New Conditions of Participation for SNFs: Phase 1

1. New Conditions of Participation for SNFs:Phase 1 H2 Healthcare, LLC Strategy, Compliance, Resources

2. Quick Overview • In September of 2106, CMS publish the Final Rule implementing the new Requirements for Participation for Nursing Homes/SNFs – first revision since 1991 • Implementation occurs in three phases • Phase 1: November 28, 2016 • Phase 2: November 28, 2017 • Phase 3: November 28, 2019 • New rules implement various elements of ACA for SNFs with provisions covering the IMPACT Act, Elder Justice Act, and other Federal regulatory requirements regarding compliance programs, ethics, etc. H2 Healthcare, LLC

3. Phase 1: November 28, 2016 • All regulatory sections with the exception of Compliance and Ethics have a Phase 1 component. • Five of 21 Regulatory Sections are fully implemented in Phase 1 • 15 of 21 Regulatory Sections are partially implemented • Citations for non-compliance begin immediately for Phase 1 requirements. • Citations follow current patterns – scope, severity and by F Tag. H2 Healthcare, LLC

4. Phase 1: What’s New • 483.5 – new and added definitions for; • Abuse • Adverse event • Exploitation • Misappropriation of Resident Property • Mistreatment • Neglect • Person-Centered Care • Resident Representative • Sexual Abuse • Willful • Implication? Nothing other than to reflect back to policies and change wording if necessary H2 Healthcare, LLC

5. Phase 1: What’s New • 483.10 Resident Rights • All existing rights retained. Language and organization is updated. Word changes and replacements occur such as Legal Representative changed to Resident Representative. Clarifications added regarding physician credentials and provisions added for electronic communication. • Implications? Many subtle changes. Existing rights have been expanded and new language inserted. • This section bears careful review and update of Resident Rights information such as brochures and pamphlets. H2 Healthcare, LLC

6. Phase 1: Resident Rights Implementation Steps • Review policies pertaining to resident rights. Look closely at; • Admission/transfer/discharge – new language restricts selective admissions, transfers and discharges – requires facilities to provide equal access to care • Policy pertaining to resident representatives and engagement with the same – right to engage a representative, facility to report bad acts of a representative, etc. • Under 483.10 (c) – new language implements more person-centered requirements during initial and ongoing plans of care – incorporate personal needs, cultural preferences, strengths/weaknesses, etc. Review along side changes in 483.15 (Admission, Transfer, Discharge) H2 Healthcare, LLC

7. Resident Rights Implementation, contd. • Policies pertaining to physician qualifications and notification – new incorporates notification of other primary care professionals • Policies pertaining to self-determination – new rights include preferences (sleeping/waking times), participate in community activities, policies pertaining to visitation and no discrimination on visitation • Policy pertaining to room mates (choice, notification of room changes, etc.) • Develop a process for working with resident/family groups including a staff liaison • Review and revise policies pertaining to resident funds (holding thereof) and use for covered and non-covered charges. • Review policies pertaining to records and communications. Must provide access to personal and medical records in a form/format the resident can understand. H2 Healthcare, LLC

8. Resident Rights Implementation, contd. • Assess your physical environment and develop a walking-rounds program to identify safety and sanitation issues. • Develop or review the Grievance Policy; • Have a grievance official responsible for oversight • Provide for written grievance decisions • Maintain 3 years of records pertaining to grievances, results, etc. H2 Healthcare, LLC

9. Phase 1: What‘s New • 483.12 – Freedom from Abuse Neglect and Exploitation – two exceptions to Phase 1. • Requires written policies and procedures to coordinate with QAPI program – required in Phase 3 • Requires policies implementing provisions under the Elder Justice Act for reporting crimes – required in Phase 2. • New rule includes exploitation and expands the prohibitions on employment to additional individuals, particularly with respect to issues pertaining to misappropriation of property. • Implications? Review policies for language changes and focus on training requirements for staff. H2 Healthcare, LLC

10. Abuse, Neglect, Exploitation Implementation • Policies must include; • Training requirements set out in 483.95 • Language regarding exploitation and misappropriation of resident property • Coordination with QAPI program (phase 3) • Incorporation of the Elder Justice Act requirements (phase 2) • Update employment policies to expand definitions of excluded individuals as provided in this section H2 Healthcare, LLC

