mega rule dhs powerpoint - leadingage wisconsin · 2016. 11. 28. · 11/28/2016 ltc final rule aka...
TRANSCRIPT
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LeadingAge Wisconsin204 South Hamilton StreetMadison WI 53703Tel: 608-255-7060 Fax: [email protected]
hosted by
Friday, December 2, 2016Sleep Inn & Suites Conference Center5872 33rd AvenueEau Claire, WI 54703715-874-2900
Tuesday, December 6, 2016Country Springs Hotel2810 Golf RoadPewaukee, WI 53187262-547-0201
Wednesday, December 7, 2016Liberty Hall Banquet& Conference Center800 Eisenhower DriveKimberly, WI 54136920-731-0164
and
Handouts
presented by
The Final Rule:Requirements for Participation,
DQA Guidance, and Key Changes from an Operator's Perspective
Handouts also are available online at:www.leadingagewi.org/media/41520/megarule.pdf
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11/28/2016
LTC Final Ruleaka Mega Rule
Pat VirnigBureau of Nursing Home Resident Care
DirectorBureau of Nursing Home Resident Care
THANK YOU!!! we have got a lot to doTHANK YOU!!! – we have got a lot to do
before November of 2017
• New regulations• New survey process• I hope to prove today that DQA is NOT a
barrier – We are all in this together!
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Trauma Informed Care & ACEsTrauma‐Informed Care & ACEs
• Adverse Childhood Experiences (ACEs) • https://www.cdc.gov/violenceprevention/acest
udy/• http://wichildrenstrustfund.org/Documents/REVI
SEDWisconsinACEs.August2012.pdfSEDWisconsinACEs.August2012.pdf• WI DHS Trauma-Informed Care Brochure
https://www.dhs.wisconsin.gov/publications/p0/p00202.pdf
“WWW W”“WWW – W”
• What did you know?• When did you know it?• What did you do about it?
Getting to Past Non-compliance
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Clinical Standards Of PracticeClinical Standards Of Practice
• Use the Clinical Resource Center the facility must have a nationally recognized, evidenced based standard of practiceevidenced based standard of practice
Just CultureJ
A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. While the organization has a duty and responsibility to employees (and ultimately to residents), all employees are held responsible for the quality of their choices. Just culture requires a change in f f d t t t d i d focus from errors and outcomes to system design and management of the behavioral choices of all employees. • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/• http://nursingworld.org/psjustculture
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ALWAYS
Start with the Resident
• Or… let them eat Oreos and take their own bath… or perhaps… SMOKE…
• Nursing Process
Set the Survey Up RightSet the Survey Up Right
• Shared Expectations Document• Questionnaires• Imagine this… a typical day at the NH… in
walks 5 folks with briefcases and cards!walks 5 folks with briefcases and cards!• How are we not Monday morning
quarterbacks…
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MDS Focused SurveysMDS Focused Surveys
• MDS/Staffing level focused surveys• 10 facilities selected• CMS/OIG attempt to determine if MDS filled
out correctlyout correctly• CMS S&C memo 15-06
The 3 T’sThe 3 T’s
• These are the rules
• This is how we survey to ensure the rules are met
• This is what happens when the rules are not met
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BackgroundBackground
• No comprehensive update since 1991 – despite substantial changes to service delivery
• The Reform of Requirements for Long-Term Care Facilities “Proposed Rule” was published in the p pFederal Register on July 16, 2015
• CMS received nearly 10,000 comments
OverviewOverview
• Reform of Requirements for Long-Term Care Facilities final rule or “Mega Rule”
• Published in Federal Register on October 4, 2016
• Revises regulations on a comprehensive basis
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Updated GuidanceUpdated Guidance• Phase-in approach over 3 years to allow for
changes in survey processes and to update survey guidance
• CMS will provide updated guidance to facilities, update the survey process, update , p y p , psurvey tags in accordance with the reorganization of the regulation, and provide training to surveyors on new tags
Implementation TimelineImplementation Timeline
• The Final Rule is effective November 28, 2016• Implementation is divided into 3 phases based
on complexityo Phase 1: implementation deadline is Nov. 28, 2016
Ph 2 i l t ti d dli i N 28 2017o Phase 2: implementation deadline is Nov. 28, 2017o Phase 3: implementation deadline is Nov. 28, 2019
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We are all in this together.g
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Key Changes
• Comprehensive Person-Centered Care Planning• Arbitration Agreements• Training Requirements• Infection Control• Infection Control• Compliance and Ethics Program• Quality Assurance and Performance
Improvement
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Comprehensive Person‐Centered Care PlanningComprehensive Person‐Centered Care Planning
• Requires facilities to develop and implement a baseline care plan for each resident within 48 hours of admission
• Adds a nurse aide and a member of the food and nutrition services staff to the required members of nutrition services staff to the required members of the interdisciplinary team (IDT) responsible for developing the comprehensive care plan
• Requires facilities to develop and implement a discharge planning process
Arbitration AgreementsArbitration Agreements• Final Rule prohibits the use of pre-dispute
binding arbitration agreements• LTC facilities cannot enter into agreements for
binding arbitration with a resident or their representative until after a dispute arises between the parties
• The Final Rule will not affect existing pre-dispute arbitration agreements; such existing agreements can still be enforced
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Training RequirementsTraining Requirements• Sets forth requirements of an effective training
program that facilities must develop, implement, and maintain for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers.
• Required staff training:R id t ’ i ht d f ilit ibilitio Residents’ rights and facility responsibilities
o Activities that constitute abuse and neglecto Infection controlo Compliance and ethicso QAPI training that outlines the elements and goals of the
QAPI program
Infection ControlInfection Control
• The Final Rule requires facilities to develop an Infection Prevention and Control Program (IPCP)
• The program must include at a minimum:o A system for preventing, identifying, reporting,
investigating and controlling infections and investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement
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Infection Control, cont.Infection Control, cont.• Include an Antibiotic Stewardship Program
• Antibiotic Stewardship Program must include antibiotic use protocols and system to monitor antibiotic use
• Designate at least one Infection Preventionist (IP)o IP is responsible for the IPCPo IP is responsible for the IPCPo IP’s primary professional training must be in nursing,
medical technology, microbiology, epidemiology, or other related field. Can be qualified by education, training, experience or certification.
o IP must work at the facility at least part-time
Compliance and Ethics ProgramCompliance and Ethics Program• Requires the operating organization of each facility
to have in effect a compliance and ethics program• Program must establish written compliance and
ethics standards• Must establish policies and procedures that are
capable of reducing the prospect of criminal, civil, d d i i t ti i l ti and administrative violations
• Facility must take steps to effectively communicate the standards, policies, and procedures to entire staff, contractors, and volunteers
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Quality Assurance and Performance ImprovementQ y p
• Requires all LTC facilities to develop, implement, and maintain a comprehensive, data-driven QAPI program
• Program designed to monitor and evaluate performance of all services and programs of the facility
• Facility’s governing body is responsible and accountable for the QAPI program
• Facility must submit QAPI plan to State Agency or federal surveyor at recertification survey 1 year after effective date
Pharmacy ServicesPharmacy Services• Drug Regimen Review
o A pharmacist must complete a monthly drug regimen review and medical record review
o Defined irregularities• Unnecessary drugsUnnecessary drugs
o Reporting irregularitieso Responding to irregularitieso Development of policies and procedures
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Pharmacy Services, cont.Pharmacy Services, cont.• Use of psychotropic medications
o Antipsychoticso Antidepressantso Antianxieties
H tio Hypnotics• PRN orders limited to 14 days• Non-renewal without assessment
Questions?
