Hot Topics and Trends in LTC Stefanie Mozgai, BA, RN, CPM Assistant Commissioner

2. Hot Topics and Trends in LTC Stefanie Mozgai, BA, RN, CPM Assistant Commissioner NJ Department of Health Health Facility Survey & Field Operations

3. Disclaimer • This power point presentation is an educational tool prepared by the Department of Health & Senior Services that is general in nature. It is not intended to be an exhaustive review of the Department’s administrative code & is not intended as legal advice. Materials presented should not substitute for actual statutory or regulatory language. Always refer to the current edition of a referenced statute, code &/or rule or regulation for language.

4. Desired Outcomes Enhanceprofessional development Broaden knowledge of updates released by CMS and NJDOH Update awareness of current NJ survey results Share with partners

5. Agenda • Citation Trends • Plans of Correction and e-POC Implementation • MDS Focused Survey • Infection Control in Nursing Homes • New Nursing Home Survey Process • Guidance for Inmates in Long Term Care • ESRD – Dialysis in Nursing Homes • Upcoming DoH Training • Pressure Ulcer Reduction • Drug Diversion Coalition

6. What Surveyors See

7. NJ Top Ten Citations: 10/1/15- 3/1/16 • F 281 Service Provided Meet Professional Standards • F 323 Accident Hazard Prevention/Supervision • F 371 Food Safety and Sanitation • F 441 Infection Control • F 309 Maintain Highest Practical Function and Well Being • F 425 Pharmaceutical Services • F 279 Comprehensive Care Plans • F 514 Resident Records: Complete, Accurate, Accessible • F 329 Drug Regimen is Free from Unnecessary Medications • F465 Safe, Functional, Sanitary, Comfortable Environment

8. CMS Top Ten Citations: 10/1/14- 9/30/15 • F 441 Infection Control* • F 371 Food Safety and Sanitation* • F 323 Accident Hazard Prevention/Supervision* • F 309 Maintain Highest Practical Function and Well Being* • F 431 Drug records, label/storage drugs & biologicals • F 329 Drug Regimen is Free from Unnecessary Medications* • F 279 Comprehensive Care Plans* • F 514 Resident Records: Complete, Accurate, Accessible* • F 241 Dignity and Respect of Individuality • F 282 Services by Qualified Persons/Per Care Plan • *Also on NJ’s Top Ten

9. Plans of Correction - Five Elements Element #1- Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; Element #2 - Addresshow the facility will identify other residentshaving the potential to be affected by the same deficient practice. Element #3 - Address what measures will be put into place or systemic changesmade to ensure that the deficient practice will not recur; Element #4 - Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Element #5 - Dates when corrective action will be completed • practice

10. Plans of Correction – Key Points • One POC per Tag • One Completion date per Tag • The Statement of Deficiencies (CMS-2567) must be signed and dated by the Administrator on Initial Comments page of: • Federal Health Report : FOOO • Life Safety Code Report: KOOO • State Deficiency Report: SOOO • Sending e-mail to LTC POC: Include Facility’s full name on subject line

11. e – POC Implementation • Transition – current electronic DOH pilot to federal electronic process • Initial use coincided with the recertification survey starting in Spring 2015, after which, will include Revisits, Complaints, Federal Monitoring Surveys • Web-based training available now at: www.qtso.com • Password required – To obtain: e-mail Debi Chapman; Subject line: “e-POC Training” • The 2567 e-POC system is open - Providers may enroll now • Training – Surveyors and Providers • State Contacts: Debi Chapman at: Debra.Chapman@doh.state.nj.us, Pamela Gendlek at: Pamela.Gendlek@doh.state.nj.us

12. MDS Focused Surveys • Expansion of Pilot – Process works • All States participated • Nursing Homes and surveys per State to be announced by CMS • Approximately two days onsite per survey • Conducted by two specialty trained surveyors • Exit Conference to be provided • Deficiencies can be issued

13. Infection Control in NHs • CMS is in process of piloting an infection control worksheet • It is not being piloted in NJ at this time

14. New Nursing Home Survey Process • CMS is in process of piloting a new electronic survey process • Currently being piloted with the CMS Regional Office staff not in NJ at this time • NJ has volunteered to participate when the pilot is rolled out to States

15. Guidance for Inmates in LTC • CMS is in the process of formulating regulatory guidance • Focus may be on patient rights and facility’s ability to meet conditions for participation in Medicare program

16. Dialysis in LTC • CMS is in the process of formulating regulatory guidance • Guidance is being developed by both the CMS LTC Division as well as the ESRD Division

17. Upcoming Training on 8:43E • The regulations in NJAC 8:43E pertain to all State Licensed facilities • During Calendar Year 2016, NJDOH will work with NJHA on providing education to providers on the various sub chapters of these regulations

18. Pressure Ulcer Reduction • NJDOH issued a memo March 2016 encouraging participation in the Nursing Home Quality Improvement Project • Facilitated by HQSI and funded by CMS

19. Drug Diversion Coalition • NJDOH is sponsoring a Drug Diversion Conference to educate providers about how to respond, detect, and prevent drug diversion in health care settings • Tuesday, June 14, 2016 from 9:30am-3:30pm at Rutgers University-Busch Campus in Piscataway • Questions: Contact Laura Taylor at laura.taylor@doh.nj.gov

20. Resources • CMS Appendix P & PP • S & C Letters – www.cms.gov • www.pioneernetwork.net • Advancing Excellence in America’s Nursing Homes Campaign - • www.nhqualitycampaign.org • New Jersey Alliance for Culture Change

21. Thank You