AHCA to Launch Major Grassroots Campaign Regarding CMS Proposed Rule on Requirements of Participation

First a look back at what the key areas of interest are in the Proposed Rule on Requirement of Participation courtesy of http://rhislop3.com/2015/07/15/cms-releases-proposed-new-snf-rule/

  • Transitions of Care: There are two elements of change – one in 483.15 (Transfer, Discharge) and the other in 483.30 (Physician Services). First, any transition from the SNF to any provider will require additional documentation to accompany the resident such as present illness, reason for transfer, medical history, etc. This isn’t major.  The major element is for any non-scheduled hospital transfer, the rule would require an in-person evaluation of the resident prior to the transfer by a physician, physician assistant, or advance practice nurse (qualified nurse specialist or NP).  This means the 2:00 AM transfer to the hospital for an urgent/emergent condition could not occur without one of the aforementioned individuals being “on-site” and certifying the need for the discharge.  I believe this element will either evaporate from the final rule or be substantially changed and better defined.  It is not only impractical but frankly, in rural areas, etc., completely improbable and virtually impossible (heavy emphasis on “virtual’ as that is the only way it could occur, via tele-medicine).
  • Care Planning: A new section is added titled “Comprehensive Person-Centered Care Planning” that will require an initial care plan in 48 hours, an expanded definition of Interdisciplinary Team to include a CNA, a food service/nutrition staff member and a social worker. The rule also proposes to implement the requirements of the IMPACT Act (Improving Medicare Post-Acute Care Transformation Act) as pertaining to discharge planning (med reconciliation to include pre-admission meds and current meds plus OTCs, discharge summary recommendations for follow-up care, resources and information for the resident regarding his/her discharge plan, etc).  I believe this element will remain in the final rule, substantially unchanged.
  • Nursing Services: The proposed rule would incorporate a competency requirement for determining sufficient number of staff based on a facility assessment which incorporates number of residents, acuity, diagnoses and care plans.  This one I see changing quite a bit as it is so vague and potentially fraught with huge implementation and oversight problems.  It also as written, is a bit confusing and disconcerting in terms of a survey element.
  • Behavioral Health: This is proposed as a new section.  It, similar to Nursing Services prior, would require a facility assessment to determine direct care staff needs regarding staff competency and skill sets to meet resident psychological and mental health needs.  Again, I see this changing dramatically as it is horribly vague and fraught with implementation challenges.
  • Pharmacy Services: The proposed rule includes a required 6 month pharmacist review of resident medication regimes and upon admission when the resident is new and post-hospitalization (return). And monthly when the resident is on an antibiotic, psychotropic drug or any other drug that a QAA (Quality Assurance) committee requests the pharmacist review.  Irregularities are to be noted and reported to the attending physician, the medical director and the director of nursing.  Attending physicians are then to document that the irregularity was reviewed and any action taken/not taken plus the reasoning for the action.  I see this fundamentally staying with some clarifications.
  • Dental Services: The “big” shift is the proposed requirement that facilities are prohibited from charging a Medicare resident for loss or damage of dentures, if the facility is responsible for the dentures.  I’m not sure where this will fall out but if it remains fundamentally intact, facilities will be paying for lots of dentures, regardless of how the loss or damage occurred.
  • Food Service: Following thematically with other elements in the proposal, the requirement is for a facility to assess the resident population by care needs, diagnoses, acuity and census and employ sufficient staff with sufficient competency to provide food and nutritional services.  A Director of Food Service in the proposal must meet certain education and training requirements such as Certified Dietary Manager, Certified Food Service Manager, have at least an Associate’s degree in food service management or similar from an accredited institution.  The proposal also requires facility menus to reflect the cultural, religious and ethnic needs and preferences of residents, be periodically updated and not limit the resident’s right to make food choices.  In addition, facilities will have to allow residents to consume and store foods brought by visitors and families.  I see major changes forthcoming in this requirement, especially around the staff adequacy determination, menus and food brought into the facility by visitors and families.  The latter is a huge infection control risk.
  • QAPI: This requirement is added anew – not surprising.
  • Facility Assessment: This also is a new element requiring the facility to conduct and document a facility-wide assessment to insure the resources necessary to care for residents are available daily and in emergencies.  This assessment must be updated regularly.  The assessment must address the resident population by number, overall care delivered and the staff competency to provide the care and meet resident preferences plus incorporate a facility-based and community-based risk assessment.  I see this element changing dramatically as it is vague and potentially problematic to enforce and implement.
  • Binding Arbitration Agreements: The rule will require facilities that use such agreements to meet certain requirements. Chief among the provisions is that a resident and/or his/her legal representative cannot be required to sign the agreement upon admission.  Additionally, the agreement must indicate the resident’s right to communicate with federal, state and local officials (regulatory) including Ombudsmen. I do not see much change in this element.
  • Infection Control: In addition to having an Infection Control Program, the facility would be required to have an Infection Control Officer and this individual’s primary responsibility must be infection control. I see the Infection Control Officer element subject to change.
  • Compliance and Ethics Program: This is a new element requiring the operating organization (not just the facility if part of a larger organization) to have at each facility a compliance and ethics program with written standards, policies and procedures such that the same are capable of reducing criminal, civil ad administrative violations.  I see this element staying but changing to be a bit more definitive and relevant.
  • Staff Training Requirements: This is also a new element requiring facilities to develop, implement and maintain for all staff, a training program that encompasses (minimally) the following (I don’t see much change in this requirement);

In a statement August 3rd, AHCA alerted its membership that it would be seeking volumes of individual facility/provider support to provide feedback and comments to this proposed rule stating  the “typical approach to a CMS proposed rule has been to seek member input and then file one large response from AHCA. That will not work here. In this instance, more is better.”

Why is your participation important?  Per AHCA “Collectively, these provisions are a time and cost nightmare. CMS itself projects that the cost of implementing the provisions is $726 million in year one. That equates to a cost of $47,000 for every facility in the country. After closely examining the potential impact of the individual provisions, we believe that CMS has understated the costs, and the actual burden may be as high as twice the original forecast.”

Stay tuned for the full grass roots plan.

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