DHS Program Name Here 26
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SOM Changes from an Operators Perspective -
Requirements for Participation
©Pathway Health 2013
The NEW MegaRule – Requirements for Participation for Skilled Nursing Facilities
Objectives
• Understand the new and revised final rule for Skilled Nursing Facility Requirements for
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g y qParticipation
• Be able to conduct a facility self assessment to determine your organizational needs for compliance
• Learn leadership strategies for implementing the new and revised regulations
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• Health and safety standards LTC must meet in order to participate in MC & MA
History & Background
p p• Requirements found at 42CFR Subpart B• No comprehensive update since 1991• Revisions reflect changes in theory and practice• Implements sections of ACA• Proposed rule was published in federal register
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7/16/15• Rule: www.https://federalregister.gov/d/2016-23503
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1 Person Centered Care
Themes of the Rule
1. Person Centered Care2. Quality3. Facility Assessment 4. Alignment with HHS Priorities5. Comprehensive Review & Modernization
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6. Implementation of Legislation
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• Consumers are informed, involved, and in control• Quality is overarching principle in all we do for
our residents
Summary of Provisions
• Choices are more defined• Care and DC Planning• Additional special care issues addressed• Competency based approach• Updates in standards of practice
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• ACA & IMPACT Act
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• Phase 1: November 28, 2016
Phases of Implementation
• Phase 2: November 28, 2017
• Phase 3: November 28, 2019
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§483.10 Resident rights
Timeline for Implementation
The section will be implemented in Phase 1 with the following exception:
(g)(4)(ii) – (v) Providing contact information for State and local advocacy organizations, Medicare
f
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and Medicaid eligibility information, Aging and Disability Resources Center and Medicaid Fraud Control Unit — Implemented in Phase 2.
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– Abuse– Adverse event
– Neglect– Nurse aide
Definitions
– Common area– Distinct part– Exploitation– Licensed health
professional
– Person-centered care
– Resident representative
– Sexual abuse
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professional– Misappropriation– Mistreatment
– Transfer and discharge
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F150 ‐ §483.5
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• Eliminates language such asI d f il b
Resident Rights
– Interested family member– Legal representative
• Replaces it with– Resident Representative
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Resident Representative
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• An individual of resident choice who has access to information and participates
Resident Representative
in health care discussions• Personal representative with legal
standing in accordance with state law– Power of Attorney– Representative payee and other fiduciaries
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p p y– Legal Guardian or conservator– Health Care Surrogate– Legal representative
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• Representativeh h i h i id ’
Resident Representative
– has the right to exercise resident’s rights to the extent those right are delegated to the resident representative
– Resident retains right to exercise those rights not delegated to a representative and the right to revoke a delegation of
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and the right to revoke a delegation of rights, except as limited by state law
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• If selected as the personal representative must be afforded
Same Sex Spouse
representative, must be afforded treatment equal to an opposite sex spouse if marriage was valid in the jurisdiction it was celebrated in
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1. Right to exercise his/her rights as resident of facility and as citizen or
id t f th U it d St t
Resident Rights
resident of the United States2. Right to be free from interference,
coercion, discrimination, and reprisal from facility in exercising those rights and to be supported by the facility in
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exercising those rights3. Right to designate a representative in
accordance with state law
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4. If resident is adjudged incompetent under state law or court of competent
Resident Rights
jurisdiction the rights of the resident devolve to and are exercised by the representative appointed under state law to act on the resident’s behalf
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Resident may exercise his/her rights to the extent not prohibited by court order
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• Court appointed representative exercises the resident’s rights to the
Resident Rights
exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction in accordance with state law
• Resident wishes and preferences must b d d h f h
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be considered in the exercise of the rights by the representative
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• To the extent possible, the resident must be provided with the opportunity
Resident Rights
must be provided with the opportunity to participate in the care planning process
5. Any legal surrogate designated in accordance with state law may exercise the resident’s rights to the
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exercise the resident s rights to the extent provided by state law if the resident has not been adjudged incompetent
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6. Planning and implementing care: resident has a right to be informed of and participate in his/her treatment
Resident Rights
and participate in his/her treatment including:– Right to be fully informed in a language
he/she can understand of total health status, including but not limited to medical condition
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medical condition– Right to be informed in advance of care
to be furnished and disciplines involved
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6. Planning and implementing care– Right to be informed in advance of risks
Resident Rights
and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/she prefers
– Right to request, refuse, and/or d
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discontinue treatment, to participate or refuse to participate in experimental research, and to formulate advance directives
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6. Planning and implementing care (F154)
Right to participate in the development
Resident Rights
– Right to participate in the development and implementation of his or her person centered care plan
– Right to sign his or her person centered care plan
7 Ri ht t lf d i i t di ti if
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7. Right to self-administer medications if the IDT has determined that this practice is clinically appropriate (F175)
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8. Resident does not have right to receive provision of medical treatment or medical services deemed medically
Resident Rights
yunnecessary or inappropriate (F155)
9. Right to choose his/her attending physician (F163)
10.Right to respect and dignity (F221)11 Ri ht t b f f h i l
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11.Right to be free from any physical or chemical restraints imposed for discipline or convenience of staff and not required to treat medical symptoms (F221) 20
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12. Right to retain and use personal possessions including furnishings, and clothing as space permits unless to do
Resident Rights
clothing as space permits, unless to do so would infringe on the rights or health and safety of other residents (F252)
13. Right to share a room with a roommate of his/her choice when practicable, when both residents live in the same facility
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both residents live in the same facility and both consent (F175)
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14. Right to receive notice before the resident’s room or roommate in the facility is changed (F247)
Resident Rights
y g ( )15. Right to refuse to transfer to another
rooms if the purpose is to relocate for staff convenience (F177)
16. Self Determination (F242)
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• Notices required– State & local advocacy organizations,
State Long Term Care Ombudsman
Resident Rights
State Long-Term Care Ombudsman program
– Information regarding Medicare and Medicaid eligibility and coverage & Medicaid fraud control unit (Phase 2)Contact information for Aging &
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– Contact information for Aging & Disability Resource Center
– How to file grievances or complaints about abuse, neglect, misappropriation
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• Access to Information– Right to access medical records
t i i t hi h lf (F153)
Resident Rights
pertaining to him or herself (F153)• Upon oral or written request in a readable
format requested within 24 hours excluding weekends and holidays and….
