Frequently Asked Questions Related to Long Term Care ...

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Frequently Asked Questions Related to

Long Term Care Regulations, Survey Process, and

Training

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_______________________________________________________________________________________ Table of Contents

A. 483.10 Resident Rights.......................................................................................................... 1 B. 483.12 Freedom from Abuse, Neglect, and Exploitation ................................................... 1

Reporting of Abuse ............................................................................................................................................ 2 Restraints............................................................................................................................................................ 3

C. 483.15 Admission, Transfer, and Discharge ....................................................................... 4 D. 483.20 Resident Assessments................................................................................................ 4 E. 483.21 Comprehensive Resident Centered Care Plans...................................................... 4 F. 483.24 Quality of Life ........................................................................................................... 5 G. 483.25 Quality of Care .......................................................................................................... 5 H. 483.30 Physician Services ..................................................................................................... 7 I. 483.35 Nursing Services ........................................................................................................ 7 J. 483.40 Behavioral Health Services....................................................................................... 7 K. 483.45 Pharmacy Services .................................................................................................... 7

F756..................................................................................................................................................................... 7 F758..................................................................................................................................................................... 8

L. 483.50 Laboratory, Radiology, and Other Diagnostic Services ...................................... 10 M. 483.55 Dental Services ........................................................................................................ 10 N. 483.60 Food and Nutrition Services................................................................................... 10 O. 483.65 Specialized Rehabilitative Services........................................................................ 10 P. 483.70 Administration ........................................................................................................ 10

F838 Facility Assessment................................................................................................................................. 10

Q. 483.75 Quality Assurance and Performance Improvement (QAPI) .............................. 11 R. 483.80 Infection Control ..................................................................................................... 11 S. 483.85 Compliance and Ethics Program ........................................................................... 11 T. 483.90 Physical Environment ............................................................................................. 11 U. 483.95 Training Requirements........................................................................................... 11 V. LTC Survey Process Training ........................................................................................... 11 W. LTC survey Process ............................................................................................................ 11

Offsite Prep ...................................................................................................................................................... 11 Facility Entrance.............................................................................................................................................. 12 Facility Task ..................................................................................................................................................... 13 Initial Pool Process .......................................................................................................................................... 14 Sample Selection .............................................................................................................................................. 16 Investigation ..................................................................................................................................................... 17

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Ongoing and Other Survey Activities ............................................................................................................ 17 Potential Citations ........................................................................................................................................... 17

X. Complaints/Facility Reported Incidents ........................................................................... 17 Y. Software Questions ............................................................................................................. 18

Investigation ..................................................................................................................................................... 18 Sample Finalization ......................................................................................................................................... 19 Resident Manager............................................................................................................................................ 19 Interviews, Observations, and Record Review.............................................................................................. 19 Data Sharing .................................................................................................................................................... 20

Z. General Questions ............................................................................................................... 21

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Long Term Care Frequently Asked Questions ____________________________________________________________________________________

About this Document

This Frequently Asked Question (FAQ) document contains questions and answers about Long Term Care (LTC) regulations, the survey process, technical questions, and other related LTC areas. Newly added questions and answers are in red font and older questions and answers are in black font.

The Table of Contents (TOC) contains direct links to the various sections of this FAQ document. Also, there is a direct link back to the TOC at the bottom of each page starting on page 1. The direct link to the TOC is only accessible in the PDF format due to the link being in the footer of the document.

This FAQ document will be updated frequently and will be posted on the LTC Final Rule webpage.

A. 483.10 Resident Rights

If a resident is declining to be weighed or has asked that weights be discontinued can the MD write an order for weights to be discontinued? Will the facility incur a citation if we do not obtain weight and are aware that the resident is losing weight?

Per federal requirements at ?483.10(c)(6), the resident has "The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive." If a resident declines treatment, the resident may not be treated against his or her wishes. This would include a decline or discontinuation of weights. To meet the requirements at ?483.10(c)(6), the resident must be provided with the necessary information, i.e., risks related to the discontinuation of weights, to make an informed decision and the resident's medical record should contain appropriate documentation of this process.

Can we put signs at the head of a resident's bed if they have impaired vision or hearing so staff will know?

Per federal requirements at ?483.10(h) - "The resident has a right to personal privacy and confidentiality of his or her personal and medical records." Posting signs in residents' rooms or in areas visible to others that include clinical or personal information could be considered a violation of a resident's privacy. It is allowable to post signs with this type of information in more private locations not visible to the public. An exception can be made in an individual case if a resident or his or her representative requests the posting of information at the bedside (such as instructions to not take blood pressure in right arm). This does not prohibit the display of resident names on their doors nor does it prohibit display of resident memorabilia and/or biographical information in or outside their rooms with their consent or the consent of his or her representative. (This does not include isolation precaution information for public health protection, as long as the sign does not reveal the type of infection).

