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Joint Provider Training (October 13, 2022)
MDH held a joint provider training event on October 13, 2022 to review changes to regulatory changes mentioned in QSO-22-19 NH (cms.gov) (PDF). The presentation covers Revisions to Surveyor Guidance for Phases 2 and 3, Arbitration Agreement Requirements, Investigating Complaints and Facility Reported Incidents; and the Psychosocial Severity Guide. The slides, resources, and a recording of the event will be available on this page until January 31st, 2022.
If you have any questions or need these materials made available in an alternative format, please email contact email@example.com.
The deck for the presentations has been combined into a single file: 2022-10-13 Joint Provider Training Presentation (PDF).
Questions and answers
Abuse and Neglect
F600 in the SOM identifies the following: “Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse. These steps should include evaluating whether the resident has the capacity to consent to sexual activity.
NOTE: For information related to determining consent, refer to "Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists" © American Bar Association Commission on Law and Aging – American Psychological Association (PDF). This resource includes a discussion on determining issues related to determining consent including:
- The legal standards and criteria for sexual consent vary across states (Lyden, 2007; Stavis et al., 1999).
- The most widely accepted criteria, which are consistent with those applied to consent to treatment, are:
- knowledge of relevant information, including risks and benefits;
- understanding or rational reasoning that reveals a decision that is consistent with the individual’s values (competence);
- voluntariness (a stated choice without coercion)
- (Grisso, 2003; Kennedy, 1999; Stavis, 1991; Stavis et al., 1999; Sundram et al., 1993).
NOTE: CMS is not requiring facilities to adopt a specific approach in determining a resident’s capacity to consent. However, the facility administration, nursing and medical director may wish to consider establishing an ethics committee, that includes legal consultation, in order to assist in the development and implementation of policy related to aspects of quality of life and/or care, advance directives, intimacy and relationships.”
F600 in the SOM includes the following: “Abuse,’ is defined at §483.5 as ‘the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are residents from abuse. necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.’
‘Sexual abuse’ is non-consensual sexual contact of any type with a resident, as defined at have the capacity to consent. 42 CFR §483.5. Sexual abuse includes, but is not limited to:
- Unwanted intimate touching of any kind especially of breasts or perineal area;
- All types of sexual assault or battery, such as rape, sodomy, and coerced nudity;
- Forced observation of masturbation and/or pornography; and
- Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident.
- Appears to want the contact to occur, but lacks the cognitive ability to consent; or
- Does not want the contact to occur.
Further F600 identifies the following: “Residents with Designated or Legally Appointed Representatives A resident may have a representative that has been appointed legally under State law through, for example, a power of attorney, guardian, limited guardian, or conservatorship. These legal appointments vary in the degree that they empower the appointed representative to make decisions on behalf of the resident. While a legal representative may have been empowered to make some decisions for a resident, it does not necessarily mean that the representative is empowered to make all decisions for the resident. The individual arrangements for legal representation will have to be reviewed to determine the scope of authority of the representative on behalf of the resident. A resident may also have designated an individual to speak on his/her behalf for decisions for care or other issues. However, it is necessary for the resident, his/her representative and the facility to have a clear understanding of the types and scope of decision-making authority the representative has been delegated.”
Reporting Incidents to the State Agency
F609 identifies what is reportable to the SA and includes:
- §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
- §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
F600 identifies the psychosocial severity guide may apply the reasonable person concept when consider scope and severity of the deficiency. See also the definition of abuse at F600.
You must report allegations of abuse, neglect and mistreatment as defined above at F609 if it meets the definition of abuse at F600. In addition, refer to the definitions identified in F609. Further, F609 identifies the following related to resident-to-resident abuse: “Resident-to-resident altercations that must be reported in accordance with the regulations include any willful action that results in physical injury, mental anguish, or pain, as defined at §483.5.” Therefore, if it can be identified the incident of potential abuse, neglect or maltreatment did not result in physical injury, mental anguish, or pain it would not be reportable.
If it is a true AMA, then you should report to MAARC. There is a lot of guidance in the updated SOM on AMA and will help differentiate between LOA’s, therapeutic leaves and AMA. Please see the following tags for additional information: F622, F623, F626, F689, F740.
F609 identifies the following should be made aware the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. F609 does not identify a provider needs to be made aware of the allegation.
No, there is not a process for this for skilled facilities.
Yes, in the meantime please add any extra information to the boxes that expand. You can also provide additional information in a “word” document and attach.
Physician Services/Resident Assessment
F635 identifies: "At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care. ‘Physician orders for immediate care’ are those written and/or verbal orders facility staff need to provide essential care to the resident, consistent with the resident’s mental and physical status upon admission to the facility. These orders should, at a minimum, include dietary, medications (if necessary) and routine care to maintain or improve the resident’s functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan."
F710 identifies the following: "A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident’s immediate care and needs." The guidance identifies the following: A physician’s personal approval of an admission recommendation must be in written form. The written recommendation for admission to the facility must be provided by a physician and cannot be provided by a NPP.