• After receipt for inspection, the opportunity to purchase a copy or portions of upon
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p py p prequest and 2 working days advance notice to facility
• Charges may include, labor for copying, supplies for creating copies, postage if mailed
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• Right to examine the results of the most recent survey of the facility
Resident Rights
most recent survey of the facility conducted by the Federal or State surveyors and any plan of correction in effect with respect to the facility (F167)
• Right to receive information from agencies acting as client advocates
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agencies acting as client advocates, and be afforded the opportunity to contact these agencies (F168)
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• Right to personal privacy and confidentiality of his/her own personal
Resident Rights
y pand medical records (F164)
• Right to privacy in his/her verbal, written, and electronic communication, including right to send and promptly receive unopened mail and other
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receive unopened mail and other letters, packages and other materials delivered to the facility for the resident (F170)
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• Right to privacy includes accommodations, medical treatment, written and telephone communications
Resident Rights
written and telephone communications, personal care, visits, and meetings of family and resident groups, but does not require facility to provide a private room for each resident (F164)Ri ht t d fid ti l
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• Right to a secure and confidential medical record (F164)
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• Communication– Right to have reasonable access to the
f t l h i l di TTY d
Resident Rights
use of a telephone including TTY and TDD services (F174)
– Right to a place where calls can be made without being overheard
– Right to retain and use a cell phone at id t’
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resident’s own expense
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• Communication– Right to have reasonable access to and
Rights
gprivacy in the use of electronic communications such as email and video if the facility has access (F170)
• At the resident’s expense if additional costs are incurred by the facility to provide such access
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access– Right to access stationary, postage, and
writing implements at resident expense
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• Right to an environment that is safe, clean comfortable and homelike
Resident Rights
clean, comfortable, and homelike environment (F252)
• Right to receive treatment and supports for safe daily living
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• Right to voice grievances to the facility or other agency or entity without
Resident Rights
reprisal and without fear of discrimination (F165)– Includes those with respect to care and
treatment which has been furnished as well as that which has not been
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furnished• Right to prompt efforts by the facility to
resolve grievances (F166)
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• Included in Resident Rights
Facility Responsibilities -NEW
• Protects resident rights• Enhances quality of life• Brings responsibilities together that are dispersed
throughout the SOM• Parallels many resident rights provisions
E d i it ti i ht
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• Expands visitation rights
Policy, Education, Update Resident and Employee Handbook
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• Facility must ensure that resident can exercise his/her rights without interference, coercion discrimination or reprisal from
Facility Responsibilities
coercion, discrimination, or reprisal from the facility (F151)
• Facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source (F240)
• Facility must establish and maintain
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• Facility must establish and maintain identical policies and practices regarding transfer, discharge, and provision of services regardless of pay source (F207)
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• Facility must treat the decisions of the representative as the decisions of the
Facility Responsibilities
representative as the decisions of the resident to the extent required by the court or as delegated by the resident (F152)
• Facility shall not extend the representative’s right to make decisions
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representative’s right to make decisions on the resident’s behalf beyond the extent required by the court or delegated by the resident (F152)
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• If the facility has reason to believe that a representative is making decisions or
Facility Responsibilities
a representative is making decisions or taking actions that are not in the best interest of the resident, the facility may report such concerns as permitted and shall report such concerns when and in the manner required by state law
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the manner required by state law (F152)
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• Planning & Implementing Care– Facility must inform the resident of the
Facility Responsibilities
right to participate in his/her treatment and shall support the resident in this right (F155)
– The planning process must• Include resident and/or representative
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• Include an assessment of the resident’s strengths and needs
• Incorporate resident personal and cultural preferences in developing goals of care
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• Attending physician– Facility must ensure that each resident
Facility Responsibilities
Facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his/her care (F163)
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• Self DeterminationF ili d f ili
Facility Responsibilities
– Facility must promote and facilitate resident self determination through support of the resident choices (F242)
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• Facility must provide immediate access to any resident by
Facility Responsibilities
to any resident by– Any representative of the Secretary,
State, Office of the State Long Term Care Ombudsman, protection and advocacy systems (including mental illness) (F172)
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illness) (F172)– His/her individual physician
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• Facility must provide immediate access to any resident by
Facility Responsibilities
– Resident representative (F172)• Immediate family member or other relatives
subject to the resident right to deny or withdraw consent at any time
• Others who are visiting with consent of resident subject to reasonable clinical and
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resident, subject to reasonable clinical and safety restrictions
• Individuals that provide health, social, legal, or other services to the resident
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• Facility must have written policies and procedures regarding the visitation
Facility Responsibilities
procedures regarding the visitationrights of the residents, including those setting forth any clinically necessary or reasonable restrictions or limitation that the facility may need to place on such rights and the reasons for the
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such rights and the reasons for the clinical or safety restriction or limitation (F172)
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• Facility must inform each resident and/or representative (F172)
Facility Responsibilities
/ p ( )– Of his/her visitation rights, including any clinical or
safety restrictions or limitations– Of the right to receive visitors he/she designates
including spouse (same-sex) or partner, family member, friend
– That facility may not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national
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visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability
– Ensure all visitors enjoy full and equal visitation privileges
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• Facility must provide a resident or family group with private space (F243)
d
Facility Responsibilities
and– Staff and visitors may attend meetings only at
the group’s invitation– Facility must provide a designated staff person
who is approved by the family or resident group and facility who is responsible for
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g p y pproviding assistance and responding to written requests from the groups
– Facility must consider and act upon grievances and recommendations of groups regarding care and life in the facility
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• Facility must not require a resident to perform services for the facility, the
id if h / h h (F169)
Facility Responsibilities
resident may if he/she chooses (F169) when– Facility has documented the resident’s need or
desire for work in the care plan– Plan specifies the nature of the services
performed and whether the services are paid
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performed and whether the services are paid or voluntary
– Compensation for paid services is at or above prevailing rates
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• Facility must not require residents to deposit personal funds with the facility (F158) if h id h
Facility Responsibilities
(F158), if the resident chooses to – Upon written authorization of the resident, the
facility must safeguard, manage, and account for personal funds of the resident
– Deposits in excess of $100 must be deposited into an interest bearing account that is separate from
ti t th t dit ll i t t
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any operating accounts, that credits all interest earned to the resident account.
