critical access hospital cops€¦ · swing beds there are around 1,348 cahs 88% provide swing beds...
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Critical Access Hospital CoPs Swing Beds
What CAHs Need to Know
SpeakerSue Dill Calloway RN, Esq.
CPHRM, CCMSCP, CCMSP
AD, BA, BSN, MSN, JD
President
5447 Fawnbrook Lane
Dublin, Ohio 43017 614 791-1468 (Call with
questions, No emails)
You Don’t Want One of These
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Introduction into the CAH Hospital CoPs
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Swing BedsCMS rewrote all the swing bed rules October 12,
2018
CMS has the swing bed regulations in Appendix W
However, CMS made a significant change
The interpretive guidelines and survey procedure are in Appendix PP
Appendix PP is the long term care manual
The swing bed regulations originally came from the LTC manual
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Swing BedsThere are around 1,348 CAHs
88% provide swing beds
Swing beds provide an opportunity to have care for those in their community closer to home
It helps CAHs to increase or stabilize their census
Medicare swing bed is reimbursed at the same per-diem rate as Medicare acute care, making swing bed, for most CAHs, an important revenue source
CAH do not need to complete the MDS or use it to do a plan of care like rural hospitals do
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Introduction Hospitals often ask how do I keep up with changes
in the future? First, have one of two people at the hospital that can do
the following
First, sign up to get the federal register
Second, go out once a month and see if any changes to the CMS manual
Third, go out once a month and see if any new CMS survey memos
CMS has a website to ask question in writing [email protected]
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Subscribe to the Federal Register
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https://public.govdelivery.com/accounts/USGPOOFR/subscriber/new
Location of CMS Hospital CoP Manual
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Email questions [email protected]
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf
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CAH Questions to CMSThe best way to ask a question on the CAH CoPs is
to email it to [email protected]
Many hospitals like to get their answer in writing and put in their file drawer in case the issue comes up later with a surveyor
Anita Moore is now in charge of the CAH at the Corporate Office and phone number is 410 786-2161
Email address is [email protected]
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CAH Manual SOM or CoP
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www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/
som107_Appendixtoc.pdf
Email questions to [email protected]
Appendix PP LTC 749 Pages
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www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads
/som107ap_pp_guidelines_ltcf.pdf
CMS Survey and Certification Website
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www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#
TopOfPage
Click on Policy & Memo to States
CMS Survey Memos
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www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-
Regions.html
Sample Survey Memo Immediate Jeopardy
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Emergency Preparedness
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CMS Surveyor Worksheet for Swing Beds Form 288
Swing Bed Surveyor WorksheetExhibit 288 is a surveyor worksheet for swing beds
and it is 11 pages
First page had information about the hospital and the survey team
It crosswalks the tag number in appendix A with the tag number under Appendix W
Hospitals should consider using it just like they should consider a gap analysis There are some things in the worksheet that were in the
old swing bed regulations still being assessed and tag numbers that no longer exists
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www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/do
wnloads/som107_exhibit_288.pdf
Assessments 17 Things
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Activities for Residents in Swing Beds
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Care Plans
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Discharge Summary
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The CAH Checklist
Center for Rural Health University of SDThe Center for Rural Health, the University of North
Dakota, School of Medicine and Health Sciences has a good website of resources for CAHs
This includes a checklist of the hospital CoPs
Includes a copy of the CoPs for Appendix W The CoPs are also called the state operations manual
The website is https://ruralhealth.und.edu/projects/cah-quality-network/cop
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CAH Checklist
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https://ruralhealth.und.edu/projects/cah-quality-network/cop
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Sample QAPI Plan from Montana
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https://ruralhealth.und.edu/assets/1370-5768/performance-improvement-plan.pdf
CAH Resources
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ResourcesAnother good website is the RHIhub-Rural Health Information HubHas tools for success
Has topic guide resources
Has case studies
Has an on-line library
Has some resources on CAH issues
Can sign up to get weekly newsletters
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www.ruralhealthinfo.org/topics/cri
tical-access-hospitals
MLN Fact Sheet on Swing BedsCMS has a Medicare Learning Network (MLN) fact
sheet on swing beds
It is 6 pages long
Provides information about the background
Discusses requirements
Payment information
Has additional resources
Helpful website on the Regional Office Rural Health Coordinators
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Resources and Other Manuals
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www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/SwingBedFactsheet.pdf
MLN CAH BookletCMS has a 14 page booklet available with
additional information www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/CritAccessHospfctsht.pdf
Includes information on payment
Grants under the rural hospital flexibility program
Helpful websites
Background information
Resources
And a list of the regional office rural health coordinators
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MLN CAH Booklet 14 Pages
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CMS WebsiteCMS has a CAH website
CMS also has a website on swing bed providers
It includes information on topics of interest to hospitals with swing beds
List of the regional office rural health coordinator
This includes a hotline or help desk
800 905-2069
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CMS CAH Website
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www.cms.gov/Center/Provider-Type/Critical-Access-Hospitals-Center.html
CMS CAH WebsiteCMS has a website for resources
Includes:
State operations manuals
Program transmittals
Guidance for laws and regulations for CAH
Medicare Learning network
Other helpful information
Email questions to [email protected]
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www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/SwingBed.html
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Swing BedsThere are other manuals that may be of interest to
CAHs on topics such as billing or the certification process
Medicare Claims Processing Manual under Chapter 4
Medicare Claims Processing Manual under Chapter 6
Medicare Benefits Manual under Chapter 8
Chapter 2 on the certification process
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www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Download
s/bp102c08.pdf
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www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf
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www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c02.
CAH Certification Process
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www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf
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www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4157CP.pdf
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AHA Critical Access Hospital Site
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www.aha.org/advocacy/critical-access-hospitals
CMS Surveyor Training Website
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CMS Surveyor Training Website CMS has a surveyor training website
Hospitals can also take the training classes and access webcasts and videos https://surveyortraining.cms.hhs.gov
Click on “provider” and has a user manual
Has CAH basic training course and infection control
No section on swing bed training
There is a help desk to assist if you need assistance 855 791-8900 or [email protected]
Course catalog to see available resources58
CMS Surveyor Training Website
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https://surveyortraining.cms.hhs.gov/
Click on Course Catalog
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Select CAH Basic Training
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https://surveyortraining.cms.hhs.gov/pubs/ClassInformation.aspx?cid=0CMSCAHBasic_CEU
_ONL
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Surveyor CAH Training Material
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Help Desk
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CAH Swing Bed Deficiency Data
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Access to Hospital Complaint DataCMS issued Survey and Certification regarding access to hospital complaint data
Includes acute care and CAH hospitals Does not include the plan of correction but can request
This is the CMS 2567 deficiency data and lists the tag numbers
Updating quarterly and includes hospital’s name and address
Remember, some of data only from Oct 201870
Updated Deficiency Data Reports
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www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html
Swing Bed Deficiencies?Failed to inform residents of their rights orally and in
writing
Failed to inform non-English speaking residents of their rights in a language they could understand
Failed to allow residents to get copies of their own medical records
Failed to provide interpreters so resident would understand their condition
No policy to advise on difference between inpatient or observation status
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Swing Bed Deficiencies?Nursing staff did not know there were specific rights
for swing bed residents
Applied restraints without an order, an assessment and failed to the restraint policy regarding siderails
Restraint orders were written prn
Policy for restraint not appropriate and allowed for a trial which is not allowed
No monitoring of patient in restraints Many restraint deficiencies
No organized activities for swing bed patients73
Swing Bed Deficiencies?Failure to have a trained activities director (many)
Did not have a plan of care
Failed to provide medically appropriate social services
No documentation to show what social services should be provided
Person doing social services was not licensed and background not appropriate to do this job
No comprehensive plan of care and physician not involved in process
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Swing Bed Deficiencies?Comprehensive assessment not done on residents
No information on a resident as to whether it was safe to smoke or not
Failed to have a dental agreement to provide care for swing bed patient
Note this changed but must still provide access to dental services if patient has a tooth abscess or toothache
Failed to do a discharge summary
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Search for Hospital Inspections
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Swing Beds
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Swing Bed ChangesSo the CAH swing bed regulations were completely
rewritten October 12, 2018
As previously discussed, Appendix W has the regulation
Now refers to Appendix PP for the interpretive guidelines and survey procedure
There were a number of changes and clarifications
These include the following: These will be discussed in more detail under each
individual section78
Swing BedsRemember, Medicare patients still need a qualifying
stay of three days as an inpatient
Observation beds don’t count to the 3 days
This is why the MOON form was created under the NOTICE ACT so patients would be informed
Patient must be admitted to a swing bed within 30 days of discharge from an acute care stay
The patient has Medicare Part A with benefit days available (see Medicare Benefit Policy Manual)
Must be medically necessary/met the criteria 79
What Sections Were Changed?When changes are made to the manual, CMS will
issue a transmittal
The transmittal is helpful to hospitals to show what tag numbers were Deleted (D) or Revised (R) or New (N)
This chart is helpful and memo has Swing bed only
Many hospitals writing policies will cite a tag number
This helps next time policy is reviewed since each tag number has the date it is implemented
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Swing Bed Only Regulations
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www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/20
18Downloads/R183SOMA.pdf
Swing Bed ChangesChoice of physician under tag C 361-still a
requirement but clarified
Name of provider so resident can contact under tag 361-clarified
Reporting abuse and the time to do so under tag 381-new changes
Plan of care under tag 399 and new changes and clarifications
PASARR- clarification and has never been a requirement to do one and still isn’t under 388
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Swing Bed ChangesProvide a culturally competent and trauma informed
plan of care under 388-clarification and new additions
Transfer and discharge and notification of ombudsman under tag 373 and 388- new requirements and much more detailed
Dental care- changes and clarifications under tag 404
Nutrition- changes and new requirements under tag 410
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Swing BedsMost of what is in the swing beds are patient rights
Patients have a right to know what these rights are
Patient rights should be given to patients prior to or upon admission
The hospital should provide these in writing
The resident should acknowledge receipt of these rights
Remember the issue of low health literacy as we have 90 million Americans so written in a way they can understand
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Swing BedsAlso remember that we have 65 million Americans
who have limited English proficiency so provide an interpreter when necessary
Information to provide includes information on selecting a physician, a list of the attending physicians who are treating the patient, rights and responsibilities, financial obligations, HIPAA notice of privacy practices, general consent form, how to file a complaint, how to report abuse or neglect, contact information on how to contact the hospital and state agency and the ombudsman, transfer policy, discharge policy, description of swing bed etc.
