RULES AND REGULATIONS

RULES AND REGULATIONS Connie Jensen Illinois Department of Public Health

RULES OF PARTICIPATIONPHASE TWO • Implementation date • November 28, 2017 • Major revision effort of Federal rules • Revised numbering system • New survey process • Emergency Preparedness

NEW SURVEY PROCESS • Tags cited under old process • Tags cited under new process • Tags cited compared to nationwide

NEW SURVEY PROCESS • RESIDENT CENTERED • Resident’s home • Resident’s schedule • Resident’s preferences • OUTCOME ORIENTED • How has the outcome affected the resident

RESIDENT RIGHTS • SUBSTANDARD QUALITY OF CARE • F558—Reasonable Accommodations Needs/Preferences (11) • F550—Resident Rights/Exercise of Rights (14) • F584—Safe/Clean/Comfortable/Homelike Environment (24) • F565—Resident/Family Group and Response

F558 REASONABLE ACCOMMODATION OF NEEDS • The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

F558, CONTINUED • Intent—The accommodation of resident needs and preferences is essential to creating an individualized home-like environment • Reasonable accommodation—means the facility efforts to individualize the resident’s physical environment.

F558, CONTINUED • Guidance—includes, but is not limited to , individualizing the physical environment of the resident’s bedroom and bathroom, as well as individualizing common living areas as feasible. • The environment must reflect the unique needs and preferences of each resident to the extent reasonable and does not endanger the health or safety of individuals or other residents

F550 RESIDENT RIGHTS/EXERCISE OF RIGHTS • The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. • A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident’s individuality.

F550, CONTINUED • INTENT • All residents have rights guaranteed to them under Federal and State laws and regulations. This regulation is intended to lay the foundation for the resident rights requirements in long-term care facilities. Each resident has the right to be treated with dignity and respect.

F550, CONTINUED • All activities and interactions with residents by any staff, temporary agency staff or volunteers, must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident’s goals, preferences, and choices. When providing care and services, staff must respect each resident’s individuality, as well as honor and value their input.

F550, CONTINUED • EXAMPLES • Dress in own clothes • Inconspicuous labeling • Promoting independence and dignity while dining • Protecting and valuing residents’ private space • Addressing resident with name/pronoun of resident’s choice

F550, CONTINUED • Refraining from practices demeaning to residents • Leaving urinary catheter bags uncovered • Refusing to comply with resident’s request for bathroom assistance during mealtimes • Restricting residents from using common areas open to the general public

F584 SAFE ENVIRONMENT • The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

F584, CONTINUED • Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; • Clean bed and bath linens in good condition • Private closet space in each resident room

F584, CONTINUED • Adequate and comfortable lighting in all areas (minimizes glare and provides maximum resident control, where feasible) • Comfortable and safe temperature levels. • Maintenance of comfortable sound levels (of particular concern is the resident’s control over unwanted noise)

F584, CONTINUED • A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members.

F584, CONTINUED • Institutional Practices • Overhead paging • Meal service using trays • Signage visible to residents and public • Medication or treatment carts • Widespread and long-term use of audible alarms • Uncomfortable furniture • Absence of window treatments • Lack of textures, absence of bedspreads • Lack of personal items in rooms

F565 RESIDENT/FAMILY GROUP AND RESPONSE • The resident has a right to organize and participate in resident groups in the facility. • Must provide with private space • Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group’s invitation

F565, CONTINUED • Facility must provide a designated staff person…who is responsible for providing assistance and responding to written requests that result from group meetings • Facility must consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups

F565, CONTINUED • The facility must be able to demonstrate their response and rationale for such response • Should not be construed to mean that the facility must implement as recommended every request of the resident or family group

RESIDENT RIGHTS • F583—Personal Privacy/Confidentiality of Records • F578—Request/Refuse/Discontinue Treatment; Formulate Advanced Directives • F585—Grievances • F554—Resident Self-Administer Medications

RESIDENT RIGHTS • F557—Respect, Dignity/Right to Have Personal Property • F577—Right to Survey Results/Advocate Agency Information • F553—Right to Participate in Planning Care • F552—Right to be Informed/Make Treatment Decisions

FOSS COMPARATIVE SURVEYS • FOCUS AREAS • Abuse and Neglect • Admission, Transfer, and Discharge • Dementia Care

ABUSE AND NEGLECT • F600 Free from Abuse and Neglect • F602 Free from Misappropriation and Exploitation • F603—Free from Involuntary Seclusion • F604—Right to be Free from Physical Restraints • F605—Right to be Free from Chemical Restraints

ABUSE AND NEGLECT • F606—Not Employ/Engage Staff with Adverse Actions • F607—Develop/Implement Abuse/Neglect Policies • F608—Reporting of Reasonable Suspicion of a Crime • F609—Reporting of Alleged Violations • F610—Investigate/Prevent/Correct Alleged Violations

F600 FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION • The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary exclusion. • INTENT: Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone

F600 ABUSE • Abuse is defined as “the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.” • Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.