– A personal fund that does not exceed $100 may be placed in non-interest bearing, interest bearing, or petty cash account
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• Accounting and records (F159)– Facility must establish and maintain a
Facility Responsibilities
system that assures a full, complete, and separate accounting of each resident’s personal funds entrusted to the facility on the resident’s behalf
– Must be according to generally accepted ti i i l
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accounting principles
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• Accounting and records– Facility system must preclude any
Facility Responsibilities
commingling of resident funds with facility funds or with the funds of any person other than the resident
– Individual financial record must be available to the resident through
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quarterly statements and upon request
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• Accounting and records– Facility must notify each resident that
Facility Responsibilities
receives Medicaid benefits • When the account reaches $200 less than
the SSI resource limit for one person• That if the amount in the account in addition
to the value of the resident’s other nonexempt resources reaches the SSI limit
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pfor one person the resident may lose eligibility for Medicaid or SSI
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• Accounting and records– Conveyance upon discharge, eviction, or
Facility Responsibilities
y p g , ,death of a resident with a personal fund with the facility, facility must convey within 30 days the resident’s funds and a final accounting of those funds to the resident, or in the case of death, the
d d l b d
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individual or probate jurisdiction administering the resident’s estate
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• Accounting and records– Assurance of financial security (F161)
Facility Responsibilities
– Facility must purchase a surety bond or otherwise provide assurance satisfactory to the Secretary to assure the security of all personal funds of residents deposited with the facility
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• Accounting and records– Facility must not impose a charge
h l f d f d
Facility Responsibilities
against the personal funds of a resident for any item or service for which payment is made under Medicare or Medicaid (except for applicable deductibles or co-insurance) (F162)F ilit h id t f
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– Facility may charge a resident for requested services that are more expensive or in excess of covered services
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• Facility may charge for– Cosmetics and grooming items
Facility Responsibilities
– Personal clothing– Personal reading materials– Gifts purchased on behalf of resident– Flowers and plants
Costs to participate in activities that fall
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– Costs to participate in activities that fall outside the scope of the activity program
– Private duty nurses or aides52
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• Facility may charge for– Telephone, including cell phone
Facility Responsibilities
– Television, radio, computer, electronics– Smoking materials, notions, novelties,
and confections
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• Facility must inform orally and in writing, the resident requesting an item
Facility Responsibilities
g, q gor service, for which a charge will be made that there will be a charge for the item and what the charge will be
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• Information and CommunicationFacility must ensure that information is
Facility Responsibilities
– Facility must ensure that information is provided to each resident in a form and manner that the resident can access and understand, including an alternative format or in a language the resident can understand (F156)
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( )
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• Information and Communication– Facility must provide the resident with
Facility Responsibilities
access to medical records pertaining to him or herself upon oral or written request in the form or format requested by the individual including electronic format, or a hard copy or other form agreed to by the facility and resident
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agreed to by the facility and resident within 24 hours excluding weekends and holidays (F153)
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• Information and Communication– Facility must make reports with respect
Facility Responsibilities
to any surveys, certification, and complaint investigations conducted by Federal or State surveyors during the 3 preceding years available for reviewupon request and any plans of correction in effect with respect to the
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correction in effect with respect to the facility readily accessible to residents (F167)
– A notice must be posted of report availability 57
• Information and Communication– Facility must post in a form and manner
accessible and understandable (F156)
Facility Responsibilities
accessible and understandable (F156)• List of names, addresses (mailing & email),
and telephone numbers of all pertinent agencies and advocacy groups such as State survey & certification agency, State licensure office, adult protective services where state law provide for jurisdiction in
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where state law provide for jurisdiction in LTC facilities, Office of Ombudsman, protection & advocacy network, home and community based service programs, and Medicaid fraud control unit
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• Information and Communication– Facility must post in a form and manner
accessible and understandable
Facility Responsibilities
accessible and understandable • A statement that the resident may file a
complaint with the State survey and certification agency concerning resident abuse, neglect, misappropriation of resident property in the facility, and non-compliance with Advance Directives
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with Advance Directives
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• Advance Directives– Inform and provide written information
Facility Responsibilities
pto all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive (F155)
– Provide a written description of the
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facility policies to implement advance directives and applicable State law
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• Advance Directives– Facilities are permitted to contract with
th titi t f i h thi i f ti
Facility Responsibilities
other entities to furnish this information but are still legally responsible for ensuring that the requirements are met
– Facility may give advance directive information to the representative if the resident is incapacitated upon admission
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resident is incapacitated upon admission– If the resident does become able to
receive the information the facility must have measures in place to follow up
61
• Advance Directives– Facility must display in the facility
itt i f ti d id t
Facility Responsibilities
written information and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered
©Pathway Health 2013
refunds for previous payments covered by such benefits
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Notification of Changes– Facility must immediately inform the
resident, consult with the physician, (F157)
Facility Responsibilities
, p y , ( )and notify representative when there is
• An accident involving the resident which results in injury and has the potential for requiring physician intervention
• A significant change in the resident’s physical, mental, or psychosocial status
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mental, or psychosocial status• A need to alter treatment significantly – due to
adverse consequences or new form of treatment• A decision to transfer or discharge the resident
from the facility63
• Notification of Changes– When making notification facility must
th t ll ti t i f ti i
Facility Responsibilities
ensure that all pertinent information is provided upon request to the physician
– Facility must promptly notify the resident and/or representative if there is
• A change in room or roommate assignmentA h i id t i ht
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• A change in resident rights– Facility must record and periodically
update the address, email, and phone number of the representative
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• Admission to a composite distinct part (F208)
l d l d
Facility Responsibilities
– Facility must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part and also the policies that apply to room changes between its different locations
©Pathway Health 2013
changes between its different locations
65
F156• Facility must provide a notice of rights
nd e i e to the e ident p io to o
Facility Responsibilities
and services to the resident prior to or upon admission and during the resident’s stay
• Facility must inform the resident orally and in writing of his/her rights and all
©Pathway Health 2013
rules and regulations governing resident conduct and responsibilities during the stay in the facility
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• Facility must provide the resident with the State developed notice of Medicaid
Facility Responsibilities
the State-developed notice of Medicaid rights and obligations
• Acknowledgement of receipt of Medicaid rights and obligations must be in writing
©Pathway Health 201367
• Facility must inform each Medicaid eligible resident in writing at the time
Facility Responsibilities
eligible resident, in writing, at the time of admission to the SNF and when the resident becomes eligible for MA of– Items and services that are included in
nursing facility servicesOther items and services that the facility
©Pathway Health 2013
– Other items and services that the facility offers and for which the resident may be charged and the amount
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• Facility must inform each Medicaid eligible resident, in writing, at the time
Facility Responsibilities
of admission to the SNF, when the resident becomes eligible for MA, and periodically of– Items and services that change under
Medicare and Medicaid (as soon as
©Pathway Health 2013
reasonably possible)– Items and/or services that facility offers
(Must give 60 day notice in writing)
69
• If a resident dies or is hospitalized or is transferred and does not return, facility must refund any deposit or any charges
Facility Responsibilities
must refund any deposit or any charges already paid less the facility per diem rate, regardless of any minimum stay or discharge notice requirements (F160)
f
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• Facility must refund money due within 30 days of discharge
70
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• Facility must furnish to each resident a written description of legal rights
Facility Responsibilities
written description of legal rights including– Manner of protection of personal funds– Requirements and procedures for
establishing eligibility for Medicaid i l di h i h
©Pathway Health 2013
including the right to request an assessment of resources
71
• Facility must furnish to each resident a written description of legal rights
Facility Responsibilities
including– A list of names, addresses (mailing and
email) and telephone numbers of State regulatory and informational agencies, advocacy groups such as State licensure
O b d d lt t ti
©Pathway Health 2013
agency Ombudsman, adult protection, community resources, and Medicaid fraud control unit
72
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• Facility must furnish to each resident a written description of legal rights i l di
Facility Responsibilities
including– A statement that the resident may file a
complaint with the State survey and certification agency concerning any suspected violation of regulations, including but not limited to abuse
©Pathway Health 2013
including but not limited to abuse, neglect, misappropriation, and non-compliance with advance directive or return to community requirements
73
• Facility must protect and facilitate that resident’s right to communicate with
Facility Responsibilities
gindividuals and entities within and external to the facility including reasonable access to– A telephone (including TTY & TDD)– Internet if available
©Pathway Health 2013
Internet if available– Stationary, postage, writing implements,
and ability to send mail
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• Facility must protect the resident’s right to personal privacy, including privacy in
Facility Responsibilities
p p y, g p yhis/her verbal, written, and electronic communications– Including the right to send and promptly
receive mail that is unopened both from a postal service and by other means
©Pathway Health 2013
p y
75
• Facility must protect the resident’s right to personal privacy, including privacy in hi /h b l itt d l t i
Facility Responsibilities
his/her verbal, written, and electronic communications– Privacy includes accommodations,
medical treatment, written and telephone communications, personal ca e isits and meetings ith famil
©Pathway Health 2013
care, visits, and meetings with family and resident groups, but does not require facility to provide private room for each resident
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• Facility must comply with resident rights regarding his/her medical
Facility Responsibilities
rights regarding his/her medical records
• Facility must allow Ombudsman to examine a resident’s medical, social, and administrative records in
d h l
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accordance with State law
77
• Facility must provide a safe, clean, comfortable, and homelike environment
Facility Responsibilities
allowing the resident to use his or her personal belongings to the extent possible (F252)
• Facility must provide housekeeping and maintenance services necessary to
©Pathway Health 2013
ymaintain a safe, orderly, and comfortable interior (F253)
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• Facility must provide clean bed and bath linens that are in good condition
Facility Responsibilities
• Facility must provide closet space in each room
• Facility must provide adequate and comfortable lighting levels in all areas
• Facility must provide comfortable and
©Pathway Health 2013
Facility must provide comfortable and safe temperature levels (if initially certified after 10/1/90 must maintain a temperature range of 71-81°F)
79
• Grievances (F165 & F166) – Facility must make information on how to file a
i l i il bl h
Facility Responsibilities
grievance or complaint available to the resident
– Facility must make prompt efforts to resolve grievances including those with respect to the behavior of other residents
– Facility must establish a grievance policy to
©Pathway Health 2013
ensure prompt resolution of all grievances regarding resident rights
– Upon request the facility must give a copy of the policy to the resident
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• Grievance Policy must include– Residents will be notified individually or
Facility Responsibilities
through postings in prominent locations throughout the facility of the right to files grievances verbally or in writing
– Right to file grievances anonymously– Contact information of the grievance
©Pathway Health 2013
official with whom a grievance can be filed including name, business address, email, phone number
81
• Grievance Policy must include– A reasonable expected time frame for
Facility Responsibilities
A reasonable expected time frame for completing the review of the grievance
– The right to obtain a written decision regarding his/her grievance
– Contact information of independent entities with whom grievances may be
©Pathway Health 2013
entities with whom grievances may be filed
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– Identify a Grievance Official who is responsible for
• overseeing the grievance process receiving
Facility Responsibilities
• overseeing the grievance process, receiving and tracking grievances through their conclusion
• Leading investigations• Maintaining confidentiality• Communicating grievance decisions to
©Pathway Health 2013
resident and coordinating with agencies• Taking immediate action to prevent further
potential violations of any resident right while the alleged violation is being investigated.
