For all Administrators, Directors of Nursing, and Quality Assurance (QA)/Quality Improvement (QI) Directors or Coordinators, this is not only required reading for your facilities, but more important, it is a practical tool to guide you as you prepare for your survey. As the saying goes, "Your facility must be survey-ready 365 days a year." So use this book to help you get ready-and stay ready.
The Fundamentals of Quality for LTC, Part I gives you the F-Tags, as well as the Centers for Medicare and Medicaid (CMS) Interpretive Guidelines and Guidance to Surveyors. This is a comprehensive monitoring tool for all disciplines to use in an interdisciplinary format. It covers the Federal Long Term Care Regulations 42 CFR §483.10 Resident Rights through §483.20 Resident Assessment. Because this is such a practical tool, it is a book that staff will keep handy at their desks to use for monitoring purposes and for quick reference. It will help the Interdisciplinary Team (IDT)-including one of the most important and busiest groups, the Certified Nursing Assistants (CNAs)- maintain awareness of the expectations of the Federal and State Surveyors. It will also keep the staff's focus on Quality of Care and Quality of Life.
The Fundamentals of Quality for Long Term Care
Part 1By Nora J. Wellington Alicia A. Creighton-AllenAuthorHouse
Copyright © 2010 Nora J. Wellington and Alicia A. Creighton-Allen
All right reserved.ISBN: 978-1-4520-6839-8Contents
About the Authors......................................................................................................viiAcknowledgments........................................................................................................viiiIntroduction...........................................................................................................xResident Rights §483.10 – Summary Highlights................................................................xiiiAdmission, Transfer, and Discharge Rights §483.12 – Summary Highlights......................................xivResident Behavior and Facility Practices §483.13 – Summary Highlights.......................................xvQuality of Life §483.15 – Summary Highlights................................................................xviResident Assessment §483.20 – Summary Highlights............................................................xviiiHow to Use the Monitoring Tool.........................................................................................xx§483.10 Resident Rights...........................................................................................3Admission Packet.......................................................................................................5Notification of Changes................................................................................................5Protection of Resident Funds...........................................................................................7Management of Resident Funds...........................................................................................7Conveyance Upon Death..................................................................................................9Surety Bond............................................................................................................9Limitation on Charges to Personal Funds................................................................................9Free Choice............................................................................................................9Privacy and Confidentiality............................................................................................9Prompt Effort to Resolve Grievances....................................................................................11Examination of Survey Results..........................................................................................11Work...................................................................................................................11Mail...................................................................................................................11Access and Visitation..................................................................................................13Ombudsman Visits.......................................................................................................13Telephones.............................................................................................................13Self-Administration of Drugs...........................................................................................15Refusal of Certain Transfers...........................................................................................15§483.12 Admission, Transfer, and Discharge Rights.................................................................17Right to Refuse Certain Transfers......................................................................................19Transfer and Discharge Requirements....................................................................................19Documentation by Resident's Physician..................................................................................19Notice before Transfer.................................................................................................21Orientation for Transfer and Discharge.................................................................................21Bed Hold...............................................................................................................21Resident Return to the Facility........................................................................................23Admissions Policy......................................................................................................23§483.13 Resident Behavior and Facility Practices..................................................................25Restraints.............................................................................................................27Staff Treatment of Residents...........................................................................................27Abuse Prevention.......................................................................................................29Abuse-Prevention Policies and Procedures...............................................................................29§483.15 Quality of Life...........................................................................................33Resident's Dignity and Self-Respect....................................................................................35Participation in Activities............................................................................................37Resident Council.......................................................................................................37Council's Grievances...................................................................................................39Participation in Other Activities......................................................................................39Accommodation of Needs.................................................................................................39Room Change............................................................................................................41Activities.............................................................................................................41Qualifications.........................................................................................................43Social Services........................................................................................................43Environment............................................................................................................45Housekeeping and Maintenance Services..................................................................................47Linens.................................................................................................................47Lighting...............................................................................................................47Comfort................................................................................................................47§483.20 Resident Assessment.......................................................................................49Admission Order........................................................................................................51Comprehensive Assessment...............................................................................................51Admission Assessment...................................................................................................55Significant Change Assessment..........................................................................................55Annual Assessment......................................................................................................57Quarterly Assessment...................................................................................................57MDS Certification by RN................................................................................................57IDT Care Plans.........................................................................................................57Review and Revisions of Care Plans.....................................................................................59RAP Triggers...........................................................................................................59Resident Participation in Care Plan....................................................................................59Accepted Standards.....................................................................................................61Qualified Providers....................................................................................................61Discharge Planning Process.............................................................................................61Post-Discharge.........................................................................................................63Pre-Admission Screening and Resident Review (PASRR)....................................................................63Retention of MDS.......................................................................................................63Encoding and Transmitting MDS..........................................................................................65Comprehensive Monitoring Tool Notes....................................................................................69Comprehensive Monitoring Tool – Staff Signature..................................................................71
Introduction
Those of us in long term care (LTC) are clearly aware of the importance of being knowledgeable of the Federal Tags (F-Tags), as delineated in the Federal Long Term Care Regulations. All disciplines/departments and employees of a Skilled Nursing Facility (SNF) and Nursing Facility (NF) should have a working knowledge of the Federal OBRA*/Long Term Care Regulations, the State Operations Manual, and other related Long Term Care (LTC) regulations. [* OBRA refers to the
Omnibus Budget Reconciliation Act of 1987.]
