OHCA District II LTC Update

1. OHCA District IILTC Update Kenneth Daily, LNHA kenn@qissurvey.com OCTOBER 2016

2. District News • CEUs for today’s program is 2.0 hours • Next meeting • November • Kenn Daily • LSC and Disaster Management • NOTE – 4 Hour Program • December • Scripts Gerontology (invite) • January 2017 • Jackie Mathews • Palliative Care

3. MVLTCA 50th Celebration • Attended by nearly 70 members • Elderly Brothers preformed • Recognized facilities and leaders over the 50 year history • Provided more than 130 scholarships amounting to more than $100,000

4. OHCA Fall Conference November 8 - 9, 2016 Executive-level briefing featuring updates on the most pressing issues. The program will include sessions providing information on: • Ohio Medicaid: Recap of Key Initiatives and New Developments • Ohio Benefits: Update on System Conversion, DDR, 9401 and LOC Next Steps • Building Preparation & Patient Safety: Compliance with 2012 NFPA and New Emergency Preparedness Rule • Enhanced Regulations: Understanding CMS' New Requirements of Participation • Immediate Jeopardies: How Not to Fall Victim to Increased Citations • Alternative Payment Systems: Recap of Today's Models and What's to Come • Market Forces: The Intricacies of 5-Star and Rehospitalizations on Your Business Success • What's Changed in 2016: Recap of Regulatory Changes and Reimbursement Highlights

5. PELI Project Webinar • Scripps Gerontology Center will hold a PELI Project webinar on Wednesday, October 26 from 2-3 p.m. • "When you can't ask the resident: practice guidelines for asking proxies about resident preferences." • Provide in-depth guidance on how nursing homes can engage proxies (such as family members, close friends, and direct care workers) for PELI interviews.

6. OBRA 2.0 Here is Comes

7. There are Lots of Changes Ahead • Life Safety Code 2012 101 and 99 • July 5, 2016 • Survey begins November 1, 2016 • Emergency Management • November 16, 2016 • Enforcement November 16, 2017 • Requirements of Participation (OBRA) November 28, 2016 • Phase 1 November 28, 2016 • Phase 2 November 28, 2017 • Phase 3 November 28, 2019

8. Life Safety Code • CMS has confirmed that effective 11/1 facilities must meet any new daily, weekly, or quarterly ITM • BUT will not yet be required to meet the new annual, 3-year, or 5-year ITM until… • The FIRST annual test/inspection activity that is a new requirement of the 2012 LSC is due July 5, 2017. • The FIRST 3-year activity is due July 5, 2019 • The FIRST 5-year is due July 5, 2021.

9. Emergency Management • 4 Key Points • Risk Assessment • All-hazard approach using a hazard vulnerability to determine individual facility risks • Policies and Procedures • Tied to the risk assessment and updated annually • Communications Plan • Well-coordinated to protect health and safety • Training and Exercises • Employees must reasonable adequate response

10. Requirements of Participation • Basis & Scope(§483.1) • Definitions (§483.5) • Resident Rights (§483.10) • Abuse & neglect, (§483.12) • Admission, transfer, and discharge rights (§483.15) • Resident assessment (§483.20) • Comprehensive person centered Care planning (§483.21) • Quality of life (§483.24) • Quality of care §483.25) • Physician services (§483.30) • Nursing services (§483.35) • Behavioral health services (§483.40) • Pharmacy services (§483.45) • Laboratory, radiology, and other diagnostic services (§483.50) • Dental services (§483.55) • Food & nutrition services (§483.60) • Specialized rehabilitative services (§483.65) • Administration (§483.70) • QAPI (§483.75) • Infection control (§483.80) • Compliance and ethics (§483.85) • Physical environment (§483.90) • Training requirements (§483.95)

11. Themes in the Rule • Person-Centered Care • Staffing & Competency • Training and the need for competency specific skills and procedures • Quality of Care & Quality of Life • Care planning • Emphasis on patient goals and their involvement in decision making • Behavioral Health • Focus on adverse events • Medication related • QAPI • Infection prevention • Increase monitoring of facility, staff and residents

