Revisions to the Interpretive Guidelines and where appropriate, Investigative Protocols for 20 F-Tags will be provided during this presentation. Many of.

Revisions to the Interpretive Guidelines and where appropriate, Investigative Protocols for 20 F-Tags will be provided during this presentation. Many of these are not new as they go back as far as However, CMS sent a collection of these revisions out in the S&C memo (14-37-NH) back in July of this year. A link for the entire Appendix PP (Guidance to Surveyors for Long Term Care Facilities) of the SOM is provided here as well. This is a handy resource to have available. Remember, “Guidelines” are not enforceable – however they do reflect best practices and, you should expect that a surveyor will attempt to determine if your facility is demonstrating best practices. As I go through these slides, Words in Red reflect the revisions, IG means Interpretative Guidelines and SP means surveyor procedure or the investigative process which includes observation, interview and record review. NEXT SNF Regulatory Webinar #5: Review of Top Citation trends Revised Surveyor Guidance’s S&C:14-37-NH Revisions to Appendix PP of the SOM and of the Interpretive Guidelines and Investigative Protocols Incorporating S&C policy memos issued from October 2003 through May 2014 guidance/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

Assurance of Financial Security - F161
483.10(c)(7) The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. IG - The surety bond is not limited to personal needs allowance funds. Any resident funds that are entrusted to the facility for a resident must be covered by the surety bond, including refundable deposit fees. SP - As part of Phase 2, if the team has any concerns about resident’s funds, check the amount of the surety bond to make sure it is at least equal to the total amount of residents’ funds, as of the most recent quarter. If the SA cannot determine whether or not the facility is in compliance with this requirement, a referral to the State’s fiscal department would be appropriate. The first tag to be reviewed is F161 – Assurance of Financial Security. This regulation requires you to purchase a surety bond. NEXT Added to the interpretative guidelines is that the surety bond is not limited to personal needs allowance funds. Any resident funds that are entrusted to the facility for a resident must be covered by the surety bond, including refundable deposit fees. NEXT As part of Phase 2, if the team has any concerns about resident’s funds, they are to check the amount of the surety bond to make sure it is at least equal to the total amount of residents’ funds, as of the most recent quarter. NEXT

Documentation for Transfer and Discharge - F202
483.12(a)(3) When the facility transfers or discharges a resident due to the facility’s inability to meet the resident’s welfare/needs, or when the resident’s health has improved sufficiently and no longer needs the facility services, or when the safety of individuals in the facility is endangered, the resident’s clinical record must be documented … by the resident’s physician IG - If a nursing home discharges a resident or retaliates due to an existing resident’s failure to sign or comply with a binding arbitration agreement, the State and Region may initiate an enforcement action based on a violation of the rules governing resident discharge and transfer. A current resident is not obligated to sign a new admission agreement that contains binding arbitration. SP - During closed record review, evaluate the extent to which the discharge summary and the resident’s physician justify why the facility could not meet the resident’s needs. Look for changes in source of payment coinciding with transfer. F202 – Documentation requirements for Transfer and Discharge of a Resident. NEXT Added to the interpretative guidelines for this regulation is if a nursing home discharges a resident or retaliates due to an existing resident’s failure to sign or comply with a binding arbitration agreement, the State and Region may initiate an enforcement action based on a violation of the rules governing resident discharge and transfer. A current resident is not obligated to sign a new admission agreement that contains binding arbitration. NEXT Surveyors are directed to evaluate the extent to which the discharge summary and the resident’s physician justify why the facility could not meet the resident’s needs. The surveyors are directed to look for changes in source of payment coinciding with transfer. NEXT

Admission Policy - F (d)(3) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a recondition of admission, expedited admission or continued stay in the facility. However, — A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State plan as included in the term “nursing facility services” so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident’s admission or continued stay on the request for and receipt of such additional services; and A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident. F208 has to do with the Admission Policy. This is not new. NEXT

This requirement applies only to Medicaid certified nursing facilities.
IG - Facilities may not charge for any service that is included in the definition of “nursing facility services” and, therefore, required to be provided as part of the daily rate. This regulation does not preclude a facility from charging a deposit fee to, or requiring a promissory note from, an individual whose stay is not covered by Medicaid. In instances where the deposit fee is refundable and remains as funds of the resident, the facility must have a surety bond that covers the deposit amount. IG - A nursing facility is permitted to charge an applicant or resident whose Medicaid eligibility is pending, typically in the form of a deposit prior to admission and/or payment for services after admission. Medicaid eligibility will be made retroactive up to 3 months before the month of application if the applicant would have been eligible had he or she applied in any of the retroactive months. IG - In addition, the nursing facility must accept as payment in full the amounts determined by the state for all dates the resident was both Medicaid eligible and a nursing facility resident. Therefore, a nursing facility that charged a recipient for services between the first month of eligibility established by the state and the date notice of eligibility was received is obligated to refund any payments received for that period less the state’s determination of any resident’s share of the nursing facility’s costs for that same period. A nursing facility must prominently display written information in the facility and provide oral and written explanation to applicants or residents about applying for Medicaid, including how to use Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. IG - Under the post-eligibility process, if the Medicaid-eligible resident has income and is required to make a monthly payment to the nursing facility (which is portion of the Medicaid payment amount), then the nursing facility is permitted to retain the amount it is legally owed. However, the nursing facility must not charge administrative fees. NEXT Interpretative guideline revisions however reads that facilities may not charge for any service that is included in the definition of “nursing facility services” and, therefore, required to be provided as part of the daily rate. NEXT This regulation does not preclude a facility from charging a deposit fee to, or requiring a promissory note from, an individual whose stay is not covered by Medicaid. In instances where the deposit fee is refundable and remains as funds of the resident, the facility must have a surety bond that covers the deposit amount. NEXT A nursing facility is permitted to charge an applicant or resident whose Medicaid eligibility is pending, typically in the form of a deposit prior to admission and/or payment for services after admission. Medicaid eligibility will be made retroactive up to 3 months before the month of application if the applicant would have been eligible had he or she applied in any of the retroactive months. NEXT In addition, the nursing facility must accept as payment in full the amounts determined by the state for all dates the resident was both Medicaid eligible and a nursing facility resident. Therefore, a nursing facility that charged a recipient for services between the first month of eligibility established by the state and the date notice of eligibility was received is obligated to refund any payments received for that period less the state’s determination of any resident’s share of the nursing facility’s costs for that same period. A nursing facility must prominently display written information in the facility and provide oral and written explanation to applicants or residents about applying for Medicaid, including how to use Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. NEXT Under the post-eligibility process, if the Medicaid-eligible resident has income and is required to make a monthly payment to the nursing facility (which is portion of the Medicaid payment amount), then the nursing facility is permitted to retain the amount it is legally owed. However, the nursing facility must not charge administrative fees. The surveyor investigative protocol has not been changed. NEXT