B. 483.12 Freedom from Abuse, Neglect, and Exploitation

The scenario: A registered nurse received a disciplinary action on her license related to resident abuse back in 2011. She did whatever was called for to keep her license, and in 2017 she is still licensed, free and clear of any restrictions.

The question: Is the registered nurse banned under the new regulations from working at a nursing home, or does the usage of "in effect" mean that she can because the disciplinary action was back in 2011 and is no longer active?

If the disciplinary action is no longer in effect, 483.12(a)(3) (iii) would not prohibit that nurse from working at the facility. Also, the facility would still need to make sure the registered nurse had not "been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a

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court of law" or "had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property" per the requirements of 483.12(a)(3(i) and (ii).

Reporting of Abuse When the regulation refers to reporting immediately but not later than 2 hours, is this reporting internally or externally? For example, does the agency have to report to the appropriate external agencies not later than 2 hours after the allegation is made?

483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

(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.

According to 42 CFR 483.12(c)(1), reports must be made to the facility's administrator and to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities and to other officials in accordance with State law.

Which cases of abuse and neglect need to be reported within 2 hours? Within 24 hours? The following must be reported immediately but not later than 2 hours:

1. Is there an allegation of abuse? If yes, then the facility must report immediately to the administrator, State Survey Agency, adult protective services and other officials in accordance with State law, but not later than 2 hours.

2. Is there an allegation that a resident has suffered serious bodily injury due to neglect, exploitation, mistreatment, or an injury of unknown source?

If yes, then the facility must report immediately to the administrator, State Survey Agency, adult protective services and other officials in accordance with State law, but not later than 2 hours.

Is there a reasonable suspicion of a crime involving a resident suffering serious bodily injury?

If yes, then covered individuals must report immediately to the State Survey Agency and local law enforcement, but not later than two hours.

The following must be reported not later than 24 hours:

1. Is there a reasonable suspicion of a crime not involving serious bodily injury? If yes, then covered individuals must report to the State Survey Agency and local law enforcement, not later than 24 hours.

2. Is there an allegation that doesn't involve serious bodily injury of neglect, misappropriation, exploitation, mistreatment, or injury of unknown source?

If yes, then the facility must report to the administrator, State Survey Agency, adult protective services and other officials in accordance with State law, not later than 24 hours.

How do you investigate Abuse if you have a complaint about abuse but a resident is not named in the complaint?

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The team should ensure they consider the abuse allegation during the initial pool process. If no residents in the initial pool had concerns with abuse, the TC needs to add a generic placeholder so the abuse care area can still be investigated. To do this the TC will:

? Go to the Resident Manager screen. ? Select the Add New Resident button. ? Enter "Anonymous" for the first name and "Resident" for the last name. ? Do not add a room number or admission date. You will then be able to add the Abuse care area for the resident (either during the sample meeting or on the investigation screen) and complete the investigation for Abuse.

If a nurse that currently works for a facility has a disciplinary action on her license are we expected to terminate their employment based on the new regulation?

In order to meet the Federal requirement at 42 CFR 483.12(a)(3)(iii), a facility must not employ, or otherwise engage individuals, who have a disciplinary action in effect against his/her professional license as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. If a facility employs a nurse where a probation is in effect on his/her nursing license, as a result of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, then the facility would not be in compliance with Federal requirements. We would encourage you to review the terms of the disciplinary action on the license status to determine this.

Restraints

Does CMS consider bed and chair alarms as restraints and/or abuse? Determination of the Use of Position Change Alarms as Restraints

Position change alarms are any physical or electronic device that monitors resident movement and alerts the staff when movement is detected. Types of position change alarms include chair and bed sensor pads, bedside alarmed mats, alarms clipped to a resident's clothing, seatbelt alarms, and infrared beam motion detectors. Position change alarms do not include alarms intended to monitor for unsafe wandering such as door or elevator alarms.

While position change alarms may be implemented to monitor a resident's movements, for some residents, the use of position change alarms that are audible to the resident(s) may have the unintended consequence of inhibiting freedom of movement. For example, a resident may be afraid to move to avoid setting off the alarm and creating noise that is a nuisance to the resident(s) and staff, or is embarrassing to the resident. For this resident, a position change alarm may have the potential effect of a physical restraint.

Examples of negative potential or actual outcomes which may result from the use of position change alarms as a physical restraint, include:

? Loss of dignity; ? Decreased mobility; ? Bowel and bladder incontinence; ? Sleep disturbances due to the sound of the alarm or because the resident is afraid to move in bed

thereby setting off the alarm;and ? Confusion, fear, agitation, anxiety, or irritation in response to the sound of the alarm as residents

may mistake the alarm as a warning or as something they need to get away from.

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F604 Physical Restraints Question: Are all bedrails considered to be physical restraints? Response: No.

A bedrail is considered to be a physical restraint if it meets all of the following criteria:

? Is attached or adjacent to the resident's body; ? Cannot be removed easily by the resident; and ? Restricts the resident's freedom of movement or normal access to his/her body.

To clarify the examples found in Appendix PP of the State Operations Manual found under Tag F604, a bed rail that prevents a resident from voluntarily getting out of bed and the resident cannot lower the bed rail in the same manner as staff would be considered to be a physical restraint.

The resident's physical condition and his/her cognitive status may be contributing factors in determining whether the resident has the ability to lower the bedrail.

C. 483.15 Admission, Transfer, and Discharge

For our long term residents, they may be sent out to the emergency room for some acute issue going on. We do not know if they are going to be admitted or come back from the ER that same day after some treatment. Our intent is to accept them back when their health status is stable. These transfers can happen day, evening or weekends. Do we do the transfer/discharge notification?

Regarding facility-initiated emergency transfers or discharges to an acute care facility our interpretive guidance says: "Emergency Transfers--When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable, according to 42 CFR 483.15(c)(4)(ii)(D).

Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis." This requirement also applies in situations where a Medicare beneficiary must be discharged because of admission to an acute care facility.

When we have unplanned discharges to the hospital, say for a UTI, or Altered Mental Status and the hospital treats the resident....then sends them back to our facility....do we have to notify the Ombudsman about this?...or do we only notify the Ombudsman when our facility is NOT ABLE to take the resident back from the hospital?

When a facility transfers or discharges a resident, notification of the ombudsman is required (in addition to the resident and resident representative). CMS has allowed an exception in the timing of providing notice for emergency transfers; notice may be provided as soon as practicable for emergency transfers. Additionally, facilities have the option of notifying the ombudsmen about emergency transfers using a monthly list, which must meet the requirements for content of the notice.

D. 483.20 Resident Assessments

E. 483.21 Comprehensive Resident Centered Care Plans

How long do we have to we have to give the family a written summary baseline careplan? I'm aware the baseline careplan must be made in 48 hours but unclear how much time a written summary of plan to give to family.

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At F655, the guidance states, "The facility must provide the resident and the representative, if applicable with a written summary of the baseline care plan by completion of the comprehensive care plan." This means the resident or their representative must be provided a written summary before the completion of the comprehensive care plan.

Additionally, if the comprehensive assessment identifies changes which would result in a different approach or goal on the comprehensive care plan, these changes must also be reflected in the summary. This is reflected in the following guidance, which goes on to say "Given that the baseline care plan is developed before the comprehensive assessment, it is possible that the goals and interventions may change. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes must be incorporated into an updated summary provided to the resident and his or her representative, if applicable."

`Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident's care plan must be reviewed after each assessment, as required by ?483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions."

Can you please confirm that a Care Plan review is required after each assessment for both OBRA and PPS assessments (with the exception of the discharge MDS)? And does this review require documentation that the review was completed.

The regulation at 483.21(b)(2)(iii) (F657) states: "?483.21(b)(2) A comprehensive care plan must be--

... (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments."

Draft interpretive guidance at F657 states, ""After each assessment" means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS) as required by ?483.20, except discharge assessments."

Additionally, you ask if the care plan review requires documentation. The expectation is that facilities can demonstrate that they have reviewed the care plan, even if no revisions are required. How facilities demonstrate this is up to each facility.

F. 483.24 Quality of Life

G. 483.25 Quality of Care

F700 Bedrails

Question: Does CMS expect bed rails to be removed between residents, given the language in the regulation which says "...prior to installing a side or bed rail." ? For example a resident was discharged and the bed is empty, are we expected to remove the rails? Response: CMS recognizes that there are many different types of beds, some with bed rails installed, or bed rails with the call button and lights incorporated into the rail, and others without bed rails, for which a separate rail could be installed. CMS regulations do not specify that bed rails must be removed when not in use.

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