13. Some of “big changes” - Phase 1 • Expanded resident rights 483.10 • Expanded the drug regimen review process • Require a discharge planning process & plan for all residents • Require a person-centered care plan • Expanded resident assessment process • PASARR incorporated into assessment, care plan and discharge plan • Behavioral health services (§483.40) • Binding Arbitration Agreements can not be used until after a dispute arises between the parties

15. Some of “big changes” Phase 2&3 • Added quality assurance and performance improvement (QAPI) • Added compliance and ethics section • Greater monitoring and documentation related to appropriateness of meds • Psychotropic & antibiotic stewardship • Require Infection Control Program & Infection Preventionist • Added a staff competency requirement to determine nursing staffing levels • Based on a facility assessment, which includes but is not limited to the number of residents, resident acuity, range of diagnoses, and the content of individual care plans. • Require facility provide behavioral health care and services training (for patients with trauma)

16. Survey Process • CMS developing a new survey process • S&C Memo 17-03-NH • Phase 1 Surveyor Training • Merges QIS with traditional survey and will incorporate new requirements • November 2017 • New Tags will be developed

18. Definitions • Nurse aide is amended to include those individuals who furnish services who provide these services through an agency or under contract. • Licensed health professional adds respiratory therapist and certified respiratory therapy technician. • Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices; having control over their daily lives. • Resident representative is an individual chosen by the resident to act on his/her behalf to support decision-making; access medical, social or other personal information; manage financial matters, receive notifications; a person authorized by State or Federal law to act on behalf of the resident in decision-making access medical, social or other personal information; manage financial matters, receive notifications; legal representative; court- appointed guardian or conservator.

19. Abuse Definitions • Abuse is “...the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.” It includes deprivation by an individual of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through use of technology. • Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. • Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. • Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. • Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s belongings or money without the resident’s consent. • Mistreatment is inappropriate treatment or exploitation of a resident. • Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. • Sexual abuse is non-consensual sexual contact of any type with a resident.

20. Resident Rights §483.10 • CMS has combined proposed §483.10 and §483.11 to create a comprehensive section that includes in a single location both statements of resident rights and the attendant facility responsibilities to support those rights. Person-centered care is an over- arching principle of this section. • Introductory language expands on existing requirements that reinforce a resident’s right to dignity, self-determination and person-centered care, and includes a statement that the facility must protect and promote the rights of the resident. CMS explains that the “protect and promote” language is meant to ensure clarity that it is a facility’s responsibility to recognize/effectuate resident rights. • Relocates language from current rule §483.12(c) regarding equal access but adds the underlined language: “The facility must provide equal access to quality care regardless of diagnosis, severity, condition or payment source.” The preamble explains that the provision is not intended to require that every facility have every possible capability and unlimited capacity, but neither is it intended to facilitate selective admissions or transfers.

21. §483.10 Resident Rights • Resident must receive information (oral and written) in language that he or she can understand about various topics, including medical condition • Facility must have P&Ps re: visitation rights of resident, including any clinically necessary or reasonable restriction or limitation or safety restriction or limitation when consistent with the regulations • If resident deposits personal funds with facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident’s funds (NOTE: moved from guidance into regulation to strengthen the expectation of facilities) • Facility must have a grievance policy and a Grievance Official

22. §483.10(c) Planning and Implementing Care • Adds new, detailed statements of a resident’s right to participate in the development and implementation of his or her person-centered plan of care, including requirements that affect both the initial planning process and changes to the plan of care. Among other requirements, the planning process must facilitate inclusion of the resident/representative, assess both strengths and needs, and incorporate his/her personal and cultural preferences. •  Adds new provisions (broadly consistent with current rules and interpretive guidelines) specifying the right of residents to receive advance information about his/her care, type of professional delivering care, and risks and benefits of treatments and options.

23. Abuse • CMS re-designates current section §483.13 “Resident Behavior and Facility Practices” as §483.12 and retitles it as “Freedom from Abuse, Neglect and Exploitation,” to more accurately reflect the section’s contents and intent. • Must not hire anyone with a disciplinary action in effect against professional license by a state licensure body as result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. CMS notes that this prohibition applies to disciplinary actions against a professional license that are currently in effect,

24. Abuse • Revise policy and procedures to reflect the new requirements, including all new and revised definitions, including the new concept of exploitation. 
 • Revise policies and procedures for applicant screening and employee discipline to reflect the revised employment prohibitions; extend the same to individuals whom a facility does not employ but otherwise engages – such as a volunteer or contractor. 
 • Compare existing staff training to the requirements in new §483.95, and align as needed. 
 • As you begin to develop your QAPI program and written plan, note the Phase 3 requirement to ensure that a method for monitoring of incidents (trends, patterns etc.) indicating abuse, neglect, misappropriation and exploitation are reviewed and discussed within the QAPI program.

25. §483.15 Admission, transfer, and discharge rights • Facility must establish and implement an admission policy • Requires orientation of resident for transfer or discharge to ensure safe and orderly transfer or discharge • Must have written policy on permitting residents to return to facility after they are hospitalized or placed on therapeutic leave; the policy must include specific provisions outlined in regulation

26. Admission Policy • Transfers – Reflect new requirements and language changes • Internal • Composite distinct part • External • Involuntary • Notice of transfer • Bed hold • Return from LOA - written policy on permitting residents to return to facility after they are hospitalized or placed on therapeutic leave: the policy must include specific provisions . • Discharge – • Composite distinct part • Death • Community • Another health care organization • Acute care • Documentation requirements

27. §483.21 Comprehensive person-centered care planning • Provides specific information that must be included in the comprehensive care plan • Plan must be developed within 7 days after completion of the comprehensive assessment • Requires the following be included in IDT preparing plan • Nurse aide with responsibility for the resident • Member of food and nutrition services staff • If participation of resident and representative in development of plan not practicable, explanation must be in resident’s medical record

28. §483.21 Comprehensive person-centered care planning • Discharge planning process • Must focus on discharge goals and residents must be active partners in the planning and transition process • Regular re-evaluation and modification of plan • Specifies what must be included in the plan and considerations that must be taken in development of the plan

29. §483.40 Behavioral health services • Based on comprehensive assessment, resident with mental disorder or psychosocial adjustment difficulty receives appropriate treatment and services to correct the problem or attaint he highest practicable mental and psychosocial well-being • If assessment does not reveal mental or psychosocial adjustment difficulties, no pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors unless clinical condition demonstrates development of such a pattern was unavoidable • Facility must provide medically-related social services for highest practicable well-being

30. §483.45 Pharmacy services • Psychotropic drug: any drug that affects brain activities associated with mental processes and behavior; includes but not limited to: • Anti-psychotic • Anti-depressant • Anti-anxiety • Hypnotic • Pharmacist must report irregularities to attending physician, medical director and director of nursing and reports must be acted upon • Irregularities include and are not limited to specific issues listed in rule

31. §483.75 Quality assurance and performance improvement • QA&A committee – all provisions except the inclusion of the infection prevention control officer • State may not require disclosure of the records of the committee except related to requirements of the committee (e.g., who is on committee; that committee meets as required; etc.) • Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

32. QAPI • Facility must develop a QAPI Plan by November 27, 2017 and submit to the 
Survey Agency at the first annual recertification survey. After first annual recertification, Survey Agency can request a copy of the Plan at each annual recertification visit or at any other survey. It must implement, and maintain an effective, comprehensive, data-driven QAPI program, reflected in its QAPI plan, that focuses on systems of care, outcomes, and services for residents and staff

33. QAPI • QAPI program is across all levels and all departments • The QAPI program shall be designed to monitor and evaluate performance of 
ALL services and programs of an organization, including contractual services. • Elements of the program must include the following areas: • Design and Scope
 • Governance and Leadership
 • Feedback, Data Systems and Monitoring • Performance improvement projects
 • Systematic analysis and systemic action

34. §483.80 Infection Control • Infection prevention and control program • Does not include references to facility assessment • Written standards, policies, and procedures for the program including specified topics • Annual review of the infection prevention and control program and update as necessary

35. §483.95 Training requirements • Training program for all new and existing staff, individuals providing services under a contractual arrangement and volunteers, consistent with their expected role • Abuse, neglect and exploitation • In-service training for nurse aides • Must include dementia management training and resident abuse prevention training • If providing care for individuals with cognitive impairment, training on care of the cognitively impaired

36. Arbitration Agreements • CMS has banned pre-dispute arbitration agreements in SNFs • Pre-dispute arbitration agreements entered into before 11/27/16 are not prohibited • AHCA’s litigation has been filed along with several other states