Let’s take a pause here for any questions or comments for these Resident Rights and Admission, Transfer & Discharge regulations. Please type in any question or comment regarding these highlighted revisions to the interpretative guidelines. They will be collected, reviewed and responded to at the conclusion of this presentation. If an answer to any question requires further inquiry, it will be sent via to all participants post webinar. NEXT

Restraints: F221 - Physical
483.13(a) The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms. Overview - Restraints may not be used for staff convenience. However, if the residents needs emergency care, restraints may be used for brief periods to permit medical treatments to proceed unless the facility has a notice indicating that the resent has previously made a valid refusal of the treatment in question. The use of side rails as restraints is prohibited unless they are necessary to treat a resident’s medical symptoms or assist with physical functioning. It is expected that the process facilities employ to reduce the use of side rails as restraints is systematic and gradual to ensure the resident’s safety while treating the resident’s medical symptom. Before a resident is restrained, the facility must determine the presence of a specific medical symptom that would require the use of restraints, and how their use would treat the medical symptom, protect the resident’s safety, and assist the resident in attaining or maintaining their highest practicable level of physical & psychosocial well-being. This includes the facility’s discussion with the resident, (and/or if indicated) their legal surrogate or representative of potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use. Medical symptoms that warrant the use of restraints must be documented in the resident’s medical record, ongoing assessments and care plans. Physical restraints as an intervention do not treat the underlying causes of medical symptoms and that they should be used temporarily and not be used without also seeking to identify and address the physical or psychosocial condition causing the medical symptoms. F221 – The right to be free from physical restraints NEXT Here, CMS primarily restated their overview of this regulation and highlighted the use of side rails as restraints is prohibited unless they are necessary to treat a resident’s medical symptoms or assist with physical functioning. Facilities are reminded that before a resident is restrained, the facility must determine the presence of a specific medical symptom that would require the use of restraints, and how their use would treat the medical symptom, protect the resident’s safety, and assist the resident in attaining or maintaining their highest practicable level of physical & psychosocial well-being. NEXT

While there must be a physician’s order reflecting the presence of a medical symptom, the facility is ultimately accountable for the appropriateness of that determination. A physician’s order alone is not sufficient to warrant the use of the restraint. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. Orthotic body devices may be used solely for therapeutic purposes to improve the overall functional capacity of the resident. Before using a device for mobility or transfer, assessment should include a review of the resident’s bed mobility and ability to transfer between positions/surfaces. SP - For sampled residents observed as physically restrained during the survey or whose clinical records show the use of physical restraints within 30 days of the survey; determine whether the facility used the restraint for convenience or discipline, or a therapeutic interventions for specific periods to attain and maintain the resident’s highest practicable well-being. determine if the facility follows a systematic process of evaluation and care planning prior to using restraints. determine if the interdisciplinary team addressed the risk of decline at the time restraint use was initiated and that the care plan reflected measures to minimize a decline. determine if the plan of care was consistently implemented And, that Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint And, Orthotic body devices may be used solely for therapeutic purposes to improve the overall functional capacity of the resident. And, Before using a device for mobility or transfer, assessment should include a review of the resident’s bed mobility and ability to transfer between positions/surfaces NEXT

SP - Through observation, interview and record review – the surveyor will investigate the following: What are the medical symptoms that led to the use of restraints? Are the symptoms cause by failure to meet the resident’s assessed needs, use rehabilitative/restorative care, provide meaningful activities, or manipulate the resident’s environment, including seating? Has the facility attempted to use alternatives? Does the facility use the least restrictive restraint for the least amount of time? Is this being monitored? Was informed choice sought? The surveyor investigative protocol has not been revised. NEXT

Let’s take a pause here for any questions or comments for this Resident Behavior & Facility Practice regulation. Please type in any question or comment regarding these highlighted revisions to the interpretative guidelines. They will be collected, reviewed and responded to at the conclusion of this presentation. If an answer to any question requires further inquiry, it will be sent via to all participants post webinar. NEXT

Accuracy of Assessment - F278
483.20(i) A registered nurse must sign and certify that the assessment is completed and each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. IG - Facilities may use electronic signatures on the MDS when permitted to do so by state and local law and when this is authorized by the long-term care facility’s policy. IG - Facilities must have written policies in place to ensure that they have proper security measures to protect use of an electronic signature by anyone other than to which the electronic signature belongs. IG - The policy must also ensure that access to a hard copy of clinical records is made available to surveyors and others who are authorized access to clinical records by law. IG - Facilities that are not capable of maintaining the MDS signatures electronically must adhere to the current requirements addressing the need for either a hand-written copy or a computer-generated form. IG - Backdating completion dates is not acceptable - not that recording the actual date of completion is not considered backdating. SP - Verify the appropriate certifications are in place, including the RN Coordinator’s certification of completion of an assessment or Correction Request and the individual assessors. F278 – Accuracy of Assessment - (A little heads up) Be prepared for targeted surveys in FY2015 that examines the resident assessment process and look behind the MDS report to ensure adequacy and accuracy. In mid-2014, CMS piloted a short-term focused survey to assess MDS 3.0 coding practices and its relationship to resident care in nursing homes in five states. Michigan was not one of the five states. CMS will expand these survey in 2015 to be conducted nationwide. The pilot completed in August 2014 found inaccurate staging and documentation of pressure ulcers, lack of knowledge regarding the classification of antipsychotic drugs and poor coding regarding the use of restraints. NEXT Interpretative guideline revisions here includes: Facilities may use electronic signatures on the MDS when permitted to do so by state and local law and when this is authorized by the long-term care facility’s policy NEXT Facilities must have written policies in place to ensure that they have proper security measures to protect use of an electronic signature by anyone other than to which the electronic signature belongs. NEXT The policy must also ensure that access to a hard copy of clinical records is made available to surveyors and others who are authorized access to clinical records by law. NEXT Facilities that are not capable of maintaining the MDS signatures electronically must adhere to the current requirements addressing the need for either a hand-written copy or a computer-generated form. NEXT Backdating completion dates is not acceptable - not that recording the actual date of completion is not considered backdating. NEXT

Services Provided Meet Professional Standards of Quality - F281
483.20(k)(3)The services provided or arranged by the facility must meet professional standards of quality… IG - “Professional standards of quality” means services that are provided according to accepted standards of clinical practice. SP - Does staff follow facility policies for assuring each resident has a sufficient supply of medications to meet the needs of residents and does the staff adhere to the facility’s system for reordering medications? F281 – Services provided meet professional standards of quality. Professional standards of quality means services that are provided according to accepted standards of clinical practice. NEXT CMS has added to the surveyor’s protocol. The surveyors will attempt to determine if your staff follow facility policies for assuring each resident has a sufficient supply of medications to meet the needs of residents and if your staff adhere to the facility’s system for reordering medications? NEXT

