The final rule for Requirements of Participation was published in the Federal Register on October 4, 2016. The rule was divided into three phases of implementation which included a new survey process. Phase 3 of the implementation will take effect on November 28, 2019.
The Phase3 requirements were last to take effect due to the time to develop and implement. Because of this, each facility should have started their processes for implementing Stage 3 requirements.
Develop/implement Abuse/Neglect policies as stated in 483.13(c) and tag F-607 changes include: (4) establish coordination with the QAPI program. The facility should review and revise abuse policy and training so that QAPI is part of the system.
Services must be provided or arranged by the facility as directed by the comprehensive care plan and must be culturally-competent and trauma-informed as outlined in 483.20 (k)(3)(ii)-(iii) and F-659. It is important the staff are trained to understand what culturally-competent and trauma-informed services are and that these needs are met by the facility and if not available, then the facility arranges for the required services.
A new requirement for facilities is 483.25 (m) and tag F-699 – 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. The facility will need to include this in their training so that all staff can recognize and report behaviors that may be post trauma induced. Trauma-informed care is woven throughout the requirements of Phase 3.
483.40(a)(1)(2) requires Sufficient/Competent Staff and now has been expanded in Phase 3 to include trauma. F-741 requires sufficient staffing provisions including consideration of the appropriate competencies and skills sets to provide the necessary behavioral health and services. These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for: (1) caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma, and/or post-traumatic stress disorder, and (2) implementing non-pharmacological interventions.
The requirement for Governing Body, 483.75(d)(1)-(2), and tag F-837 requires that the governing body is responsible and accountable for the QAPI program. It is important that the processes for communication and guidance for QAPI include the governing body.
The QAPI Program/Plan, Disclosure/Good Faith Attempt as required in 483.75(a)(b)(f)(h)(i) and tag F-865 has changed. Phase 2 required only that the plan be presented to the state agency surveyor at each annual recertification survey and upon request during any other survey. Now, each facility 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 maintain documentation and demonstrate evidence of its ongoing QAPI program, presenting this evidence to a state agency, federal surveyor, or CMS upon request. The facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. The governing body is responsible and accountable for the ongoing QAPI program, ensuring it is sustained during transitions in leadership/staffing and is adequately resourced.
In addition to F-865, tag F-866 is also about QAPI. 483.75(c)(1)-(4) requires that the facility establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility should have evidence of feedback and input from all departments, direct and indirect access workers, residents, and resident representatives.
The next QAPI tag is F-867, and the regulation is 483.75 (d)(1)(2)(e)(1)-(3)(g)(2). The facility must develop policies and take actions aimed at performance improvement, including how the facility intends to implement those actions, measure success, and track performance to ensure that improvements are realized and sustained. It is required that the facility sets priorities for its performance improvement activities, tracks medical errors/adverse resident events, and conduct at least one distinct performance improvement project annually. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility’s services and available resources, as reflected in the facility assessment. The regulation also specifies that the Quality Assessment and Assurance committee duties include reviewing and analyzing data collected under the QAPI program.
The next Phase 3 requirement is F-868 for 483.75(g)(1)(i)-(iv)(2)(i) which is about the QAA Committee. The Phase 3 change adds infection preventionist to the Quality Assessment and Assurance Committee. The facility should review their policies on Quality Assessment and Assurance Committee and revise to include infection preventionist if not already included.
F-882 relates to the new requirement to have an infection preventionist. 483.80 (b)(1)-(4)(c) adds a new provision that the facility must designate one or more individual(s) as the infection preventionist with responsibility for the facility’s Infection Prevention and Control Program. The individual must be a clinician who works at least part time at the facility and has completed specialized training in infection prevention and control. This person must be a member of the facilities QAA committee and report to the committee on the IPCP on a regular basis.
Compliance and Ethics is now required in Phase 3. 483.85(a)-(e) requires the operating organization for each facility to have in operation a compliance and ethics program that has been reasonably designed, implemented, and enforced so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations and in promoting quality of care. The minimum requirements for all facilities: (1) established written compliance and ethics standards, policies, and procedures that designate an appropriate contact for reporting violations, an alternative method of reporting violations anonymously, and disciplinary standards that set out the consequences for committing violations; (2) assignment of specific high-level individuals with the overall responsibility to oversee compliance with the program’s standards; (3) sufficient resources and authority to assure compliance; (4) due care not to delegate substantial discretionary authority to individuals who have a propensity to engage in criminal, civil, and administrative violations; (5) takes steps to effectively communicate the standards, policies, and procedures in the program to all staff, contractors, and volunteers; (6) takes reasonable steps to achieve compliance with the program, including the use of monitoring and auditing systems, and having a process for ensuring the integrity of any reported data; (7) consistent enforcement of the program through appropriate disciplinary mechanisms; and (8) after a violation is detected, the organization must respond appropriately to the violation, modifying the program as needed to prevent further similar violations. There are additional components required for organizations operating with five or more facilities. The organization must review its compliance and ethics program annually and revise as needed to reflect changes in applicable laws or regulations to improve its performance in deterring, reducing, and detecting violations, and in promoting quality of care.
Each facility needs to look at their resident call system to ensure it meets the requirements of 483.70(f)(1)-(2) and f-919. The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident’s bedside. If the call system relays the call directly to a centralized staff work area, the area must be staffed.
The training requirements have changed in Phase 3 as 483.95 (a)(b)(d)(e)(f) requires the facility to 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 based on the facility assessment. If the facility fails to meet this requirement they will be cited under F-940.
In addition to the training aligned with the facility assessment, there are specific training also required. F-941 is Communication Training; the facility must include effective communications as mandatory training for direct care staff. F-942 is Resident Rights Training; the facility must ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. F-944 QAPI Training; the facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility’s QAPI program. F-945 Infection Control Training; the facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program. F-946 Compliance and Ethics Training; The operating organization for each facility must include as part of its compliance and ethics program, an effective way to communicate the program’s standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program. F-949 Behavioral Health Training; the facility is required to provide behavioral health training consistent with the requirements at 483.40 and as determined by the facility assessment.
Resources such as LTC Survey Pathways, LTCSP Initial Pool Care Areas, LTCSP Procedure guide and LTC Survey FAQs can be found on CMS Nursing Home page that will assist the facility in survey readiness.