83
– Identify a Grievance Official who is responsible for
• Immediately reporting all alleged violations
Facility Responsibilities
• Immediately reporting all alleged violations involving neglect, abuse, injuries of unknown origin, and/or misappropriation to the Administrator and a required by State law
• Ensure that all grievance decisions include the date received a summary statement of
©Pathway Health 2013
the date received, a summary statement of the resident grievance, steps taken to investigate, summary of findings, a statement of confirmed or not, any action taken as a result of the grievance, date written decision was issued 84
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– Identify a Grievance Official who is responsible for
• Taking appropriate corrective action in
Facility Responsibilities
• Taking appropriate corrective action in accordance with State law if the alleged violation is confirmed by the facility or an outside entity having jurisdiction
• Maintaining evidence demonstrating the results of all grievances for a period of no less than three years
©Pathway Health 2013
less than three years• Not prohibiting or discouraging a resident
from communicating with state or advocacy agencies
85
§483.12 Freedom from abuse, neglect, and exploitation.
Implementation Timeline
This section will be implemented in Phase 1 with the following exceptions:
(b)(4) Coordination with QAPI Plan—Implemented in Phase 3
©Pathway Health 2013
Implemented in Phase 3.(b)(5) Reporting crimes/1150B—Implemented in Phase 2.
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• Revised Title – “Freedom from Abuse, Neglect & Exploitation”S f h l d d l h
Abuse, Neglect, & Exploitation
• Specifies that you cannot employ individuals who have discipline on license by state licensure body– Abuse– Neglect– Mistreatment– Misappropriation
©Pathway Health 2013
Policy, Education, HR Forms
87
• Facility must not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion
Abuse, Neglect, & Exploitation
punishment, or involuntary seclusion (F226)
• Facility must not employ or otherwise engage individuals who F(225)– Have been found guilty of abuse,
©Pathway Health 2013
neglect, misappropriation, or mistreatment by a court of law
– Findings on the CNA registry concerning abuse, neglect, mistreatment, or misappropriation 88
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• Facility must not employ or otherwise engage individuals who
H h d di i li ti t k
Abuse, Neglect, & Exploitation
– Have had a disciplinary action taken against a professional license by a state licensure body for abuse, neglect, mistreatment, or misappropriation
©Pathway Health 201389
• Facility must develop & implement written policies and procedures that
Abuse, Neglect, & Exploitation
– Prohibit abuse, neglect, exploitation, and misappropriation
– Establish policies and procedures to investigate any such allegations
– Include training for staff
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g– Establish coordination with QAPI
program
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• Facility must develop & implement written policies and procedures that
Abuse, Neglect, & Exploitation
– Ensure reporting of crimes in federally funded facilities
• Policy must include annually notification of covered individuals of obligation to comply with, Posting a conspicuous notice of resident
©Pathway Health 2013
• Posting a conspicuous notice of resident rights
• Prohibiting and preventing retaliation
91
• In response to an allegation the facility must
Abuse, Neglect, & Exploitation
• Ensure all alleged violations are reported immediately to Administrator and other officials
– No later than 2 hours after allegation if events causes serious bodily injury
– No later than 24 hours if events did not result in serious bodily injury
©Pathway Health 2013
serious bodily injury• Have evidence that alleged violations are
thoroughly investigated
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• In response to an allegation the facility must
Abuse, Neglect, & Exploitation
must – Prevent further violations while
investigation is in process– Report results within 5 days with
corrective actionIf ifi d t k i t ti
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– If verified, take appropriate corrective action
93
§483.15 Admission, transfer, and discharge h
Implementation Timeline
rights.
This section will be implemented in Phase 1 with the following exceptions:
©Pathway Health 2013
(c)(2) Transfer/Discharge Documentation—Implemented in Phase 2.
