1. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Federal Nursing Home Regulations Family Medicine Digital Resources Library

2. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Objectives  Be able to discuss the Federal nursing home regulations as they relate to the medical director of the nursing home and to the attending physician.  Be able to discuss the inspection process and the different level of deficiencies.  Be able to discuss the resident’s rights and the physicians role in those rights.

3. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

4. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

5. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Regulations and Deficiencies  Increasing federal and state regulations increase burden on physicians  Guidelines are available to help http://www.cms.hhs.gov/GuidanceforLawsAndRegulations/12_NHs.asp http://www.cms.hhs.gov/GuidanceforLawsAndRegulations/12_NHs.asp  State inspections occur annually and if needed in interim  Deficiencies issued if warranted (F-tags)

6. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Inspection Process http://www.cms.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdf http://www.cms.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdf  Step 1: Off-site preparation (review of the Quality Indicators Survey by trained surveyors)  Step 2: Entry conference and on-site preparation  Step 3: Initial nursing home tour  Step 4: Resident sample selection  Step 5: Information gathering  A. General observation of the facility  B. Kitchen/food service observation  C. Resident review  D. Quality of life assessment  E. Medication pass  F. Quality assessment and assurance review  G. Abuse prevention review  Step 6: Deficiency determination  A. Determination of substandard quality of care  Step 7: Exit conference

7. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Deficiency Categorization  Survey team, composed of trained surveyors and possibly specialty surveyors (pharmacist, dietician or physician), determines that a deficiency exists  Survey team determines the effect on resident outcome (severity)  Survey Team determines the number of residents affected (scope)

8. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Severity Level  Level 1- no actual harm with potential for minimal harm  Level 2 – no actual harm with potential for harm less than immediate jeopardy  Level 3 – actual harm without immediate jeopardy  Level 4 – immediate jeopardy

9. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Scope Level  Isolated – one or a very limited number of residents are affected or the situation is infrequent or not prevalent  Pattern – more residents involved, more staff involved, more frequent or prevalent  Widespread – many residents, staff, locations or instances involved

10. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Scope and Severity Grid Severity of the deficiency Level 4: A situation that has caused or is likely to cause serious resident injury, harm, impairment, or death. Level 3: A situation that has caused resident harm. Level 2: A situation that has caused minimal discomfort to a resident OR has the potential to cause resident harm. Level 1: A situation that has the potential of causing no more than minimal discomfort to a resident. Scope of the deficiency Isolated - Pattern - Widespread J K L G H I D E F A B C

11. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

12. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Resident Rights  F tags 151 to 177  Basically, the resident has the right to a dignified existence, self-determination and communication with access to persons and services inside and outside of the facility. It is the facilities duty to promote and protect these rights.

13. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements The resident has the right to…  Exercise their rights  Be informed  Manage funds  Choose a physician  Privacy (HIPAA)  Voice grievances  Examine survey results  Work or not  Refuse care/research  Privacy in mail, email, phone  Visit and be visited  Retain personal possessions  Share a room with spouse (sex)  Self administer medications  Refuse change of room

14. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

15. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Admission, Transfer, and Discharge Rights  F tag 208  Basically, the facility must not require residents to waive rights to Medicare or Medicaid or require assurance that they are eligible for M’care/M’caid. Can not choose residents preferentially based on payer source.

16. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Transfer and Discharge  Can not transfer or discharge to allow for financial gain to the facility.  Can not segregate residents based on payer source or provide services based only on payer source (i.e. better dining services for certain residents)

17. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

18. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Resident Behavior and Facility Practices  F tags 221 to 226  Concerned with  Restraints  Physical  Chemical

19. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Restraints  Physical  Manual, physical or mechanical device that the resident can not easily remove and restricts freedom of movement (side rail, Velcro, lap tray, belts)  Chemical  Any drug used for discipline or convenience and not required to treat medical symptom

20. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Restraints  Document medical symptoms that led to use of restraint  Document attempt to meet individual needs, use of rehab, provision of meaningful activities, attempts to alter environment  Document attempt to eliminate or reduce medical symptoms

21. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Restraints  Document use of alternative treatments to decrease decline in function  Document use of least restrictive restraint  Document informed consent  Document re-evaluation of need for restraint

22. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

23. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Quality of Life  F tags 240 to 258  Concerned with dignity, self- determination, participation in groups and activities, social services and the general environment

24. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Quality of Life (dignity)  Must care for resident in a manner that maintains dignity and respect  Groom and dress as desired  Attend activities of own choosing  Tastefully label clothes  Dine with respect  Respect private space  Respect social status

25. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements QOL (self-determination)  Resident has right to choose activities, schedules and healthcare consistent with their own interests, assessments and plans of care  Resident has the right to interact with persons in and out of facility

26. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements QOL (groups)  Resident has the right to organize groups and meet with other residents or families  Resident has the right to response from facility concerning grievances  Resident has right to participate in outside groups

27. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements QOL (other)  Resident has right to notice before room or room mate change  Resident has right to pursue activities of their choice (sex, sky diving, etc)  Rights of resident to pursue activity does not over ride other residents rights (wandering, plundering, etc)

28. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

29. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Resident Assessment  F tag 271 and F tag 285  Concerns proper evaluation at the time of admission and pre- admission screening of mentally ill or mentally retarded residents.

30. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Admission Orders  Facility must have physician orders at time of admission of resident’s immediate care.  Includes diet  Medication  Routine care  PT and/or OT

31. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Pre-admission Screening  PASRR (pre-admission screening and resident review) requires all patients with mental illness or retardation to be screened by the state since Jan 1, 1989 to ensure that this subpopulation receive proper care.

32. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

33. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Quality of Care  F tags 309 to 354  Concerned with ADLs, vision/hearing, pressure sores, incontinence, ROM, NG tubes, accidents, nutrition, hydration, unnecessary meds, med errors, immunizations

34. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements QOC  Facility must provide services and care to allow for the highest, practical physical, mental and psychosocial well-being  Facility must ensure that resident does not deteriorate within the limits of their right to refuse care and within limits of normal progression of disease state  If decline occurs need to document whether avoidable or unavoidable

35. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements QOC  Document whether resident is independent, requires supervision, requires limited assistance or extensive assistance.  Document risk factors and preventive measures for decline.  Document plan of care, evaluation and reassessment.

36. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

37. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Pressure Sores  F tag 314  After a comprehensive assessment of the resident, the facility must ensure that:  Those without pressure sores do not develop them  Those with pressures sores are provided care to allow for healing, prevent infection and prevent new lesions

38. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Pressure Sores  Definition- any lesion caused by unrelieved pressure that results in damage to the underlying tissues  Friction and shear are contributing factors to pressure lesions

39. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Pressure Sores-Risk Factors  Impaired mobility  Co-morbid conditions  Medications  Impaired blood flow  Resident refusal of care  Cognitive impairment  Exposure to urine/feces/moisture  Nutrition or hydration deficiencies  History of previous ulcer

40. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Stages of ulcers  Stage I- Intact skin  Change in skin temperature, consistency, sensation, and/or color  Stage II- Partial thickness (epidermis/dermis)  Stage III- Full thickness (not through fascia)  Stage IV- Full thickness with extensive destruction

41. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Pressure Sores  Avoidable vs. Unavoidable  Cleansing vs. Irrigation  Colonized vs. Infection  Debridement  Autolytic, enzymatic, mechanical, surgical, MDT  Eschar vs. Slough  Exudate  Granulation Tissue  Tunnel vs. Sinus Tract vs. Undermining

42. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

43. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Incontinence  F tag 315  Ensure that incontinent residents maintain as much urinary function as possible  Urinary catheters used only when medically justified  Urinary catheter discontinued if not justified  Services are provided to restore function when catheter removed  Services provided to prevent infection

44. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Incontinence- Definitions  Bacteremia vs. bacteriuria  Urinary incontinence  Functional  Mixed  Overflow  Stress  Transient  urge  Urinary retention  Urinary tract infection  Urosepsis

45. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Incontinence- Interventions  Manage pain  Optimize function  Remove environmental obstacles  Treat underlying conditions  Adjust medications  Fluid/bowel management program

46. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

47. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Range of Motion  F tag 317-318  Ensure that a resident that enters a facility without a limited range of motion does not experience reduction in ROM unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable

48. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Range of Motion  Primary risk factors  Immobilization  Deformity, neurological deficit  Pain, spasm, immobility  Documentation  Was resident at risk, why  What care was provided  Was it provided consistently  Intervention  Passive vs. active ROM  Re-evaluation and alteration to plan

49. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

50. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Nasogastric Tubes  F tag 321-322  Ensure NG tubes are not used by those able to eat alone or with assistance unless clinically necessary

51. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements NG Tubes  Intended to prevent the use of tube feeding when ordered over the objection of the resident.  Unavoidable conditions  Inability to swallow without aspiration or choking  Lack of sufficient alertness  Reversible malnutrition

52. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements NG Tubes  Documentation  Evaluation for risk of malnutrition  How was oral nutrition maintained  Services to improve swallowing  Assessment for cause  Dietary consult  Interventions  Is placement correct  Correct feeding procedure  Complication prevention  Aspiration  Infection  Long term use

53. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

54. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Accidents  F tags 323 and 324  The facility must ensure that the resident environment remains as free of accident hazards as is possible.  The facility must provide adequate supervision and assistive devices to avoid accidents.

55. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Accidents  Hazards can endanger a resident  Physical restraints  Defective equipment  Bathing facilities  Side rails (F tag 221)  Handrails  Water temperature

56. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

57. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Nutrition  F tags 325 to 327  After comprehensive assessment, the facility must ensure acceptable parameters of nutritional state (weight, protein)  Facility must ensure therapeutic diet when needed.  Facility must provide resident with sufficient fluid intake.

58. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Nutrition  Weight loss is measurable parameter  Time frameSignificantSevere 1 month5%>5% 3 months7.5%>7.5% 6 months10%>10% % of wt loss = (usual-actual/usual) x 100

59. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Evaluation of Nutritional Status  Labs (in general > 60 yo)  Albumin3.4-4.8g/dl  Transferrin 180-380 g/dl  Hb m=14-17g/dl f=12-15 g/dl  Mg++ 1.3-2.0 mg/L

60. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Risks for Poor Nutrition  Drugs  Diuretics, Digoxin, NSAIDs  Poor oral health  Depression or dementia  Dislike of foods served  Cancer

61. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Nutrition Documentation  Document why maintenance may be impossible  Refusal to eat  Advanced disease  Increased nutritional needs  Chemotherapy or radiation  Document steps taken to correct and resident response

62. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Hydration  Must provide with sufficient fluid intake to maintain proper hydration and health  Document unavoidable risks (coma, fluid loss, dementia, refusal)  Document steps taken to decrease risk  Document response and ongoing changes to plan…

63. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

64. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Special Needs  F tag 328  The facility must ensure that residents receive proper treatment and care for:  Injections, parenteral and enteral feedings, colostomy, tracheostomy care, tracheal suctioning, respiratory care and prostheses

65. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Special Needs  Ensure proper technique (sterile when applicable)  Document and treat signs of infection or irritation  Document patient response to treatment  Ensure proper upkeep of needed equipment  As much as possible ensure that resident is involved in care

66. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

67. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Unnecessary Drugs  F tag 329  Every resident’s drug regimen must be free from unnecessary drugs  Excessive dose  Excessive duration  Lack of adequate monitoring  Lack of adequate indication  Presence of adverse consequences

68. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Unnecessary Drugs  Long acting benzodiazepines  Benzodiazepine or sedatives  Drugs for sleep induction  Antipsychotics  Medications potentially inappropriate for the elderly (Beers)

69. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

70. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Antipsychotic Drugs  F tag 330-331  Residents who have not used antipsychotic drugs should not be given these drugs unless necessary to treat a specific condition diagnosed and documented in the medical record

71. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Antipsychotic Drugs  Must document one of following conditions:  Schizophrenia  Schizo-affective disorder  Delusional disorder  Psychotic mood disorders  Acute psychotic episodes  Brief reactive psychosis  Atypical psychosis  Tourette’s disorder  Huntington’s disease

72. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Antipsychotic Drugs  Must document:  Attempts at dose reduction  Side effects and actions taken to minimize  Other interventions used to avoid use of medication  Resident reaction to medication, intervention, dose reduction

73. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

74. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Medication Errors  F tag 332  Facility must ensure that facility is free of medication error rates of 5 percent or greater

75. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Medication Errors  Medications and biologicals must be given in accordance with:  Physicians orders  Manufacturers specifications  Accepted professional standards and principles

76. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Significant Medication Error  Leads to patient discomfort or jeopardizes health and/or safety  Significant vs. nonsignificant

77. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

78. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Physician Services  F tag 385-390  Starts with written approval for admission  MD must review total program of care  Write, sign and date progress notes at each visit  Must sign and date all orders

79. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Physician Services  Resident must be seen by a physician at least once every 30d for the first 90d and once every 60d thereafter  A visit is still timely if occurs within 10d after the date the visit was required  PA, NP or clinical nurse specialist may alternate visits after the initial physician visit

80. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Physician Services  Facility must provide emergency services 24 hours a day  Physician tasks may be delegated to PA, NP or clinical nurse specialist as allowed by law

81. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

82. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Pharmacy Services  F tag 430  Required to respond (not necessarily agree) to the pharmacist reports.  Not required to provide a rationale for decision (it is a good idea to…) but must act on the report.

83. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Topics Covered in this Presentation  Deficiencies  Resident’s Rights  Admission  Behavioral  Quality of Life  Resident Assessment  Quality of Care  Pressure Sores  Incontinence  Range of Motion  NG Tubes  Accidents  Nutrition  Special Needs  Unnecessary Drugs  Antipsychotics  Medication Errors  Physician Services  Pharmacy Services  Administration

84. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Administration  F tag 501  Facility must designate a physician to serve as medical director  Medical director is:  responsible for implementation of resident care policies  responsible for coordination of medical care in the facility

85. Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements Administration  Medical Director must guide, approve and help oversee the implementation of the policies and procedures  Admission policies  Integration of delivery of care and various services  Medical staff issues

86. Bibliography  Centers for Medicare and Medicaid Services http://www.cms.hhs.gov/GuidanceforLawsAndRegulations/12_NHs.asp  Survey Protocol for Long Term Care Facilities http://www.cms.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdf  Guidance to Surveyors for Long Term Care Facilities http://www.cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf  Certification and Compliance http://www.cms.hhs.gov/CertificationandComplianc/12_NHs.asp Alice Aumann House, MD, FAAFP, CMD Federal Nursing Home Requirements