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SNF 2018 Survey Workshop

Presented by:

Brian Purtell, WHCA/WiCAL Legal/Regulatory Advisor

Tina Belongia, Director of Quality Advancement and Regulatory Affairs

Lori Koeppel, owner - Koeppel Healthcare Solutions

Learning Objectives

• Review regulatory and survey developments over the past year, including the implementation of RoP Phase II and the revised survey process.

• Examine and prepare for the Phase III requirements coming in September 2019.

• Develop proactive efforts, including maximizing a facility QAPI program, towards enhancing quality improvement and regulatory compliance.

Continuing Education

This educational offering has been approved by the National Continuing Education Review Service (NCERS) of the National

Association of Long-Term Care Administrator Boards (NAB) and approved for 4 clock hours and 4 participant hours.

Eau Claire Approval #20190911-4-A39002-IN

Appleton Approval #20190911-4-A47273-IN

Brookfield Approval # 20190911-4-A47292-IN

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Important Info

• Ask questions! There is no “dumb” question!

• We will break at around 10:00

• We will adjourn NO LATER than 1:00

• Please put your phones on SILENT mode

• One person per chair

Review of Survey Timelines

• Day 0-10• POC• IDR Option• Fast track termination technically possible

• Day 10-60• Perform POC (note does not need to wait until day 10 to start or complete)• Discretionary remedies possible, e.g. Discretionary Denial of Payment for New

Admission• Termination possible at day 23 if IJ not corrected• Revisit (if not eligible for desk review)• Appeal for state citation (rare but still possible)

Review of Survey Timelines

• Day 90- mandatory denial of payment for new admissions if not corrected within 3 months of SOD.

• Day 180- mandatory termination from participation in Medicare and Medicaid

• Day ? CMS Imposition of Remedies letter:• IIDR option within 10 days, only if CMP imposed.

• 60 day federal appeal for remedies imposed at this time

• 60 day period to accept 35% reduction in exchange for waiving appear• Note: Action required, not simply choosing not to appeal.

• 15 day hardship request for CMP (rarely granted)

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Survey Developments

• IDR/IIDR Review Change: Maximus Federal• Account needed for submission.

• Takes a day or two to establish (don’t wait until day 10 to set up)

• Expires after 30 days if not used

• Experience thus far?

• IDR vs. IIDR refresher:• Same basic process

• 10 day submission period (SOD sent date is day 0)• Note: If SOD on Friday, POC and IDR due day 12. DOES NOT APPLY if CMS enforcement

letter received on Friday.

• TIPs and discussion.

Survey Developments

• Immediate Imposition of Remedies implementation QSO-18-18 June 15, 2018

• Transfer/Discharge Notice and SQC clarified S&C: 17-27-NH May 12, 2017

• Appendix Q: Immediate Jeopardy revision coming “soon”

• Emergency Preparedness Rule:

• CMS Emergency Preparedness Rule Toolkit (revised Sept 2017)

Review of WI Survey Statistics

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DQA Listserv

Be sure that you are registered for the emails from DQA:

https://public.govdelivery.com/accounts/WIDHS/subscriber/new?topic_id=WIDHS_58

DONs

NHAs

Nurse Managers

Department Heads

F880 Infection Control

What are the common issues?

• Handwashing?

• Outbreak management?

• ATB Stewardship?

• Surveillance?

Infection Control Resources

IPCO training program

• Designed and taught by subject matter experts who have real life experience working in long term/post-acute care.

• Addresses both clinical and organizational systems, processes and cultural aspects of infection prevention and control.