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Swing Beds LTC Services Must meet following to provide post-hospital SNF care
(350),
Must be certified by CMS,
SNF services must be in compliance with Subpart B of part 483 (the swing bed requirements),
Allows CAH to use beds interchangeable for either acute care or SNF level,
Swings from acute care reimbursement to SNF services and reimbursement,
Will survey swing beds during full survey, or if conducting a swing bed complaint or is requesting swing bed approval
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Swing BedsMust be discharge orders from acute care, progress
notes and discharge summary and subsequent admission orders,
If patient does not change facilities can use same MR with chart separator,
Medicare requires 3 day qualifying stay in CAH or qualified hospital prior to admission to swing bed,
3 day rule only applies to Medicare patients,
Will review at least 2 swing bed closed medical records if no swing bed patients are present
Discharge from acute care and admit to skilled bed
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Swing BedsNo LOS restriction for swing beds but intended to be
transitional time while recovering to go home or waiting placement in a nursing home facility,
No transfer agreement needed between CAH and nursing home,
CAH does not have to use the MDS form for recording patient assessment,
Swing bed patients receive SNF level of care and CAH is reimbursed for SNF level,
Can use same record for swing bed patient but be sure to have order for swing bed and discharge orders
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Eligibility 351 Must be certified as CAH,
Have no more than 25 beds,
Must screen to make eligible for swing bed,
CMS RO makes the determination if eligible requirements are met
Section on facilities participating as rural health care hospital (see 352),
Have to be in compliance with SNF requirements in subpart B of part 483,
Residents rights, nutrition, dental, admission and discharge rights, patient activities, social services, comprehensive assessment etc.,
SNF Services 361Must be substantially in compliance with following
SNF requirements:
If resident adjudicated incompetent then representative acts on their behalf
Patient has right to be informed of his treatment
To be informed in a language he can understand (issue of low health literacy)
To be informed in changes to the plan of care
Choice of a physician who meets requirements like licensed and comes to the facility
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SNF Services 361Must make sure resident is given information of the
name and specialty of physician and how to contact
Author’s Note: CMS has always allowed a resident to pick their own physician or provider CMS is confirming this continues
However, the new part is to provide the resident with a list of physicians on your medical staff in writing
Or if hospitalists then the name of the group
Will need to rewrite your P&P to include this
Patient has right to refuse treatment or to participate in research and to make an advance directive
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SNF Services 361Author’s Note (continued): If the physician does not typically treat swing bed patients
the physician must still accept the patient
Can provide a list and highlight those that accept residents in swing beds
Will need to educate your staff
The revised part is also that once the resident selects a physician, then the resident is given information on how to contact him or her with specific information on that provider
Make sure patient informed of rights in language he can understand including his medical condition so use interpreters
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Patient Rights 361Right to retain and use personal possessions
include furnishings and clothing as space permit
Access by immediate family and friends and resident can change mind
Right to choose or refuse to perform services and can’t require it Document need or desire to work
Is it voluntary or paid and if so must have prevailing rate and have in plan of care
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Patient Rights 361Right to receive and send mail including means
other than the post office Right to access to stationery and postage at resident
expense
Must notify of any charges not covered by M/M at time of admission and periodically and if resident becomes eligible for Medicaid
Has right to personal privacy and confidentiality
Right to receive written and telephone communications
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Patient Rights 361Right to secure medical records and to refuse
release of records
CMS now says to refer to Appendix PP for the interpretive guidelines
Also refers to Appendix PP for survey procedure on patient rights
Appendix PP is the interpretive guidelines for long term care facilities
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Appendix PP LTC 749 Pages
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www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads
/som107ap_pp_guidelines_ltcf.pdf
Patient Rights F550Tag 550 in appendix PP discusses resident rights
Patient has a right to be treated with respect and dignity
Resident has a right to self-determination and communication with people outside the hospital
Must promote the resident’s rights
Right to equal access to quality of care regardless of payment source, severity of condition, or diagnosis
Can’t discriminate or interfere with these rights100
Patient Rights F550Can dress in their own clothes
Place label in clothes that is conspicuous
Promote independence in dining so make resident wear a bib or stand over while assisting to eat
Respect personal space so knock on door
Staff interacting with themselves and not with residents when assisting them with meals
Restricting them from public areas like the lobby
Leaving urinary catheter bags uncovered101
Patient Rights F550Maintain eye contact when speaking
Can’t retaliate for residents for exercising their rights
Section on residents under the care of law enforcement as they are entitled to same rights
Can’t prohibit resident from participating in group activities as a form of reprisal or discrimination
Can’t require resident to get approval to post or communicate information about the hospital
Not following resident rights could have a negative psychosocial outcome
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Planning and Implementing Care F552Resident has a right to be informed of his care
Has the right to participate in his care
The right to be informed in a language that he can understand
The right to be informed in a language she can understand related to her medical condition
The right to know in advance the type of healthcare provider that will provide care
To be informed or risks and benefits of proposed care and treatment
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Other Rights Appendix PPRight to self administer medication if appropriate
F554
Right to choose attending physician F555 Give list of attending and can select from list
Physician must agree and meet requirements
Must give name and specialty of each physician and way to contact them
Right to be treated with dignity and respect and use personal possession and furnishing if space permits F557
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Other Rights Appendix PPRight to receive services with reasonable
accommodation unless a danger F558
Right to share a room with spouse if both agree F559 Or share a room with a roommate of choice when
practicable and both consent
Right to receive written notice of reason for change in room
Right to refuse to transfer to another room if for convenience of staff or a change from SNF to one that is not or vice versa F560
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Other Rights Appendix PPRight to receive visitors of their choice F563 Must provide immediate access
Resident can change their mind
No limitation of visiting hours by hospital of family members
Inform of visitation rights F564
Can choose to work or not work F566 Must determine if paid or volunteer
Must be in the plan of care
Right to manage his financial affairs F567106
Other Rights Appendix PPCan’t charge resident if payment made under M/M
F571 Can charge for phone or tv
Can charge for clothing, reading material, cosmetics, flowers, plants, private duty nurses
Cannot charge for meals, prescribed dietary supplements,
Right to be informed of writing both orally and in writing F572
Right to access medical records on request F573 Within 2 working days and can charge for records
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Other Rights Appendix PPRight to receive notices orally and in writing and in a
format and language he can understand F574 Including Braille and may need an interpreter
List of required notices such as can file a complaint with the state survey agency, name, phone numbers, and addresses of state agencies such as state survey agency and LTC ombudsman etc.
Right to reasonable access to use the telephone F576 Right to receive mail
Right to receive calls without being overheard108
Other Rights Appendix PPRight to make an advance directive or to request or
refuse to participate in research F578
Provide written information on how to apply for M/M benefits F579
Must inform the physician or resident representative if resident has an accident with an injury F580 This includes a change in her physical, mental, or
psychosocial status
A decision to transfer or discharge the resident
Right to privacy and confidentiality F583109
Other Rights Appendix PPSafe, comfortable, and clean environment F584 Clean bed and bath linens
Private closet in each room
Adequate lighting
Comfortable temperature 71-81 degrees
Right to voice grievances F585 Must inform on how to file one
Must promptly resolve
Must have a grievance officer
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Admission, Transfers, Discharge 373 Transfer means outside of the facility (373)
Purpose to restrict transfer by facility to prevent dumping of high care or difficult residents
Only when initiated by the facility and not the patient
May not transfer or discharge a resident unless necessary to meet their welfare such as care cannot be met in the facility
Appropriate because no longer needs the services provided or facility closes
Can transfer if resident or others in the facility would be endangered due to clinical or behavioral status
Admission, Transfers, DischargeCannot transfer while an appeal is pending unless
endangers resident’s health or safety and if so must document
Has specific documentation requirements such as attempts to meet the resident’s needs and basis for the transfer
Information must be provided to the receiving practitioner which include contact information for resident’s representative, advance directives, care plan goals, discharge summary, contact information of the practitioner responsible for the resident’s care
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Admission, Transfers, DischargeNotice must be made asap before transfer or
discharge
Includes content of the notice such as reason for transfer, date, location, statement of the appeal rights and phone number
Name and telephone number of the Office of the State LTC Ombudsman
If intellectual and developmental disabilities or mental health disorder then information on agency responsible such as address, email, and phone number
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Admission, Transfers, DischargeMust provide notice in advance of a facility closing
Must provide and document sufficient preparation and orientation for the transfer or discharge
Room changes in a distinct part must be limited to moving within a particular building unless the resident agrees to the move
CMS states the interpretive guidelines and survey procedure for this tag number are referenced to Appendix PP
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Notifying the Ombudsman 373CMS issued a written response to an email asking
about when do you need to notify the ombudsman
A notice does not have to be sent to the ombudsman if it the discharge is patient initiated
For example, the patient had a broken hip and was in the hospital for three day and a swing bed for 7 days
The patient is felt to be able to go home or to return to the assisted living facility This is discussed with the patient and representative
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Notifying the Ombudsman 373The patient agrees to the desired goal
Since patient initiated you do not have to notify the ombudsman
If the facility initiates a discharge or transfer then a notice needs to be sent to the ombudsman
Some CAHs reported that reading this section was confusing
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Content of the Notice 373The facility’s notice must include the following:
• The specific reason for the transfer or discharge
• The effective date of the transfer or discharge
• The location to which the resident is to be transferred or discharged
• An explanation of the right to appeal to the State
• The name, address (mail and email), and telephone number of the State entity which receives appeal hearing requests
• Information on how to request an appeal hearing
• Information on obtaining assistance in completing and submitting the appeal hearing request and
