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Phase 3 of the Nursing Home Final Rule: Let’s Go!

Christine LaRocca, MD April 26, 2019

This material was prepared by Telligen, the Medicare Quality Innovation Network

Quality Improvement Organization, under contract with the Centers for Medicare &

Medicaid Services (CMS), an agency of the U.S. Department of Health and Human

Services. The contents presented do not necessarily reflect CMS policy. This

material is for informational purposes only and does not constitute medical advice;

it is not intended to be a substitute for professional medical advice, diagnosis or

treatment. 11SOW-QIN-C2-01/18/19-3168

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Objectives

• The Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care (LTC) Facilities: Why the Revisions?

• Broad Overview of Selected Phase 3 Changes

• Five Elements of Quality Assurance and Performance Improvement (QAPI) and the Medical Director

This Photo by Unknown Author is licensed under CC BY-SA-NC

Credits: Dr. David Gifford, Senior Vice President of Quality and

Regulatory Affairs at the American Health Care Association

(AHCA), generously shared slides and content for this

presentation

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Why the Revisions?

• Significant innovations in resident care and quality assessment practices have emerged

• The population of LTC facilities has changed:• More diverse

• More clinically complex

• Extensive evidence-based research has been conducted and has enhanced knowledge about:• Resident safety

• Health outcomes

• Individual choice

• QAPI

Medicare and Medicaid Programs; Reform of Requirements for LTC Facilities

https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf

This Photo by Unknown Author is licensed under CC BY-SA-NC

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Three Phase Implementation

Phase 1• The first phase of implementation

occurred upon the effective date of the final rule

• Included those requirements that were unchanged or received minor modification

• Specific sections in some regulations• Implemented, practiced and

sustained in each nursing home by November 28, 2016

This Photo by Unknown Author is licensed under CC BY-NC-ND

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Phase 2

• The regulations included in Phase 2 had to be

implemented by November 28, 2017

• In addition to those requirements implemented in

Phase 1, Phase 2 includes sections of new

regulations that require more complex revisions

• Time for implementation allowed for changes in

survey processes as well as updates to the survey

guidance

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• The regulations included in Phase 3 must be implemented by November 28, 2019

• Includes all the remaining requirements not implemented in Phases 1 and 2

• Final Phase allows for the complete set of revised requirements to be incorporated into the practices of LTC facilities and sufficiently enforced through the updated survey process

Phase 3

This Photo by Unknown Author is licensed

under CC BY-NC-ND

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Sections with Changes in the Requirements for Participation (RoP)

• Basis & Scope(§483.1)

• Definitions (§483.5)

• Resident Rights (§483.10)

• Freedom from abuse, neglect, and exploitation (§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)

• Quality assurance and performance improvement (§483.75)

• Infection control (§483.80)

• Compliance and ethics program (§483.85)

• Physical environment (§483.90)

• Training requirements (§483.95)

Red Text = Sections that include Phase 3

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Let’s Talk About:

• Infection Preventionist (IP)

• Trauma-Informed Care

• Comprehensive Training Requirements*

• QAPI Program*

*Entire section will be implemented in Phase 3 with a few

exceptions • This Photo by Unknown Author is licensed under CC BY-ND

Broad Overview of Selected Phase 3 Changes (This Isn’t All of Them!)

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Infection Preventionist

Regulations§ 483.80 (b) Infection preventionist. The

facility must designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility’s IPCP.

The IP must:

• Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

• Be qualified by education, training, experience or certification;

• Work at least part-time at the facility; and

• Have completed specialized training in infection prevention and control.

To Do List• Designate or hire a staff person (e.g.

nurse or other clinician) who has or will obtain additional training in infection control.

• Opportunity for Training:

• CDC IP Training

https://www.train.org/cdctrain/training_plan/3814

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CDC Nursing Home Infection Preventionist Training

Created by the Centers for Disease Control and Prevention (CDC) in collaboration with the Centers for Medicare & Medicaid Services (CMS). The course covers:

• Core activities of effective IPC programs

• Recommended practices to reduce pathogen transmission, healthcare-associated infections and antibiotic resistance

• IPC program implementation resources, including policy and procedure templates, audit tools and outbreak investigation tools

This Nursing Home Infection Preventionist Training (new in March 2019) is designed for individuals responsible for infection IPC programs in nursing homes.

• Includes 23 modules that can be completed in any order and over multiple sessions

• Free continuing medical education (CME), continuing nursing education (CNE) or continuing education units (CEUs) available upon course completion

To learn more: https://www.telligenqinqio.com/resource/our-work/nursing-home-care/nursing-home-care-resources/cdc-nursing-home-infection-preventionist-training/

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Infection Preventionist

Regulations§ 483.80 (c) IP participation on the Quality Assessment and Assurance committee.

• The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

To Do List

• Identify at least one staff person to serve as the IP

• Have a back-up person to help the IP and also to serve as the IP if the IP leaves

▪ So…get the back-up person trained

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• Appears in Multiple Areas in the Regulations

• Requires Providers to be Able to:

• Assess for past trauma

• Provide care to treat past trauma

• Assure staff competency in recognizing and caring for trauma survivors

Trauma-Informed Care

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42 CFR§483.25(m) Trauma-informed care.

• The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Trauma-Informed Care: Appears in Multiple Areas in the Regulations

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Trauma-Informed Care: Appears in Multiple Areas in the Regulations

42 CFR§483.21(b)(iii) (3) Comprehensive Care Plans.

The services provided or arranged by the facility, as outlined by the comprehensive care plan, must—

(ii) Be provided by qualified persons in accordance with each resident’s written plan of care.

(iii) Be culturally-competent and trauma–informed.

42 CFR§483.40 (b) Behavioral Health Services

Based on the comprehensive assessment of a resident, the facility must ensure that

(1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being…

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Comprehensive Person-Centered Care Planning

“We do not believe that a definition of trauma-informed care should be added to the definitions section, but note that the interpretative guidelines and the resource noted previously will provide further information regarding culturally-competent and trauma-informed care.” https://store.samhsa.gov/system/files/sma144884.pdf

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SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach

“Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”https://www.integration.samhsa.gov/clinical-practice/trauma

“A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.”

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The Four “R’s”: Key Assumptions in a Trauma-Informed Approach

• In a trauma-informed approach, all people at all levels of the organization or system have a basic realization about trauma and understand how trauma can affect families, groups, organizations, and communities as well as individuals

• People in the organization or system are also able to recognize the signs of trauma.

• The program, organization, or system responds by applying the principles of a trauma-informed approach to all areas of functioning.

• A trauma-informed approach seeks to resist re-traumatization of clients as well as staff.

https://store.samhsa.gov/system/files/sma14-4884.pdf

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• There are many psychosocial screening and assessment tools available at the following SAMHSA website: https://www.integration.samhsa.gov/clinical-practice/screening-tools#TRAUMA

• A multi-pronged approach for identifying a resident’s history of

trauma may include:• History and Physical

• Social History/Assessment

• Resident Assessment Instrument (RAI)

• Admission Assessment

• Review of Medical Records

• Discussion with Family and Friends

• Observation of Behaviors that may Indicate Past Trauma

Screening for Trauma

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Trauma-Informed Care

Get Ready

• Assess for past trauma

• Provide care to treat past trauma

• Assure staff competency in recognizing and caring for trauma survivors

To Do List• Develop and/or adopt a screening tool to assess

all admissions

• Should be driven by triggers for trauma (per resident or family)

• Include access to psychiatry and psychology services

• Develop a real-time reporting program on behaviors suggestive of past trauma (e.g. huddles at change of shift on any changes to resident)

• Develop in-service (or access online programs) to include:

▪ How can past trauma affect an individual?

▪ How does past trauma manifest itself in trauma survivors?

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Topics must include but are not limited to:

(a) Communication

(b) Resident’s rights and facility responsibilities

(c) Abuse, neglect, and exploitation

(d) Quality assurance and performance improvement

(e) Infection control

(f) Compliance and ethics

(g) Required in-service training for nurse aides

(h) Required training of feeding assistants

(i) Behavioral health

Training Requirements

This Photo by Unknown Author is licensed under

CC BY-NC-ND

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Training Requirements

Regulations§483.95 Training Requirements. A facility must develop, implement, and maintain an effective training program for all

• new and existing staff;

• individuals providing services under a contractual arrangement;

• and volunteers,

consistent with their expected roles.

A facility must determine the amount and types of training necessary based on a facility assessment as specified at §483.70(e).

To Do List• Review your current in-service curriculum

against required list

• Develop short in-services; consider posting the videos for your policy and procedures

• Develop a tracking mechanism for all employees, contractors and volunteers

• Ask contractors to assure their employees have received and can provide documentation for in-services on required topics

• Review your current CNA in-service curriculum against gap analysis from:

• Facility assessment for resident characteristics and treatment requirements

• Ongoing monitoring of CNA practice

• QAA committee findings and root cause analyses

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If You’re Searching for a Place to Start…(Big Shout Out to April Burdorf and the Team at CDPHE!)

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Quality Assurance and Performance Improvement (QAPI)

Regulations§ 483.75 (a) QAPI program. Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must …

…the regulation section won’t fit in this box

To Do List

Lots to do…☺

• Let’s focus on the role of the Medical Director in the Framing Elements of your QAPI program

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QAPI at a Glance

This guide is a resource for nursing homes striving to embed QAPI principles into their day to day work of providing quality care and services• Five Elements for Framing QAPI in

Nursing Homes

• 12 Action Steps for QAPI

• QAPI Principles Summarized

• QAPI Tools and Related Resourceshttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIAtaGlance.pdf

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Medical

Director

Engagement

in QAPI

QAPI at a Glance : Step 1

“It is also important to have a medical director who is actively engaged in QAPI.”

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIAtaGlance.pdf

This Photo by Unknown Author is licensed under CC BY-NC

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Five Elements of QAPI and the Medical Director

Five QAPI Plan Framing Elements

What Medical Directors Enjoy

• Performance Improvement

• Blue Sky Design and Scope

• Systematic Analysis

• Data Monitoring

• Leading

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Element 1 Medical Director Role

Design and Scope

• Provide input on the development of the QAPI plan and ensure work is being done to meet the goals established in the plan

• Assist in articulating the balance between providing a safe environment and establishing a culture that honors resident choices and autonomy

Five Elements of QAPI and the Medical Director

Adapted from

https://www.goodsam.com/assets/uploads/general/QAPI_fact_sheet_for_medical_directors.pdf

This information was produced solely for use by The Evangelical Lutheran Good Samaritan Society. The

information provided does not, and is not intended to, constitute legal or professional advice; instead, all

information, content, and materials provided are for general informational purposes only.

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Element 2 Medical Director Role

Governance and Leadership

• Help build and support a culture of quality improvement and safety

• Promote effective teamwork that engages all staff in the QAPI process

• Encourage all staff members to bring forward ideas and concerns and participate in quality assurance and performance improvement work.

• Encourage high standards for quality care and services

Five Elements of QAPI and the Medical Director

Adapted from

https://www.goodsam.com/assets/uploads/general/QAPI_fact_sheet_for_medical_directors.pdf

This information was produced solely for use by The Evangelical Lutheran Good Samaritan Society.

The information provided does not, and is not intended to, constitute legal or professional advice;

instead, all information, content, and materials provided are for

general informational purposes only.

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Element 3 Medical Director Role

Feedback Systems, Data and Monitoring

• Learn about the important sources of data in the center, including Quality Measure scores and other results

• Provide guidance in use of the data to evaluate current performance, and assist with decisions on where improvement is needed

• Help set performance targets• Emphasize a focus on process and outcome

improvement• Model data-driven decision making

Five Elements of QAPI and the Medical Director

Adapted from

https://www.goodsam.com/assets/uploads/general/QAPI_fact_sheet_for_medical_directors.pdf

This information was produced solely for use by The Evangelical Lutheran Good Samaritan

Society. The information provided does not, and is not intended to, constitute legal or professional

advice; instead, all information, content, and materials provided are

for general informational purposes only.