F600 ABUSE • Willful as defined at 483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm

F600 ABUSE • Staff to Resident abuse of any type • When a nursing home accepts a resident for admission, the facility assumes the responsibility of ensuring the safety and well-being of the resident. It is the facility’s responsibility to ensure that all staff are trained and knowledgeable in how to react and respond appropriately to resident behavior.

F600 ABUSE • A facility cannot disown the acts of staff, since the facility relies on them to meet the Medicare and Medicaid requirements for participation by providing care in a safe environment. • Retaliation by staff is abuse, regardless of whether harm was intended, and must be cited.

F600 ABUSE • Resident to Resident Abuse of Any Type • A resident to resident altercation should be viewed as a potential situation of abuse. • When investigating an allegation of abuse between residents, the surveyor should not automatically assume that abuse did not occur, especially in cases where either or both residents have a cognitive impairment or mental disorder.

F600 ABUSE • Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. • Example of (deliberate) willful would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements and his/her body movements impact a resident who is nearby.

F600 ABUSE • The facility may provide evidence that it completed a resident assessment and provided care planning interventions to address a resident’s distressed behaviors such as physical, sexual or verbal aggression.

F600 ABUSE • However, based on the presence of resident to resident altercations, if the facility did not evaluate the effectiveness of the interventions and the staff did not provide immediate interventions to assure the safety of residents, then the facility did not provide sufficient protection to prevent resident to resident abuse. • For example, redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected

F600 ABUSE • Staff should monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to: • Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating;

F600 ABUSE • Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; • Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing • Taking, touching, or rummaging through other’s property; and • Wandering into other’s room/space

F600 ABUSE • Also, resident to resident abuse could involve a resident who has had no prior history of aggressive behaviors, since a resident’s behavior could quickly escalate into an instance of abuse. • For example, a resident pushes away or strikes another resident who is rummaging through his/her possessions.

F609 REPORTING OF ALLEGED VIOLATIONS • The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency…

F609 REPORTING OF ALLEGED VIOLATIONS • The facility must report the results of all investigations to the administrator or his or her designated representative and to other official in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

F609 REPORTING OF ALLEGED VIOLATIONS • NOTE: In cases where a deficiency is identified and CMS imposes a civil money penalty based on the noncompliance, CMS will reduce the amount of the penalty by 50% if all of the following apply: • The facility self-reported the noncompliance to CMS or the State before it was identified by CMS or the State and before it was reported to CMS or the State by means of a complaint lodged by a person other than an official representative of the nursing home

F609 REPORTING OF ALLEGED VIOLATIONS • NOTE, continued: • Correction of the self-reported noncompliance occurred on whichever of the following occurs first: • 15 calendar days from the date of the circumstance or incident that later resulted in a finding of noncompliance; or • 20 calendar days from the date the civil money penalty was imposed;

F609 REPORTING OF ALLEGED VIOLATIONS • NOTE, continued • The facility waives its right to a hearing under 42 CFR 488.436 • The noncompliance that was self-reported and corrected did not constitute a pattern of harm, widespread harm, immediate jeopardy, or result in the death of a resident; • The civil money penalty was not imposed for a repeated deficiency that was the basis of a CMP that previously received a reduction; and • The facility has met mandatory reporting requirements for the incident or circumstances upon which the civil money penalty is based, as required by Federal and State law.

F609 GUIDANCE REPORTING ALLEGED VIOLATIONS • It is the responsibility of the facility to ensure that all staff are aware of reporting requirements and to support an environment in which staff and others report all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.

F609 GUIDANCE REPORTING ALLEGED VIOLATIONS • An individual (e.g., a resident, visitor, facility staff) who reports an alleged violation to facility staff does not have to explicitly characterize the situation as “abuse,” “neglect,” “mistreatment,” or “exploitation” in order to trigger the Federal requirements at 483.12(c). Rather, if the facility staff could reasonably conclude that the potential exists for noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, then it would be considered to be reportable and require action under 483.12(c).

F609 GUIDANCE REPORTING ALLEGED VIOLATIONS • For example, if a resident is abused but does not allege abuse, the resident’s failure or inability to provide information about the occurrence is immaterial when the abuse may be substantiated by other supporting evidence. Another example is when a nurse aide witnesses an act of abuse but fails to report the alleged violation, the failure to report does not support a conclusion that the abuse did not occur and the facility would not meet the reporting requirements.

F610 INVESTIGATE ALLEGED VIOLATIONS • The facility must have evidence that all alleged violations are thoroughly investigated. • The facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

F610 INVESTIGATE ALLEGED VIOLATIONS • GUIDANCE: • There is no specific investigation process that the facility must follow, but the facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary (if any) for the protection of residents. Depending upon the type of allegation received, it is expected that the investigation would include, but is not limited to:

F610 INVESTIGATE ALLEGED VIOLATIONS • Conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents, and interactions/relationships between resident to other residents;

F610 INVESTIGATE ALLEGED VIOLATIONS • Conducting record review for pertinent information related to the alleged violation, as appropriate, such as progress notes (Nurse, social services, physician, therapist, consultants as appropriate), financial records, incident reports (if used), reports from hospital/emergency room records, laboratory or x-ray reports, medication administration records, photographic evidence, and reports form other investigatory agencies

RULES AND REGULATIONS