MDS Alert

Published on Wed May 03, 2017 PDF

Brace yourself now for surveyors to focus on this new document.

Phase 2 of the revised Nursing Home Requirements of Participation (RoP) is upon us, with a compliance deadline of Nov. 28, 2017. One of the key items in the Phase 2 RoP is the new facility assessment, and it’s a little more involved than you might think.

Hopefully, you’ve managed to survive your compliance endeavors for Phase 1 and are ramping up to comply with the Phase 2 provisions (see “What to Expect from the Second Round of RoP Challenges,” MDS Alert Vol. 15, No. 3, page 25). In §483.70 Administration, the revised RoPs require you to conduct a facility-wide assessment of your resources and ability to provide necessary daily care to your residents.

Map Out Your Facility Assessment Plan

The Centers for Medicare & Medicaid services (CMS) expects you to review and update your facility assessment at least once per year and as necessary. You should also review and update the assessment whenever there is any change that would substantially modify any part of the assessment.

Your facility assessment must address or include:

1. Your facility’s resident population, including (but not limited to):

     i. Both the number of residents and the facility’s resident capacity;
     ii. The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
     iii. The staff competencies that are necessary to provide the level and types of care needed for the resident population;
     iv. The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
     v. Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

2. Your facility’s resources, including (but not limited to):

     i. All buildings and/or other physical structures and vehicles;
     ii. Equipment (medical and non-medical);
     iii. Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
     iv. All personnel, including managers, staff (both employees and contractors), and volunteers, as well as their education and/or training and any competencies related to resident care;
     v. Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
     vi. Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

3. a facility-based and community-based risk assessment, utilizing an all-hazards approach.

Watch Out: Surveyors Will Focus on Your Assessment

Surveyors will use the facility assessment in a variety of ways, including to assess your staff competencies and resources in the instance of an adverse event, according to the American Health Care Association (AHCA)/national Center for assisted Living (NCAL). This really underscores the importance of preparing the facility assessment the way in which CMS mandates.

Unfortunately, CMS has yet to provide specific guidance on how to perform the facility assessment.

But the revised RoP regulation explained that the purpose of the facility assessment is to ensure that facilities know themselves, their staff, and their residents, said Karen Tritz, CMS Division of Nursing Homes Director, in an MLN Connects National Provider Call. The assessment is meant to be tailored to individual facilities and account for diversity in resident populations.

CMS designed the facility-wide assessment requirement to enable each facility to thoroughly assess the resident population and resources necessary to provide care at a macro level, according to attorneys Alan Horowitz and Genevieve Razick with Arnall Golden Gregory LLP. Also, the requirement to document the assessment will provide a record for future management to understand the reasoning behind decisions made on staffing and other resources.

Get Ready for New Training Requirements, Too

The facility-wide assessment requirements ties into the final rule’s requirements for an effective training program. Your facility must develop, implement, and maintain a training program for all new and existing staff, contractors, and volunteers, Horowitz and Razickexplain.

The training program must train staff on:

• The rights of the resident and the responsibilities of the facility to properly care for its residents;
• Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, including outlining procedures for reporting such incidents;
• Mandatory Quality Assurance and Performance Improvement (QAPI) training that outlines the elements and goals of the facility’s QAPI program;
• Infection control policies and procedures;
• Dementia management and abuse prevention; and
• Behavioral health training (to the entire staff).

Your facility must also have a compliance and ethics program. If the operating organization governs five or more facilities, it must have mandatory training annually. And your facility must employ only paid feeding assistants if they have successfully completed a state-approved training program.

For the most part, these training requirements are part of Phase 3, with a compliance deadline of Nov. 28, 2019, Horowitz and Razick say. But Phase 1 included the training requirement for feeding assistants, in-service training requirements for Nursing Aides, and the requirement for the abuse, neglect, exploitation, and misappropriation training.

Link: The final rule for nursing facility RoPs, published in the Oct. 4, 2016 Federal Register, is available at www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities.