Describe Physicians in LTCHs
*MD's or DO's responsible for overall medical supervision
*Physical presence is limited
*Frequency of visits range from once a month to once a year
*Communication is mainly done through nursing staff via phone
In a _____ or _____ frequency of physician involvement is greater and can range to several visits a week to once a month being the longest
SNF or Subacute unit of long term care
What is the minimum visit requirement for physicians to visit an SNF?
Once every 30 days for the first 90 days and then once every 60 days then after.
Describe: Physician extenders in LTCHs
NP, PA, clinical nurse specialist that work with physician to assist in caring for their pts. who resides in the facility
Describe: RNS in LTC
*Primary coordinator of daily care
*A DON (Director of nursing) is typically required to be a licensed, registered nurse
Describe: LPNs
*most predominant caregiver among the other pros in the long term care setting
-responsibility ranges from admin. of meds, tube feeding, serving in a supervisory capacity
Describe: Nursing assistance
*comprise the bulk of nursing depts. in long term care
*non-licensed with basic training
*under supervision of a licensed nurse
Describe: restorative aides
*strictly provide restorative therapy
*given responsibility for providing maintenance service to resident after skilled rehab has been discontinued
Describe Certified Medication Tech (CMT)
*Distinct to LTC
*Vary state to state
*generally require a nursing assistant training with additional course in medicine admin.
Does social services always have a credentialed social worker such as BSW or MSW?
depends on size of the facility
What does federal regs. require of LTC facilities with more than 120 beds?
employ a FT social worker or person who meets qualification under federal regs.
how does the fed. regs describe their qualification for a social worker in LTC
An individual with a bachelors degree in social work or in human services such as psychology, rehab, etc…. with 1 year of supervised social work experience
Describe activities/therapeutic recreation
*provides stimulation activities
*not usually directed by a licensed individual
Is licensing of activity of pros. other than recreation therapist universal?
NO
What alternative options are fed. & state regs giving as qualification for an activity professional?
2 years direct experience in a pt. activities program in healthcare or completion of a training program approved by a state agency.
Describe: Independent contractors
most ancillary services and pro. services are provided by outside sources such as labs, pharm, rehab, etc...
Social service staff take on the responsibility that affect ____ and ___ of the resident.
care and well-being
Describe: lab and radiology
*necessary to further eval. or treat conditions
*performed in accordance with physical orders
describe: rehab services
typically provided through independent contractors due to volume of rehab cases and they don’t warrant FT employees in It
describe: respiratory therapist
more prevalent in facilities with longterm ventilator or facilities with a high number of residents requiring daily suctioning and treatments
describe: registered dietitians
*fed regs require the services of a registered dietitian on either a FT or consulting basis
*may be a FIT employee in a facility with more& than 150 beds especially in a population that requires skilled care and complex diet needs.
What if the facility doesn't employ a FT registered dietitian?
the day to day management is done by the food service manager and the dietitian acts as a consultant
Are pharmaceutical service often found in LTC
No typically use a supplier from remote location
Does fed. regs require the services of a pharmacist in LTC
yes (FT, PT, or consultant)
Is LTC one of the most regulated industries in the US
Yes
What type of regs are seen in LTC
*fed regs in LTC
*Medicaid and Medicare
*State laws
Describe: standard surveys in LTC
must be conveyed once every 15 months and unannounced
2 general survey outcomes in LTC
1. substantial compliance brig
comes in LTC
2. substandard quality of care
describe: Substantial compliance
any deficiencies found were minimum
Describe: Substandard quality of care
more than one deficiency found that could cause patients harm
are survey results available publicly?
Yes
Are LTC facilities subject to complaint investigations?
Yes
The Health Care Financing Administration is now
CMS
When did CMS implement remedies for substantial noncompliance and substandard quality of care?
1995
Describe remedies given by CMS for substantial noncompliance
*civil money penalties of up to $10000 per day
*individual state may also enforce fines and civil money penalties
Federal enforcement regs may also punish a facility for substantial noncompliance in what ways?
*mandated temp. management of a facility
*termination from Medicaid/Medicare
*denial of Medicaid/Medicare payments for new admits
(in addition to civil money penalties)
If a facility does not participate in Medicaid or Medicare do fed. regs apply?
No only subject to state regs.
describe long term care
Care of the frail, institutionalized elderly, or those who are permanent residents of a nursing facility
Describe: Freestanding nursing facilities
licensed by the state as a nursing facility/home nursing facilities
where the majority of pts are regarded as perm. residents for long term nursing care
freestanding nursing facility aka
*Nursing facility (NF)
*Nursing home
*long term care facility
describe: freestanding skilled nursing facility
licensed by the state as a skilled nursing facility and certified wither wholly or in part as a medicare part a skilled nursing facility provider
a NF is qualified for reimbursement under
Medicaid
SNF’s are reimbursed under
Medicare
how are LTCHs and SNFs different
*different levels of care
*different licensing
*different payment systems
LTCH facilities are licensed as ____
Hospital
Do LTCHs have their own PPS under Medicare?