MDS Data Storage & Maintenance - F286
483.20(d) A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record. IG - Facilities may maintain MDS data electronically regardless of whether the entire clinical record is maintained electronically and regardless of whether the facility has an electronic signature in place. IG - This is in accordance with state and local law, and when this is authorized by the long-term care facility’s policy. F286 – MDS Data storage & maintenance. This regulation requires the facility to maintain all resident assessment completed with the previous 15 months in the resident’s active record. NEXT The added interpretative guideline indicates the facility is to have a written policy authorizing the maintenance of electronic MDS data regardless of whether the entire clinical record is maintained electronically and regardless of whether the facility has an electronic signature in place. NEXT

Let’s take a pause here for any questions or comments for these Resident Assessment regulations.
Please type in any question or comment regarding these highlighted revisions to the interpretative guidelines. They will be collected, reviewed and responded to at the conclusion of this presentation. If an answer to any question requires further inquiry, it will be sent via to all participants post webinar. NEXT

Medication Errors - F332 483.25(m)(1) The facility must ensure that it is free of medication error rates of 5 percent or greater IG -“Medication Error” the observed preparation or administration of medications or biologicals which is not in accordance with: The prescriber’s orders Manufacturer’s specifications (not recommendations) regarding the preparation and administration of the medication or biological IG - The error rate must be 5% or greater in order to cite F332 – (rounding up is not permitted) IG - A medication error rate of 5% or greater may indicate that the facility has systemic problems with it medication distribution system. IG - Any significant medication error included in the F332 (5% or greater) citation should also be cited at F333. F332 – The facility must ensure that is is free of medication error rates of 5% or greater. Multiple interpretative guidelines have been added here. NEXT These revisions provide more direction to the surveyor – for both the investigative process and at decision making time. Next F332 is to be cited when an observation of a medication or biological in not given as directed by the prescribers orders NEXT Or when it is not given according to manufacturers specifications. NEXT The survey team is reminded they are not to round up – the error rate must be 5% or greater in order to cite They have been informed basically to determine if the facility has a systemic problem with medication distribution when f332 is cited. NEXT And, that any significant medication error included in F332 should also be cited at F333. F332 has been on the top 10 frequently cited list since at least the 2nd quarter – CASPER reports as of June. In September, 18% of Michigan’s nursing homes have been cited with this tag. NEXT

Significant/Non-Significant Medication Errors - F333
483.25(m)(2) The facility must ensure that Residents are free of any significant medication errors. IG - Determining Significance - the relative significance of medication errors is a matter of professional judgment. Considerations include the Resident’s condition, the category of drug, and frequency of errors. IG - Significant medication errors are in the following circumstances: When observed during the medication administration – regardless of whether the facility error rate is 5% or greater. When identified during the course of a resident record review, including a revisit survey or a complaint investigation. F333 – Facility must ensure that resident’s are free of any significant medication errors. CMS provided clear instances for when significant med error could be cited – not to the facility’s benefit. NEXT Nurses or Pharmacist’s typically perform the medication observation task. The interpretive guidance revisions includes a statement of reality – that the significance of medication errors is a matter of professional judgment. And provides pertinent data such as the Resident’s condition, the category of drug and frequency of errors as considerations in whether the facility is in compliance with this regulation. NEXT CMS also documented two specific scenarios for which F333 could be cited. A significant medication error is citable when observed during the medication administration – regardless of whether the facility error rate is 5% or greater Or, when identified during the course of a resident record review – including a revisit survey or a complaint investigation. NEXT

Medication Errors due to Failure to Follow Manufacturers Specifications or
Accepted Professional Standards: The failure to “shake” a medication that is labeled “shake well” may lead to an under dose or over dose depending on the product and the elapsed time since the last “shake”. The crushing of tablets or capsules for which the manufacturer instructs to “do not crush” requires further investigation. Please note there are exceptions to this rule. Administering medications without adequate fluid when the manufacturer specifies that adequate fluids be take with the medication, i.e. bulk laxatives, NSAIDS, K+ supplements Medications Administered Via Enteral Feeding Tubes; the placement of the feeding tube should be confirmed in accordance with the facility’s policy (NG, J-tube, G-tube). If the placement of the tube is not checked, it is not a medication error, but should be reviewed under F322-Nasogastric tubes. *Failure to flush before and in between each medication administration is considered a single medication error and would be included in the facility’s medication error rate. The interpretative guideline revisions also includes specific procedural - accepted professional standards of practices, that if are not observed, could be citable. For instance, NEXT The failure to “shake” a medication that is labeled “shake well”. This may lead to an under dose or over dose depending on the product and the elapsed time since the last “shake”. NEXT The crushing of tablets or capsules for which the manufacturer instructs to “do not crush” . This requires further investigation as there are exceptions to this rule. NEXT Medications Administered Via Enteral Feeding Tubes; the placement of the feeding tube should be confirmed in accordance with the facility’s policy (NG, J-tube, G-tube). If the placement of the tube is not checked, it is not a medication error, but should be reviewed under F322-Nasogastric tubes. NEXT Please note - *Failure to flush before and in between each medication administration is considered a single medication error and would be included in the facility’s medication error rate. NEXT

Nutritional and Dietary Supplements - Nutritional Supplements are medical foods that are used to complement a resident’s dietary needs, i.e. - ensure, glucerna etc. Herbal and alternative products are considered to be dietary supplements. If a dietary supplement that is given to a resident between meals and has a vitamin(s) as one or more of its ingredients, it should be documented and evaluated as a dietary supplement, rather than a medication. For clinical purposes, it is important document a resident’s intake of such substance elsewhere in the clinical record and to monitor their potential effects, as they can interact with other medications. *Medication errors involving vitamins and/or minerals should be documented at F322 and counted towards the error rate calculation Medication errors involving vitamins and minerals would not be considered to a significant medication error unless the criteria at F333 were met. Medications Instilled into the Eye - eye drops should make full contact with the conjunctival sac, so that the medication is washed over the eye with the resident closes their eyelid. It must contact the eye for a sufficient period of time (3-5 minutes) before the next eye drop is instilled. Systemic effects of eye medications can be reduced by pressing the tear duct for one minute after eye drop administration or by gentle eye closing for approximately three minutes. CMS has directed surveyors to not consider nutritional supplements with or without vitamins as a medication. NEXT But, actual Medication errors involving vitamins and/or minerals should be documented at F332 and counted towards the error rate calculation Medication errors involving vitamins and minerals would not be considered to a significant medication error unless the criteria at F333 were met. NEXT Medications Instilled into the Eye - eye drops should make full contact with the conjunctival sac, so that the medication is washed over the eye with the resident closes their eyelid. It must contact the eye for a sufficient period of time (3-5 minutes) before the next eye drop is instilled. Systemic effects of eye medications can be reduced by pressing the tear duct for one minute after eye drop administration or by gentle eye closing for approximately three minutes. NEXT

Sublingual Medications - if the resident persists in swallowing a sublingual tablet despite efforts to train otherwise, the facility should endeavor to seek an alternative dosage form for this medication. Metered Dose Inhalers (MDI - ensuring that a device is administered correctly is vital to optimizing inhalation therapy which includes shaking the container well, positioning the inhaler in front of or in the resident’s mouth (may use a spacer or valved holding chamber). *If more than one puff is required (whether the same medication or a different medication) follow the manufacturer’s product information for administration instructions including the acceptable wait time between inhalations. IG - Medication Errors; Timing, Prescriber’s Orders, Omitted Dose (most frequent type of error) SP - Medication Administration Observation Methodology Do not rely on a paper review to determine medication errors - detection of blank spaces on a MAR does not constitute the detection of actual medication error. Surveyor may ask the person administering medication to describe their system for administering medications. Some times people may share medication carts. Those people should be interviewed about an omitted dose. If the facility is not aware that there is a potential for an interaction between two medications given at same time via an enteral tube and is not monitoring for unwanted side effects, surveyor is directed to consider administration of a med. error failure. Multiple tablets or capsules required to deliver a dose of medication count as one observation. Observe infection prevention practices by staff administering medication, including the procedures used for insulin pens and single dose vial use (F441 may be a concern) Additional accepted standards of practices that have been included the interpretive guideline revisions are NEXT Sublingual Medications - if the resident persists in swallowing a sublingual tablet despite efforts to train otherwise, the facility should endeavor to seek an alternative dosage form for this medication. NEXT Metered Dose Inhalers (MDI - ensuring that a device is administered correctly is vital to optimizing inhalation therapy which includes shaking the container well, positioning the inhaler in front of or in the resident’s mouth (may use a spacer or valved holding chamber). *If more than one puff is required (whether the same medication or a different medication) follow the manufacturer’s product information for administration instructions including the acceptable wait time between inhalations NEXT Revisions to the Surveyor Protocol for the medication administration observation task. NEXT Do not rely on a paper review to determine medication errors - detection of blank spaces on a MAR does not constitute the detection of actual medication error. NEXT Surveyor may ask the person administering medication to describe their system for administering medications. Some times people may share medication carts. Those people should be interviewed about an omitted dose. NEXT If the facility is not aware that there is a potential for an interaction between two medications given at same time via an enteral tube and is not monitoring for unwanted side effects, surveyor is directed to consider administration of a med. error failure NEXT Multiple tablets or capsules required to deliver a dose of medication count as one observation. NEXT Observe infection prevention practices by staff administering medication, including the procedures used for insulin pens and single dose vial use (F441 may be a concern) NEXT

Let’s take a pause here for any questions or comments for these Quality of Care regulations.

Sanitary Conditions - F371
483.35(i)(1)(2) The facility must procure food from sources approved or considered satisfactory by Federal, State or local authorities and store, prepare, distribute and serve food under sanitary conditions. The revised guidance’s for this tag will be addressed within the power points on top cited regulations. NEXT

Frequency of Physician visits - F387 & F388
(1)The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter; (2) a physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. (3) except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally. (4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialists F387 & F388 has to do the with frequency of physician visits. NEXT Revisions to the interpretative guidelines provides clearer expectation for the first physician visit in a SNF (including the initial comprehensive visit) must be conducted within the first 30 days and then at 30 day intervals up until 90 days after the admission date. NEXT After the first 90 days, visits must be conducted at least once every 60 days thereafter. NEXT IG - The timing of physician visits is based on the admission date of the resident. In a SNF, the first physician visit (this includes the initial comprehensive visit) must be conducted within the first 30 days and then at 30 day intervals up until 90 days after the admission date. After the first 90 days, visits must be conducted at least once every 60 days thereafter.

IG - Permitting up to 10 days slippage of a due date will not affect the next due date. Although the physician may not delegate the responsibility for conducting the initial visit in a SNF, NPP’s (non-physician practitioner i.e. - nurse practitioner, clinical nurse specialist, or physician assistant) may perform other medically necessary visits prior to and after the physician’s initial visit as allowed by State law. IG - After the initial physician visits in SNF’s, a qualified NP, CNS, or PA may make every other required visit. These alternate visits as well as medically necessary visits, may be performed and signed by the NPP. (Physician co-signatures is not required) IG - In a NF, the physician visit requirement may be satisfied in accordance with State law by NP, CNS, or PA who is not an employee of the facility but who is working in collaboration with a physician and who is licensed by the State and performing within the states’ scope of practice. (Michigan Compiled Law ) IG - In a facility where beds are dually-certified under Medicare and Medicaid, the facility must determine how the particular resident is being paid in order to identify whether physician delegation of tasks is applicable and if a NPP may perform the tasks. For a resident receiving Part A Medicare benefits for the nursing home stay in a Medicare certified bed, the NPP must follow the requirements for physician services in a SNF. This includes, at the option of a physician, required physician visits alternated between personal visits by the physician and visits by a NPP afar the physician makes the initial first visit. For a resident receiving Medicaid benefits, the NPP must follow the requirements for physician services in a NF. The NPP may perform required physician task for Medicaid beneficiary in a Medicaid stay certified bed. The NPP may not be an employee of the facility and must be working in collaboration with a physician. Additional revisions to the interpretative guidelines regarding the frequency of physician visits include NEXT Although the physician may not delegate the responsibility for conducting the initial visit in a SNF, NPP’s (non-physician practitioner i.e. - nurse practitioner, clinical nurse specialist, or physician assistant) may perform other medically necessary visits prior to and after the physician’s initial visit as allowed by State law. NEXT After the initial physician visits in SNF’s, a qualified NP, CNS, or PA may make every other required visit. These alternate visits as well as medically necessary visits, may be performed and signed by the NPP. (Physician co-signatures is not required) NEXT In a NF, the physician visit requirement may be satisfied in accordance with State law by NP, CNS, or PA who is not an employee of the facility but who is working in collaboration with a physician and who is licensed by the State and performing within the states’ scope of practice NEXT In a facility where beds are dually-certified under Medicare and Medicaid, the facility must determine how the particular resident is being paid in order to identify whether physician delegation of tasks is applicable and if a NPP may perform the tasks. NEXT For a resident receiving Part A Medicare benefits for the nursing home stay in a Medicare certified bed, the NPP must follow the requirements for physician services in a SNF. This includes, at the option of a physician, required physician visits alternated between personal visits by the physician and visits by a NPP afar the physician makes the initial first visit. NEXT For a resident receiving Medicaid benefits, the NPP must follow the requirements for physician services in a NF. The NPP may perform required physician task for Medicaid beneficiary in a Medicaid stay certified bed. The NPP may not be an employee of the facility and must be working in collaboration with a physician. NEXT

Physician Delegation of Tasks Performed in SNF/NF - F390
(f)At the option of the State, any required physician task in a NF (including tasks which the regulations specify must be performed personally by the physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialists or physician assistant who is not an employee of the facility but who is working in collaboration with a physician. F390 has to do with physician delegation of tasks performed in a SNF/NF NEXT The performance of physician tasks in a NF includes NPP’s (as defined in F388) performing required visits at the option of the State. The resident must be seen every 30 days for the first 90 days and every 60 days thereafter. NEXT NPPs that have a direct relationship with a physician and who are not employed by the facility may perform the initial visit, any other required physician visit and other medically necessary visits, and verify and sign orders for a resident of a NF as the State allows. NEXT NPP – Nonphysician practitioner IG - The performance of physician tasks in a NF includes NPP’s (as defined in F388) performing required visits at the option of the State. The resident must be seen every 30 days for the first 90 days and every 60 days thereafter. IG - NPPs that have a direct relationship with a physician and who are not employed by the facility may perform the initial visit, any other required physician visit and other medically necessary visits, and verify and sign orders for a resident of a NF as the State allows.

IG - The physician of NPP must review the resident’s total program of care including medications and treatments, at each required visit, write, sign and date progress notes at each visit, and sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. IG - The timing of physician visits is based on the admission date of the resident. In a NF, the first physician visit must be conducted within the first 30 days, and then at 30 day intervals up until 90 days after the admission date. After the first 90 days, visits must be at least once every 60 days there after. Permitting up to 10 days slippage of a due date will not affect the next due date. Do not specifically look at the timetables for visits unless there is indication of inadequate medical care. IG - Facility policy that allows an NPP to make required visits, and that allows a 10 day slippage in the time of the visit, does not relieve the physician of the obligation to visit a resident when the resident’s medical condition makes that visit necessary. More revisions to the interpretative guidences regarding the delegation of physician tasks NEXT The physician of NPP must review the resident’s total program of care including medications and treatments, at each required visit, write, sign and date progress notes at each visit, and sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications NEXT The timing of physician visits is based on the admission date of the resident NEXT In a NF, the first physician visit must be conducted within the first 30 days, and then at 30 day intervals up until 90 days after the admission date. NEXT After the first 90 days, visits must be at least once every 60 days there after. NEXT Permitting up to 10 days slippage of a due date will not affect the next due date. NEXT Do not specifically look at the timetables for visits unless there is indication of inadequate medical care. NEXT Facility policy that allows an NPP to make required visits, and that allows a 10 day slippage in the time of the visit, does not relieve the physician of the obligation to visit a resident when the resident’s medical condition makes that visit necessary. NEXT

Here is are two charts – lists the authority for NPP in SNF’s NEXT
Authority for NPP to Perform Visits and Sign Orders when Permitted by the State Initial Comprehensive Visit/Orders Other Required Visits Other Medically Necessary Visits and Orders SNF’s PA, NP & CNS employed by the facility May not perform/May not sign May perform alternate visits (except radiology and other diagnostic services) PA, NP & CNS not a facility employee Here is are two charts – lists the authority for NPP in SNF’s NEXT

Authority for NPP to Perform Visits and Sign Orders when Permitted by the State
Initial Comprehensive Visit/Orders Other Required Visits Other Medically Necessary Visits and Orders NF’s PA, NP & CNS employed by the facility May not perform/May not sign May not perform May perform and sign PA, NP & CNS not a facility employee May perform/May sign May perform And in NF’s NEXT

Let’s take a pause here for any questions or comments for these Physician Services regulations.

To ensure their resident has a sufficient supply of medication NEXT
Pharmacy Services - F425 The facility must provide routine and emergency drugs and biologicals to its residents…provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet he the needs of the resident. IG - Procedures should identify how staff - who are responsible for medication administration: ensure each resident has a sufficient supply the system is expected to include a process for timely ordering and reordering of medication monitor the delivery of medications when they are ordered determine the appropriate action (e.g. contact the prescriber or pharmacist) when a resident’s medication is not available for administration IG - Foreign Acquired Medication - The Federal Food, Drug, and Cosmetic Act (FFDCA) strictly limits the types of drugs that my be imported into the U.S. F425 is the pharmacy tag which includes having procedures to assure the accurate acquiring, receiving, dispensing and administering of drugs. Revisions to the interpretive guidelines includes having a procedure which directs staff (who are responsible for the administration of medications) NEXT To ensure their resident has a sufficient supply of medication NEXT The procedure is to identify who a process for timely ordering and reordering of medications NEXT What the process is for monitoring the delivery of medications when they are ordered NEXT And, what the appropriate action is to take when a resident’s medication is not available for administration NEXT

SP - if a surveyor becomes aware that a resident has in their possession imported prescription medications, the surveyor should determine whether the facility is aware of the presence of the imported medications. if the facility is unaware of the imported medications, the surveyor should determine whether the medications are delivered to the resident via the facility staff or are self-administered. if the medication are administered by facility staff, the surveyor should cite F425 for unsafe practice. if the resident self-administers the medication without the facility’s knowledge, the surveyor should notify the facility of the unsafe practice. In addition, if it is determined that the facility is providing/obtaining foreign medications for use by the resident that are not FDA approved, the State Agency must make referrals to appropriate agencies such as the FDA, DEA, State Boards of Nursing, Pharmacy, Nursing Home Administrators. Surveyors are directed to attempt to determine whether the facility (nurse, CNA, physician etc) is aware - if / when a resident has in their possession imported prescription medications. NEXT If the resident has imported prescription medications in their possession, the surveyor should determine whether the medications are delivered to the resident via the facility staff or are self-administered. NEXT if the medication are administered by facility staff, the surveyor should cite F425 for unsafe practice NEXT if the resident self-administers the medication without the facility’s knowledge, the surveyor should notify the facility of the unsafe practice. NEXT In addition, if it is determined that the facility is providing/obtaining foreign medications for use by the resident that are not FDA approved, the State Agency must make referrals to appropriate agencies such as the FDA, DEA, State Boards of Nursing, Pharmacy, Nursing Home Administrators NEXT

IG - Procedures addressing administration of medications include:
defining the schedules for administrating medications to maximize the effectiveness of the medication i.e. - antibiotics, antihypertensives, insulins, pain medications, proton pump inhibitors, metered dose inhalers, and medications via enteral feeding tubes and NOT administering medications with known incompatibilities at the same time. defining pertinent techniques and precautions that meet current standards of practice for administering medications through alternate routes such as eyes ear, buccal, injection, intravenous, inhalation therapy or enteral tubes. For example, for enteral feeding tubes, define procedures including but not limited to: types of medications that may be safely administered via enteral feeding tube appropriate dosage forms techniques to monitor and verify that the feeding tube is in the right location before administering medications preparing drugs for enteral administration, administering drugs separately, diluting drugs as appropriate, and flushing the tube appropriately. In addition to pharmacy procedures, the interpretative guidelines include having procedures which address NEXT the schedules for administrating medications to maximize the effectiveness of the medication i.e. - antibiotics, antihypertensives, insulins, pain medications, proton pump inhibitors, metered dose inhalers, and medications via enteral feeding tubes and NOT administering medications with known incompatibilities at the same time. NEXT And procedures which define pertinent techniques and precautions that meet current standards of practice for administering medications through alternate routes For example, for enteral feeding tubes, define procedures including but not limited to: types of medications that may be safely administered via enteral feeding tube appropriate dosage forms techniques to monitor and verify that the feeding tube is in the right location before administering medications NEXT preparing drugs for enteral administration, administering drugs separately, diluting drugs as appropriate, and flushing the tube appropriately NEXT

