Long-Term Care Survey Alert

Published on Thu Nov 12, 2015 PDF

Tip: Pay special attention to staffing requirements.

The push for person-centered care in the nursing home has been on the cards for decades. But only now are federal regulators getting serious about using the survey process to promote a true focus on long-term care residents. Fail to read the resident-centric fine print in the feds’ new survey rule — designed “to bring nursing home regulation into the 21^st century” — and you will be sorry when surveyors come to call.

Background: The proposed rule — Reform of Requirements for Long-Term Care Facilities, CMS-3260-P — published in the Federal Register on July 16, packages the biggest changes to the long-term care survey process since 1991. Its reforms are broad, but at a recent Open Door Forum,  Lisa Parker  of the Centers for Medicare and Medicaid Services (CMS), put person-centered care at the top of the list of the rule’s raison d’etre.

Most directly, the proposed rule promotes person-centered care by amending current regulations to include a section titled Comprehensive Person-Centered Care Planning (§ 483.21), notes Parker, director of the Division of Institutional Quality Standards in the Clinical Standards Group at CMS. In addition, current sections have been renamed and refocused to reflect the agency’s new leanings toward person-centered care.

Case in point: CMS scrapped the section titled “Resident Behavior and Facility Practices” (read: facilities manage “resident behavior”) and introduced a section (§483.12) titled “Freedom from Abuse, Neglect, and Exploitation” (read: facilities protect and serve residents).

Likewise, the old section “Dietary Services” is likely to be reinvented in the final rule as the resident-focused “Food and Nutrition Services,” complete with an introduction that explicitly calls on facilities to take resident preferences into consideration.

Timing: The comment period on the proposed rule ended October 15, and the final rule should debut in 2016. The shift to resident-focused regulatory language is sure to prove to be more than symbolic. That is, once the rule becomes final, facilities that haven’t yet embraced person-centered care are likely to fall hard.

Providers must take a fresh and serious look at “person-centeredness” if they want to fare well under proposed survey changes, says Dr. Cheryl Phillips, MD, senior vice president of public policy and health services for Leading Age.

“Person-Centered” Care Defined

Start preparing for the coming changes by taking to heart the feds’ first definition of person-centered care: care that “[focuses] on the resident as the locus of control and [supports] the resident in making their own choices and having control over their daily lives.”

That translates to greater choice for residents on matters including visitation, roommates, and menus, as well as a person-centered foundation for all aspects of the survey.

“In these regulations, we are proposing to define person-centered care as focusing on the resident as the locus of control and supporting the resident in making their own choices and having control over their daily lives,” affirms CMS spokesperson Ronisha Blackstone.

“We believe that revising the regulations to be more person-centered could have a positive impact on the care that facilities provide, and as a result, ensure that residents live with dignity, respect, improved self-esteem, and self-determination,” she explains.

The person-centered theme is especially evident in the proposed new rule’s take on care planning and staffing.

Pay Attention to Renewed Focus On Care Planning

Twice the impact: The new Person-Centered section not only spotlights individualized care but also brings a related and renewed focus on care planning.

CMS plans, for example, to bolster the interdisciplinary team in very specific ways, stipulating that the team of the future must include a nursing assistant “who has primary responsibility for the resident.” Other requisite positions will be a social worker and a member of the food and nutrition staff.

Furthermore, the agency suggests adding to the required credentials for a qualified social worker, requiring not just a bachelor’s degree in social work or a human services field, but “adding gerontology to the list of studies that will meet this requirement,” explains Blackstone.

The proposed rule also makes it known that by default a resident is a member of his or her own care planning team. If a resident isn’t acting on his own behalf, be sure to document why.

“We propose to require facilities to provide a written explanation in the resident’s medical record if the participation of the resident or their resident representative is determined to not be practicable for the development of the resident’s care plan,” reads the proposed rule.

Arrange Staffing with Individualized Care Competency in Mind

Staffing with residents in mind will also be vital under provisions in the proposed rule: according to Diane Corning, RN, JD, of CMS’s Clinical Standards Group, facilities should start the staffing equation with their particular resident population “and then [determine] the competencies and the skill sets along with the number of staff that are needed to care for their population.”

Some provisions related to staffing are spelled out in another new section in the proposed rule, Behavioral Health Services (483.40). The Nursing Services section (§483.35) will also inform approaches to staffing.

The American Health Care Association cautions members to “carefully review and evaluate” the revised section on Nursing Services. Specifically, providers should consider the rule’s call for what it deems “sufficient staffing” — staffing newly linked to a “competency” requirement “for determining sufficient nursing staff 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 care plans.”

Implicit in CMS’s talk of competency staffing is that care should be individualized: The right staffing for Mrs. Smith may not be the right staffing for Mr. Jones.

Indeed, CMS has stipulated that facilities have a responsibility to focus on “each resident” achieving his or her highest practicable physical, mental, and psychosocial well-being.

The devil may be in the details as far as transitioning from proposed rule to a practical final rule is concerned, industry insiders say. In their comments, provider groups are asking CMS to clarify and refine key concepts, to help guide providers are such matters as training, standards, and workforce development.

“We commend the intent but [the feds] are five miles away from being able to operationalize some of the proposed changes,” says Leading Age’s Phillips.