Yes
In a long term setting a patient is often referred to as a ____
Resident
Perm. residents receiving nonskilled care
*distinguished by their need for general oversight and supervision in performing ADLs *needs can be met without direct care for 24 hrs.
*LPN/RN supervises general care under of physician
Perm residents in a non skilled care environment may require a higher level of care than _____
those in residential, assisted living environment either due to cognitive impairment or physical inactivity
an example of a perm. resident in a non-skilled environment
cant negotiate their way to safety due to an incapacity
SCUs
Special care units
Describe: SCUs
*often found as a distinct part within a long term care facility
*staff members usually receive special training for a special disease
Perm residents in a skilled care environment
*receive services from 1 or more licensed pros on a frequent and often daily basis
*pts may have plateaued in their rehab progression
*d/c potential is poor
care given to perm residents in skilled care environments
*may include tube feeding, ventilator care, performing adls
*heavy care is a term often associated with this environment
Why is the term heavy care used in environments with skilled care
b/c of the intensity of their dependence on the staff for mobility, toileting, bathing, eating, and performing ADLs
Short term patients
*stay less than 100 days
*care in these units are skilled care for tx of a specific condition
placement is often temp. be goal of tx is rehab to de the pt or move to a lower level of care
respite care
*short stay to provide relief or respite to the primary caregivers of the frail who cant live in an independent environment and dont require the intensity of services and supervision required of a traditional LTC facility
The time period for respite care may range
from overnight to several wks depending on care may range
caregivers needs
QIS
QIS - Quality Indicator Survey
-Began in 2009, In affect in IN 2011
-annual survey process transformed by CMS
-Goals: improve consistency and accuracy of care
-make the process more systematic
-there is no window for when inspection can be
-digital/computerized. used on laptops (this helps determine whether issue needs inspection or let go)
-designed to take 4-5 days with 4 surveyors (can be extended with reason)
-10% of surveys have to be during off hours or holidays
-surveyors get info from MDS prior to this QIS
-huge interview portion
-entrance conference
-focus on resident, family, and staff interviews
Two Survey Processes
1. Traditional survey process - complaints only
2. Quality Indicator Survey (QIS)
QIS Survey Forms
CMS.gov for QIS survey forms
-similar to an open book test
Quality Indicators
-data derived from MDS
-will be used to guide surveyors to look at potential problematic care areas for further investigation
QIS threshold for care areas
certain # of occurrences could be normal, if a facility's numbers are higher it will likely prompt surveyors to look closely at care area and or trigger Stage II investigation
QIS relies on MDS info
-accurate info very important
-allows a larger sample of resident info to surveyors prior to entering facility
-before entering, download last 6 months of MDS data
Offsite Preparation: Surveyors to-do list
-downloads MDS
-looks at CASPER report (QI / QM info from MDSs) (certification and survey, provider enhanced reporting)
-analyze information about the facility and identify concerns to look at
-identify residents in initial sample
-info regarding any waivers or variances
EXIT Conference
*general objective is to inform entity of survey team's observations & preliminary findings
(-will not have exit daily -When exit: completion of survey, 2567 will be completed by program)
A secondary benefit of an exit conference is
* serves to ensure the accuracy of the information (used by an internal auditor)
Scope and Severity
A system of rating the seriousness of deficiencies: citations get assigned a letter
(A-L: severity levels 1-4)
J, K, L = Immediate Jeopardy
Online Reporting System
-TC submits survey online
-facilities access 2567 and submit POC online
-POC must be approved on-line
- public able to access
- facilities must have surveys available for public to view
Post Survey Revisit (Follow-up)
-still occurs
-no stage I activities, jump straight to stage Il issues found
-use CEPs to investigate and determine compliance
(-have you done what you were supposed to do and are you back in compliance)
Managing the QIS
-quality improvement is key
-facilities have tools, CEPs, and know what questions will be asked during interviews
-must prepare before surveyors arrive
-education staff on different survey process is very important
-at this point, any complaint survey is conducted as a traditional survey
-software is not yet developed for QIS complaint survey
If a resident requests to self-administer drugs, it is the
-responsibility of IDT to determine safety (of resident to self-administer drugs before resident may exercise that right)
-team must also determine who responsible (the resident or the nursing staff) for storage / documentation as well as location of drug administration (e.g., resident's room, nurses' station, or
activities room)
-appropriate notation determinations placed in resident's care plan
-is subject to periodic re-evaluation based on change in the resident's status
ABUSE
7 components of Prevention
(Use/follow Abuse CEP Protocol to complete)
-Screening (of potential hirees /employees)
-Training (both for new employees & ongoing training for ALL)
-Prevention P&PS
-I.D. possible & actual incidents/allegations that require/need investigation
-Investigation
-Protection (of residents during investigations)
- Reporting (incidents, investigations, & facility response to investigation)
What is the CaSPER report?
FAs have the MDS 3.0 Facility Level Quality Measure Report, aka the CASPER report, updated regularly based on submitted MDS's
Principals of Immediate Jeopardy
1. Only ONE INDIVIDUAL needs to be at risk
2. SERIO US HARM, INJURY, IMPAIRMENT, OR DEATH does NOT HAVE TO OCCUR BEFORE CONSIDERING immediate jeopardy. Requires HIGH potential for those outcomes.
