1. Medical Directors Meeting
Stage 2 Implementation
Medical Directors Meeting
August 4, 2017
Jo Tansey

2. Transfer/Discharge
Necessary for the resident’s welfare and the resident’s needs can not be met in the facility;
The resident no longer needs the services provided by the facility;
The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident
The health of individuals in the facility would otherwise be endangered;
* The resident has failed to pay for their stay

3. Transfer/Discharge
The facility may not transfer or discharge the resident while the appeal is pending, pursuant to , when a resident exercised his or her right to appeal a transfer or discharge notice from the facility , unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer to discharge would pose.

4. Transfer/Discharge Documentation
The facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider. Documentation must include: The basis for the transfer. If the facility is not able to meet the resident needs, documentation needs to show what the needs are, , attempts to meet the needs and the service available at the receiving facility to meet the needs. This documentation needs to be made by the resident’s physician. The information provided to the receiving provider must include: Contact information of the practitioner responsible for the care of the resident, Resident representative information including contact information, Advance Directive information, All special instructions or precautions for ongoing care, comprehensive care plan goals and all other necessary information, including a copy of the resident’s discharge summary and any other documentation to ensure a safe and effective transition of care.

5. Transfer/Discharge
Intent The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless. . . This means that once admitted, for most residents the facility becomes the resident’s home. Facilities are required to determine their capacity and capability to care for the residents they admit. Therefore, facilities should not admit residents whose needs they cannot meet based on the Facility Assessment. The medical record should contain documentation or evidence of the resident’s /representative’s verbal or written notice of intent to leave the facility, a discharge care plan and documented discussions with the resident/representative containing details of discharge planning and arrangements for post discharge care.

6. Transfer/Discharge
Emergent Transfer Residents who are sent to the emergency room. Must be permitted to return to the facility, unless the resident meets one of the criteria under which the facility can initiate discharge. In a situation where the facility initiates discharge while the resident is in the hospital following emergency transfer, the facility must have evidence that the resident’s status is not based ono his or her condition at the time of transfer. Discharge Pending Appeal When a resident chooses to appeal his or her discharge the facility may not discharge the resident while the appeal is pending. If the resident/representative appeals his or her discharge while in a hospital, facilities must allow the resident to return pending their appeal, unless there is evidence that the facility cannot meet the resident’s needs, or the resident’s return would pose a danger to the health or safety of the resident or others in the facility.

7. Infection Control
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum the following elements:
F (a)(1) A system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services based on the facility assessment conducted according to (e) and following accepted national standards that;
Covers all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement;
Is based on the individual facility assessment;
Follows accepted national standards;
Written standards, policies and procedures in accordance with (a)(2);
A system for recording incidents identified under the IPCP and corrective actions taken by the facility; and
An antibiotic stewardship program (ASP) (F881)

8. Antibiotic Stewardship
F (a) The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Intent
The intent of this regulation is to ensure that the facility:
*Develops and implements protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic;
Reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; and
Develops, promotes, and implements a facility-wide system to monitor the use of antibiotics.

9. Antibiotic Stewardship
Definition: Refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration.

10. Antibiotic Stewardship
Guidance:
As part of their IPCP program, facilities must develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Nursing home residents are at risk for adverse outcomes associated with the inappropriate use of antibiotics that may include but are not limited to the following:
Increased adverse drug events and drug interactions
Serious diarrheal infections from C. difficile;
Disruption of normal flora; and/or
Colonization and/or infection with antibiotic-resistant organisms such as MRSA, VRE, and multidrug-resistant GNB

11. Antibiotic Stewardship
The stewardship program must include the development of protocols and a system to monitor antibiotic use. This development should include leadership support and accountability via the participation of the medical director, consulting pharmacist, nursing and administrative leadership and individuals with designated responsibility for the infection control program.

12. Antibiotic Stewardship
The program protocols shall describe how the program will be implemented and antibiotic use will be monitored, consequently protocols must:
Be incorporated in the overall infection prevention and control program;
Be reviewed annually
Contain a system of reports related to monitoring antibiotic usage and resistance data.
Incorporate monitoring of antibiotic use;
Assess residents for any infection using standardized tools and criteria; and
Include mode and frequency of education for prescribing practitioners and nursing staff on antibiotic use and the facility’s antibiotic use protocols.

13. Pharmacy Services/Antibiotic Stewardship
The assessment, monitoring and communication of antibiotic use shall occur by a licensed pharmacist in accordance with ©, F756, Drug Regimen Review. A pharmacist must perform a medication regimen review at least monthly, including review of the medical record and identify any irregularities, including unnecessary drugs.

14. Hospice
If hospice care is furnished in a LTC facility through an agreement the LTC facility must meet the follow requirements:
Ensure the hospice services meet professional standards and principles that apply to individuals providing services in the facility and to the timeliness of the services.
Have a written agreement with the hospice that sets out the following:
a. Services the hospice will provide
b. The hospice’s responsibilities for determining the appropriate hospice plan of care
c. The services the LTC facility will continue to provide based on the resident’s plan of care
d. A communication process, including how the communication will be documented to ensure the residents needs are met 24 hours per day.

15. Hospice
* e. A provision that the LTC facility immediately notifies the hospice about the following: 1. A significant change in the resident’s physical, mental, social or emotional status 2. Clinical complications that suggest a need to alter the plan of care. 3. A need to transfer the resident from the facility for any condition. 4. The resident’s death. *f. A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. *g. An agreement that it is the LTC facility’s responsibility to furnish 24-hour room and board care, meet the resident’s personal care and nursing needs in coordination with the hospice and ensure that the level of care provided is appropriate.

16. Hospice
*h. A delineation of the hospice’s responsibilities, including providing medical direction and management of the patient; nursing; counseling; social work; providing medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident’s terminal illness and related conditions. *i. A provision that when the LTC facility personnel are responsible for the administration of therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.

17. Hospice
* j. A provision stating the LTC facility must report all alleged violations involving mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violations. *k. A delineation of the responsibilities of the hospice and the LTC facility to prove bereavement services to LTC facility staff. The LTC facility must designate a member of the interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The IDT member must have a clinical background, function within their state scope of practice and have the ability to assess the resident .

18. Hospice
The designated team member is responsible for: (i)Collaborating with hospice representative and coordinating LTC facility staff participation in the hospice care planning process. (ii) Communicating with hospice and other healthcare providers to ensure quality of care. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient’s attending physician and other practitioners participating in the provision of care. (iiii) Obtaining the following from hospice: a. The most recent hospice plan of care b. Hospice election form. c. Physician certification and recertification of the terminal illness. d. Names and contact information for hospice personnel. e. Instructions on how to access the hospice 24-hour on-call. f. Hospice medication information. g. Hospice physician and attending physician orders.

19. Hospice
The LTC facility must monitor the delivery of care in order to assure that the hospice provides services to the resident in a way that meets his/her needs including: *Observation of interactions and care provided * Interviews with the resident/representative regarding hospice care and; * Review of the resident’s record for pertinent documentation regarding the delivery of hospice care. Any changes to orders initiated by the hospice should be communicated to the resident’s attending practitioner in a timely manner. The nursing home must communicate with the hospice any orders provided by the attending practitioner.