Culture Change and the New Long Term Care Regulations

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By Karen Schoeneman, MPA, Karen Schoeneman Consulting, LLC – Pioneer Network

The new nursing home regulations came out as final on October 4, and this has caused many an administrator’s heart to skip a beat. But don’t panic, CMS listened to the many commenters who said there are many large new mandates, and they need more time to put them all in place.  Given the magnitude of the changes, CMS has determined that the regulations will become effective in three phases: most of the simpler mandates on November 28, 2016, the second phase in November 2017, and the third phase in November 2019. Many current regulations were re-organized within the document, but nothing was lost and many things were clarified or enhanced to further person-centered care. Though there are too many changes to cover in this short article, I’d like to give you the “Readers Digest Condensed version,” focusing on some of the changes in requirements related to resident rights and quality of life.

CMS made it clear in their responses to comments that person-centered care is an important theme that runs through the whole set of regulations.  They developed a new section (483.21) titled “Comprehensive Person-Centered Care Planning.” The section gives strong emphasis to resident/representative participation in care planning, and to the team focusing on the resident’s goals and preferences. It also requires the care plan team to include a nurse aide with responsibility for the resident, a member of the food services staff, the physician, and a registered nurse. (They don’t each necessarily need to go to all meetings.)

There is also a new section (483.40) called “Behavioral Health Services” (effective in Phase 2). This section mandates that nursing homes hire and train “sufficient staff” to assist residents with mental and psychosocial disorders and those with a history of trauma or post-traumatic stress disorder (PTSD). This section also emphasizes trying non-drug interventions.

The new requirements also mandate that nursing homes conduct an annual assessment of their resident population, the capabilities of staff and available resources to ensure they are adequate to provide the care and services each resident needs. There is a new training section (483.95), mandating training for all staff, not just nurse aides, and lists several required topics including resident rights, abuse prevention, communication, and behavioral health, among others. The training section includes requirements to ensure contracted staff and even volunteers are trained with regard to their duties.

The long-awaited mandates of Quality Assurance and Performance Improvement (QAPI- 483.75) and Ethics and Compliance (483.85) take effect in Phase 2. The first mandates continuous assessment of issues and development of performance improvement projects, and the second mandates detection/prevention of “criminal, civil, and administrative violations . . .”

Person-centeredness appears in many other places, such as emphasis on the right to refuse treatment, the statement that the home may offer a special diet but the resident has the right to refuse it, and many more sentences that say to me that CMS has bought in to person-centered care and is expecting it from all homes.

CMS hasn’t yet developed interpretive guidelines for the new regulations but they say these are coming next year. In addition, they are making major changes to the survey process in the coming year. Training will be offered for surveyors with open access to the general public, both live and archived.

Now that you’ve had a taste of what’s in the new regulations, perhaps you are ready to delve into the entire document and read the new regulations. Well, here’s a helpful hint from me to you. Don’t fret! While the document is quite lengthy, most of it is responses to comments. In the PDF version available from the Federal Register website, the actual regulatory language is contained in the last 24 pages (beginning at the very bottom of page 161, or FR page 68847). As you read, hopefully you, too, will be pleased to see the progress made in the journey to change the culture of aging for those individuals living in our nation’s nursing homes!