3. Individuals must not be subjected to abuse by ANYONE...staff, family, visitors, volunteers
4. Serious harm can result from both abuse and neglect
5. Psychological harm is as serious as physical harm
6. When a cognitively impaired individual harmed another individual receiving care from the entity due to the entity's failure to provide care and services to avoid physical harm, mental anguish, or mental illness, this should be considered neglect.
7. any time a team cites abuse or neglect, consider IJ
- Administering the State Children's Health Insurance Program (SCHIP) with Health Resources & Services Administration
- Helping to eliminate discrimination based on health status for people buying health insurance
CLIA Laboratories approved for distinct specialties and subspecialties:
-American Association of Blood Banks
-American Osteopathy Association
-American Society of Histocompatibility & Immunogenetics
-The Joint Commission
-College of American Pathologists
-Commission on Office Laboratory Accreditation
(Each accrediting organization that has received deeming authority (under CLIA) is approved for specific laboratory specialties/subspecialties)
Which Congressional Act established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of resident test results?
What was the purpose of such legislation?
CLIA- The Clinical Laboratory Improvement Amendments of 1988 (regardless where test performed)
the 1864 Agreement with States that are TRUE:
The Governors of each state designate SAs
lifetime of agreements is unlimited
SAs must keep necessary/appropriate records to be furnished
Federal Government provides funds for costs of performing functions authorized by the agreements
Exemption of Laboratories Licensed by States
CLIA will exempt laboratories in States that have been determined to have laws and regulations in effect that are equal to or more stringent than CLIA requirements.
Exempt laboratories must hold a valid State license within the exempt State.
How are Federal regulations developed?
-CMS analysts & lawyers review the law & conference report
-then CMS drafts a proposed rule
-public may comment during comment period (usually 60 days)
-review all public comments received (Any suggested changes that will improve quality of the regulations are incorporated)
* The final rule is published in Federal Register
What purpose is served by a review of the Conference Report?
It contains how the law was introduced and may contain detailed information that sheds light on the legislator's intent.
Why is the survey/certification process necessary?
because of the following reasons:
-The population that is age 65 or over is growing, creating higher demand for LTC
-To ensure NFs meet applicable Federal requirements
-To protect residents in SNFs from poor socs
-To protect residents in SNFs from abuse and neglect.
Which groups of people are covered by Title XVIII of the Social Security Act?
-People age 65 or older
-People under age 65 with certain disabilities
-People of all ages with End-Stage Renal Disease.
CMS's mission is to assure health care security for beneficiaries.& includes all of following activities
- Regulating all lab testing (except research) performed on humans in United States
-Health insurance coverage w/Depts of Labor & Treasury
-Administering State Children's Health Insurance Program (SCHIP) with Health Resources & Services Administration
-Helping to eliminate discrimination based on health status for people buying health insurance
Resident has the Right to:
-immediate access to current active clinical record
-upon oral/written request, to access all other records pertaining to self within 24 hours
-be fully informed of total health status
-refuse treatment
- be informed by facility at least 30 days in advance of any change in rates/services that rates cover
Treatment refusals
any refusals of treatment must be accompanied by counseling on medical sequences of such refusal, and then document this happening
Facility must furnish on admission a written description of legal rights including:
-description of the manner of protecting personal funds under this section
- statement that resident may file a complaint with director concerning abuse, neglect, misappropriation of property
-most recently known contact info for dept, office of secretary of DCSS, ombudsman, area on aging, local mental health center, adult protective services
Display of facility info
-prominently displayed
-provided to resident and applications for admission oral and written information
-how to apply for and use Medicare/Medicaid benefits
-how to receive refunds for previous payments covered by such benefits
Protection of Resident Funds
-resident has the right to manage his financial affairs
-facility may not require residents to deposit their personal funds with the facility
-only with written authorization of the resident the facility must hold and manage and account for personal funds of the resident deposited at the facility
Facility MUST:
* inform each resident of name, specialty, and way of contacting the physician responsible for his or her care
* provide reasonable access during normal business hours to the funds of the account
* return to the resident in no later than 15 days upon written request
* provide reasonable access during normal business hours
* the individual financial record must be provided to the resident or his legal rep upon request and through quarterly statements
Grievances- Resident has the right to the following:
-voice a grievance without discrimination
-prompt efforts by facility to resolve grievances
-recommend changes in policy / procedure and receive reasonable responses to their requests without fear of reprisal
-each facility should have policies for investigating and responding to complaints and grievances
Transfer & Discharge rights
HFs must permit each resident to remain in facility & not transfer or discharge resident from facility, unless reason
Reasons allowed for transfer / discharge
-its necessary for the resident's welfare and needs cannot be met at the facility
-appropriate because the resident's health has improved sufficiently
-safety of the resident is endangered
-resident has failed to pay after reasonable notice
-the facility ceases to operate
Nursing Services
-sufficient staff to provide nursing & related services to attain/maintain highest practicable physical, mental, & psychosocial