94
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• Admission, Transfer, and Discharge Rights• Transfer or discharge must be documented and
Admission, Transfer, Discharge
• Transfer or discharge must be documented and include:– History of present illness– Reason for transfer– Past medical/surgical history– Exchange with receiving provider or facility
©Pathway Health 2013
Policy, education, DC documentation forms
95
• Facility must establish and implement an admissions policy (F208)
• Facility must not request or require residents or
Admissions
• Facility must not request or require residents or potential residents to waive their rights under Medicare and Medicaid
• Facility must not require oral or written assurance that residents or potential residents are not eligible for or will not apply for Medicare or Medicaid
©Pathway Health 2013
Medicaid• Facility must not request or require residents or
potential residents to waive potential liability for losses of personal property
96
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• Facility must not request or require a third party guarantee of payment to the facility
Admissions
party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in facility
• Facility may ask representative to sign the admission agreement if they have legal access to resident resources without
©Pathway Health 2013
access to resident resources, without incurring personal financial responsibility, to provide payment from the resident resources
97
• Facility must establish, maintain, and implement identical policies for transfer, discharge and the provision of services
Policies
discharge, and the provision of services for all individuals regardless of payment
• Facility may charge any amount for services furnished to non-Medicaid residents unless otherwise limited by state law
©Pathway Health 2013
law• The State is not required to offer
additional services other than what is provided in the State plan
98
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• Facility must permit each resident to remain in the facility and not transfer or discharge (F201)them unless
Discharge/Transfer
them unless– The transfer or discharge is necessary for the
resident’s welfare and the resident needs cannot be met in facility
– The transfer or discharge is appropriate because the resident’s health has improved sufficiently so that the resident no longer needs the services
©Pathway Health 2013
gprovided by the facility
– The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident
99
• Facility must permit each resident to remain in the facility and not transfer or discharge them unless
Discharge/Transfer
unless– The health of individuals in the facility would
otherwise be endangered– The resident has failed, after appropriate and
reasonable notice to pay for a stay at the facility, non-payment does not apply unless the resident has not submitted the necessary paperwork for
©Pathway Health 2013
has not submitted the necessary paperwork for 3rd party payment
– The facility ceases to operate
100
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• Facility must document the discharge or transfer in the resident medical record (F202)
Discharge/Transfer
in the resident medical record (F202)• Documentation must include
– Basis for transfer– Specific needs that cannot be met and the
attempts to meet the resident needs and the service available at the receiving facility to meet the need
©Pathway Health 2013
e eed• Documentation must be made by
– The physician – The staff processing the discharge
101
• Information provided to the receiving entity must include at a minimum
D hi
Discharge/Transfer
– Demographics– Representative information– Advance directives– History of present illness– Reason for transfer with PCP contact information– Past medical/surgical history with procedures
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– Active diagnoses/current problem list and status– Lab tests and results of pertinent lab & diagnostics– Functional status
102
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• Information provided to the receiving entity must include at a minimum– Psycho-social assessments including cognition
Discharge/Transfer
– Social Supports– Behavioral health issues– Medications– Allergies– Immunizations– Smoking status
©Pathway Health 2013
g– Vital signs– Unique identifiers for implanted devices– Comprehensive care plan goals, health concerns,
assessment and plan, preferences, interventions, efforts to meet resident needs
103
• Notice of involuntary transfer or discharge – Facility must notify resident/representative in
Involuntary DC
– Facility must notify resident/representative in writing
– Record the reasons in the clinical record– Provide 30 days notice unless
• the safety of the individuals in the facility is endangered (then as soon as practicable)
• If the resident health status improves sufficiently to allow f di h
©Pathway Health 2013
for sooner discharge • Immediate transfer or discharge is required by resident’s
urgent medical needs• Resident has been there less than 30 days
104
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• Contents of discharge notice– Reason for discharge/transfer
Involuntary DC
– Reason for discharge/transfer– Effective date of discharge/transfer– Location resident will be discharged to– Resident right to appeal notice language– Ombudsman contact information– State contact information
F ID d MH id h i d
©Pathway Health 2013
– For ID and MH residents the protection and advocacy agency contact information
105
• Changes to the notice– If the information in the notice changes prior to
Involuntary DC
effecting the transfer/discharge of the resident, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available
• Orientation for transfer or discharge (F204)– Facility must provide and document sufficient
preparation and orientation to residents to ensure
©Pathway Health 2013
preparation and orientation to residents to ensure safe and orderly transfer or discharge
– Provision of information must be in a format the resident can understand
106
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• Notice in advance of facility closure (F203)
Facility Closure
(F203)– Administrator must provide written notification
prior to the impending closure to• State survey agency• Office of Ombudsman• Residents of facility
R t ti
©Pathway Health 2013
• Representatives• Other responsible parties
– Must include plan for the transfer and adequate relocation of the residents
107
• Notice of bed-hold and readmission (F205)
Bed Hold
(F205)– Must be given before hospitalization or leave– Duration of the state bed hold policy during
which the resident is permitted to return and resume residence in the facility
– The reserve bed payment policy in the state
©Pathway Health 2013
plan– Policy regarding bed hold must be given to
resident
108
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• Comprehensive Assessment using RAI/MDS (F272)
Discharge Planning
– Facility must make a comprehensive assessment of a residents
• Needs• Strengths• Goals
©Pathway Health 2013
• Life history• Preferences
109
• Coordination (F285)– Facility must coordinate assessments with the
Preadmission Screening
PASARR (preadmission screening and resident review) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort
– Facility must incorporate recommendations from PASARR level II determination and the PASARR evaluation report into a resident’s assessment, care
©Pathway Health 2013
evaluation report into a resident s assessment, care planning, and transitions of care
– Refer all level II residents to PASARR for review when significant change occurs
110
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• A facility may not admit a resident with mental illness or intellectual disability
Preadmission Screening
mental illness or intellectual disability unless the State MH, ID or DD authority has determined prior to admission– Individual requires skilled nursing
facility services
©Pathway Health 2013
– Whether the individual requires specialized services for ID
111
• Exceptions to PASARR reviewR i f h i l
Preadmission Screening
– Returning from hospital– Admission from hospital after inpatient
acute care– Resident requires SNF services for
conditions that were treated in the
©Pathway Health 2013
hospital– If the physician certifies that SNF care is
needed less than 30 days
112
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§483.21 Comprehensive person‐centered care planning.
Implementation Timeline
planning. This section will be implemented in Phase 1 with the following exceptions:‐(a) Baseline care plan—Implemented in Phase 2(b)(3)(iii) Trauma informed care—
©Pathway Health 2013
‐(b)(3)(iii) Trauma informed care—Implemented in Phase 3.
113
F279• Baseline care plan within 48 hours - Phase 2• Specialized services or rehab follow through from
Person Centered Care Planning
• Specialized services or rehab follow through from PASARR recommendations
• IDT – must include a nursing assistant and a member of the nutrition services department to develop care plan
• Care plan must include dc planning, resident goals treatment preferences
©Pathway Health 2013
goals, treatment preferences• DC Summary – Medication Reconciliation• Post DC Plan of Care
Policy, education, care plan, dc documents114
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• Comprehensive person centered care plan
Plan of Care
• Phase 2 - Baseline care plan – (share with resident and/or representative)– Within 48 hours of admission– Initial goals based on orders
• Physician orders
©Pathway Health 2013
• Dietary orders• Therapy services• Social services
115
• Care plan must describe– Service that are to be furnished to
Plan of Care
attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being
– Any other services that would otherwise be required but are not provided due to
id t i f i ht i l di
©Pathway Health 2013
resident exercise of rights including right to refuse treatment
– Specialized services or rehab from PASARR recommendations
116
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• Care plan must describe in consultation with the resident and the
Plan of Care
with the resident and the representative– Goals for admission & desired outcomes– Preferences and potential for future DC
• Facility must document whether the id t’ d i t t t th it
©Pathway Health 2013
resident’s desire to return to the community was assessed and any referrals to community resources
• DC plan in care plan
117
• Comprehensive care plan must be– Developed within 7 days after
l ti f h i
Plan of Care
completion of comprehensive assessment
– Prepared by the IDT• Attending Physician• RN
N id
©Pathway Health 2013
• Nurse aide• Nutrition services• Resident/representative if practicable
118
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• The services provided or arranged by the facility must
Plan of Care
the facility must– Be provided by qualified persons in
accordance with each resident’s written plan of care
– Meet professional standards of quality
©Pathway Health 2013
– Phase 3 - Be culturally-competent and trauma-informed www.samhsa.gov
119
• Discharge Planning– Facility must develop and implement an
Discharge Planning
y p peffective discharge process that focuses on
• the resident’s discharge goals• preparing residents to be active partners in
post-discharge care
©Pathway Health 2013
• effective transition from SNF to post-SNF • reduction of factors leading to preventable
readmissions
120
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• The discharge planning process must
Discharge Planning
– Ensure the discharge needs are identified & result in the development of a discharge plan
– Include regular re-evaluation during stay for any needed changes to the
©Pathway Health 2013
y y gdischarge plan
– Involve the IDT in the process of developing the discharge plan
121
• The discharge planning process must
Discharge Planning
– Consider the resident or caregiver support persons capacity and capability to perform required care upon discharge
– Involve the resident and/or representative
©Pathway Health 2013
– Inform the resident/representative of the final plan
– Address the resident’s goals of care and treatment preferences
122
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• Facility must assist residents and/or representatives in selecting a post
Discharge Planning
representatives in selecting a post-acute care provider by using data that includes standardized patient assessment data, data on quality measures, and data on resource useh d b l d
©Pathway Health 2013
• The data must be relevant and applicable to the resident’s goals of care and treatment preferences
123
• Facility must document an evaluation of the resident’s discharge needs and di h l
Discharge Planning
discharge plan• Facility must discuss the results of the
evaluation with the resident/representative
• Facility must incorporate all relevant i f ti i t th di h l t
©Pathway Health 2013
information into the discharge plan to facilitate its implementation and avoid unnecessary delays in the resident’s discharge or transfer
124
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• Diagnoses• Course of illness/treatment or therapy
Discharge Summary
• Course of illness/treatment or therapy• Pertinent lab, radiology and
consultation reports• Final summary of the resident’s status
available for release to authorized
©Pathway Health 2013
persons and agencies with consent of resident and/or representative
125
• Reconciliation of all pre-discharge medications with the post-discharge
di ti i l di OTC
Discharge Summary
medications including OTC• A post discharge plan of care that is
developed with the participation of the resident and with consent the family which will assist the resident to adjust
©Pathway Health 2013
to his/her new living environment
126
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§483.24 Quality of life. ‐This entire section will be implemented in
Implementation Timeline
This entire section will be implemented in Phase 1§483.25 Quality of care. This section will be implemented in Phase 1 with the following exception:
©Pathway Health 2013
p‐(m) Trauma‐informed care—Implemented in Phase 3.