IG - Disposition of Medication procedures include:
Timely identification and removal (from current medication supply) of medications for disposition Identification of storage method for medications awaiting final disposition Control and accountability of medications awaiting final disposition consistent with standards of practice Documentation of actual disposition of medications to include: resident name, medication name, strength, prescription number (as applicable), quantity, date of disposition and involved facility staff, consultant(s) or other applicable individuals and method of disposition (including controlled medications) should prevent diversion and/or accidental exposure and is consistent with applicable state and federal requirements and standards of practice. The disposition of medications procedure is to include the documentation of actual disposition of med with records the resident’s name, medication name, strength, prescription number, quantity, date of disposition and involved facility staff NEXT And, it is to describe your method of disposition (including controlled medications) to prevent diversion and/or accidental exposure and is consistent with applicable state and federal requirements and standards of practice. NEXT

F428 is the Drug Regimen review regulation. NEXT
Drug Regimen Review - F428 483.60(c) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist and the pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon. Medication Regimen Review The requirement for the MRR applies to each resident, including residents who: are receiving respite care are at the end of life or have elected the hospice benefit and are receiving respite care have an anticipated stay of less than 30 days or have experienced a change in condition Medication review upon transition of care may prevent errors due to drug-drug interactions, omission, duplication of therapy, or miscommunication during the transition from one team of care providers to another. SP - a determination of noncompliance with F428 does not require a finding of harm to the resident. Noncompliance may include… the pharmacist failed to conduct an MRR at least monthly (or more frequently, as indicated by the resident’s condition). F428 is the Drug Regimen review regulation. NEXT Surveyors are directed that this requirement applies to each resident and the interpretative guidelines specifies residents who are receiving respite care are at the end of life or have elected the hospice benefit and are receiving respite care have an anticipated stay of less than 30 days or have experienced a change in condition Medication review upon transition of care may prevent errors due to drug-drug interactions, omission, duplication of therapy, or miscommunication during the transition from one team of care providers to another NEXT

Drug Regimen Review - continued
Common Medication-Medication Interactions in Long Term Care Medication 1 Medication 2 Impact Warfarin NSAIDs such as ibuprofen, naproxen, COX-2 inhibitors Potential for serious gastrointestinal bleeding sulfonamides such as trimethoprim/sulfamethoxazole Increased effects of warfarin, with potential for bleeding macrolides such as clarithromycin, erythromycin Increase effects of warfare, with potential for bleeding fluoroquinolones such as ciprofloxacin, levofloxacin, ofloxacin phenytoin Increased effects of warfarin and/or phenytoin ACE inhibitors such as benazepril, captopril, enalapril, and lisinopril potassium supplements Elevated serum potassium levels spironolactone digoxin amiodaron digoxin toxicity verapamil theophylline fluroquinolones such as cirpofloxacin, levofloxacin,ofloxacin theophylline toxicity The table of common medication to medication interaction comes from the SOM. It is not new. NEXT

Control, Labeling & Storage of Drugs - F431
(b)(2)(3)(e)(2)The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. F431 is the regulation which requires the facility to provide separately locked, permanently affixed compartments for storage of Schedule II controlled drugs and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. NEXT Surveyor’s are directed to review for F224 - Misappropriation of Resident’s Property when a concern is identified regarding a controlled medication and the resulting investigation identifies diversion of a resident’s medication. NEXT And, if it is determined that a resident’s medications were diverted for staff use, the State Agency must make referrals to appropriate agencies such as local law enforcement, DEA, State Boards of Nursing, Pharmacy, and possibly Nursing Home Administrators NEXT SP - if during a survey, a concern is identified regarding a controlled medication and the resulting investigation identifies diversion of a resident’s medication, the surveyor must review for F224 - Misappropriation of Resident’s Property. SP - if it is determined that a resident’s medications were diverted for staff use, the State Agency must make referrals to appropriate agencies such as local law enforcement, DEA, State Boards of Nursing, Pharmacy, and possibly Nursing Home Administrators.

Let’s take a pause here for any questions or comments for these Pharmacy regulations.

Infection Control - F441 The facility must establish and maintain and Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The revised guidance’s for F441 – infection control will be addressed within the power points on top cited regulations NEXT

Federal, State, and Local Laws - F492
483.75(b) The facility must operate and provide services in compliance with all applicable Federal, State and Local laws, regulations and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The intent of this regulation is to ensure that a facility is in compliance with Federal, State and local laws, regulations and codes relating to health, safety and sanitation and with accepted professional standards and principles that apply to professionals providing services in facilities. “Accepted professional standards and principles” means the individual State professional licensure practice acts and scope of practice regulations and/or standards. may include commonly accepted health standards established by national organizations, boards, and councils An authority having jurisdiction may include fire chief, fire marshal, labor and/or health departments, building official, electoral inspector, professional licensure boards, or others having statutory authority. “Final adverse action” means an adverse action imposed by the authority having jurisdiction that is more than a corrective action plan or the impositions of a civil money penalty, such as a ban on admissions, suspension or loss of a facility or professional license etc. and is NOT under appeal or litigation by the facility or the professional providing services in the facility. Tag F492 – The intent of this regulation is to ensure that a facility is in compliance with Federal, State and local laws, regulations and codes relating to health, safety and sanitation and with accepted professional standards and principles that apply to professionals providing services in facilities. NEXT CMS has provided further definitions in the context of this regulation - “Accepted professional standards and principles” meas the individual State professional licensure practice acts and scope of practice regulations and/or standards and it may include commonly accepted health standards established by national organizations, boards, and councils NEXT An authority having jurisdiction may include fire chief, fire marshal, labor and/or health departments, building official, electoral inspector, professional licensure boards, or others having statutory authority. NEXT “Final adverse action” means an adverse action imposed by the authority having jurisdiction that is more than a corrective action plan or the impositions of a civil money penalty, such as a ban on admissions, suspension or loss of a facility or professional license etc. and is NOT under appeal or litigation by the facility or the professional providing services in the facility. NEXT