• The name, address, and phone number of the representative of the Office of the State Long-Term Care ombudsman
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Content of the Notice 373Author’s Note: The requirement to notify the resident you are discharging
them or transferring them has not changed
But there are several new provisions
New is the requirement to give a copy of the resident’s notice to the Office of the State LTC Ombudsman at the time of transfer or discharge unless patient activated– This person is sent out to serve as an advocate for residents and
they are to improve the quality of care for residents and to help resolve complaints about services
Make sure the physician documents that the pertinent information is given to the receiving provider or facility
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Transfers and Discharges 373Author’s Note: ContinuedThere were new sections
Be sure to document the basis for transfer or discharge
Include any special instructions for ongoing care
Include contact information on the physician or provider who was responsible for the care
Send resident representative information
Send advance directive information on transfers121
Transfers and Discharges F622Transfer and discharges
Cannot transfer or discharge unless necessary for the resident’s welfare
Or the resident no longer needs the services
Or the safety of those in the hospital are endangered due to behavioral of the resident
Facility closes
Resident fails to pay after reasonable and appropriate notice
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Transfers and Discharges F622Must document the transfer or discharge including
by the physician
Must provide physician with the following; Contact information of the provider who cared for him
Resident representation information including contact information
Advance directive information
Special instructions for on-going care
Care plan goals and copy of discharge summary
Other necessary documents123
Transfers and Discharges F622Can use a universal transfer form or electronic health
summary
Use the critical element pathway for hospitalization or community discharge
Provide written notice before the transfer F623 Send copy to state LTC ombudsman (LTC O)
Record reason for transfer in the medical record
Information on the timing of the notice
Content includes reason, effective date, statement of appeal’s right, name and address of LTC O, etc.
Facility initiated verses resident initiated transfers124
Freedom from Abuse and Neglect 381Resident has a right to be free from abuse, neglect,
and exploitation
Can not use verbal, mental, or physical abuse
This includes freedom from misappropriation of property so no stealing of possessions
Freedom from restraint and seclusion including chemical restraint
Cannot use restraints for convenience or discipline
If must use restraints then must use least restrictive
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Freedom from Abuse and Neglect 381 If must use restraints must document ongoing
reevaluations of the resident
Can’t employ or hire individuals found guilty of abuse, neglect, exploitation, mistreatment
Can’t hire if found guilty of stealing a resident’s property
Author’s Note: Update P&P to contain this new information
Be vigilant to make sure staff are educated on the requirements and the importance of ensuring residents are free from abuse and neglect
Consider annual education on this 126
Reporting Abuse Timeline 381 Includes a finding in the State nurse aide registry so
need to check
Includes finding in a court of law that person is unfit to be a nurse aide or other staff member
Must make sure reported timely
Must report no later than 24 hours after allegation or within 2 hours if causes serious bodily injury Report to the administrator of the facility and State
Survey Agency and adult protective services if state law provides them with jurisdiction
127
Abuse Reporting 381Must have P&P to prohibit and prevent abuse,
neglect, and exploitation including investigations
Must investigate thoroughly and keep documentation
Must prevent further abuse or neglect
Must report to state survey agency within 5 working days
CMS refers to Appendix PP for interpretive guidelines and survey procedure
Tag 381128
Abuse Reporting 381Author’s Note: The definitions have been revised
for reporting abuse The notification requirements are new so make sure
administrator notified within 24 hours if it does not result in serious bodily injury
Or notify within 2 hours if serious injury
Report also if any specific state law reporting
You want to have evidence of an appropriate evaluation
Rewrite your P&P
Make sure all charge nurses, administrators, CNO, shift supervisors etc. is aware of the notification requirement
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Freedom from Abuse F600/602Right to be free from abuse and neglect
Right to not have your property stolen
No verbal, mental, sexual, or physical abuse
Has definitions of each of these so you can put it in your policy and how to investigate allegations
Chronic staff problems is considered abuse or staff burn out
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Freedom from AbuseNegative attitudes to the residents is abuse
Right to be free from restraint and seclusion F603
Very long section with many tag numbers
Can’t employ individuals found guilty of abuse and neglect or who have stolen property F606
Must have policies on how to prevent and how to investigate complaints F607
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Patient Activities 385Patient activities can be directed by a qualified
professional who is a qualified therapeutic recreation specialist (QTRS) or an activities professional who is licensed or registered And is eligible for certification as QTRS or activities
professional by a recognized accrediting body on or after Oct 1990 or has 2 years of experience in the last 5 years or is a OT or OY assistant or completed state training course
Or by an individual on the staff designated to be the activities director who serves in consultation with a therapeutic recreation specialist, OT, or other professional with experience or education in recreational therapy
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Patient Activities 385Must support the physical, mental, and
psychosocial well-being of each resident
Must provide an assessment and care plan and preference of each resident
Must have program to support choice of activities
Want to be sure activities are directed by a qualified person
CMS refers to Appendix PP for the interpretive guidelines and survey procedure
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Social Services 386Facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident,
