and

tested, focusing on existing regulations as well as recommended practices (such as those for antibiotic stewardship and transitions of care).

Ten pilot surveys to be conducted in Fiscal Year (FY) 2016 will occur in nursing homes.

Surveys in FY17 and FY18 will be conducted in nursing homes and hospitals.

New surveyor infection control tools and survey processes that can be used to optimize assessment of new infection control regulations.

Infection Control Focus Survey Surveys and worksheets developed with collaboration with CDC

Data about infections in nursing homes are limited, but it has been estimated in the medical literature that:

1 to 3 million serious infections occur every year in these facilities; Memorandum Summary

Common infections include urinary tract infections, diarrheal diseases, antibiotic resistant staphylococcal infections and other multi-drug resistant organisms

Infections are a major cause of hospitalization and death; as many as 380,000 people die from infections in nursing homes every year.

After the survey findings are determined, a team of infection control professionals will use those survey findings to develop an action plan for improvement and to organize on-site technical assistance.

Infection Control Focus Survey Follow up visits for technical assistance may occur and

long term impact might be measured utilizing NHSN data.

The long term goals of this pilot will be improved surveyor infection control tools and survey processes to optimize infection control.

More information: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-05.pdf

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Adverse Events Focus Survey CMS has developed and begun pilot testing the Focused Survey on Medication

Safety Systems to look at nursing home practice around high-risk and problem-prone medications, such as Coumadin.

Objectives of the Focused Survey on Medication Safety Systems are to:

Identify preventable adverse drug events that have occurred or may occur

Determine whether facilities identify residents’ risk factors for adverse drug events and implement individualized interventions to eliminate or mitigate those risk factors

Determine if the facility has implemented effective systems to prevent adverse drug events as well as recognize and respond to adverse drug events that do occur in order to minimize harm for the individual and prevent recurrence of the event

Be prepared for an adverse-events focused survey. Use the CMS Trigger Tool, attached to this CMS memo (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-15-47.html?DLPage=1&DLEntries=10&DLFilter=Adverse&DLSort=2&DLSortDir=descending)

New Survey Process Update CMS Division of Nursing Homes (DNH) has long

recognized the need to improve the effectiveness of the Traditional Survey process based on critiques that include The need to improve consistency and accuracy of surveys

The need to improve documentation of survey findings

The need to develop a systematic approach to the review of the nursing home regulatory requirements.

Since 2007, the DNH has used two separate Action Plan for Further Improvement of Nursing Home Quality 5 processes for conducting the standard nursing home recertification survey, the Traditional Survey and the Quality Indicator Survey (QIS).

New Survey Process Update

Since Fiscal Year (FY) 2012, DNH has focused on making adjustments and improvements to the QIS system for States that have implemented the QIS system rather than expanding the initiative to additional States. Examples include; Improvements to medication pathways

Addition of the desk audit report capability for supervisors

Changes to user interface

Adjustments to the sample sizes for small facilities

Solutions to certain computer and security C challenges

Additional flexibility in the system design to incorporate complaint investigations (being implemented this year).

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New Survey Process Update The DNH expects to continue to make improvements so

that the States currently participating in the QIS have the support necessary to conduct surveys as effectively as possible and to realize the benefits of the QIS process.

At the same time, we continue to evaluate both the traditional survey and the QIS processes to identify, in both quantitative and qualitative terms, the strengths and limitations of each system. These efforts involve considerable data analysis from survey results, user feedback from CMS Regional Offices and State Survey Agencies, technical expert panels, reviews of CMS Form 2567 statements of deficiencies, and observational reviews of the nursing home survey.

New Survey Process Update In May 2015, the DNH produced a survey methodology status

report that provides a high-level summary of the work done to examine nursing home survey methodologies for efficiency and effectiveness, as well as the actions that were taken to improve the processes, with particular emphasis on the QIS.

Since that time, CMS has been talking with stakeholders to explore those aspects of the survey processes that are working well at identifying quality issues and those aspects that could be improved. CMS’ intent is to build on the best of both Traditional and QIS processes in developing a single revised survey methodology that can be implemented nationwide.