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Element 4 Medical Director Role

Performance Improvement Projects

(PIP)

• Participate in PIP teams• Share and model best practices to maintain

effective interdisciplinary teams• Assist with project prioritization and review

PIP team charters• Make sure there is a feedback loop for PIP

team progress. • Monitor outcomes and reflect on lessons

learned, successes, challenges, and changes to systems or processes

Five Elements of QAPI and the Medical Director

Adapted from

https://www.goodsam.com/assets/uploads/general/QAPI_fact_sheet_for_medical_directors.pdf

This information was produced solely for use by The Evangelical Lutheran Good Samaritan

Society. The information provided does not, and is not intended to, constitute legal or professional

advice; instead, all information, content, and materials provided are

for general informational purposes only.

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Element 5 Medical Director Role

Systematic Analysis and Systemic Action

• Support a culture that avoids blame/blaming individuals but instead focuses on evaluating and improving systems and processes

• Support use of process improvement tools and tools to guide and document improvement work

• Understand and support a root cause analysis approach to problems, and sustainable solutions

Five Elements of QAPI and the Medical Director

Adapted from

https://www.goodsam.com/assets/uploads/general/QAPI_fact_sheet_for_medical_directors.pdf

This information was produced solely for use by The Evangelical Lutheran Good Samaritan

Society. The information provided does not, and is not intended to, constitute legal or professional

advice; instead, all information, content, and materials provided are

for general informational purposes only.

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Check out this Change Package when developing your PIPs

https://qioprogram.org/all-cause-harm-prevention-nursing-homes

•The Office of Inspector General reported in

2014 that 33% of all residents of skilled

nursing facilities experience an adverse event

or temporary harm event.

The Change Package: A valuable resource for

as nursing home staff and providers as they

work with residents and families to prevent,

detect, and mitigate harm.

How can the Change Package be used?

Ideas for improvement can be generated by

reviewing the practices listed and comparing

those to practices currently in place.

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Improving Lives by Delivering Solutions for Quality Care

With Gratitude to Dr. David Gifford of the American Health Care Association (AHCA) for Generously Sharing Slides for This Presentation!

www.ahcancal.org

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Contact a Telligen Nursing Home Team Member to Learn More

Gina Andersongina.anderson@area-d.hcqis.org515-223-2127

Lisa BridwellLisa.Bridwell@area-d.hcqis.org630-928-5831

Deanna Currydeanna.curry@area-d.hcqis.org720-554-1479

Stacy Gordonstacy.gordon@area-d.hcqis.org630-928-5812

Nell Griffinnell.griffin@area-d.hcqis.org630-928-5813

Elizabeth Schulte Mullinselizabeth.schulte@area-d.hcqis.org720-554-1395

Kristen Ives, NHSN Supportkristen.ives@area-d.hcqis.org720-554-1695

Anita Adamo, Project Assistantanita.adamo@area-d.hcqis.org720-554-1708

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• Colorado Department of Public Health and Environment www.colorado.gov/pacific/cdphe/hai-training

• Colorado Health Care Association & Center for Assisted Living https://www.cohca.org/

• The Evangelical Lutheran Good Samaritan Society: https://www.goodsam.com/assets/uploads/general/QAPI_fact_sheet_for_medical_directors.pdf

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

• CMS QAPI website: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapiresources.html

• AMDA – Society for Post-Acute and LTC Medicine resources. https://paltc.org/

• CMDA The Colorado Society for Post-acute and Long-term Care Medicine https://cmda.us/

• National Nursing Home Quality Improvement Campaign: https://www.nhqualitycampaign.org/

• Keep Informed: MLN (Medicare Learning Network) Calls & Webcasts: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNGenInfo/Index.html

• Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014: https://store.samhsa.gov/system/files/sma14-4884.pdf

References and Resources

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Thank you!

www.TelligenQINQIO.com

Dr. Christine LaRoccaMedical Director

CLaRocca@Telligen.com