The numerous changes to the Centers for Medicare & Medicaid Services (CMS) federal Requirements of Participation (ROP) for nursing homes, announced on June 29, 2022, in QSO-22-19-NH, will begin to be surveyed on October 24, 2022.
In our Part 1 post, we showed you the rule changes of revised ROP Phase 2 and Phase 3 guidance and the focus on quality and oversight of sensitive areas such as reporting of abuse and neglect and other resident-centered rules. We showed the changes in infection control and prevention measures, including clarified requirements for an employee Infection Preventionist; assuring visitation is permitted within facilities, even during infectious disease outbreaks; and considerations of other physical changes that may reduce potential disease spread. We covered F Tags through the low 700s.
In Part 2, we will continue to provide information on the changes and what measures may be taken to comply, moving through F Tags in the 700s, 800s, and 900s. The tags around behavioral health include significant changes and require facilities to review and update their facility assessment, assure they have identified residents with special needs, and that staff is fully prepared to manage them skillfully and with sensitivity to their person-centered needs.
The information in F847 and F848 follows up rules released in 2019 with new stipulations and further clarifies details around a sensitive area: use of arbitration agreements. This requires extensive review to assure facilities stay within the regulations with proper language, informed agreements, and clear stipulations on what is permitted and what is disallowed under these rules.
Pay close attention to the clarifications and expansion of Quality Assurance and Performance Improvement (QAPI) requirements, as additional scrutiny can be expected. And, there is much information included in the infection control and prevention tags.
Corporate compliance is a developing requirement with new guidance included in F895. And finally, nearly every F Tag has training recommendations implicit in full implementation. A well-constructed program to bring staff into full compliance will be necessary.
| F Tag # | Policy Changes Recommended | Documentation/Form Changes | Training/Education Recommended |
| F740 Behavioral Health Services | Policy should reflect behaviors, substance use disorders, and mental health disorders now included in the facility assessment and the facility’s determination about if, and how, they have the capacity, staff, and training to manage these acuities. Preadmission Screening and Resident Review (PASRR) changes. Potential specialized activities, treatments, and services. Clarifies use of behavioral contracts. Parameters for resident search. | Assure PASRR Level 2 requirements are met and monitored for changes. Care plan activities and individualized interventions specific to diagnoses. Cognitive capacity specific to behavioral contract. Diagnostic criteria used per regulations. | Staff to be trained to recognize when a mental health and substance use disorder (MH/SUD) exists, changes, or is observed; behavior management strategies and specific documentation required. Internal reporting requirements. |
| F741 Behavioral Health/Sufficient Staff; Non-Pharm Interventions | Specific references to mental disorders, substance use disorder, history of trauma, and post-traumatic stress disorder. Sufficient staff and ability to provide non-pharmacologic behavioral interventions. Staff competency to recognize and manage. | Careful care planning and documentation of manifestations of diagnosis, interventions used, and their effectiveness; risk vs. benefit. | All staff must have knowledge and skill sets to recognize and provide care for residents and their specific needs. |
| F755 Pharmacy Services | Handling and disposal of Fentanyl patches. (Also see F689). Labeling and storage of medications. Do not dispose of patches in common areas or resident rooms. | Establish tight system for managing and disposing of patches. | Train staff in system and monitor carefully. |
| F758 Psychotropic Medications | Use of psychotropic meds must be done at lowest dose and frequency effective; avoid duplicative therapies. Dose reduction requirements. Other medications used to avoid or eliminate the use of an antipsychotic are subject to the same monitoring for behaviors and side effects. | Document attempts to avoid use of psychoactives with non-medication interventions; document risk vs. benefit analysis; informed consents; behavior monitoring for effective dose; gradual dose reductions. | Train staff in policy, in behavior management, and monitoring. Awareness and documentation of observations for side effects. |
| F812 Food Safety | Emphasis on increases in sanitary food handling to reduce the risk of pathogens; food temps during distribution. Distinction between food distribution and serving. Service staff requirements: hair nets when preparing/assembling; gloves when touching ready-to-eat food. Hand hygiene clarification during food service. | Documentation of food temp monitoring, including post-distribution/prior to eating. Monitoring for staff compliance with appropriate use of hair nets and gloves. Appropriate hand hygiene. | Train staff in proper food temps, kitchen and food service hygiene. |
| F847 Entering into Binding Arbitration Agreements | Specific and extensive clarification on when, with whom, and how a facility may use binding arbitration agreements, conditions, informing of rights and conditions, and language which may be used. | Every facility should check their admission contract and review agreements included to ensure they meet the extensive changes in requirement. Must be able to validate that resident and/or representative is fully informed. | Train admission and social work staff in new language and rules around use. |
| F848 Arbitration Venues and Retention of Agreements | Addresses selection of an arbitrator and where arbitration can occur. It stipulates record retention of agreements. | See 847 | See 847 |
| F851 Mandatory Submission of Staffing Information | Facilities must report required auditable and verifiable staffing data to CMS per Payroll Based Journal (PBJ). CASPER reports will be checked and failure to report will result in citation. Review reporting requirements/job categories, job status, census data, and turnover data. | Assure system is in place to track hours of service by each and every employee and contract worker using job category. Data must be recorded in such a way as to allow for audit and verification. | Train assigned person in proper record keeping and submission of PBJ with solid backup plan in place. |
| F865 Quality Assurance and Performance Improvement | Definitions added; guidance for purpose and process; program design, scope, and documentation. Note that survey will include evidence of comprehensive projects as evidence of compliance. | QAPI documentation of at least quarterly meetings that include all quality metrics reporting and process improvement strategies. Should be very interactive and include infection control, any adverse events, sub-committee activities, and overall facility quality development. | Train all staff in quality improvement efforts to gain full participation and ability to discuss. Culture of process improvement, quality, and safety. |
