The New LTC Survey Process: First Quarter - michigan.gov · • F585 Grievances – Previously F165 – Grievance official responsibilities – Facility’s responsibility to inform

C U S T O M E R D R I V E N. B U S I N E S S M I N D E D.

The New LTC Survey Process: First Quarter

Cynthia De Leon Thelen MSN, BSN, RN

LTC State Administrative Manager, BCHS

Kirsten Nunham RN

Long Term Care Surveyor, BCHS


• Describe the rationale for implementing changes to the Long Term Care Survey

• Discuss an overview of the new structure

– Appendix PP

• Identify communication and information timeframes

• Identify Resources

Objectives


Surveyors and Providers = Shared Outcomes


Surveyors and Providers

• Our roles impact the lives of Michigan residents EVERY SINGLE DAY!

• Our profession is a choice that we EQUALLY care about!

• Our shared goals result in Positive Resident Centered Outcomes


• Affordable Care Act (ACA) and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act

– Quality Assurance and Performance Improvement (QAPI)

– 1150B requirements for reporting reasonable suspicion of a crime

– Increased Discharge Planning requirements

– Staff Training

Regulatory Reform


• Bringing survey process into the 21st century!

• Merge of Traditional (Paper) and Quality Indicator Survey (Computer Based)

• ONE Streamlined Process for ALL states

Rationale for the change


• Principals of Person-Centered Care

• Outcome-Oriented Care

• Quality of Care

• Quality of Life

• Consistent with current Health and Safety Knowledge

Rationale for the change: Focus


What has NOT changed for providers


• Implemented November 28th, 2017

• ALL states went live with new LTCSP to conduct Long Term Care Surveys

The New Survey Process: Phase 2


• Collected Immediately by Survey Team

• Step 1: Census Number

• Step 2: Matrix for new admissions who reside in the facility

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Matrix-with-Instructions-Content-Unchanged.pdf

Facility Entrance: Communication Timeframes

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Matrix-with-Instructions-Content-Unchanged.pdf


• Step 3: Alphabetical list of all residents

• Step 4: List of residents who smoke



Most Notable:

• No formal Initial Tour with facility staff

• Surveyors conduct tour independently

• Facility staff are no longer pulled for tour

• More time spent in conversations with residents

Summary: What HAS changed for providers


• Collected Within One Hour of entrance by survey team

• Schedule of meal times, locations of dining rooms, copies of all current menus including therapeutic menus that will be served for the duration of the survey and the policy for food brought in from visitors.

• Schedule of Medication Administration times.

• Number and location of medication storage rooms and medication carts.

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

• List of key personnel, location, and phone numbers. Note contract staff (e.g., rehab services).

• Paid feeding assistants



• Collected within 4 hours of entrance

• Complete Matrix for all other residents

• Provide each surveyor with access to ALL resident electronic health records

• Do not exclude any information that should be part of the residents’ medical record



• 70% of the total sample is MDS pre-selected residents chosen offsite

• 30% of the total sample is determined onsite based on observations, interviews and limited record review

Resident Sample Selection


• Total sample size is about 20% of facility census

• Resident sample may be greater due to Complaints

• Resident sample may be greater due to Facility Reported Incidents

Recertification Survey Sample Size


• Appendix PP

– Reorganized and Updated

– New F Tags

– F- tag renumbering

• First Quarter Findings

Overview of the New Structure


New Resident Rights F-Tag Numbering:

• F551 Resident Representative

• F553 Participate in Planning Care

• F555 Choice of Attending Physician

• F563 Visitation

• F564 Visitation Rights

• F578 Right to Request/Refuse Treatment/ Advance Directive

• F585 Grievances

• F586 External Entities

§ 483.10 Resident Rights


• F551 - Resident Representatives

– Previously F152

– Resident representative acts within their legal responsibility

• F553 – Participation in Care Planning

– Previously F154/F280

– Resident has the right to participate in care planning process

– Facility upholds rights



• F555 – Choice of Attending Physician

– Previously F163

– Physician must be licensed to practice

• F463/F564 – Visitation

– Previously F172

– Resident’s right to visitors

– Restriction for clinical or safety reasons

– Informing of visitation rights

– Equal visitation privileges



• F586 – External Entities

– Previously F168

– Communication with Federal, State, or local officials must be

allowed



• F578 – Right to Request/Refuse Treatment/Advance Directive

– Previously F155

– Facility’s responsibility to assist residents in establishing advance

directives

• F585 Grievances

– Previously F165

– Grievance official responsibilities

– Facility’s responsibility to inform residents of how to file a grievance,

and to maintain records

– Grievance policy



• Stand alone MDS Focus Survey is gone

• MDS is now incorporated into every survey

• The new resident assessment task reviews and investigates discrepancies identified for residents’ MDS assessments