F712, identifies a NPP could provide admission orders to a NF but not a SNF and then a NPP may provide admission orders if a physician personally approved in writing a task. For example: recommendation for admission to the facility prior to the resident’s admission. For additional requirements on physician recommendation for admission and admission orders, see §483.30(a), F710.
This is not required as F712 identifies the following: “Must be seen, for purposes of the visits required by §483.30(c)(1), means that the physician or NPP must make actual face-to-face contact with the resident, and at the same physical location, not via a telehealth arrangement. There is no requirement for this type of contact at the time of admission, since the decision to admit an individual to a nursing facility (whether from a hospital or from the individual’s own residence) generally involves physician contact during the period immediately preceding the admission.”
Please refer to the MN Nurse Practice Act. Please consult the MDS Manual for requirements with the MDS assessments.
Environment / Call Lights
F919 includes the following: “§483.90(g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from– §483.90(g)(1) Each resident’s bedside; and §483.90(g)(2) Toilet and bathing facilities.”
In addition, new guidance includes the following: “The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident’s room. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor.”
Quality of Care
F700 speaks specifically to bed/ side rails; however, F689 includes the following “§483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible. The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:
- Identifying hazard(s) and risk(s);
- Evaluating and analyzing hazard(s) and risk(s);
- Implementing interventions to reduce hazard(s) and risk(s); and
- Monitoring for effectiveness and modifying interventions when necessary.”
In addition, “Regardless of the purpose for use, bed rails (also referred to as “side rails,” “bed side rails,” and “safety rails”) and other bed accessories (e.g. transfer bar, bed enclosures), while assisting with transfer and positioning, can increase resident safety risk.” You would want to complete a safety assessment and care plan the use of a grab bar, as it could still pose a safety risk to a resident; however, a grab bar does not fall into the same category as a bed/side rail at F700.
Yes, AA would assist the resident in their attempts to remain free from substance abuse. AA may be a life long need to support the resident.
We feel the listener heard incorrectly. F622 defines the following: “Facility-initiated transfer or discharge”: A transfer or discharge which the resident objects to or did not originate through a resident’s verbal or written request, and/or is not in alignment with the resident’s stated goals for care and preferences. ‘Resident-initiated transfer or discharge’: Means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment).
NOTE: Situations in which residents sign out of the facility or leave Against Medical Advice (AMA) should be thoroughly investigated to determine if the discharge is facility-or resident-initiated. If evidence reveals that a resident or resident representative was forced, pressured, or intimidated into leaving AMA, the discharge would be considered a facility-initiated discharge, requiring further investigation to determine compliance with the requirements at 483.15(c), including the requirement to provide a notice at F623.” See additional guidance on AMA discharges at F660 and guidance on Abuse, Neglect and Exploitation at F600. Please see F689 as there is a section on Substance Abuse Disorders.
There is no blanket answer to this question as each individual and situation is different. You would need to complete a thorough assessment and identify potential risks, identify interventions, and education on the risks may be warranted, please note this response may not include everything as each situation is unique. Please refer to F689 for guidance regarding substance use disorders.
If there are true staffing crisis situations this would need to be looked at on a case-by-case basis. As F626 includes the following information: “The facility policies must provide that residents who seek to return to the facility within the bed-hold period defined in the State plan are allowed to return to their previous room, if available. Additionally, residents who seek to return to the facility after the expiration of the bed-hold period or when state law does not provide for bed-holds are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident:
- Still requires the services provided by the facility; and
- Is eligible for Medicare skilled nursing facility or Medicaid nursing facility.
Not Permitting Residents to Return Not permitting a resident to return following hospitalization or therapeutic leave constitutes a facility-initiated discharge and requires a facility to meet the requirements as outlined in §483.15(c)(1)(ii).
A facility must not discharge a resident unless:
- 1. The discharge or transfer is necessary for the resident’s welfare and the facility cannot meet the resident’s needs.
- 2. The resident’s health has improved sufficiently so that the resident no longer needs the services of the facility.
- 3. The resident’s clinical or behavioral status endangers the safety of individuals in the facility.
- 4. The resident’s clinical or behavioral status endangers the health of individuals in the facility.
- 5. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) his or her stay at the facility which applies if: the resident does not submit the necessary paperwork for third party payment; or the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay.
- 6. The facility ceases to operate.
F622 identifies the following: “The documentation required by paragraph (c)(2)(i) of this section must be made by— (A)The resident’s physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.”
There are no exceptions provided for hospice patients residing in LTC facilities. F758 includes the following information “§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident’s medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.”
Facilities are required to submit PBJ information quarterly. Surveyors will be looking at the last 3 quarters, closest to the survey. In addition, PBJ, information can be used to assist with investigating complaints with staffing concerns.
F732 identifies the following: “§483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
- (i) Facility name.
- (ii) The current date.
- (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
- (A) Registered nurses.
- (B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
- (C) Certified nurse aides.
- (iv) Resident census.
§483.35(g)(2) Posting requirements.
- (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
- (ii) Data must be posted as follows:
- (A) Clear and readable format.
- (B) In a prominent place readily accessible to residents and visitors.
§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.
§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.” There were no changes to the requirements; however, new survey procedures and probes were added to F732 for surveyor investigation for compliance.