11. Phase 1: What’s New • 483.15 – Admission, Transfer, Discharge – part of phase 1 with the exception of Transfer and Discharge documentation which is in Phase 2 • Incorporates definition of resident representative • Reflects issues pertaining to admissions, transfers and discharges between all care settings including distinct parts within a facility (dementia unit, Medicare unit, etc.) – identifies medical necessity and voluntary agreement conditions • Requires facility to have an Admissions policy and add conditions to the Admission Agreement and policies regarding room changes between different units, no waiver of rights to Medicare/Medicaid benefits, no third party guarantors • Clarifies how a resident can be discharged and the documentation for transfer by a physician including how resident needs cannot be met and will be met at the next location. H2 Healthcare, LLC

12. Admission, Transfer, Discharge Implementation • Conduct a full review of the changes under 483.15 and compare the same to current policies, procedures, practices, etc. Revise or update; • Preadmission and PASARR requirements • Admission policy and where applicable, changes to the Admission Agreement • Transfer policy covering internal, distinct parts or units, external, involuntary and notice(s) • Bed hold changes • Discharge policies to cover transitions and communication requirements among settings and conditions H2 Healthcare, LLC

13. Admission, Transfer, Discharge Implementation, contd. • Review practices pertaining to admission and discharge for care transition best practices • Develop policies and training materials for Physicians to provide for resident specific information on admission, discharge and transfer and how information will be conveyed to all interested parties (residents, representatives, payers, consultants, staff, etc. • Track and trend all resident transitions and begin a process for incorporation into QA activities. H2 Healthcare, LLC

14. Phase 1: What’s New • 483.20 - Resident Assessment • Adds strengths, goals, life history and preferences to the Assessment • Changes the wording from discharge potential to “discharge planning”. • Clarifies PASAAR requirements including the incorporation of Level II determinations, etc. into the care plan • Implications? Minor. Policy changes are needed to reflect new terminology and practices. H2 Healthcare, LLC

15. Phase 1: What’s New • 483. 21 – Comprehensive Resident-Centered Care Plans – new requirement • Requires a base-line care plan in 48 hours of admission and to communicate same to resident • Incorporates PASAAR findings (as applicable) to the care plan • Requires the implementation of an IDT (interdisciplinary team) that includes a CNA and food service person. • Requires resident participation and documentation if the resident cannot participate and provides the resident with rights to change the care plan, be informed in advance of changes, to see the care plan, etc. • Requires IMPACT Act conditions for Discharge Planning – documentation of goals for admission/discharge, establishes discharge summary requirements, adds a post-discharge plan of care summary, and have appropriate policies. H2 Healthcare, LLC

16. Comprehensive Resident Care Plans Implementation • Care plan must reflect participation by CNA and Food Service – initial schedule must be 48 hrs. from admission • Need to share info on rights pertaining to resident and representative participation in the care plan – including initial within 48 hrs. • Care plans must include discharge information/goals • Need a process for med reconciliation and teaching prior to/at discharge • Update policies accordingly with language and references, particularly process/protocols to include resident representative as applicable H2 Healthcare, LLC

17. Phase 1: What’s New • 483.25 – Quality of Care/Quality of Life – reflects clarifications and modernization • Activities and care plan to include resident preferences, including community interaction • SNF must ensure CPR availability/trained staff • Special Needs Issues to reflect restraints (least restrictive), pain management adequacy, bed rails and alarms, trauma needs for PTSD • Implications? Few other than clarification of language, focus on resident preferences and availability of CPR trained staff H2 Healthcare, LLC

18. Quality of Care/Quality of Life Implementation • Make sure staff are trained in CPR – sufficient to cover all shifts • Identify resident preferences and include aspects of community involvement to extent possible/applicable • Review Special Needs aspects. Suggest facilities look very closely at alarms, restraint use/bed rails, etc. Look for ways including best-practices to eliminate/reduce alarm use, side-rails, etc. • New requirement for pain management adequacy. Develop tools and systems to address this issue and to review frequently and care plan accordingly – unmanaged pain is a significant risk area for actual harm citations H2 Healthcare, LLC