Testing of revised survey methodology began November 2015

New Survey Process Update

Alabama experience2 surveys – 1 survey was of record and

citations counted (nothing serious)

4 10-hour days

6 surveyors ( 1 University of Colorado, 2 Alabama supervisors, 3 RN surveyors)

New Resident Roster Matrix – Had to be handwrittenBasically new items with new instructions

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New Survey Process Update – Roster Sample Matrix

Roster Sample Matrix – 1 through 6Residents’ Admitted with the Past 30 days (Date

of Admission)

Alzheimer/Dementia

Depression

PASRR Level II Services

Medication – Insulin, Anticoagulant, Antibiotic, Diuretic, Opiod, Hypnotic, Antianxiety, Antipsychotic, Mood Stabilizer, Antidepressant

Internal Bleeding


Roster Sample Matrix – 7 through 13Facility Acquired Pressure Ulcers (any stage)

Worsened Pressure Ulcers (any stage)

Excessive Weight Loss without Prescribed Weight Loss Program

Tube Feeding

Dehydration

Physical Restraints

Falls, Falls with Injury, Falls with Major Injury


New Roster Sample Matrix – 14 through 19Unplanned Hospitalizations

Frequent or Constant Pain

Indwelling Catheter

Low Risk Residents with Bladder or Bowel Incontinence

Urinary Tract Infection

Dialysis Peritoneal, Hemo

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New Roster Sample Matrix – 20 through 27Hospice

End of Life/Comfort Care/Palliative Care

Tracheostomy

Ventilator

Decline in ADL Ability

Limited Range of Motion

Restorative Nursing

Specialized Rehab Services (OT, PT, Speech, etc.)

New Survey Process Update – Entrance Conference Worksheet Immediately Upon Entrance

Census Number

Complete Matrix for New Admissions in the last 30 days who are still in the facility

A list of residents who smoke, designated smoking times, and locations

Entrance Conference

Briefing held with Administrator

Provide survey with access to all resident electronic health records – no exclusions and how they can access them outside of the conference room

Information regarding full time DON coverage – verbal acceptable

Information about the facility’s emergency water source – verbal acceptable

Signs announcing survey posted in high-visible areas

Copy of updated facility floor plan

Name of Resident Council President

Facility provided with copy of CASPER 3

New Survey Process Update – Entrance Conference Worksheet

Within One Hour of Entrance

Schedule of meal times, locations of dining rooms, copies of all current menus including therapeutic menus that will be served for the duration of the survey

Schedule of Medication Administration times

The actual working schedules for licensed and registered nursing staff for the survey time period

List of key personnel, location, and phone numbers

If using paid feeding assistants

Whether the paid feeding assistant training program was provided through a State-approved training

The names of the staff (agency included) who have successfully completed training, and who are currently assisting residents with eating meals and/or snacks

A list of residents who are eligible for assistance and who are currently receiving assistance from paid feeding assistants

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New Survey Process Update – Entrance Conference Worksheet Within Four Hours of Entrance

Complete matrix for all other residents

Dialysis contract, agreement, arrangement, and Policy & Procedure

Influenza/Pneumococcal Immunization – Policy & Procedures, list of current residents immunized

QA & A committee info (contact name, names of members, and frequency of meetings)

Abuse Prohibition Policy & Procedures

Description of any experimental research occurring in the facility

Provide any nurse staffing waivers

List of rooms meeting any of the following conditions:

Less than required square footage

More than four residents

Below ground level

No window to the outside

No direct access to an exit corridor

New Survey Process Update – Entrance Conference Worksheet Within 24 Hours of Entrance

Completed Medicare/Medicaid Application – CMS 671

Completed Census and Condition Information – CMS 672

Completed ”Closed Record Review – Residents Discharged Within the Last 90 Days” – Residents discharged and did not return within the last 90 days Resident Name

Discharge Date

Discharged to: Home/Lesser Care or Hospital or Death (Exclude Hospice or End of Life)

Completed “Beneficiary Notice – Residents Discharged Within the Last 6 Months” – Residents discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months Resident Name

Discharge Date

Discharged to: Home/Lesser Care or Remained in Facility

New Survey Process– Beneficiary Notification Checklist

Surveyor will randomly select 3 residents from the “Beneficiary Notice…” Worksheet

Facility must complete Beneficiary Notification Checklist Resident name

Medicare Part A Skilled Services Episode Start Date

Last covered day of Part A Service – Part A terminated/denied or resident discharged

How was the Medicare Part A Service Termination/Discharge Terminated?