127
• Clarifies ADL abilities• Minimum requirements for Activity Director
qualifications
Quality of Care & Life
qualifications• Assisted nutrition and hydration – new name• Pain management• Moves unnecessary meds, medication errors,
immunizations to pharmacy services
©Pathway Health 2013
Policy, education, assessment, care plan
128
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• F 309– Pain management
Quality of Care & Life
g– Dialysis– Recognition and management of
dementia and behavior management– Non-pressure related skin ulcer/wound
Hospice
©Pathway Health 2013
– Hospice
129
• The facility must ensure– A resident is given the appropriate
treatment and services to maintain or
Quality of Care & Life
treatment and services to maintain or improve his/her ability in ADLs (F310)
– A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, personal & oral hygiene (F311)
©Pathway Health 2013
personal & oral hygiene (F311)– That personnel provide basic life support
including CPR subject to the resident’s advance directives (F155)
130
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• Activities of daily living– Hygiene (bathing, dressing, grooming,
Quality of Care & Life
yg ( g, g, g g,and oral care)
– Mobility (transfer and ambulation)– Elimination (toileting)– Dining (including meals and snacks)
Communication (Speech language
©Pathway Health 2013
– Communication (Speech, language, other functional communication systems)
131
• Activities (F248)– Facility must provide, based on the
comprehensive assessment and care
Quality of Care & Life
pplan and the preferences of each resident an ongoing program to support residents in their choice of activities both facility sponsored group, individual, and independent activities d d h f d
©Pathway Health 2013
designed to meet the interests of and support the physical, mental, and psychosocial well being of each resident, encouraging both independence and interaction in the community 132
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• Activities– The program must be directed by a qualified
professional who is a qualified therapeutic
Quality of Care & Life
p q precreation specialist or an activities professional who
• Is licensed or registered by the state in which practicing
• Is eligible for certification as a therapeutic specialist or as an activities professionalHas two years of experience in a social or
©Pathway Health 2013
• Has two years of experience in a social or recreational program within the last 5 years, 1 of which was full time in an activity program
• Is an OT or OTA• Has completed a training course approved by the
state 133
• Special Treatments and Procedures– Based on the comprehensive
t th f ilit t th t
Quality of Care & Life
assessment the facility must ensure that residents receive treatment and care related to special concerns• Restraints• Bed Rails (F461)
©Pathway Health 2013134
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• Special Care Issues• Vision and hearing
Quality of Care & Life
– Facility must assist the resident in making arrangements and arranging for transportation to and from appointments
©Pathway Health 2013135
• Skin Integrity– Facility must provide care consistent
Quality of Care & Life
Facility must provide care consistent with professional standards of practice to prevent pressure injuries unless unavoidable
– For residents with pressure injuries they receive treatment and services to
©Pathway Health 2013
promote healing, prevent infection, and prevent new pressure injuries from developing
136
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• Foot Care (F328)– Facility must provide foot care and
Quality of Care & Life
Facility must provide foot care and treatment including preventing complications from the resident’s medical condition
– Facility must assist the residents with making appointments and arranging for
©Pathway Health 2013
g pp g gtransportation to and from appointments
137
• Mobility (F317 & 318)– Facility must maintain range of motion
Quality of Care & Life
Facility must maintain range of motion unless clinical condition demonstrates that a reduction is unavoidable
– Facility must provide appropriate treatment and services if limited range of motion/limited mobility to increase
©Pathway Health 2013
/ yrange/mobility and to prevent further decrease in range of motion/mobility
138
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• Urinary Incontinence (F315)F ili h id h
Quality of Care & Life
– Facility must ensure that a resident who is continent on admission receives services and assistance to maintain continence unless the resident’s condition becomes such that continence is not possible to maintain
©Pathway Health 2013
is not possible to maintain– Assess for removal of a catheter as soon
as possible unless clinically necessary
139
• Fecal Incontinence (F315)B d h h i
Quality of Care & Life
– Based on the comprehensive assessment facility must ensure the resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible
©Pathway Health 2013
bowel function as possible
140
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• “Assisted nutrition and hydration”(F322)
Quality of Care and Life
( )– NG tubes– G tubes– Enteral fluids– Facility must ensure that a resident
M i t i t bl t f
©Pathway Health 2013
• Maintain acceptable parameters of nutritional status such as usual body weight, protein levels, unless the condition demonstrates that it is not possible or resident preferences indicate otherwise
141
• “Assisted nutrition and hydration”Facility must ensure that a resident
Quality of Care and Life
– Facility must ensure that a resident• who is fed by enteral means receives
treatment and services to restore oral eating skills
• and to prevent complications of enteral feeding including but not limited to
©Pathway Health 2013
aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers
142
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• Accidents– Facility must ensure that resident
Quality of Care and Life
yenvironment remains as free of accident hazards as is possible
– Facility must ensure that each resident receives adequate supervision and assistive devices to prevent accidents
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• Accidents– Bed Rails
Quality of Care and Life
Bed Rails • assess for risk of entrapment prior to installation
• Review risks and benefits with resident/representative and obtain informed consent
©Pathway Health 2013
informed consent• Ensure bed dimensions are appropriate for resident’s size and weight
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• Respiratory Care– Respiratory care including tracheostomy
Quality of Care
Respiratory care including tracheostomy care and tracheal suctioning have been added to specialized services
• Prostheses– Provide rehab services if needed
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§483.30 Physician services.