This book is based on the Federal Long Term Care Regulations (F-Tags) and the Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines, and the intent of the regulations. It is the intention of the authors of this book, Fundamentals of Quality for Long Term Care (LTC) Part I: Comprehensive Monitoring Tool for Skilled Nursing Facility (SNF)/Nursing Facility (NF), to help and assist facilities and their staff, and to increase their knowledge base of the detailed aspects of the regulations. Providing a high level quality care for the residents of the SNF and NF requires that all staff have a working knowledge of the basics and fundamentals of the Code of Federal Regulations (CFR): 42 CFR §483.10 through 42 CFR §483.75. This book (Part I), covers Resident Rights (42 CFR §483.10) through Resident Assessments (42 CFR §483.20), as defined by the regulations.
The CMS continues to introduce new elements to an already heavily regulated LTC industry/ profession. In the past several years, there have been changes to different aspects of the survey process. CMS and State Survey Agencies now publish survey results on their websites, and the Nursing Home Compare webpage has much more information for consumers to use in order to be able to compare nursing homes. The newest among these, the Five Star System, not only helps consumers compare nursing facilities, but also helps staff determine care areas that need improvement in their facilities. The Five Star System highlights three areas of focus, which are: (1) Annual and Complaint Survey results, (2) Staffing, and (3) Quality Measures. CMS has recently implemented the Quality Indicator Survey (QIS). Some States are already participating in the QIS, and the remainder of States will be phased in.
CMS describes the QIS as a computer-assisted survey process utilized by some States to determine if NFs and SNFs meet the Federal requirements for certification and continued certification in the Medicare and Medicaid programs. Both the traditional survey process and the QIS process are governed by the Federal Regulations and CMS Interpretive Guidelines, thereby giving continued importance to the basics and fundamentals of the Federal Regulations (F-Tags). The CMS objectives for the implementation of the QIS are as follows: to improve the consistency and accuracy of the survey process; to systematically review requirements and objectively investigate all triggered regulatory areas within survey resources; to enhance documentation by organizing survey findings through automation; and to focus survey resources on facilities that have the greatest quality concerns.
QIS is a two-stage process, which enables surveyors to focus more on areas that are triggered during the data collection process. Stage I is the data-collection process. There are two sets of sampling done during stage I. There is sample of forty randomly selected residents who are in the facility at the time of the survey. There is also a sample of thirty newly admitted residents (i.e., admitted within thirty days of the start of the survey). The admission sampling looks at re- hospitalization, death, and functional loss as the main focal areas. Stage I data is collected based on surveyors' observations, interviews of residents, interviews of families and responsible parties, interviews of staff, and record reviews. During this Stage I process, surveyors identify those care areas that are triggered for in-depth review in the Stage II process.
With the introduction of all these new elements to the survey process, one thing remains constant: the F-Tags. CMS periodically adds higher care requirements and focus to the F-Tags, as well as to the CMS Interpretive Guidelines (e.g., Pressure Ulcer F-Tags and Activities F-Tags); however, F-Tags remain the basic tenets and foundation for the LTC requirements on Resident Rights, Quality of Life, and Quality of Care for NFs and SNFs. The Fundamentals of Quality for Long Term Care, Part I will aid staff as they prepare for annual surveys, and will also help staff maintain survey-readiness in the areas covered by this book, if monitoring is done regularly. As all of us in LTC are aware, surveyors or inspectors utilize the F-Tags and Interpretive Guidelines to determine compliance of Resident Rights, Quality of Care, Quality of Life, and Life Safety Code.