IG - The State is responsible for making decisions about whether there are violations of State laws and regulations. Licenses, permits and approvals of the facility must be available to the SA upon request. IG - Failure of the facility to meet a Federal, State of local law, regulation, code or accepted professional standards and principles that apply to professionals providing services in facilities may only be cited when the Federal, State or local authority having jurisdiction has both made a determination of non-compliance AND has taken a final adverse action. SP - Do not cite F492 as past non-compliance if at the time of the survey, the facility or professional within the facility is in compliance. SP - If during the survey, there is suspect of an observed non-compliance wit a law, regulation, code etc. which is under the purview of another Federal agency other than CMS, notify the RO. The RO may assist in contacting the appropriate Federal agency to refer the observation/concern to. The State is responsible for making decisions about whether there are violations of State laws and regulations. Licenses, permits and approvals of the facility must be available to the SA upon request. NEXT Revisions to the interpretive guidelines for this regulation clearly states F492 may only be cited when the Federal, State or local authority having jurisdiction has both made a determination of non-compliance AND has taken a final adverse action. NEXT Surveyor protocol includes not citing F492 as past non-compliance if at the time of the survey, the facility or professional within the facility is in compliance NEXT And, If during a survey, there is suspect of an observed non-compliance wit a law, regulation, code etc. which is under the purview of another Federal agency other than CMS, notify the RO. The RO may assist in contacting the appropriate Federal agency to refer the observation/concern to. NEXT

Clinical Records - F514 483.75(l) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized. IG - Electronic Health Records and Use of Electronic Signatures In cases in which facilities have created the option for an individual’s record to be maintained by computer, rather that hard copy, electronic signatures are acceptable whether or not the record is entirely electronic, and when permitted to do so by state and local low and when this is authorized b the facility’s policies. If a facility implements the use of electronic signatures, they must have policies in place and implemented that identify those who are authorized to sign electronically and describe the security safeguards to prevent unauthorized use of electronic signatures. Such security safeguards (policies) include, but are not limited to: built-in safeguards to minimize the possibility of fraud each staff responsible for an attestation has an individual identifier F514 tag - The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized. NEXT CMS has addressed Electronic Health Records and use of electronic signatures in the interpretive guidelines. NEXT In cases in which facilities have created the option for an individual’s record to be maintained by computer, rather that hard copy, electronic signatures are acceptable whether or not the record is entirely electronic, and when permitted to do so by state and local low and when this is authorized b the facility’s policies NEXT If a facility implements the use of electronic signatures, they must have policies in place and implemented that identify those who are authorized to sign electronically and describe the security safeguards to prevent unauthorized use of electronic signatures. Such security safeguards (policies) include, but are not limited to: built-in safeguards to minimize the possibility of fraud each staff responsible for an attestation has an individual identifier NEXT

Revisions to the interpretative guidelines include: NEXT
The date and time is recorded from the computer’s internal clock at the time of entry an entry is not to be changed after it has been recorded, and; the computer program controls what sections/areas any individual can access or enter data, based on the individual’s personal identifier (and therefore his/her level of professional qualifications). IG - As there are no regulatory requirements delineating the use of specific Electronic Health Records (EHR)system, a facility may utilize the EHR system that meets their specific needs. IG - The facility must grant access to any medical record, including EHRs when requested by the survey team. IG – If access to an EHR is requested by a surveyor, access the system, respond to any questions or assist the surveyor as needed in accessing electronic information in a timely fashion. Each surveyor will determine the EHR access method that best meets the need for that survey. IG – If the facility is unable to provide direct print capability to the survey team, the provider must make available a printout of any record or part of a record upon request in a timeframe that does not impede the survey process. Revisions to the interpretative guidelines include: NEXT As there are no regulatory requirements delineating the use of specific Electronic Health Records (EHR) system, a facility may utilize the EHR system that meets their specific needs. The facility must grant access to any medical record, including EHRs when requested by the survey team. NEXT If access to an EHR is requested by a surveyor, access the system, respond to any questions or assist the surveyor as needed in accessing electronic information in a timely fashion. Each surveyor will determine the EHR access method that best meets the need for that survey. NEXT If the facility is unable to provide direct print capability to the survey team, the provider must make available a printout of any record or part of a record upon request in a timeframe that does not impede the survey process. NEXT

Safeguard Clinical Records - F516
483.75(l)(3) The facility must safeguard clinical record information against loss, destruction, or unauthorized use IG - Electronic Health Records (EHR) All providers and suppliers that conduct standard transactions (electronic claims filing, etc.) are “covered entities” and, as such, they must comply with the HIPAA Privacy and Security Rules. The Department of Health and Human Services Office of Civil Rights has the primary responsibility for enforcing the HIPAA Privacy Rule. The Office of eHealth Standards and Services within CMS is responsible for enforcing the HIPAA Security rule. The surveyors’ responsibility is to assess compliance with the provider specific requirements for maintaining the content and confidentiality of the medical record. F516 tag requires the facility to safeguard clinical record information. NEXT The interpretative guideline revisions address the use of electronic health records All providers and suppliers that conduct standard transactions (electronic claims filing, etc.) are “covered entities” and, as such, they must comply with the HIPAA Privacy and Security Rules. The Department of Health and Human Services Office of Civil Rights has the primary responsibility for enforcing the HIPAA Privacy Rule. The Office of eHealth Standards and Services within CMS is responsible for enforcing the HIPAA Security rule. The surveyors’ responsibility is to assess compliance with the provider specific requirements for maintaining the content and confidentiality of the medical record. NEXT

IG - If access to an EHR is requested by a surveyor, the facility will: provide the surveyor with a tutorial on how to use its particular system and designate an individual who will, when requested by the surveyor, access the system, respond to any questions or assist the surveyor as needed in accessing electronic information in a timely fashion. the facility is unable to provide direct print capability to the survey team, the provider must make available a printout of any record or part of a record upon request in a timeframe that does not impede the survey process. impeding the survey process by unnecessarily delaying or restricting access to the medical records may lead to determinations of noncompliance and enforcement actions. the facility should ensure that data are backed up and secure, and access does not impede the survey process or the provision of care and services to the resident. If access to an EHR is requested by a surveyor, revisions to the interpretative guideline specifies that the facility will: Provide the surveyor with a tutorial on how to use its particular system and Designate an individual who will, when requested by the surveyor, access the system, respond to any questions or assist the surveyor as needed in accessing electronic information in a timely fashion. If the facility is unable to provide direct print capability to the survey team, the provider must make available a printout of any record or part of a record upon request in a timeframe that does not impede the survey process. Impeding the survey process by unnecessarily delaying or restricting access to the medical records may lead to determinations of noncompliance and enforcement actions. The facility should ensure that data are backed up and secure, and access does not impede the survey process or the provision of care and services to the resident. NEXT

Let’s take a pause here for any questions or comments for these Administration regulations.