Minimum Data Set (MDS)


MDS Clinical Indicators

• Alzheimer’s or Dementia

• Anticoagulant with Internal Bleeding

• Anticoagulant without Internal Bleeding

• Bowel and Bladder

• Catheter with UTI

• Catheter without UTI

• Constant Pain

• Decline in ADL’s

• Dehydration

• Dialysis

• Dehydration

• Dialysis

• Falls with Major Injury

• Feeding Tube/NO Dehydration

• Feeding Tube with Dehydration

• Four (4) or More Re-hospitalizations

• Frequent Pain

• Hospice

• Insulin


MDS Clinical Indicators

• One (1) Re-hospitalization

• Preadmission Screening and Resident Review (PASARR)

• Major Infections

• One (1) Re-hospitalization

• Preadmission Screening and Resident Review (PASARR)

• Pressure Ulcers Facility Acquired

• Pressure Ulcers Worsening

• Restraints

• ROM Limitation/Not Receiving Therapy

• ROM Limitation/Receiving Therapy

• Tracheostomy

• Two (2) or Three (3) Re-Hospitalizations

• UTI

• Ventilator

• Wandering

• Weight Loss


– Facilities need to have some type of quality assurance process that ensures the accuracy of MDS data.

– Each Critical Element Pathways starts with:

“Is the MDS accurately coded?”

Key Point


• CE Pathways are completed for EACH sampled resident

Key changes to the Survey Process


• SNF Beneficiary Protection Notification Review

• Dining Observation

• Infection Prevention Control and Immunizations

• Kitchen Observation

• Medication Administration Observation

Critical Element Pathways


• Resident Council Interview

• Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Plan Review

• Abuse

• Environmental Observations



• Sufficient and Competent Nurse Staffing Review

• Personal Funds Review

• Activities

• Activities of Daily Living (ADL)

• Behavioral and Emotional Status



• Urinary Catheter or Urinary Tract Infection

• Communication and Sensory Problems (Includes Hearing and Vision)

• Dental Status and Services

• Dialysis

• General (Quality of Care)



• Hospice and End of Life Care

• Death

• Nutrition

• Pain Recognition and Management

• Physical Restraints

• Pressure Ulcer/Injury

• Specialized Rehabilitative or Restorative Services



• Rehab & Restorative Services

• Respiratory Care

• Unnecessary Medications (Psychotropic Medications & Medication Regimen Review)

• Medication Storage and Labeling

• PASARR

• Hydration

• Tube Feeding Status



• Positioning, Mobility, ROM

• Hospitalization

• Bladder and Bowel Incontinence

• Accidents

• Neglect

• Resident Assessment

• Discharge

• Dementia Care



Minimum Data Set

Critical Element

PathwaysCare Plans

Process Links: Positive Resident Outcomes


• CMS uses the terminology ‘locus of control’

• The care plan should show that the resident is making their own choices and that they have control over their daily lives.

• Focusing on person centered care plans

Care Plans


§ 483.21(a)(1)

Baseline Care Plan developed within 48 hours of resident

admission and contain the minimum healthcare information

necessary to care for resident, which includes:

• Initial goals

• Physician/Dietary orders

• Therapy services

• Social services

• Applicable PASRR recommendations

F655 Baseline Care Plan-New Requirement


§ 483.21(a)(2)

A Comprehensive Care Plan may be developed in place of

Baseline Care Plan, but must be developed within 48 hours of

admission and meet all requirements for the Comprehensive Care

Plan.

• Baseline care plan must include the resident goals for his/her care

• Enhanced involvement of the resident and/or representative

• Recognizing the residents rights related to care

F655 Baseline Care Plan


Key Point

§ 483.21(a)(3)

A written summary of the baseline care plan must be

provided to the resident and their representative, if

applicable.


§ 483.21(b)(2)(i) (Formerly F280)

Comprehensive care plan must be developed within 7 days after

completion of the comprehensive assessment.

F657 Care Plan Timing and Revision


§ 483.21(b)(2)(ii) New Requirements for who must be on the interdisciplinary team:

• Attending physician

• A registered nurse with responsibility for the resident

• A nurse aide with responsibility for the resident - new

• A member of food/nutrition services - new

• The resident or, if applicable, their representative - new

• Other appropriate staff or professionals as determined by the resident or their

needs

New requirement to document an explanation in the medical record if attendance by the

resident or their representative is determined not practicable.



§ 483.21(b)(2)(iii)

New requirement: The comprehensive care plan must be

reviewed/revised after each RAI assessment.



Care Plans should address what the resident is requesting to have done to help accomplish their goals, incorporating both personal and cultural preferences.

Key Point


What has changed for Surveyors


• “User-friendly” software

• Surveyors becoming acclimated to the new LTCSP and use of the software

• How findings are documented= computerized

Computer Based Software


• Requests for electronic documents

• Software triggers potential citations

• Downtime procedures

• Basic Ergonomics

Computer Based Software


Perceptions


• Provider resources are FREE and open to the PUBLIC

• Every facility has EQUAL access to CMS resources

• Centers for Medicare and Medicaid Services – https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

Reality

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html


• Long Term Care Survey Process (LTCSP) Review Course

• Located on the Integrated Surveyor Training Website (ISTW)

• https://surveyortraining.cms.hhs.gov/index.aspx

Provider Resources

https://surveyortraining.cms.hhs.gov/index.aspx


• Click on I am a provider

• Click on Course Catalog at the top of the page

• Type in Long Term Care Survey Process Review

• Click on Title

• Click Launch the course

Accessing LTCSP Review Course


• LTCSP Procedure Guide

• List of Revised F-Tags/Substandard Quality of Care (SQC) F tags

• Appendix PP- Guidance to Surveyors for LTC facilities

• Appendix Q-Guidelines for Determining Immediate Jeopardy

Provider Resources


• Chapter 7 Survey and Enforcement Process for Skilled Nursing Facilities of the State Operations Manual

• Psychosocial Outcome Severity Guide

• Principals of Documentation

Provider Resources


Long Term Care Survey Process Review Resource Documents List:https://surveyortraining.cms.hhs.gov/data/139/cf81cb17-47bf-e711-9524-0e63451df8f4/assets/Resources.pdf

Nursing Homes page at CMS.gov :https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

Resource List

https://surveyortraining.cms.hhs.gov/data/139/cf81cb17-47bf-e711-9524-0e63451df8f4/assets/Resources.pdf

https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html


• Integrated Surveyor Training Website:https://surveyortraining.cms.hhs.gov/pubs/providertraining.aspx

Resident Interview Care Areas and Probes

Resident Observations Care Areas and Probes

Resident Record Review Care Areas and Probes

Representative Interview Care Areas and Probes

Resource List

https://surveyortraining.cms.hhs.gov/pubs/providertraining.aspx


• Frequently Asked Questions Related to Long Term Care Regulations, Survey Process, and Training:

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTC-Survey-FAQs.pdf

• Updated 2/6/2018

Questions

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTC-Survey-FAQs.pdf


• Appendix PP State Operations Manual (Revised 11/22/2017) [PDF, 3MB]

• List of Revised FTags [Effective November 28, 2017] [PDF, 152KB]

• S&C Memo: Revision to State Operations Manual Appendix PP for Phase 2 (Includes Training Information and Related Issues) [PDF, 121KB]

• F-Tag Crosswalk [XLSX, 495KB]

• Training for Phase 1 Implementation of New Nursing Home Regulations [PDF, 108KB]

Nursing Homes

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/List-of-Revised-FTags.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Survey-and-Cert-Memo-Revision-SOM-Appendix-PP-Phase-2.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/F-Tag-Crosswalk.xlsx

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Survey-Cert-Letter-17-03.pdf


• New Long-term Care Survey Process – Slide Deck and Speaker Notes [PPTX, 8MB]

• Entrance Conference Form Beneficiary Notice Worksheet (Updated 12/06/2017) [ZIP, 164KB]

• Entrance Conference Form Beneficiary Notice Worksheet (Updated 12/06/2017) [ZIP, 164KB]

• LTC Survey Pathways - Updated 12/13/2017 [ZIP, 2MB]

Nursing Homes

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/New-Long-term-Care-Survey-Process%E2%80%93Slide-Deck-and-Speaker-Notes.pptx

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Entrance-Conference-Form-Beneficiary-Notice-Worksheet.zip

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Entrance-Conference-Form-Beneficiary-Notice-Worksheet.zip

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTC-Survey-Pathways.zip


• LTCSP Procedure Guide [PDF, 1MB]

• LTCSP Initial Pool Care Areas - Updated 11/17/2017 [ZIP, 1MB]

• Survey Resources - Updated 01/18/2018 [ZIP, 10MB]

• Matrix with Instructions - Content Unchanged [PDF, 299KB]

Nursing Homes

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTCSP-Procedure-Guide.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/LTCSP-Initial-Pool-Care-Areas.zip

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Survey-Resources.zip

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Matrix-with-Instructions-Content-Unchanged.pdf


• CMS is the Authoritative Resource for the New Long Term Care Survey Process for Federally Certified Facilities

Summary Key Point


The New Emergency Preparedness Survey: First Quarter

Laura Remus, BS, REHS

Environmental Health and Safety Section Manager, BCHS

Gerald Rodabaugh, Fire Safety Supervisor, BCHS


• List the required components of an Emergency Preparedness Plan

• Identify areas for improving a facility’s emergency preparedness survey

• Identify examples of correct and incorrect emergency preparedness plans

Objectives


Four Provisions for All Provider Types

Risk Assessment and Planning

Policies and Procedures

Communication Plan Training and Testing

Emergency Preparedness

Program

8


Risk Assessment and Planning

• Develop an emergency plan based on a risk

assessment.

• Perform risk assessment using an “all-hazards”

approach, focusing on capacities and capabilities.

• Update emergency plan at least annually.

9


All-Hazards Approach:

• An all-hazards approach is an integrated approach to

emergency preparedness planning that focuses on capacities

and capabilities that are critical to preparedness for a full

spectrum of emergencies or disasters, including internal

emergencies and a man-made emergency (or both) or natural

disaster. This approach is specific to the location of the

provider or supplier and considers the particular type of

hazards most likely to occur in their areas.

7


All-Hazards Approach:

• These may include, but are not limited to, care-

related emergencies, equipment and power

failures, interruptions in communications,

including cyber-attacks, loss of a portion or all

of a facility, and interruptions in the normal

supply of essentials such as water and food.


Policies and Procedures

• Develop and implement policies and procedures

based on the emergency plan and risk

assessment.

• Policies and procedures must address a range of

issues including subsistence needs, evacuation

plans, procedures for sheltering in place, tracking

patients and staff during an emergency.

• Review and update policies and procedures at

least annually.

10


Communication Plan

• Develop a communication plan that complies with

both Federal and State laws.

• Coordinate patient care within the facility, across

health care providers, and with state and local

public health departments and emergency

management systems.

• Review and update plan annually.

11


Training and Testing Program

• Develop and maintain training and testing

programs, including initial training in policies and

procedures.

• Demonstrate knowledge of emergency procedures

and provide training at least annually.

• Conduct drills and exercises to test the emergency

plan.

12


Training & Testing Program Definitions

• Facility-Based: When discussing the terms “all-hazards

approach” and facility-based risk assessments, we consider

the term “facility-based” to mean that the emergency

preparedness program is specific to the facility. Facility-based

includes, but is not limited to, hazards specific to a facility

based on the geographic location; Patient/Resident/Client

population; facility type and potential surrounding community

assets (i.e. rural area versus a large metropolitan area).

70


• Full-Scale Exercise: A full scale exercise

is a multi-agency, multijurisdictional, multi-

discipline exercise involving functional (for

example, joint field office, emergency

operation centers, etc.) and ‘‘boots on the

ground’’ response (for example, firefighters

decontaminating mock victims).




• Table-top Exercise (TTX): A table-top exercise is a group

discussion led by a facilitator, using narrated, clinically-

relevant emergency scenario, and a set of problem

statements, directed messages, or prepared questions

designed to challenge an emergency plan. It involves key

personnel discussing simulated scenarios, including

computer-simulated exercises, in an informal setting. TTXs

can be used to assess plans, policies, and procedures.

72


Requirements Vary by Provider Type

• Long-term care facilities must share information

from the emergency plan with residents and family

members or representatives.

14


Temperature Controls and Emergency and Standby

Power Systems

• Under the Policies and Procedures, Standard (b)

there are requirements for subsistence needs and

temperature controls.

• Additional requirements for long-term care facilities

are located within the Final Rule under Standard

(e) for Emergency Power and Stand-by Systems.

13


Interpretive Guidelines

• Appendix Z (remember:

Z= Zombie Apocalypse)

• Are formatted into one

new Appendix within the

State Operations Manual

(SOM) applicable to all 17

provider/supplier types

17


• The plan has not been tested (Tag E-39)

• Emergency food within the facility does not match with the plan (Tag E-15)

• Some other policy/procedure cites

• Make the plan specific to your needs and your facility

• Organize the plan so that staff can use it when in an actual emergency

What are we seeing on surveys so far?


Questions?