19. Phase 1: What’s New • 483.30 – Physician Services – new section • Requires that orders for intermediate care needs be provided at admission (initial care orders). • Physicians can delegate the task of writing therapy orders and dietary/nutrition related orders to qualified therapists and dieticians – subject to state law. • Implications? Minimal. Review policies and make sure that orders on admission reflect physician recommendation for inpatient care plus provide for initial care orders. H2 Healthcare, LLC

20. Phase 1: What’s New • 483.35 – Nursing Services – Phase 1 implications, followed by Phase 2 implications • Assure that facility has sufficient number of staff with appropriate skills/knowledge to provide care to residents based on resident acuity and needs. Initial evaluation begins in Phase 1 • Determining the number and competencies via a competency-based staffing model is implemented in Phase 2 – guidance here still not available. • Implications? Facilities need to review their staffing and staff education initially. Compare via review the staff number and knowledge to the resident Case Mix. H2 Healthcare, LLC

21. Phase 1: What’s New • 483.40 – Behavioral Health Services – new section; biggest implication is in Phase 3 • In Phase 1, the facility must ensure (based on assessment) that a resident with mental/psychological disorders (documented and supported) receives appropriate care and if necessary, receives appropriate services for their condition(s). • By Phase 3, facilities must provide medically related social services to the resident to maintain and enhance their psychological well-being. • Implication? Not much – yet facilities need to assure adequacy of resources for residents that have histories of mental/psychological disorders…partnerships with mental health providers are warranted. H2 Healthcare, LLC

22. Phase 1: What’s New • 483.45 – Pharmacy Services – Phase 1 implications with additional implications in Phase 2 • Phase 1 requires a regimen review within 48 hours of admission and after transfer from (returns) from other facilities (Hospital, etc.) and any time requested by the QA committee plus monthly reviews. • Phase 2 requires the regimen review to include a concurrent review of the medical record by the pharmacist during any Drug Regimen Review and report irregularities to the Physician and DON. Also in Phase 2, limitations on PRN orders for psychotropics come into play – 14 days (anti-psychotic, hypnotic, anti-depressant, anxiolytic) • Implications? Most facilities should be fine but time to review policies and procedures with your Pharmacy to assure drug review requirements are met timely. Reinforce reviews and stops on PRN psychotropics H2 Healthcare, LLC

23. Phase 1: What’s New • 483.50 – Laboratory, Radiology and Other Diagnostic Services – all Phase 1 • Have identified, providers for each service and policies for notification of diagnostic results with parameters (as applicable) to medical practitioners. • Facility must assist with transportation to and from if needed. • Facility is responsible for timeliness and quality of services and appropriate record keeping. • Implications? Should be minimal. Review policies for MD notification on results and diagnostic provider relationships – assure quality, responsiveness, etc. H2 Healthcare, LLC

24. Phase 1: What’s New • 483.55 – Dental Services – two elements; Phase 1 and Phase 2 • Phase 1 – facility must provide or assist residents in accessing dental services, including transportation to and from and assist in with reimbursement for services under Medicaid – as applicable. Facilities must accommodate food/meal service and assure nutritional adequacy (documentation if needed) if resident has dental issues. • Phase 2 – facilities must financially replace dentures if loss is caused by the facility and make a referral within 3 days of loss for replacement or document cause for delay. • Implications? Few in Phase 1 – assure adequacy of dental care. Address policies/procedures for denture replacement for Phase 2. H2 Healthcare, LLC

25. Phase 1: What’s New • 483.65 – Specialized Rehabilitative Services – relocated from 483.45 • Only real issue here is Respiratory Therapy – facilities must source and provide if needed by residents – this was added to the existing list of specialized services • Implications? Only if the facility has residents with significant respiratory issues warranting the need for Respiratory Therapy H2 Healthcare, LLC

