MDS Alert

Heads up: PRN orders for these medications are now limited to 14 days.

If your facility’s staff has been hard at work striving to comply with the revised Requirements of Participation (RoP) Phase 1 provisions, you’re not alone. But beware that implementation deadline for Phase 2 is right around the corner — you have only until Nov. 28, 2017 to be in compliance. Here’s what you need to do right now to prepare for the Phase 2 requirements.

Prove that You Provide Behavioral Health Services

The Centers for Medicare & Medicaid Services (CMS) has new requirements in §483.40 Behavioral Health Services, most of which will be implemented in Phase 2. This section mandates that your facility ensure that staff are competent and sufficient to care for residents who require behavioral health services and that you have treatment and services to meet their needs, according to the Oklahoma State Department of Health (OSDH) Quality Improvement & Evaluation Service (QIES).

Staff should consider comprehensive assessments and medically related social services when caring for residents with behavioral needs. Also, this section encourages implementing non-pharmacological approaches whenever possible to reduce medication use for behavioral issues.

Note: Most of this section will be implemented in Phase 2, except for two items:

• (b)(1), (b)(2), and (d) Comprehensive assessment and medically related social services (Phase 1); and
• (a)(1) As related to residents with a history of trauma and/or post-traumatic stress disorder (Phase 3).

Develop a Baseline Care Plan

For §483.21 Comprehensive, Person-Centered Care Planning, only (a) Baseline care plan is included in Phase 2, and (b)(3)(iii) Trauma informed care will be implemented in Phase 3. The rest of this section was implemented in Phase 1. (see “5 Crucial Facts You Need to Understand About the Baseline Care Plan,” MDS Alert, Vol. 15, No. 2, page 13)

This section includes the requirements for baseline care plans as well as comprehensive care plans and discharge planning, says Linda elizaitis, Rn, RaC-Ct, Bs, President of CMs Compliance Group inc. in Melville, N.Y.

Phase 2 requires that you have a person-centered baseline care plan in place for each resident within 48 hours of admission to your facility, Elizaitis notes. You will also need to provide the resident and his representative with a summary of this baseline care plan.

Create a Denture-Replacement Policy

Most of §483.55 Dental Services was implemented in Phase 1, except for the following for Phase 2:

• (a)(3) and (a)(5) Loss or damage of dentures and policy for referral; and
• (b)(3) and (b)(4) Referral for dental services regarding loss or damaged dentures.

Translation: In Phase 2, your facility must have a policy identifying the circumstances in which the loss or damage of dentures is the facility’s responsibility, according to the american Health Care association/National Center for Assisted Living (AHCA/NCAL). The policy must also state that your facility cannot charge a resident for the loss or damage of dentures, when determined in accordance with facility policy to be your facility’s responsibility.

Get Ready to Perform a Facility Assessment

In §483.70 Administration, most of the provisions were implemented in Phase 1, but Phase 2 will include (e) Facility assessment, and Phase 3 will implement (d)(3) Governing body responsibility of QAPI program.

In Phase 2, this section requires you to perform and document a facility-wide assessment to determine what resources are necessary to care for your residents during both day-to-day operations and emergencies, according to long-term care consultant Linda Farrar, Rn, LnHa, who is part of the AHCA Quality Network.

You must review and update the facility assessment as needed and at least annually, Farrar says. The required components of the facility-wide assessment are:

• The facility’s resident population (number of residents and facility’s resident capacity);
• Spectrum of care that the resident population requires considering:
       o Diseases,
       o Conditions,
       o Physical and cognitive disabilities,
       o Overall acuity, and
       o Other pertinent factors present in the population;
• Staff competencies required to provide the level and types of care needed;
• The physical environment, equipment, services, etc.;
• Any ethnic, cultural, or religious factors that may affect the care provided, including but not limited to activities as well as food and nutrition services;
• All buildings, other physical structures, and vehicles;
• Equipment (medical and non-medical);
• Services provided such as physical therapy, pharmacy, and specific rehab therapies;
• All personnel (employees, contractors, and volunteers) and their education/training related to resident care;
• Contracts, memorandums of understanding, and other agreements with third parties to provide services or equipment to the facility;
• Health information technology resources; and
• A facility-based and community-based risk assessment utilizing an all-hazards approach.

Problem: Unfortunately, CMS has not yet issued specific guidance on how to comply with this requirement, Farrar says. And this guidance will be crucial – surveyors may use your facility assessment in a variety of ways, including to assess your staff competencies and resources in an adverse event.

Launch Your Antibiotic Stewardship Program

Although most of §483.80 Infection Control was implemented mostly in Phase 1, these items were not:

• (a) As linked to Facility Assessment at §483.70(e) (Phase 2)
• (a)(3) Antibiotic stewardship (Phase 2)
• (b) Infection preventionist (IP) (Phase 3)
• (c) IP participation on QAA committee (Phase 3)

In Phase 2, you will need to focus on the antibiotic stewardship component of this section. “Antibiotic stewardship is a coordinated program that promotes the appropriate use of antimicrobials, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms,” OSDH QIES states.

Your antibiotic stewardship program should include antibiotic use protocols as well as a system to monitor antibiotic use, Farrar notes. The other Phase 2 requirement is to use your facility assessment to re-evaluate your system and make changes as needed.

Limit PRN Antipsychotics & Psychotropics to 14 Days

Two parts of §483.45 Pharmacy Services will be implemented in Phase 2 (the rest in Phase 1):

• (c)(2) Medical chart review; and
• (e) Psychotropic drugs.

Drug regimen review and reporting, as well as a review of the medical chart will be mandatory by Nov. 28, OSDH QIES states. CMS also updated the definition of psychotropic medication to include the PRN usage and the difference between psychotropic versus antipsychotic medications.

Important: The regulations now state that residents don’t receive PRN psychotropic meds unless they’re necessary to treat a diagnosed specific condition that’s documented in their medical record, Farrar explains. PRN orders for psychotropic drugs are now limited to 14 days, unless the ordering physician documents the rationale in the medical record and indicates the duration for the PRN order.

The regulations also limit PRN orders for antipsychotic drugs to 14 days, with no renewal allowed unless the attending physician evaluates the resident for the medication’s appropriateness, Farrar says. CMS emphasizes addressing “distressed behavior” through nonpharmacological approaches, instead of relying on medications.

Don’t Overlook Other Revisions

The Phase 2 changes also include a variety of other, albeit more minor, provisions that are still important for your compliance efforts.

§483.10 Resident Rights: Although CMS implemented most of this section in Phase 1, Phase 2 will implement the provision in (g)(4)(ii)-(v) Providing contact information for State and local advocacy organizations, Medicare and Medicaid eligibility information, Aging and Disability Resources Center and Medicaid Fraud Control Unit.

§483.12 Freedom from abuse, neglect, and Exploitation: Nearly all this section was implemented in Phase 1, except for (b)(5) Reporting crimes/1150B which will be implemented in Phase 2. Phase 3 implements (b)(4) Coordination with QAPI Plan.

§483.15 admission, transfer, and Discharge Rights: In Phase 2, (c)(2) Transfer/Discharge Documentation will be implemented, while the rest of the section was implemented in Phase 1.

§483.35 nursing services: This section was implemented in Phase 1, but Phase 2 will implement “specific usage of the Facility Assessment at §483.70(e) in the determination of sufficient number and competencies for staff.”

§483.75 Quality assurance and Performance Improvement: Most of the QAPI section will be implemented in Phase 3, but Phase 2 will implement (a)(2) Initial QAPI Plan must be provided to State Agency Surveyor at annual survey. Phase 1 implemented (g)(1) QAA committee, (h) Disclosure of information, and (i) Sanctions.

In Phase 2, you will need to have a QAPI plan in place and have begun implementing your QAPI.

§483.90 Physical environment: This entire section was implemented in Phase 1, except for (h)(5) Policies regarding smoking (Phase 2), as well as (f)(1) Call system from each resident’s bedside (Phase 3).

In Phase 2, you must establish policies regarding smoking, smoking areas, and smoking safety. The policies must comply with applicable federal, state, and local laws and regulations, and they must take into account nonsmoking residents.

Link: To access the RoP regulations, go to www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities.