1. Requirements of Participation Phase II
Colorado Medical Directors Association
Ann Kokish, CHCA

2. Facility Assessment F838
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.

3. Facility Assessment
* The facility’s resident population, including, but not limited to, * Both the number of residents and the facility’s resident capacity; * The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; * The staff competencies that are necessary to provide the level and types of care needed for the resident population; * The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and * Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

4. Facility Assessment
The facility’s resources, including but not limited to,
** All buildings and/or other physical structures and vehicles;
** Equipment (medical and non-medical);
** Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
** All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
** Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
** Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

5. Facility Assessment
CMS specifically called out that the Facility Assessment should address “how the medical director will fulfill his/her duties”.
To ensure the required thoroughness, individuals involved in the facility assessment should, at a minimum, include the administrator, a representative of the governing body, the medical director, and the director of nursing.

6. Facility Assessment
The regulation outlines that the individualized approach of the facility assessment is the foundation to determine staffing levels and competencies. Therefore, the facility assessment must include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident’s needs. Furthermore, the assessment must include a competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice.

7. Facility Assessment
An example of Actual harm (physical or psychological) that is not immediate jeopardy, includes, but is not limited to:
One of the sampled residents had experienced a fall while staff were transferring them bed to a chair. The resident’s care plan indicates requiring a two-person assist using a mechanical lift. After the fall, the resident was evaluated and although he did not suffer any physical harm, upon interview he did express psychological harm and stated he was afraid of using these lifts and would prefer to remain in bed. Interviews with nursing staff indicated that many of the lifts are old, in frequent need of repair and often malfunction when used. They also stated that they have brought this matter to the attention of management many times. A review of the most recent Facility Assessment did not include or address equipment necessary to provide for the needs of residents.

8. Psych Meds
Limiting the timeframe for PRN psychotropic medications, which are not antipsychotic medications, to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner. Can be extended for “what is reasonable and rational for the individual”.
Limiting PRN psychotropic medications, which are antipsychotic medications, to 14 days and not entering a new order without first evaluating the resident.

9. Psych Meds NOTE: While there may be isolated situations
where a pharmacological intervention is
required first, these situations do not negate the
obligation of the facility to develop and
implement non-pharmacological interventions.

10. Psych Meds
The required evaluation of a resident before writing a new PRN order for an antipsychotic entails the attending physician or prescribing practitioner directly examining the resident and assessing the resident’s current condition and progress to determine if the PRN antipsychotic medication is still needed. As part of the evaluation, the attending physician or prescribing practitioner should, at a minimum, determine and document the following in the resident’s medical record:
•Is the antipsychotic medication still needed on a PRN basis?
•What is the benefit of the medication to the resident?
•Have the resident’s expressions or indications of distress improved as a result of the PRN medication?
NOTE: Report of the resident’s condition from facility staff to the attending physician or prescribing practitioner does not constitute an evaluation.

11. UTIs URINARY TRACT INFECTIONS Catheter-Related Bacteriuria and UTIs
Bacteriuria (e.g., pyuria) alone in a catheterized individual should not be treated with antibiotics. In someone with nonspecific symptoms such as a change in function or mental status, foul smelling or cloudy urine and/or, bacteriuria (e.g. pyuria), does not necessarily warrant antibiotic treatment. The decision to treat a UTI is based upon the attending practitioner conducting a thorough evaluation and assessment of the resident and providing documentation of a rationale for the indication of use of an antibiotic.
NOTE: For a non-catheterized resident with symptoms associated with a UTI, the attending practitioner should order a urine culture prior to the initiation of antibiotic therapy to help guide treatment. According to current standard of practice, an accurate urine culture for a non-catheterized resident should be obtained by a clean catch or mid-stream specimen for residents who are able to follow instructions. For those unable to provide a clean-catch, a specimen may be obtained preferably by a freshly placed condom catheter for males, or in and out catheterization for females or males unable to provide a specimen by a condom catheter. If the resident has a long-term indwelling urethral catheter, a specimen should be obtained from a freshly placed indwelling catheter.

12. Baseline Care Plans
Completion and implementation of the baseline care plan within 48 hours of a resident’s admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident / representative are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan.

13. Baseline Care Plan Baseline care plan must include:
The resident’s initial goals for care;
The instructions needed to provide effective and person-centered care that meets professional standards of quality care;
The resident’s immediate health and safety needs;
Physician and dietary orders;
PASARR recommendations, if applicable; and
Therapy and social services.
Determine the residents immediate needs!

14. Behavioral Health F740-F745
Providing behavioral health care and services is an integral part of the person-centered environment. This involves an interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident’s distress or loss of abilities.

15. Behavioral Health
It is the expectation that all staff will be competent in the following areas:
Communication and interpersonal skills;
•Promoting residents' independence;
•Respecting residents' rights;
•Caring for the residents' environment;
•Mental health and social service needs; and
•Care of cognitively impaired residents.
Phase three will require formalized BH training.

16. Behavioral Health
Sufficient staff and competency of staff are mentioned throughout the Behavioral Health section.
“The facility must provide the necessary behavioral health care and services to support the resident in attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.”
* Dementia Care
* Anxiety
* Depression
* Trauma Informed Care (phase 3)
* Psycho-social adjustment

17. Behavioral Health
Facility Assessment will determine how behavioral health, dementia, substance abuse, any mental health issue that you might imagine will be addressed with appropriate, sufficient and trained staff.

18. BEST NEWS FOR LAST
Medical director responsibilities must include their participation in:
Administrative decisions including recommending, developing and approving facility policies related to residents care. Resident care includes the resident’s physical, mental and psychosocial well-being;
Issues related to the coordination of medical care identified through the facility’s quality assessment and assurance committee and other activities related to the coordination of care;
Organizing and coordinating physician services and services provided by other
professionals as they relate to resident care;
Participate in the Quality Assessment and Assurance (QAA) committee or assign a designee to represent him/her.

19. Medical Director Con’t
Ensuring the appropriateness and quality of medical care and medically related care.
Assisting in the development of educational programs for facility staff and other professionals; Working with the facility’s clinical team to provide surveillance and develop policies to prevent the potential infection of residents.
Cooperating with facility staff to establish policies for assuring that the rights of individuals (residents, staff members, and community members) are respected;
Supporting and promoting person-directed care

20. Medical Director
An example of Level 4, immediate jeopardy to resident health and safety, includes, but is not limited to:
o The facility’s medical director was aware of and did not intervene when a health care practitioner continued over several months to provide inappropriate medical care for infection prevention to a resident that was inconsistent with current professional standards of care. As a result this resident’s health continued to decline, and was hospitalized with a severe infection.