| F867 QAPI ImplementationAnd F868 Quality Assurance and Assessment Committee | Establishes implementation standards, what should be included, systematic analysis, and actions in response; further defines criteria for QAPI action and priorities; establishes structure and process for Performance Improvement Projects; defines who should be included and frequency of meetings. | Thorough outline of QAPI structure, criteria for inclusion; meetings; who to attend. Demonstrate process is fully carried out. Provide evidence of two projects in action from beginning to in-process or completion. | QAPI team to be fully trained in understanding process and projects. |
| F880 Infection Control | New definitions included. Expectation of what to include in ICP (Infection Control and Prevention); discussion about facility assessment and policy inclusions; focus on cleaning and disinfection standards; Water Management defined; categorization of transmission-based precautions; ICP incident management. | Robust and clear policies; surveillance process and tools; tools to monitor employee compliance with ICP policies; tools to track and trend infections; clear evidence of screening, identification, response, and monitoring of ICP. | Train all staff in ICP policies and procedures. Staff should be able to discuss these as well as consistently demonstrate compliance. |
| F881 ICP Implementation | Antibiotic stewardship daily, weekly, and monthly process, as well as education and compliance. | Document new illnesses against infection standards; daily review for/of new infections/antibiotics; process of review, culture response, clarification. Tracking and trending use of antibiotics and infections. | Train all nurses to question new illness, infections, and use of antibiotics. Reporting and response requirements. |
| F882 Infection Preventionist | Define role, responsibilities, qualifications, hours of work, and specialized training. Assure compliance with hours based on facility size, facility assessment and community assessment, and facility history. | Maintain file of Infection Preventionist with specialized training and basis for decisions about hours and responsibilities. Note: may have to justify shared responsibilities against outcomes. | Train all staff to know the role, who is responsible, and expectations for reporting and interaction. |
| F895 Compliance and Ethics Program | Policies to include robust procedures intended to reduce the opportunity for legal or ethical infractions; monitoring for non-compliance and actions to be taken; rules and trainings to include all staff, including contract, with high level focus on operational staff and structure. Program is active and dynamic. | Documentation of policy communicated to all staff with specific requirements focused on appropriate level of staff involvement. Investigation of any suspected non-compliance. | Requires annual training to include reporting requirements with emphasis on commitment to make reporting easy and without negative consequences. |
| F919 Resident Call System | Call system must be available from bed and bath; must remain operational; must have plan for call system malfunction or power failure. | Up-to-date policy. | Staff to report any malfunction or other difficulties maintaining adequate access and performance. |
| F940 Training Requirements | Facilities are required to develop, implement, and maintain an effective training program for all new and existing staff, including contract staff. Facility will rely on facility assessment to direct training needs and methods. | Policy is clear; staff is assigned to develop and implement training; system to monitor process assuring full compliance of new, existing, and contract staff. | Assign and train a person to manage training of staff. All staff to be included with the standard “prior to contact with residents.” |
| F941 Effective Communication as Required Training | Effective communication is to be included as mandatory training for direct care staff. Note specifics in expectations of direct staff interaction with residents. | Include active listening, observation of verbal and non-verbal cues; understanding what a resident is trying to communicate. | All direct staff to be trained in effective communication. |
| F942 Resident Rights and Facility Responsibilities | To ensure all staff understand and protect the rights of residents as a required training. | Document and monitor. | Staff should be prepared for surveyor interview. |
| F943 Abuse, Neglect, and Exploitation | To ensure all staff is trained before contact with residents; at least annually and periodically in what constitutes abuse, neglect, and exploitation; prevention, identification, and how to handle situations; reporting. Special considerations for residents with dementia and other special needs; person-centered thinking. | Document and monitor. | Staff should be thoroughly trained with constant monitoring and retraining for any events that suggest poor understanding or non-compliance. |
| F944 Quality Assurance and Performance Improvement | Coordinated effort to engage and involve all staff, at every level, in QAPI projects, intentions, and efforts. | Document and monitor. | All staff should be able to discuss QAPI projects in action. |
| F945 Infection Control | Includes specific topics to be included in training of all staff, including contract; monitoring competency and compliance. | Document and actively monitor for compliance. | New and existing staff and contractors at least annually. |
| F946 Compliance and Ethics | Includes topics to be included in training for all staff, including contract. | Document training. | Annual requirement for training if the organization includes five or more facilities. |
| F947 In-service Training of Nurse Aides | Must be sufficient to ensure continuing competence and not less than 12 hours per year; include dementia; for aides who provide care to those with cognitive impairment, specialized training in communication. | Use facility assessment, document, and monitor for additional training needs. Be sure competencies are complete and comprehensive. | Training requirements for certification, ongoing 12-hour minimum, and as needed based on facility assessment. |
| F949 Behavioral Health | Based on standard of care and facility assessment, all staff to be trained in care, communication, and management to appropriately care for residents with special needs, mental health disorders, and substance use disorders; to be able to identify changes and exacerbations, and to report to designated person. | Validate basis for training through facility assessment, paying attention to changes in census, new or changing needs, and responding with appropriate education. Document. | All staff who will care for residents with behavioral health needs must receive training. |
HDG is Here to Help
The changes we are preparing for are numerous. At Health Dimensions Group (HDG), we fully understand the magnitude and complexity of these new and shifting requirements. Please let us know if we can be of service to you as you anticipate these changes. HDG is prepared to assess your situation, provide review of your processes, and offer the level of guidance or service you need. Please contact us at info@hdgi1.com or 763.537.5700.