Implementation Timeline
• This entire section will be implemented in Phase 1
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• Delegation of Orders– Dieticians
• Delegation of Orders– Dieticians
Physician Services
– Therapists– NP, PA, CNS
State practice laws Policy, education
– Therapists– NP, PA, CNS
State practice laws Policy, education
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• Physician Visits• The physician must
Physician Services
– Review the resident’s total program of care including medications and treatments at each visit
– Write sign and date progress notes at each visit
– Sign and date all orders except for flu and
©Pathway Health 2013
Sign and date all orders except for flu and pneumovax which can be administered per physician approved policy after assessment for contraindications
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• Physician Visit Frequency– The resident must be seen every 30 days for
Physician Services
The resident must be seen every 30 days for the first 90 days after admission and then every 60 days thereafter
– Timely if done no later than 10 days after visit is required
– Visits may be alternated by physician and NP, PA or CNS
©Pathway Health 2013
PA, or CNS– Facility must provide availability of physician
coverage 24 hours per day
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• *Delegation of TasksPh i i d l h k f
Physician Services
– Physician may delegate the task of writing dietary orders to a qualified dietician or other qualified nutritional professional and therapy orders to a therapist who
• **Is acting within the scope of practice
©Pathway Health 2013
• **Is acting within the scope of practice according to State law
• Is under supervision of the physician
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§483.35 Nursing services.
Implementation Timeline
This section will be implemented in Phase 1 with the following exception: • Specific usage of the Facility Assessment at §483 70(e) in the determination of sufficient
©Pathway Health 2013
§483.70(e) in the determination of sufficient number and competencies for staff —Implemented in Phase 2
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• Sufficient Staffing (F353)• Adds competency requirement for determining
Nursing Services
dds co pete cy equ e e t o dete gsufficient nursing staff based on facility assessment– Capacity– Census– Acuity– Assure resident safety
©Pathway Health 2013
Assure resident safety – Range of diagnoses– Care plan content
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• Facility must ensure that licensed nurses have the specific competencies
Nursing Services
nurses have the specific competencies and skill sets necessary to care for resident needs as identified through assessments and care plans
• Providing care includes assessing, l l d l
©Pathway Health 2013
evaluating, planning and implementing resident care plans and responding to resident needs
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• Hiring and Use of Nurse Aides (F494)
Facility may not use an use an individual
Nursing Services
– Facility may not use an use an individual working in the facility as a nurse aide for more than 4 months, on a full time basis unless
• The individual has completed a CNA training program
©Pathway Health 2013
• A facility may not use a temporary, per diem, leased, or any basis other than permanent who does not meet requirements
• Facility must seek information from every State registry that may include information
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• §483.40 Behavioral health services.
Implementation Timeline
• This section will be implemented in Phase 2 with the following exceptions:
– (a)(1) As related to residents with a history of trauma and/or post‐traumatic stress disorder—Implemented in Phase 3
©Pathway Health 2013
– (b)(1), (b)(2), and (d) Comprehensive assessment and medically related social services‐‐Implemented in Phase 1
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• Provision of behavioral & mental health services for mental health and psychosocial
Behavioral Health - NEW
services for mental health and psychosocial illnesses
• Competency approach• Staffing• Non pharmacy interventions• Adds gerontology to allowed human service fields
f
©Pathway Health 2013
for social service workers
Policy, education, competency, care plan, partnership contracts
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• Facility must have sufficient direct care/direct access staff with
Behavioral Health
/appropriate competencies and skills to provide nursing and related services
• Staffing must be based on the facility assessment
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• Behavioral health competencies– Caring for residents with mental illness and
psychosocial disorders as well as residents
Behavioral Health
psychosocial disorders, as well as residents with a history of trauma or PTSD and implementing non-pharmacy interventions
– Based on comprehensive assessment ensure that
• A resident receives appropriate care and i
©Pathway Health 2013
services• A resident who does not have a diagnosis of
mental health or history of trauma does not display a pattern of decreased social interaction or behaviors unless unavoidable
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• If rehab services for mental illness and intellectual disability are required the f ilit t
Behavioral Health
facility must– Provide the required services including
specialized rehab– Obtain the required services from an
outside resource from a Medicare d/ M di id id f i li d
©Pathway Health 2013
and/or Medicaid provider of specialized rehab services
– Provide medically-related social services
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§483.45 Pharmacy services.
Implementation Timeline
This section will be implemented in Phase 1 with the following exceptions:
• (c)(2) Medical chart review—Implemented in Phase 2
©Pathway Health 2013
• (e) Psychotropic drugs—Implemented in Phase 2
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• Re-designation of requirements – relocates to pharmacy services
Pharmacy Services
to pharmacy services– Unnecessary drugs– Antipsychotic drugs– Medication errors– Influenza– Pneumovax
©Pathway Health 2013
Policy, education, pharmacy consultant agreement, forms/assessments
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• Drug Regimen Review (F428)– At least every month– When resident is “new”
Pharmacy Services
– When resident returns – prior resident– Transferred from hospital or another facility– Monthly if on ABX or psychotic medication– Any drug requested by QAA Committee
• Pharmacist & MD documentation guidelines• Must be sent to MD Medical Director & DON
Not yet included at F 428
©Pathway Health 2013
• Must be sent to MD, Medical Director, & DON• Definition of “irregularities”• Terminology – “psychotropic drugs” any drug that
affects brain activity associated with mental process and behavior
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• A psychotropic drug is any drug that ff t b i ti iti i t d ith
Pharmacy Services
affects brain activities associated with mental processes and behavior– Anti-psychotic– Anti-depressant– Anti-anxiety
©Pathway Health 2013
– Hypnotic
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• Pharmacist must report any irregularities to
Pharmacy Services
irregularities to – Attending physician– Medical Director– Director of Nursing
• Reports must be acted upon
©Pathway Health 2013
p p• Irregularities include any drug that
meets the criteria for unnecessary drug
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• Irregularities noted by pharmacist during the review must be documented
t itt t i l di
Pharmacy Services
on a separate written report including– Resident name– Relevant drug– Irregularities identified
• Physician must document
©Pathway Health 2013
y– Irregularity that was reviewed and action
taken, if no changes rationale must be documented
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F 329 Phase 2• Facility must ensure that
R id t d t i PRN
Pharmacy Services
– Residents do not receive PRN psychotropic drugs unless that medication is necessary to treat a specific diagnosed condition
– PRN orders are limited to 14 days and cannot be continued beyond that time
©Pathway Health 2013
cannot be continued beyond that time unless the PCP documents the rationale for this continuation in the record
– PRN orders for antipsychotics extended after PCP evaluation of the resident 166
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§483.50 Laboratory, radiology, and other d
Timeline Implementation
diagnostic services.
• This entire section will be implemented in Phase 1
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• NEW Section• Ordering Services may be done by:
Lab, Radiology, & Other Diagnostic Services
– Physician Assistant– Nurse Practitioner– Clinical Nurse Specialist
• Ordering clinician must be notified of abnormal labs when they fall outside clinical reference ranges, in accordance with policy or per provider
©Pathway Health 2013
a ges, acco da ce t po cy o pe p o deorders
Policy, education, contracted provider agreements
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• The facility must– Provide or obtain lab or radiology services only
Lab, Radiology, & Other Diagnostic Services
when ordered by an MD, PA, NP or CNS in accordance with State and scope of practice laws