• 23-hrs of training – all completed online (lectures, case studies and interactive components)

• Course must be completed within 9 months of starting

• Certificate of completion good for 3 yrs. (must pass @80%)

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Infection Control Resources

IPCO training program

• Cost $450 (renewal is $200 for the competency exam)

• Access the training here: https://educate.ahcancal.org/products/infection-preventionist-specialized-training-ipco

Core Elements of Antibiotic Stewardship for Long-Term Care

https://www.cdc.gov/longtermcare/

Infection Control Resources• Clinical Resource Center https://crc.chsra.wisc.edu/nh/infection/resources.php

• Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria: https://www.jstor.org/stable/10.1086/667743

• Wisconsin Healthcare-Associated Infections (HAIs) in Long-Term Care Coalition Resources: https://www.dhs.wisconsin.gov/regulations/nh/hai-resources.htm

• Infection Prevention, Control and Immunizations Critical Element Pathway: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

Outbreak surveillance/management

Resources:

• https://www.dhs.wisconsin.gov/publications/p0/p00653.pdfRecommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities• Make sure Infection Control Nurse has this readily available

• Make sure Housekeeping Supervisor has info related to cleaning and disinfection

• Make sure all Department Heads understand the importance of tracking call-ins and maintenance of the line listing

• Floor nurses need to know what to do in case of a suspected outbreak

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Outbreak surveillance/management

• https://www.dhs.wisconsin.gov/dph/memos/communicable-diseases/bcd-2017-04.pdf Reporting, prevention and control of acute respiratory illness outbreaks in long-term care facilities October 2017

*A respiratory disease outbreak in a LTCF is defined by DPH as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other and who have:

• Pneumonia, or • ARI, or • Laboratory-confirmed viral or bacterial infection (including influenza).

OUTBREAKS: NOW IS THE TIME TO PREPARE

Medical Director involvement crucial-review, input, agreement/approval of plan.

Make sure contact info for Public Health Nurse is available

Hand Hygiene Campaign

Review facility cleaning guidelines to ID any gaps

Review policy on employee illness

Review plan for additional resources (signs, extra PPE, cleaning materials, etc.)

Review your surveillance plan

Review policy for Contact and Resp Isolation

Legionella and other Waterborne Diseases

Refer to CMS memo QSO-17-30

• Facility risk assessment must include risk for waterborne diseases

• Determine if testing should be conducted, and if so, how frequent

Resources:

Does your Center need a water management program? https://www.cdc.gov/legionella/wmp/toolkit/wmp-risk.html

Legionella toolkit: https://www.cdc.gov/legionella/wmp/toolkit/index.html

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F686 Pressure Ulcers

What are the common issues?

• Staffing related?

• Prevention?

• Treatment?

• Is it really unavoidable?

Pressure Ulcer Resources

• NPUAP

• MetaStar/Lake Superior Quality Initiative: https://www.lsqin.org/initiatives/nursing-home-quality/

• Wound Treatment Associate Program: https://www.whcawical.org/publications/care-connection/may-25-2018/wound-care/ Click on “register” to be notified as soon as the next class is open for enrollment!

• Pressure Ulcer/Injury Critical Element Pathway: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

F689 Accidents

Common issues:

• Falls

• Elopements

• Hot liquids

• Smoking

• Resident to resident altercations

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Accident Resources

• Accident Critical Element Pathway: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

• Fall Investigation Toolkit: https://www.lsqin.org/wp-content/uploads/2018/05/Falls-Investigation-Guide-Toolkit-How-To-Guide.pdf

• Smoking in Wisconsin Nursing Homes: https://www.dhs.wisconsin.gov/publications/p01957.pdf

• Resident to resident flowchart: https://www.dhs.wisconsin.gov/publications/p0/p00361.pdf

F812 Prevention of Foodborne Illness

Common issues:

• Kitchen sanitation

• Food temps

• Storage of foods

• Handwashing

• What else?

Prevention of Foodborne Illness Resources

• Dining AND Kitchen Critical Element Pathways: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

• Association of Nutrition & Food Service Professionals: http://www.anfponline.org/

• CDC Food Safety for Healthcare Professionals: https://www.cdc.gov/foodsafety/groups/healthcare-professionals.html

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Care Plans/Bladder (tied for 5th most commonly cited tag)• Failure to update care plans with changes

• Failure to follow care plans

Bladder:

• Still using “canned care plans”, (i.e. every 2 hours or 2 hours before bed or meals, etc.)