Need bachelor’s degree in social work or human services field (psychology, rehab counseling, etc.) and 1 year supervised social work experience in health care setting if the facility has more than 120 beds
Refers to Appendix PP
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Resident Assessments 388 Must perform comprehensive assessment, care plans and discharge planning Not required to use RAI or resident assessment instrument so clarified this
Clarified not required to comply with the requirements for frequency, scope, and number of reassessments
Required elements of the assessment did not change
Resident Assessments 388 Assessment should include:
Identification information
Demographic information
Customary routine
Cognitive patterns
Communication
Vision
Mood and behavior patterns
Discharge planning136
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Resident Assessments 388 Psychosocial well-beingPhysical functioning and structural problems Continence Disease diagnoses and health conditions Dental and nutritional status Skin condition Activity pursuit Medications Document participation in the assessment
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Resident Assessments 388 Special treatments and procedures Discharge planning Documentation of summary information
regarding the additional assessment performed by completion on the MDS or Minimum Data Sheet (CAH do not have to use the MDS) Documentation of participation in assessmentMust do direct observation and communicate
with resident and licensed members on all shifts Intent to do this to develop care plan
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Assessments 388 Assessment within 14 days after admission but
states time frames do not apply to CAH but do it timely
Assessment if significant change Excludes readmissions if no significant change in condition
Very detailed information on what constitutes a significant change
Must do a comprehensive care plan Care plan must include measurable objectives to met
patient’s needs
Assessments 388 Care plan must include if patient refuses treatment
Include any specialized services as result of the PASARR recommendations (Preadmission Screening and Resident Review Process) If disagree with the recommendations must indicate a
rationale in the resident’s medical record
PASARR is a federally mandated screening and evaluation tool that is used to assess people with mental illness or developmental disabilities who are being considered for nursing facility placements to determine if nursing facility placement is appropriate or if these individuals can be better served in a more integrative setting
140
Assessments 388 Care plan to include:
Goals for admission and desired outcomes
Preferences and potential for discharge Must document whether wants to return to the community
Must document any referrals to local contact agencies
Must include discharge plans
Care plan must be developed within 7 days after comprehensive assessment done 7 day does not apply to CAH so don’t have this in your
P&P and have appropriate time frame to do this141
Resident Assessment F636Assessment starts at tag F636 in Appendix PP
Must do an assessment of the 17 things previously covered; vision, communication, continence, nutritional status, dental status, activity pursuit, etc.
The assessments must accurately reflect the resident’s status F641
RN must conduct the assessment with the appropriate participation of health professionals F642
Care plan start at F655142
143
Care Plans 388 Review and revise as necessary such as after each assessment
Services provided by staff who are culturally competent, qualified and who meet standards of quality Interdisciplinary team should develop objectives
to attain highest level of functioning Includes attending doctor, NA and RN responsible
for the resident, food and nutrition staff member, resident and their representative and other appropriate staff
Care Plans 388 The resident and resident’s representative should
be consulted about:
The goals for admission
The desired outcomes
The preference and potential for future discharges
Author Note: This section is new so be sure to add it to the admission
assessment
It should be considered in the plan of care
Make sure the goals are measurable144
Care Plans 388 Author’s Note:Requirements for the development of a plan of care
did not change
What did change was who should participate in the plan of care as described above
Other appropriate staff as determined by the resident’s needs should also attend
Try and schedule meeting at a convenient time for the team and resident
Consider bedside conferences and rounding145
Care Plans F655Development of comprehensive care plan F565 Include measurable objectives and time frames to meet
the resident’s needs
Must be person centered and reflect goals for admission and desired outcomes
Must be comprehensive and individualized
Care plan timing and revision F657
Service provided to meet professional standards F 658
Qualified person F658146
Care Plans F655Baseline care plan must be developed within 48
hours of admission Or can do comprehensive care plan if done within 48 hours
This includes: Minimum information to care for the resident
Initial goals based on admission orders
Physician orders
Dietary orders
Therapy orders
Social services147
PASARR or RAI 338Has never been a requirement to use the PASARR
Is not a requirement to complete one now
However, if the resident has one already then use it and incorporate into the plan of care
If the resident has been in a LTC then will probably have one
Include a review in the plan of care
Physician must document that the information is communicated to the receiving provider or facility
148
PASARR or RAI
149
Trauma Patient 388 If the resident is recovering from trauma there are
some specific consideration
The assessment should include that the resident was a trauma patient
The plan of care should reflect this
Care must be culturally competent and trauma informed (F659, effective November 28, 2019)
You want to eliminate or mitigate triggers that could cause re-traumatization of the resident (F699 11/8/2019)
Make sure staff are qualified to do this150
Trauma-Informed CareSo in summary, the care plan must be culturally-
competent and trauma-informed
Trauma-informed care The hospital must ensure that that residents who are
trauma survivors receive culturally competent, trauma informed care
That is in accordance with professional standards of practice
Must account for the resident’s experiences and preferences in order to eliminate or mitigate triggers that cause re-traumatization of the resident
151