26. Phase 1: What’s New • 483.70 – Administration – multiple changes, issues but most occur in Phases 2 and 3 • Phase 1 – administrator accountable to Governing Board or similar level (direct to CEO). Also ends arbitration agreements/clauses. • Phase 2 – Facilities must conduct a complete facility-wide assessment to document that resources are adequate to provide daily care and emergency care for residents. Assessment will need to take into account, resident population and number, care needs including physical and cognitive, the environment, services, etc. • Phase 3 – Board is responsible for QA/QAPI – correlates to the QAPI development/implementation in Phase 3 • Implications? In Phase 1, few other than arbitration clauses or contracts need to change. Likewise, some tweaks to the org. chart for reporting structure of Administrator may be needed. H2 Healthcare, LLC

27. Phase 1: What’s New • 483.75 – QAPI – biggest implication is in Phase 3 • Phase 1 – facility QA committee/functions as is under current law • Phase 2 – Initial facility QAPI plan must be provided/available to surveyor during annual survey • Phase 3 – QAPI program as defined in COPs must be operational, report to the Board, include Infection Control, etc. • Implications? Facilities need to, if not already started, transition from current QA structure and requirements to the QAPI model and requirements. H2 Healthcare, LLC

28. Phase 1: What’s New • 483.30 – Infection Control – changes in Phases 2 and 3 • Phase 1 – have a program that investigates, control and prevents infection. Program should include procedures and protocols for prevention, isolation, etc. plus a record keeping function to document infections, corrections, etc. • Phase 2 – link Infection Control program to Facility Assessment plus develop/have in-place, an Antibiotic Stewardship program (use and monitoring protocols for antibiotics) • Phase 3 – Have an Infection Control Specialist(s) trained and qualified by education to maintain program of infection control with a designated budget and resources. Tie this to QAPI. • Implications? Facilities need to focus on Phases 2 and 3 NOW. Review policies and procedures accordingly with regard to prevention, monitoring, education, vaccinations H2 Healthcare, LLC

29. Phase 1: What’s New • 483.90 – Physical Environment – mostly effects construction and remodeling • New construction/reconstruction – max occupancy of 2 residents per room, bathroom for each room (not shared between rooms). • Must conduct regular inspections of beds and mattresses to ensure compatibility of frame to mattress (minimize gaps) • Phase 2 includes adoption of smoking policies/areas consistent with local laws and Phase 3 includes nurse call provisions – direct relay to staff and centralized staff areas. • Implications? Minimal unless undergoing construction. Facilities need to review beds and mattresses. H2 Healthcare, LLC

30. Where to Next?: Recommendations • Most facilities should be good for Phase I compliance save review of policies and incorporation of new COP language • Risk areas for compliance in Phases 2 and 3. While Phase 3 is two plus years away, much can be done now to get ready while accomplishing Phase 2 requirements • Review and develop a game plan for all phases. While Phase I is here, survey tasks are slow-rolling. Overall compliance and progress is key. • Use a consultant if necessary to conduct a quick compliance review to identify weakness/gaps for Phases 1 and 2 H2 Healthcare, LLC

31. Focal Areas: Where to Start • Review policies and procedures for language and reference changes (resident rights, etc.) • Review and update Admissions, Care Planning and Discharge Planning protocols and procedures • 48 hour initial care plan/assessment requirements • Discharge and care coordination requirements starting with initial care plan • Integrate resident preferences, goals, etc. into care planning • Conduct a simple review of resident case-mix against staff numbers and skills. Adjust staffing plans and education based on this review – engage a consultant if need be. H2 Healthcare, LLC

32. Focal Areas, continued • Work with your pharmacy/pharmacist on timing and content of drug regimen reviews. Get them integrated into on admission, with care transitions and with changes in psychoactive medications • Move your QA to a QAPI format. Review the requirements and get started, including identification of Infection Control staff • Review procedures and policies for alarm use, bed rails, etc. – eliminate or minimize any use • Review staff orientation and training – incorporate requirements for abuse, neglect and exploitation training plus QAPI information H2 Healthcare, LLC

33. About H2 Healthcare, LLC • Dedicated experts in compliance with real life, past and current experience in the SNF industry – at the 5 Star provider level • Resources that cover every area of operations from Nursing to Rehabilitative Therapies to Billing • Consultants with decades of experience in all aspects of health care operations • Cost-effective, client-focused solutions H2 Healthcare, LLC is a national healthcare advisory practice with offices in Nevada, Kansas, Illinois and Wisconsin H2 Healthcare, LLC