What Nursing Homes Should Consider As CMS’s Requirements of Participation Deadline Nears

As nursing homes make final preparations for Phase 3 updates to the requirements of participation set to take effect in the coming days, providers and legal experts expect infection prevention and behavioral health to be where surveyors focus first.

Readiness for the “low hanging fruit” is a good place for providers to start given the sheer amount of updates included in the 800-plus page document, according to Todd Selby, attorney for health care law firm Hall Render Killian Heath & Lyman in its Indianapolis office.

“[Operators are] going to have to narrow it down to the things that [they] think are going to be the most significant. Infection control is going to be big, trauma-informed care, taking into account cultural aspects of the residents, behavioral health,” Selby told Skilled Nursing News.

The Centers for Medicare & Medicaid Services (CMS) in June issued updated guidance for nursing home surveyors under the requirements of participation for Medicare and Medicaid, and in support of nursing home reform initiatives first unveiled in February.

Staffing and infection control were among the main areas of focus in the CMS guidance; the agency gave surveyors and providers until Oct. 24 before guidelines go into effect.

Debbie Meade, CEO of Health Management in Georgia, said her staff have had to go “back to basics” with the wide-ranging effects of ROP updates. Meade echoes advice Relias’ Trish Richardson had for operators more broadly in back August on compliance issues providers should watch for in the coming months and looking ahead to 2023.; Richardson serves as the director of post-acute care solutions for the consulting firm.

“We’re taking a step back,” Meade said. “Let’s look at the new requirements of participation – what do we tweak as we reintroduce systems that fell by the wayside because of Covid? Let’s reinvent some of our systems to then incorporate the requirements of participation.”

Connecticut-based iCare Health Network COO Mike Landi said he is in constant communication with their chief clinical officer ahead of ROP changes.

Most recently, Landi and iCare’s clinical team worked together to identify trauma-related risk factors that might be tied to substance abuse history, or tangential issues related to homelessness, physical or mental abuse.

iCare specializes in serving a SNF population with behavioral health needs. In addition to this service, iCare also works with the state to admit parolees in need of skilled nursing care.

Behavioral health-related ROP updates make sure trauma-informed care is clearly supported and substance abuse history documented, added Landi.

Until operators actually see what surveyors are focused on once the changes officially go into effect, they’ll need to “fly by the seat of their pants,” Selby said.

Other regulatory bodies at play, under-the-radar updates

Apart from infection control and behavioral health guidance updates, it’s a good idea for operators to have a plan to implement the required training outlined by CMS, since it will take some time for programs to take off if they are not already in place.

For Selby, the sheer amount of topics SNFs must train employees on is in itself an under-the radar concern.Training regulations will come back to bite operators if they’re only focusing on the “big stuff.”

“T​here’s a multitude of training requirements now; facilities have to train on everything from QAPI to residents’ rights to infection control,” he added.

All the necessary training will be time consuming for operators, he said, as clinical workers are pulled away from delivering direct care.

During the last two years, Meade said she spent more time revamping policies and guidance whenever there was an update from the Centers for Disease Control and Prevention (CDC) or CMS.

“It’s really difficult when you’re an independent owner and you don’t have a policy writing division, you don’t have [someone] to go into the buildings and do training,” she added.

Another major factor operators should consider regarding Phase 3 guidance and surveys are the updates roped in that involve other government entities besides CMS.

“Facilities are being held to Centers for Disease Control and Prevention standards, they’re being held to Food and Drug Administration (FDA) standards. There’s citations to the Environmental Protection Agency (EPA) there, the National Institutes of Mental Health … it’s not just the ROP,” said Selby.

That’s a slippery slope for operators, he added, when guidance piles on “layers and layers” of compliance agency guidance, all with new definitions of what constitutes excessive doses of a drug or what constitutes duplicate therapy, for example.

“The surveyor is going to lean on these new definitions, and they’re going to use them to cite facilities,” Selby said. “I think with the use of the FDA and the CDC guidance, I think it’s a problem.”

CMS has also warned operators since 2006 that it may institute a compliance and ethics program under the Affordable Care Act (ACA), and now the time has come, Selby said. Implementing such a program isn’t a problem for larger operators, but he considers it a challenge for smaller providers.

“We’ve been telling them for years and years and years that they’re going to need a compliance program and it never happened – but now it’s happening,” he said.

Behavioral health focus

There’s a “big, new focus” on behavioral health services in nursing homes as part of rules of participation, Selby said, which translates to F-tags linked to trauma-informed care and substance abuse disorders among residents.

“If a resident comes to the facility with a known substance abuse disorder, the facility has to take steps to find treatment for that individual,” he said.

For an operator like iCare with decades of experience serving residents with behavioral health needs, these particular updates only require some review and tweaking, iCare CEO Chris Wright said.

“We don’t have to reinvent the wheel on some of these behavioral-type guidances that are coming out. That was encouraging to us,” added Wright.

Meade and her team at Health Management is treating behavioral health updates as patient-centered care initiatives. In terms of medication reduction, or reducing antipsychotic medication among residents, staff must do some digging into hospital discharge paperwork.

Clinical staff have increasingly sought out family members as well about medication that might have carried over from other care settings as a way to prepare for behavioral guidance updates, she said.

Just like other operators, iCare is more generally making sure its policies and procedures are in line with CMS guidance — particularly regarding safety and resident rights.

iCare has had to balance resident rights with safety policies and regulations on a daily basis, according to Landi. Executives are encouraged by CMS’s realization that this population, which is traditionally underserved, needs to be served by the long-term care community.

“They need skilled nursing services, and care for their addiction or mental illness. [This population] has generally not been represented in the long-term care community,” Landi said.