The purpose of this book (Part I) is to help facilities and their staff determine the level of their regulatory compliance within the facility, in the areas of 42 CFR §§483.10–20 (Resident Rights through Resident Assessments). The Quality Assurance (QA)/Quality Improvement (QI) Director or Coordinator should utilize this book as a tool to establish routine monitoring of the regulations and also to assess the compliance level of the facility. Because of the comprehensive nature of the monitoring tool, it is recommended that monitoring be done in an interdisciplinary manner and on a regular basis. The effectiveness of the tool is enhanced when all disciplines participate as a team in the monitoring exercise and when the monitoring is done regularly
This book is Part I of a three-part series of the comprehensive monitoring tool. Part I covers 42 CFR §483.10 (Resident Rights) to 42 CFR §483.20 (Resident Assessment). Part II and Part III (still to be published) will cover the remainder of the Federal Long Term Care Regulations, from 42 CFR §483.25 Quality of Care to 42 CFR §483.75 Administration.
CMS continues to reinforce the importance of facilities maintaining and sustaining Quality of Care and Quality of Life for their residents. It is the expectation of residents, families, surveyors, and governmental agencies that facilities stay survey-ready 365 days a year. SNFs and NFs must maintain compliance with the regulatory requirements. The authors recommend that facilities have several copies of the Federal Long Term Care Regulations, the CMS Interpretive Guidelines, and the State Operations Manual for the staff. The authors also recommend that, in addition to the Administrator, Director of Nursing, and QA/QI Director or Coordinator, the Nurse Managers should keep copies of the regulations in the units for regular reference. Staying in compliance reduces the risk of poor quality care, which could result in severe negative resident outcomes and deficiencies. Everyone in LTC is aware that residents are prone to various health risks, which lead to complications and deterioration in the individual's health status, up to and including fatality. To name a few of the health risks that staff are aware of, or that staff should be aware of, are: falls, pressure ulcers, chocking, unexplained rise in body temperature, and infections. Pressure ulcers are one of the most common and expensive health risks that pose complications in LTC residents.
All staff, regardless of their positions within the organization, need to be exposed to the Deficiency Report Form 2567, and scope and severity, as this report usually outlines the areas in which the facility did not maintain compliance with the regulations. Some facility administrators do not share this report with all staff, but it will be a benefit to the residents and to the facility for all staff to know the details of the survey results; after all, the staff have a stake in how well the facility does.
There are four severity levels of deficiencies in the survey process: Level 4 is the most severe. It is classified as Immediate Jeopardy and is a situation in which noncompliance of part(s) of the regulations are so severe that this can cause harm, serious injury, or death to one or more residents. This is a situation that requires immediate corrective action from the facility. In spite of facilities taking immediate action to correct the situation, CMS will place sanctions on such facilities.
Level 3 is classified as Actual Harm that is not Immediate Jeopardy. The deficient practice could be the result of clinical compromise of a resident, decline in a resident's condition, or the resident's inability to reach or to maintain his/her highest practical physical, mental, or psychosocial well-being. CMS also imposes penalties on facilities that find themselves in this level.
Level 2 is classified as No Actual Harm with the Potential for More Than Minimal Harm that is not Immediate Jeopardy. The deficient practice could be the result of a clinical outcome where there is the potential to compromise the resident's ability to reach or to maintain his/her highest practical physical, mental, or psychosocial well-being. CMS may impose sanctions.
Level 1 is the least severity. It is classified as No Actual Harm with Potential for Minimal Harm. All facilities will like to be in a Level 1 severity-or with no deficient practices at all.
It is recommended that facility administrators share this information on the survey process with the key personnel in the facility, and that key personnel, in turn, share this with their staff, so everyone in the facility becomes aware of the consequences of noncompliance with the Federal Regulations and State Operations Manual. All F Tags of the Federal Long Term Care Regulations for SNF and NF is the minimum health and safety standards that facility staff must meet during annual surveys in order for facilities to receive their annual Medicare and Medicaid certification. This serves as a major requirement for what CMS refers to as, Conditions of Coverage, and Conditions of Participation.
Excerpted from The Fundamentals of Quality for Long Term Careby Nora J. Wellington Alicia A. Creighton-Allen Copyright © 2010 by Nora J. Wellington and Alicia A. Creighton-Allen. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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