• No pericare

• No toileting when they should be or when the resident prefers it

• Not cleansing catheter port

Abuse/Neglect reporting/investigating

• Refresh reporting timelines:• Immediately=as soon as possible, but not to exceed 24 hrs., but-

• 2 hours if:

• Abuse OR

• Serious bodily injury

• Report to law enforcement if “reasonable suspicion” that a crime as been committed against a resident.

• TIP: Allegation does not equal “reasonable suspicion”: be prepared to discuss with surveyor and explain

Let’s take a short break

This Photo by Unknown Author is licensed under CC BY

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Review of Phase 2

Transfer/Discharge

Smoking

Baseline Care Plan

Facility Assessment

Quality Plan

Transfer/Discharge

• Documentation requirements when:• Needs can no longer be met

• No longer needs services

• Safety is endangered due to clinical or behavioral status

• Health of individuals in the facility would be endangered

• Failure to pay for services (after sufficient notice)

• The facility ceases to operate

• Notice to be provided for all “facility initiated” transfer/discharge.• Consider separate notice containing appeal rights for transfers that are not

involuntary discharge.

• Monthly spreadsheet to ombudsman office (but true NOID should be cc)

Smoking

Must establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents.

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Baseline Care Plan

• Must be developed within 48 hours of admission

• Must include:• Initial goals based on admission orders

• Physician orders

• Dietary orders

• Therapy services

• Social services

• PASARR recommendation, if applicable

• Must provide resident and representative with a summary of the baseline care plan by completion of the comprehensive care plan.

Facility Assessment

• Facility-wide assessment to determine what resources are needed top care for its residents completely during day-to-day operations and emergencies

➢The facilities resident population:• Number of residents and capacity

• Care required by the resident population

• Necessary staff competencies

• Environment, equipment, and physical plant considerations necessary to care for the resident population

• Ethnic, religious, or cultural factors that may impact care

Facility Assessment

➢The facility’s resources, including but not limited to:• All buildings and/or other physical structures and vehicles • Equipment (medical and nonmedical)• Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies• All personnel, including managers, staff (both employees and those who provide services

under contract), and volunteers, as well as their education and/or training and any competencies related to resident care

• Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies

• Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations

➢A facility-based and community based risk assessment, utilizing an all hazards approach.

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Facility Assessment Resources

• ahcancalED: https://educate.ahcancal.org/ (search for facility assessment)

• QIO sample facility assessment: https://qioprogram.org/facility-assessment-tool

Quality Plan

• Must have had it developed for Phase 2

• How does it “fit” into your QAPI meeting?

Resources:

• CMS: https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/qapiplan.pdf

• Sample QAPI plan template: http://www.hqi.solutions/wp-content/uploads/2017/05/QAPI_Plan_Template.pdf

Prepping for Phase 3

Call system

Infection Preventionist

Dietician

Trauma Informed Care

Compliance and Ethics Program

Training requirements

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Call System

From each resident’s bedside• Direct to staff or to

centralized work area

Infection Preventionist

• Participation in QAA Committee (QAPI)

• Has primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field

• Qualified by education, training, experience or certification

• Work at least part-time at the facility

• Have completed specialized training in infection prevention and control

Infection Preventionist Resources

• Refer to slides 12 and 13 (IPCO training)

• CMS training coming Spring 2019• https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertificationGenInfo/Downloads/QSO-18-15-NH.pdf

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Dietician/Food Service Director – “Phase 3”

• Not truly Phase 3, but 5 years from implementation, director requirements apply

• CMS has indicated SafeServe course not sufficient because it does not include management expectations.

• Further clarification expected

Trauma Informed Care

“The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.”

Trauma Informed Care Resources

• State of WI: https://www.dhs.wisconsin.gov/tic/index.htm

• Person Centered Care: https://www.ahcancal.org/facility_operations/Clinical_Practice/Pages/Quality%20of%20Life%20and%20Person-Centered%20Care.aspx

• Wisconsin Coalition for Person Directed Care: https://www.wisconsinpdc.org/

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Compliance and Ethics Program

• Establish written standards, policies and procedures “likely to be effective” to reduce the prospect of criminal, civil and administrative violations and promote quality of care.