Voluntary

Facility/Provider initiated

Other (explain)

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New Survey Process– Beneficiary Notification Checklist

Facility must complete Beneficiary Notification Checklist - continued Was a SNF ABN, Form CMS-10055 or any of the 5 alternate denial notices

provided the the resident

Yes – Provide copy of form that were acknowledged by beneficiary/representative

No – Explain why form not provided

Other (Explain)

Was a NOMNC (CMS 10123) provided to the resident

Yes – Provide copy of form that were acknowledged by beneficiary/representative

No – Explain why form not provided

Other (Explain)

Checklist reviewed with facility by surveyor

US Food and Drug Administration (FDA) Nationwide Research Project designed to assess food preparation procedures and

practices specific to the various segments of the retail food industry

Facilities randomly selected

Voluntary participation

Not a regulatory visit

No inspection report left with facility

90 – 120 minute visit (30 minutes of data collection focuses on nature of the facility operation)

If significant public health risk is identified and not corrected then the regulatory authority that issued the permit will be contacted to ensure corrective action is taken

Research project is designed to protect the privacy of participating establishments to the extent the law permits.

Data collected is tabulated using broad industry segments and is not associated with any specific establishment

Civil Money Penalties Department of Health and Human Services (HHS) issued an

interim final rule in early September increasing Civil Money Penalty (CMP) amounts, consistent with the requirements of the Bipartisan Budget Act (BBA) of 2015.

Penalty per day for a Skilled Nursing Facility or Nursing Facility that has a Category 2 violation of certification requirements:

Prior minimum penalty: $50 New minimum penalty: $103

Prior maximum penalty: $3,000 New maximum penalty: $6,188

Penalty per instance of Category 2 noncompliance by a Skilled Nursing Facility or Nursing Facility:

Prior minimum penalty: $1,000 New minimum penalty: $2,063


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Civil Money Penalties Penalty per day for a Skilled Nursing Facility or Nursing

Facility that has a Category 3 violation of certification requirements with or without Immediate Jeopardy: Prior minimum penalty: $3,050 New minimum penalty: $6,291


Penalty per instance of Category 3 noncompliance by a Skilled Nursing Facility or Nursing Facility with or without Immediate Jeopardy: Prior minimum penalty: $1,000 New minimum penalty: $2,063


Scope and Severity of Deficiencies – Category CMP Amounts

D – Optional Category 2

E – Optional Category 2

F – Required Category 2

G – Required Category 2

H – Required Category 2

I – Required Category 2

J – Required Category 3

K – Required Category 3

L – Required Category 3

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Civil Money Penalties Grounds to prohibit approval of Nurse Aide Training Program-if

assessed a penalty in 1819(h)(2)(B)(i) or 1919(h)(2)(A)(ii) of ''not less than $5,000'' [Not CMP authority, but a specific CMP amount (CMP at this level) that is the triggering condition for disapproval]:

Prior penalty amount: $5,000 New penalty amount: $10,314

Grounds to waive disapproval of nurse aide training program-reference to disapproval based on imposition of CMP ''not less than $5,000'' [Not CMP authority but CMP imposition at this level determines eligibility to seek waiver of disapproval of nurse aide training program]:

Prior penalty amount: $5,000 New penalty amount: $10,314

Bibliography Policy & Memos to States and Regions:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

MDS-Focused Survey Tip Sheet, March 20, 2015, AHCA Workgroup comprised of members of Clinical Practice and Survey/Regulatory Committees

CMS Action Plan 2016-2017: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/2016-2017-Nursing-Home-Action-Plan.pdf

Forms distributed by surveyors to facilities in pilot of new survey process

Adjustment of Civil Monetary Penalties for Inflation; Interim Final Rulehttps://www.gpo.gov/fdsys/pkg/FR-2016-09-06/pdf/2016-18680.pdf

the rest of the story: other new - capital real estate …anha.org/uploads/new-regs-part1.pdfthe...

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