[On-demand webinar] The RoPs are here! Are you ready for Phase 2?

This detailed webinar dives into the latest information on new Requirements of Participation (RoPs), which became effective Nov. 28, 2016. Since Phase 1 was introduced, a number of changes have occurred and Phase 2 is almost upon us! This training covers details of Phase 2, helping you understand where RoPs have been and where they’re going next, including a preview of Phase 3 and helpful tips/resources.

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FAQ/Questions & answers from the webinar

There were many more questions than could be answered during the live webinar, so we asked our speaker, Mary Madison, to follow up with more information. Below are all the questions asked during the webinar, along with her specific answers.

  • Where does the facility document the facility assessment?
    • There are no specific requirements for how the facility assessment is done. It needs to address the elements I identified on slides 36 and 37. We may get more details during the Sept. 7 CMS call.
  • Where would the PASRR information be placed in the care plan?
    • I would place that information within the care plan itself, in either the “I” format or a specific problem or need. Speak to the need, then include the facility’s approaches, etc.
  • Are we now saying the PASRR must be completed within 48 hours of admission to place information on the baseline care plan?
    • No, that is not the case. CMS says that the baseline care plan should contain PASRR recommendations, if applicable.
  • Are non-CAH swing bed units held to these same ROPs?
    • No, they have their own Appendix from the State Operations Manual with their Conditions of Participation.
  • For the baseline care plans to be implemented in the first 48 hours, are there examples of forms or documents created for implementation?
    • Briggs Healthcare plans to publish some guidance for this soon.
  • Can you clarify if the baseline care plan summary for the patient and family is due in 48 hours or by the time the comprehensive care plan is due.
    • It’s the latter. The baseline care plan must be developed and implemented by facility staff within 48 hours of the resident’s admission. The summary isn’t due in that same timeframe.
  • Should the DNR be included in the care plan?
    • Yes, DNR status should be included in the baseline care plan and communicated to all staff. It should continue to be included in the care plan that is compiled following the admission assessment; review and confirm that status at least quarterly as well as with changes in condition. This is good clinical practice.
  • Should dementia training include therapists? Also, is it only for lock down units?
    • Yes, dementia training does include therapists. Such training is not specific to a locked unit but the entire facility. Residents with dementia, depending on stage and symptoms, don’t always require a locked unit.
  • Has CMS published any training documents to support competencies in cognition and dementia?
    • F943 speaks to dementia training; also F947. Hand in Hand comes to mind right away. More info on this program can be found here and here. There are also YouTube videos (2) that explain this. Your best bet is to check with CMS or your state survey agency for more information on this training requirement.
  • How can a facility show the physician participated with IDT? Who is included under the physician description (for example, RNP included)?
    • In my past life as DON, I included a statement on the 60-day recertification of physician orders. I also made sure the physician at least looked at the resident’s care plan during a visit/examination. There is some guidance beneath F710 of Appendix PP (starts on page 384 of the Advance Copy of Appendix PP). You should also check to see if your state has specific requirements.
  • Is there already a form developed for facility risk assessment?
    • Briggs Healthcare is working on that as well. Remember that I mentioned the CMS provider event on Sept. 7, during which we should all receive additional information on this requirement.
  • On the activities director, is it “either/or” on the three qualifications? Or do they need to have all three bullet points?
    • Good eyes! The bullets are “ors”. Here’s what you’ll find on page 244/F680:
      • “The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who— (i) Is licensed or registered, if applicable, by the State in which practicing; and (ii) Is: (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or (B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or (C) Is a qualified occupational therapist or occupational therapy assistant; or (D) Has completed a training course approved by the State.”
    • That’s a lot of “ors”!
  • Regarding the baseline care plan, if therapy is involved, does the actual evaluation (PT, OT, or ST) have to be completed within 48 hours of admission? Or can the baseline care plan indicate that physician orders for therapy have been requested or received and specific disciplines will evaluate and treat as indicated? Challenge: Patient admits after-hours on Friday night (with or without therapy orders) and therapy evaluates on Monday. How are weekends managed for nursing services and the care plan?
    • No, the therapy evaluation does not need to be completed within 48 hours of admission. The resident’s baseline care plan will reflect an approximate date for the evaluation based on the physician’s admission orders. Admits starting on Thursday and going through the weekend will indeed be a challenge. Charge nurses will need to be trained to put together the baseline care plan for those late-week admissions, so provide a template or a form to guide them then teach them how and why this is done.
  • Regarding the baseline summary, when does the baseline need to be provided to the resident/resident family?
    • Reviewing the RoPs/Appendix PP, it appears that the baseline summary is not required to be given to the resident and representative until the first care conference. Having said that, as a clinician I would provide it as soon as possible after the baseline care plan is implemented. I see no reason to wait. Information and communication is critical. Providing the summary sooner rather than later speaks to your desire to involve the resident and family in his/her care. It starts off the admission on the right foot, in my opinion.
  • We have “interim” care plans that are within our admission observation. Does this qualify as a “baseline” care plan?
    • That depends. We’ve lived with interim care plans since OBRA ‘87. If your interim care plan has all the elements of what’s required for the baseline, you’re good. Does it include the resident goals? I haven’t seen one that did. Does it have room for the orders and services to be provided? Review slide 27 and if your interim care plan has those elements, you’re good to go!
  • What are the MCOs expected to do to facilitate or oversee the nursing facilities’ implementation of phase 2?
    • I have not seen anything that speaks to MCO oversight of Phase 2 implementation. I believe it’s safe to say that this responsibility lies solely within the scope of work for the state survey agency. I would encourage you to check with that agency to see if your MCO plays a part in any of the RoPs.
  • Regarding abuse, what is the difference between “acted deliberately” and “Intended to inflict injury or harm”?
    • CMS provides a “clue” to this on page 288 of Appendix PP. Here’s what’s found in the Interpretive Guidance area for resident-to-resident altercations:
      • “Willful” as defined at §483.5 and as used in the definition of “abuse,” “means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.” Even though a resident may have a cognitive impairment, he/she could still commit a willful act.”
    • To me that says that the intent may not have been to cause harm but the individual went ahead and did it anyway. Checking with a non-CMS dictionary doesn’t help as the definition of “deliberate” includes “intentionally.” I’m sticking with the definition found on page 288. As always, that question could be submitted to CMS for clarification.
  • Regarding discharges, are we to notify the ombudsman for the normal discharges to home when the resident no longer needs PAC/LTC?
    • I can speak for the state of Iowa. Our LTC Ombudsman has asked for a list of all discharges monthly. I encourage you to check with your state’s LTC Ombudsman to what they want from facilities in your state.

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