• Assign “high level” individual[s] (e.g., Chief Executive Officer (CEO), Board Member, Division Director, etc.) to oversee the program standards, policies and procedures.

• Allocate sufficient resources and authority to individual(s) overseeing the program to “reasonably assure compliance” with standards, policies and procedures.

• Exercise “due diligence” to ensure individual(s) overseeing the program do not have the “propensity” to engage in illegal behavior.

Compliance and Ethics Program

• Act to “effectively” communicate the program standards, policies and procedures to staff, contractors and volunteers.

• Take “reasonable steps” to achieve compliance with the program’s standards, policies and procedures.

• Apply consistent enforcement of the program standards, policies and procedures through appropriate disciplinary mechanisms including as appropriate, discipline for individual(s) failure to detect and report a violation to the program contact.

• Ensure all “reasonable steps” are taken to “respond appropriately” to a violation and to “prevent further similar violations” including any necessary modification to the program.

Compliance and Ethics Program

Organizations with 5+ NFs must also:

• Conduct annual and mandatory program training as explained in 42 CFR 483.95(f).

• Designate a compliance officer whose “major responsibility” is to oversee the program, and who reports to the “governing body.” Note: The compliance officer cannot be “subordinate to the general counsel, chief financial officer [CFO] or chief operating officer [COO].”

• Designate a compliance liaison at each of the organization’s centers.

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Training

• Effective Communication

• Resident Rights and Facility Responsibilities

• QAPI elements and goals

• Infection Control

• Compliance and Ethics

• Nurse aide training on areas of weakness determined by performance reviews and the facility assessment

• Behavioral health

Past non-compliance discussion

7510.1 – Determining Citations of Past Noncompliance at the Time of the Current Survey (Rev.) Past noncompliance may be identified during any survey. For the purpose of making determinations of current noncompliance or past noncompliance, the survey team is expected to follow the investigative protocols and surveyor guidance. To cite past noncompliance with a specific survey data tag (F-tag or K-tag), all of the following three criteria must be met:

1. The facility was not in compliance with the specific regulatory requirement(s) (as referenced by the specific F-tag or K-tag) at the time the situation occurred;

2. The noncompliance occurred after the exit date of the last standard (recertification) survey and before the survey (standard, complaint, or revisit) currently being conducted; and

3. There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by the specific F-tag or K-tag.

Past non-compliance discussion

A nursing home does not provide a plan of correction for a deficiency cited as past noncompliance because the deficiency is already corrected; however, the survey team documents the facility’s corrective actions on the CMS-2567.

Regulations at 42 CFR 488.430(b) provide that a civil money penalty (CMP) may be imposed for past noncompliance since the last standard survey. CMS strongly urges States to recommend the imposition of a CMP for past noncompliance cited at the level of immediate jeopardy.

When a CMP is recommended, the State Survey Agency notifies the CMS Regional Office (RO) and/or State Medicaid Agency within 20 days from the last day of the survey that determined past noncompliance of its recommendation to impose a CMP. The CMS RO and/or State Medicaid Agency responds to the recommendation within 10 days, and if accepted, sends out the formal notice in accordance with the notice requirements in §7305 and §7520.

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Past non-compliance discussion

“Clarifying that Past Noncompliance deficiencies (as described in §7510.1 of Ch. 7 of the State Operations Manual (i.e. Determining Citations of Past Noncompliance at the Time of the Current Survey) are not included in the criteria for Immediate Imposition of Remedies” CMS QSO 18-18-NH June 15, 2018

Past non-compliance discussion

• If critical event, e.g. fall with serious injury; elopement; stage III or IV PI; abuse/neglect, etc.

• Refer to IDT/QAPI

• RCA

• “POC”

• Document plan of action including monitoring

Final Thoughts

One more resource for you: Survey FAQs from CMS: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTC-Survey-FAQs.pdf

Make use of your QAPI committee!

Share what is working!

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Thank you for attending!

This Photo by Unknown Author is licensed under CC BY