Guide to Tag Numbers F-150 Definitions Resident Behavior & Facility Practice F221 Physical restraints Resident Rights F222 Chemical restraints F151 Exercise of rights F223 Abuse/involuntary seclusion F152 Resident competency F224 Treatment of resident & their property F153 Access to records F225 Report/investigate allegations of abuse F154 Informed of health status or care F226 Develop/implement Abuse/neglect policies F155 Refusal of treatment F156 Medicaid services and changes Quality of Life F157 Notification of changes F240 Care and environment promotes quality of life F158 Protection of resident funds F241 Dignity and respect of individuality F159 Personal fund management F242 Self-determination/participation F160 Conveyance upon death F243 Participate in resident/family group F161 Assurance of financial security-surety bond F244 Listen/act on group grievance/recommendation F162 Limitation on charges to personal funds F245 Participate in social/religious act/community Resident Assessment F163 Right to chose a personal physician F246 Reasonable accommodation of needs/preferences F271 Admission physician orders for immediate care F164 Person privacy/confidentiality of records F247 Notification of rooms changes F272 Comprehensive assessments F165 Right to voice grievances without reprisal F248 Activities F273 Comprehensive assessment 14 days after admit F166 Right to prompt efforts to resolve grievances F249 Qualified activity professional F274 Comprehensive assessment after significant change F167 Right to survey results-readily accessible F250 Provision of medically related social services F275 Comprehensive assessment at least annually F168 Right to info from/contact advocate agencies F251 Qualification of social worker > 120 beds F169 Right to perform facility services or refuse F252 Safe/clean/comfortable/homelike environment F276 Comprehensive assessment at least quarterly F170 Right to privacy – send/receive unopened mail F253 Housekeeping and maintenance services F278 Assessment accuracy/coordination/RN certified F171 Access to stationary/postage/pens, etc. F254 Clean bed/bath linens in good condition F279 Develop comprehensive care plan F172 Right to/facility provision of visitor access F256 Adequate and comfortable lighting levels F280 Right to participate in planning care F173 Allow ombudsman to examine resident records F257 Comfortable and safe temperature levels F281 Services provided meet professional standards F174 Right to telephone access with privacy F258 Maintenance of comfortable sound levels F282 Services by qualified persons/per care plan F175 Right of married couples to share a room F283 Anticipate discharge: recap stay/final status F176 Resident self-administer drugs if deemed safe Quality of Care F284 Anticipate discharge: post-discharge plan of care F177 Right to refuse certain transfers F309 Quality of Care F285 PASRR requirements for MI/MR F310 ADL abilities F286 Maintain 15 months of resident assessments Admission, Transfer & Discharge F311 Appropriate treatment & services F287 Encoding/transmitting resident assessments F201 Reasons for transfer/discharge of resident F312 Care for ADL dependent residents F202 Documentation for transfer/discharge of resident F313 Vision & hearing F203 Notice requirements before transfer/discharge Nursing Services F314 Pressure sores F204 Preparation for safe/orderly transfer/discharge F353 Sufficient 24 hour nursing staff per care plan F315 Urinary incontinence F205 Notice of bed hold policy F354 Registered nurse hours F206 Policy to permit readmission beyond bed hold F317 No reduction in ROM F355 SNF waiver for Licensed nurse F207 Equal practices regardless of payment source F318 Range of motion treatment & services F356 Posting nursing staff F208 Prohibiting certain admission policies F319 Mental & psychosocial functioning F320 Adjustment difficulty F322 NG treatment/services to prevent aspiration **** F323 Free of accident hazards/adequate supervision Substandard Quality of Care (SQOC) = F325 Nutrition one or more deficiencies F327 Hydration with S/S levels of F, H, I, J, K or L F328 Treatment/care for special needs in a red lettered group F332 Medication errors 5% or greater F333 Significant medication error F334 Influenza & pneumococcal immunizations This is a two page chart which lists all the Ftags and provides a brief identity to the tag. The reddened tags are subject to Substandard Quality of Care (SQOC) determination when there are one or more deficiencies with S/S levels of F, H, I, J, K or L. NEXT

Guide to Tag Numbers Dietary Services F461 Bedrooms – window/floor at grade level, bed/furniture/closet F360 Dietary services F462 Bedrooms equipped/near lavatory/toilet F361 Qualified Dietician – Director of food services F463 Resident call system F362 Sufficient dietary support personnel F464 Dining & resident activities F363 Menus and nutritional adequacy F465 Safe/functional/sanitary/comfortable environment F364 Nutritive value/appear, palatable/preferred temp F466 Procedures to ensure water availability F365 Food in form to meet individual needs F467 Adequate outside ventilation F366 Substitutes of similar nutritive value F468 Corridors have firmly secured handrails F367 Therapeutic diet prescribed by physician F469 Maintains effective pest control program F368 Frequency of meals/snacks at bedtime F369 Assistive devices Administration F371 Sanitary Conditions F490 Effective administration/resident well-being F372 Dispose garbage & refuse properly F491 Facility licensed under state and local laws F373 Paid feeding assistants F492 Comply with federal/state/local laws/professional standards F493 Governing body Physician Services F494 Nurse aide work > 4 mo – training/competency F385 Resident’s care supervised by a physician F495 Nurse aide work < 4 mo – training/competency F386 Physician visits – review care/notes/orders F496 Nurse aide registry verification, retraining F387 Frequency & timeliness of physician visits F497 Nurse aide performance review – 12 hr/yr inservice F388 Personal visits by physician, alternate PA/NP F498 Nurse aide demonstrate competency/care needs F389 Physician for emergency care, available 24 hours F499 Employ qualified FT/PT/Consult professions F390 Physician delegation of tasks in SNFs & NFs F500 Outside professional resources – arrange/agreement F501 Responsibilities of Medical Director Specialized Rehabilitation Services F502 Provide/obtain laboratory services – quality/timely F406 Provision of services F503 Laboratory requirements F407 Qualifications F504 Physician ordered laboratory services F505 Promptly notify physician of findings Dental F506 Transportation to/from F411 Routine/emergency dental services in SNFs F507 Lab results in resident medical record F412 Routine/emergency dental services in NFs F508 Radiology & diagnostic services meets resident needs F509 Radiology & diagnostic requirements Pharmacy F510 MD ordered radiology services F425 Pharmacy services/procedures F511 Transportation to/from F428 Drug regimen review F513 Xray reports in resident medical record F431 Control, labeling, & storage of drugs F514 Complete/accurate/assessable resident medical records F515 Retention of resident clinical records Infection Control F516 Safeguard of resident clinical records F441 Infection Control, prevent spread, linen F517 Written plans to meet emergency/disasters F518 Train all staff-emergencies/disasters Physical Environment F519 Transfer agreement with hospital F454 Life Safety from fire F520 QAPI F455 Emergency electrical power system F522 Disclosure of Ownership F456 Essential equipment, safe operating condition F457 Bedrooms accommodate no more than 4 residents F458 Bedrooms measure at least 80 square foot/resident F459 Bedrooms have direct access to exit corridor F460 Bedrooms assure full visual privacy So, let’s move now to look at the top three most frequently cited federal regulations in Michigan. NEXT

Revisions to the Interpretive Guidelines and where appropriate, Investigative Protocols for 20 F-Tags will be provided during this presentation. Many of.

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Revisions to the Interpretive Guidelines and where appropriate, Investigative Protocols for 20 F-Tags will be provided during this presentation. Many of.

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Presentation on theme: "Revisions to the Interpretive Guidelines and where appropriate, Investigative Protocols for 20 F-Tags will be provided during this presentation. Many of."— Presentation transcript:

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