History of Trauma or PTSD F742Treatment or Services for Mental or Psychosocial
Concerns
Based on the comprehensive assessment, the facility must ensure that the resident who is diagnosed with a mental disorder, psychosocial adjustment difficulties, PTSD, or a history of trauma receives appropriate treatment and services
This is to correctly assess the problem
This is attain the hospital practicable mental and psychosocial well-being Need person centered and individualized attention
152
History of Trauma or PTSDWant to make sure the interdisciplinary team (IDT)
develops and implements approaches that are appropriate and person centered This includes the resident and the family or representative
Any distress, lack of improvement, or decline should be documented in the medical record
Must make reasonable attempts to provide services May include providing residents with opportunities for
autonomy; arrangements to keep residents in touch with their communities, cultural heritage, former lifestyle, and religious practices; and maintaining contact with friends
153
Trauma Patient 388 F659 F699Author’s Note: This is new
Need to amend assessment tool to identify if trauma patient and include in plan of care
Need to educate staff on this requirement
Need to make sure trauma-informed care is in accordance with professional standard of practice (F699)
Trauma informed care is a treatment framework that involves understanding, recognizing, and responding to all types of care
154
Trauma Informed CareAuthor’s Note: (continued)
Trauma informed care emphasizes a culture shift to a physical, psychological and emotional safe environment
It is to help trauma survivors build a sense of control and empowerment This could be trauma from a past abusive relationship
Healing may be through creative writing, journaling, music, or visual expressions
There is a National Center for Trauma-Informed Care organization which is funded by the Center for Mental Health Services
155
156
http://traumainformedcareproject.org/resources/Laying-the-Groundwork-for-TIC_012418.pdf
157
www.chcs.org/resource/key-ingredients-for-successful-trauma-informed-care-implementation/
158
http://traumainformedcareproject.org/
Free Recorded Webinar on Trauma Informed
HealthTechS3 is offering a free recorded webinar on implementing trauma-informed care
www.healthtechs3.com/past-webinars/
159
Plan of Care F553Has right to participate in his plan of care To be informed of any changes in the plan of care
Right to participate in establishing the goals and outcomes of care
To receive services listed in the plan of care
Must include resident and resident representative in his treatment and plan of care Must include his personal and cultural preference in developing
goals of care
Schedule meeting to accommodate resident and representative
160
161
Discharge Summary 388 Resident must have a discharge summary that includes;Summary of the resident’s stay
Includes diagnosis, course of illness and treatment, pertinent lab, x-rays, or consult results
Final summary of the resident’s status
Medication reconciliation including OTC
A post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment
Refers to Appendix PP for IGs and survey procedure
Discharge Summary 388 Author’s Note:There were some additional elements that are
required in the discharge summary
Make sure one is done when residents are discharged from the swing bed
Ensure a copy is sent if the patient is sent to another facility
Note if the patient’s needs were not able to be met as this is a requirement
162
Discharge Summary 388 Author’s Note: Continued Audit charts to ensure all pertinent information is
contained in the discharge summary
Do medication reconciliation of all medication of what the resident was on and what they will take post discharge including OTC (over the counter medications)
Document that the post discharge plan has been discussed with the resident and with their consent their representative– This should include information about the discharge care such as
follow up care, medical and non-medical services they will need when discharged and where they are going (home, hospice, assisted living
163
164
Rehab Services 402 If specialized rehabilitative services such as, but not limited to,
Physical therapy, speech-language pathology, occupational therapy, respiratory therapist and mental health rehabilitative services and for mental illness and intellectual disability, are required in the resident’s comprehensive plan of careFacility must provide the required service
May get from outside source
165
Rehab Services 402 Need physician order
Interpretive guidelines refers to Appendix PP
Survey Procedure refers to Appendix PP
166
Dental Services 404The facility must assist residents in obtaining
routine and 24-hour emergency dental care. May provide or obtain from an outside resource Make appt and arrange transportation
May charge a Medicare resident for routine and emergency dental servicesMust have policy identifying when loss or damage to
dentures is facility’s responsibility so may not charge resident Must refer residents within 3 days for lost or damaged
dentures and document what they eat or drink in the mean time Refers to Appendix PP Tag F676, 677, 790 and 791
Dental Services 404Author’s Note: This was a new requirement Be sure to have a P&P on this Be sure staff are educatedDocument compliance in the medical recordMany CAH will complete an incident report on this
alsoHave someone in charge such as the risk manager Put on I&O to monitor if dentures lostDocument amount eaten when tray picked upDocument referral to get new dentures
167
Nutrition 410 Assisted Nutrition and Hydration
This includes NG tubes (naso-gastric) and gastrostomy tubes (G-tubes)
Both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy (J-tube), and enteral feeding
Based on assessment and must make sure maintains usual body weight and electrolyte balance
Unless can show not possible or resident preference
168
Nutrition 410 Is offered sufficient fluid intake
Appendix PP for IGs and survey procedure- Tag F692
Author’s Note: Information about how to assess nutritional status was deleted
Make sure a nutrition assessment is done and recommendations followed
The new standard is that the patient must maintain acceptable parameters of nutritional status
New standard talks about offering sufficient fluid to maintain proper hydration
Document amount eaten on food tray169
Nutrition 410 Author’s Note: (continued)Considering adding hydration to the daily nursing
assessment
Ensure staff know symptoms of dehydration
Consider documentation such as present or absence of thirst, dry mouth, dry nose, dark urine, headache, light headed, irritability, confusion, low blood pressure, fast heart rate etc.
Low sodium, high potassium, or elevated BUN (blood urea nitrogen) are signs of dehydration
170
171
Nutrition 410 Suggested
parameters for evaluating significance of unplanned and undesired weight loss are:
Interval Significant Loss
Severe Loss
1 month 5% Greater than 5%
3 months 7.5% Greater than 7.5%
6 months 10% Greater than 10%
172
AHA Website on CAHProvides updates,
Directory of resources,
Federal legislation, OIG report on CAH
Growth of the program,
Grants, Newsletters,
State hospital association links, and supervision of hospital outpatient therapeutic services http://www.aha.org/advocacy-issues/cah/index.shtml
173
http://www.aha.org/advocacy-issues/cah/index.shtml
AHA Poster on CAH
174
175
Statement of Deficiencies and Plan of corrections,
Based on documentation of surveyor worksheet or notes and form CMS-2567,
176
The End! Questions??Sue Dill Calloway RN, Esq.
CPHRM, CCMSCP, CCMSP
AD, BA, BSN, MSN, JD
President
5447 Fawnbrook Lane
Dublin, Ohio 43017 614 791-1468 (Call with
Questions, No emails
178
The End
Are you up to the challenge??
See additional resources including patient safety resources,
179
WebsitesAmerican Association for Respiratory Care AARC- www.aarc.org,
American College of Surgeons ACS-www.facs.org,
American Nurses Association ANA-www.ana.org
180
Websites
Center for Disease Control CDC –www.cdc.gov,
Food and Drug Administration- www.fda.gov,
Association of periOperative Registered Nurses at AORN- www.aorn.org,
American Institute of Architects AIA-www.aia.org,
Occupational Safety and Health Administration OSHA – www.osha.gov,
National Institutes of Health NIH-www.nih.gov,
181
WebsitesUnited States Dept of Agriculture USDA-
www.usda.gov,
Emergency Nurses Association ENA-www.ena.org,
American College of Emergency Physicians ACEP- www.acep.org,
Joint Commission Joint Commission-www.JointCommission.org,
Centers for Medicare and Medicaid Services CMS- www.cms.hhs.gov,
182
Websites American Association for Respiratory Care AARC-
www.aarc.org,
American College of Surgeons ACS-www.facs.org,
American Nurses Association ANA- www.ana.org,
AHRQ is www.ahrq.gov,
Institute for Safe Medication Practice-www.ismmp.org
Institute for Healthcare Improvement at www.ihi.org
AORN at www.aorn.org
183
WebsitesAmerican Hospital Association AHA- www.aha.org,
American Society of Anesthesiologist at www.asahq.org
CMS Life Safety Code page -http://new.cms.hhs.gov/CFCsAndCoPs/07_LSC.asp
COPs available in word and PDR at http://www.access.gpo.gov/nara/cfr/waisidx_04/42cfr485_04.html,
American College of Radiology- www.acr.org,
CRNA at www.aana.org
184
WebsitesFederal Emergency Management Agency (FEMA)-
www.fema.gov,
Drug Enforcement Administration –www.dea.gov (copy of controlled substance act),
US Pharmacopeia- www.usp.org,
CMS manuals at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_Appendixtoc.pdf
Survey memos at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html
185
Websites Rural Health is at www.ruralhealthinfo.org/topics/critical-
access-hospitals
The Institute for Safe Medication Practices-www.ismp.org U.S. Pharmacopeia (USP) Convention, Inc.-
www.usp.org U.S. Food and Drug Administration MedWatch-
www.fda.gov/medwatch Institute for Healthcare Improvement- www.ihi.org, AHRQ at www.ahrq.gov, Sentinel event alerts at www.jointcommission.org,
186
Websites American Pharmaceutical Association-
www.aphanet.org
American Society of Heath-System Pharmacists-www.ashp.org
Enhancing Patient Safety and Errors in Healthcare-www.mederrors.com
National Coordinating Council for Medication Error Reporting and Prevention-www.nccmerp.org,
FDA's Recalls, Market Withdrawals and Safety Alerts Page: http://www.fda.gov/opacom/7alerts.html
187
Pa Patient Safety Authority www.psa.state.pa.us/psa/site/default.asp
188
The End!Sue Dill Calloway RN, Esq.
CPHRM. CCMSCP, CCMSP
AD, BA, BSN, MSN, JD
President
5447 Fawnbrook Lane
Dublin, Ohio 43017 614 791-1468
188188