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Requirements of Participation: Preparing for Phase 3

Phase 3 of the RoPs went into effect on November 28, 2019. AHCA has developed resources to help you navigate the new requirements. AHCA will continue to add and update these resources as more information becomes available and after CMS issues interpretive guidelines for Phase 3. 

New & Popular Now

  • Water Management Training

    Contains 4 Component(s)

    Post-acute and long-term care facilities provide care and services to vulnerable populations who may become critically ill when steps are not taken to reduce the risk of waterborne diseases. Healthcare facilities are integral to the health and well-being of the communities and residents they serve. In order to maintain daily operations and care services, healthcare facilities need to develop an effective water management plan to prepare for, respond to, and recover from a total or partial interruption of the facility’s normal water supply. The water management course will provide post-acute and long-term care facilities with information on what a water management plan is, how to identify the elements of an effective water management program, and how to develop and maintain a comprehensive water management program in your facility.

    Post-acute and long-term care facilities provide care and services to vulnerable populations who may become critically ill when steps are not taken to reduce the risk of waterborne diseases. Healthcare facilities are integral to the health and well-being of the communities and residents they serve. In order to maintain daily operations and care services, healthcare facilities need to develop an effective water management plan to prepare for, respond to, and recover from a total or partial interruption of the facility’s normal water supply. The water management course will provide post-acute and long-term care facilities with information on what a water management plan is, how to identify the elements of an effective water management program, and how to develop and maintain a comprehensive water management program in your facility. 

    Audience: appropriate for both NF, as is required by regulation, and as best practices for AL.

    Module Outcomes:

    1. Describe what a water management plan is.
    2. Identify elements of an effective water management program.
    3. Discuss how to develop and maintain a comprehensive water management program for your facility.

    Pamela Truscott, MSN, RN, DNS-CT, QCP

    Senior Manager, Clinical and Regulatory Services with the American Health Care Association

    Pamela Truscott, MSN, RN, DNS-CT, QCP is the Senior Manager, Clinical and Regulatory Services with the American Health Care Association (AHCA).  She joined the AHCA family in June 2019 and has been actively involved with a variety of education, tools and resources such as: trauma-informed care, behavioral health, functional outcomes improvement, and infection prevention and control.  Prior to joining AHCA, Pam worked for the Nebraska Health Care Association as the Vice President of Professional Development for seven years.  She is an active member in the American Nurses Association as well as the American Association of Post-Acute Care Nurses.  Pam has over 20 years of long-term care experience and shares a passion for growing education and cultivating new leaders in long-term care.  

    Linda Behan, BSN, RN, CWCN, CIC

    Sr. Director of Infection Prevention and Control, Genesis HealthCare

    Linda Behan BSN, RN, CIC is the Corporate Senior Director of Infection Prevention and Control for Genesis HealthCare.  Linda has been certified in infection prevention and control for over 10 years. She leads a team of Infection Preventionists in developing policies and procedures as well as developing and delivering education across the company.  Linda serves on the APIC Professional Development Committee and frequently presents at healthcare and professional organization conferences.

  • Life Safety Tips

    Contains 1 Component(s)

    The tips are for individual deficiencies which have been frequently cited across the U.S. The tips provided are intended for reference only. If you have further questions, refer to the applicable NFPA Code manuals and/or please contact regulatory@ahca.org.

    The Centers of Medicare and Medicaid (CMS) require participating skilled nursing facilities to comply with the requirements of the National Fire Protection Association 101-2012 Edition, commonly referred to as the Life Safety Code (LSC) as well as the NFPA 99 – 2012 edition known as the Health Care Facilities Code.  These codes are a comprehensive set of requirements, which provide nursing home residents a high level of safety and security due to the nature of illness, impairment and the inability to self-evacuate in an emergency.

    There are specific occupancy chapters of the LSC which apply to your center.  Facilities certified originally before July 5, 2016 are considered existing and Chapter 19 applies.  Facilities that have been certified after July 5, 2016 are addressed as new facilities and then Chapter 18 applies.  The Life Safety and Health Care Facilities Codes themselves are not all inclusive and often reference other editions of NFPA codes.

    A number of issues have arisen based on the requirements of the NFPA 99, Health Care Facilities Code.  NFPA 99 establishes criteria for systems in nursing facilities such as gas and vacuum, electrical, etc. The requirements, however, generally are applied only to new construction and new equipment. Several chapters begin with specifying which criteria are applicable to existing facilities. Generally, existing facility systems are permitted to remain, even if they are not in strict compliance with the code, unless the authority having jurisdiction determines that their continued use constitutes a distinct hazard to life. If facilities are consider altering, modernizing or replacing equipment, the ‘new’ system or individual component are required to meet the installation and equipment requirements stated in NFPA 99.

    The tips are for individual deficiencies which have been frequently cited across the U.S.  The tips provided are intended for reference only. If you have further questions, refer to the applicable NFPA Code manuals and/or please contact regulatory@ahca.org. 

  • Provider Self-Assessment and Mitigation Tools for Resident to Resident Occurrences

    Contains 3 Component(s)

    It is critical for nursing centers and assisted living communities to address and mitigate resident-to-resident occurrences or potential incidents of resident-to-resident mistreatment. While mistreatment may or may not meet the definition of abuse, it would include negative and aggressive physical, sexual, or verbal interactions between long-term care residents that is unwelcome and have high potential to cause physical or psychological distress in the recipient.

    Click the image button found in the upper right corner of your screen 

    OR 

    Follow these three easy steps below! 

     

    Step 1

    image

    Click the orange log in button in the upper left hand corner.

    Use your user name and password that you would use for LTC Trend Tracker or the AHCA NCAL website.  

    Don’t have an account or can’t remember?

    Click the CREATE ACCOUNT button.

    Non-members can create an account with your first, last name and email. 

    AHCA/ NCAL Members - *Please note* you must add your member facility name to your login

    Once you are in and can see your name in the upper left hand corner, you are ready to go!

    Step 2

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    From the home page click on a category (Resources, Training, Webinars or On-Demand Training) For this demonstration, let’s try Webinars- Upcoming Live

    On the “upcoming webinars” page go to a product in which you are interested. Click the green REGISTER button.

    Or click the title of the webinar and you will be redirected to the page where you can view the overview, handouts or resources associated with that product. You can also click REGISTER in the upper right hand corner. The content will be available in your dashboard

    Step 3

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    Almost there!

    If the resource you are trying to access is a paid-for product, fill out the registration details and voila! The products are yours to use and can be found in your dashboard.

    Need further help? Email us at educate@ahca.org

    We’ll walk you through it.

     

    It is critical for nursing centers and assisted living communities to address and mitigate resident-to-resident occurrences or potential incidents of resident-to-resident mistreatment. While mistreatment may or may not meet the definition of abuse, it would include negative and aggressive physical, sexual, or verbal interactions between long-term care residents that is unwelcome and have high potential to cause physical or psychological distress in the recipient.

    Objectives:

    1. Conduct a thorough investigation with proper documentation, follow up, and monitoring and care planning as needed.  
    2. Create a structured self-assessment process to address the resident-to-resident occurrence and minimize or mitigate similar events for all residents. This includes a need to:
      • Document immediate interventions;
      • Conduct a root cause analysis process to identify the specific/source, root cause or causal factor of the problem; and 
      • Identify future actions to ensure sustained efforts to identify and prevent potential resident-to-resident mistreatment.
    3. Identify existing AHCA/NCAL resources to support providers in addressing resident-to-resident mistreatment. 


    Note: These tools were developed by members of AHCA/NCAL’s Survey/Regulatory Committee to assist centers and communities in addressing adverse events and potential adverse events, documenting and tracking the steps they have taken, and identifying best practices for ongoing improvement. Use of these tools does not guarantee regulatory compliance nor mitigate potential liability. Providers should adapt their tools, policies, and processes as needed to ensure compliance with current federal and state requirements and use both professional judgement and the advice of legal counsel in determining whether or how to share these mitigation tools.

  • Proposed Rule on Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency and Transparency

    Contains 2 Component(s)

    Member Webinar on Proposed Rule on Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency and Transparency

    image

    How to Register in ahcancalED 

    Easy as 1, 2, 3 !

    click the image button found in the upper right corner of your screen or follow these three easy steps below! 

     

    Step 1

    image

    Go to the ahcancalED site at https://educate.ahcancal.org/and log in using the orange button in the upper left hand corner.

    Use your usual user name and password that you would use for LTC Trend Tracker or the AHCA NCAL website.  


    Don’t have one or can’t remember?

    Click the log in button and follow the directions found under the search button that reads-“If you need help retrieving your Username or Password, click here”.

    *Please note* you must add your member facility name to your login


    Once you are in and can see your name in the upper left hand corner, you are ready to go.

    Step 2

    image

    From the home page click on a category (Resources, Training, Webinars or Trending Now) For this demonstration, let’s try hovering over Webinars until upcoming webinars displays. 

    Under “upcoming webinars” go to a product in which you are interested. Click on the title.

    You’ll be redirected to the site where you can register for the product. This allows you to view the overview, handouts or resources associated with that product.

    Step 3

    image

    Almost there!

    Click the green register button.

    Fill out the registration details and voila! The products are yours to use indefinitely and can be found in your dashboard.

    FYI: after registering, you will be automatically notified when the recording of the webinar is ready.


    Need further help? Email us at educate@ahca.org

    We’ll walk you through it.

     

    On July 16, the Centers for Medicare and Medicaid Services (CMS) issued the proposed rule that is intended to ease some of the administrative and paperwork burdens of the Requirements of Participation (RoPs). Click here for a full detailed summary.

    The proposed rule provides a 60-day public comment period that allows AHCA and all of you an opportunity to submit comments to CMS in support of proposed changes that will reduce administrative paperwork burden on your centers and to provide targeted feedback on areas where CMS has asked for additional information and insight, or areas that you believe have the biggest impact on your ability to provide quality care to your residents. We will share additional details on how you can support these proposals via the public comment process.

    Speakers:

    Dr. David Gifford, AHCA SVP of Quality and Regulatory Affairs and Chief Medical Officer

    Holly Harmon, AHCA Vice President of Quality, Regulatory & Clinical Services

    Sara Rudow, AHCA Senior Director of Regulatory Services

    If you have any questions, please send them to regulatory@ahca.org.

  • Compliance and Ethics Program (Phase 3) – 42 CFR § 483.85

    Contains 15 Component(s)

    As part of the Requirements of Participation (RoP) Phase 3, nursing centers must have a Compliance and Ethics Program that meets specified requirements. Starting November 28, 2019, CMS and state survey agencies will be authorized to issue survey deficiencies under federal Ftag F895 to centers that do not have an effective compliance program.

    image

    How to Register in ahcancalED 

    Easy as 1, 2, 3 !

    click the image button found in the upper right corner of your screen or follow these three easy steps below! 

     

    Step 1

    image

    Go to the ahcancalED site at https://educate.ahcancal.org/and log in using the orange button in the upper left hand corner.

    Use your usual user name and password that you would use for LTC Trend Tracker or the AHCA NCAL website.  


    Don’t have one or can’t remember?

    Click the log in button and follow the directions found under the search button that reads-“If you need help retrieving your Username or Password, click here”.

    *Please note* you must add your member facility name to your login


    Once you are in and can see your name in the upper left hand corner, you are ready to go.

    Step 2

    image

    From the home page click on a category (Resources, Training, Webinars or Trending Now) For this demonstration, let’s try hovering over Webinars until upcoming webinars displays. 

    Under “upcoming webinars” go to a product in which you are interested. Click on the title.

    You’ll be redirected to the site where you can register for the product. This allows you to view the overview, handouts or resources associated with that product.

    Step 3

    image

    Almost there!

    Click the green register button.

    Fill out the registration details and voila! The products are yours to use indefinitely and can be found in your dashboard.

    FYI: after registering, you will be automatically notified when the recording of the webinar is ready.


    Need further help? Email us at educate@ahca.org

    We’ll walk you through it.

     

    ** In July 2019, CMS proposed several changes that would affect the compliance and ethics section in the Requirements of Participation, including delaying implementation of this requirement for a year from the date the rule is finalized. AHCA recommends providers continue implementing the requirement because it is unknown if or when CMS will finalize the proposal. As of now, the regulations still require providers be in compliance as of November 28, 2019. AHCA will continue to closely monitor and notify members when any changes are finalized. **

    As part of the Requirements of Participation (RoP) Phase 3, nursing centers must have a Compliance and Ethics Program that meets specified requirements. Starting November 28, 2019, CMS and state survey agencies will be authorized to issue survey deficiencies under federal Ftag F895 to centers that do not have an effective compliance program.

    AHCA has created a webinar series and resources to support members in developing or adapting their existing program to meet this requirement. Although the interpretive guidelines have not yet been published (as of September 2019), the RoP Compliance and Ethics Program stems from the Office of Inspector General’s (OIG) long-standing guidance for the 7 elements of a compliance program. The numbering and titling of the specific elements within an effective Compliance and Ethics Program can be different, yet the content generally remains the same, with a few specific additions in the RoP. So even though CMS has not yet released guidance for the Compliance and Ethics Program, reviewing existing OIG resources will support a nursing center to develop an effective compliance program overall. This webinar series and the AHCA toolkit offers tools and distills the information into a webinar series to provide practical explanation and tips for how to create or update your compliance program.

     This webinar series are presented by various compliance experts. It includes:

    • Overview
    • A different session on each of the 7 elements for an effective compliance program and how this fits in with the RoP Compliance and Ethics Program
    • The Interdependence between Compliance, Ethics and Quality
    • What Administrators and Compliance Liaisons Need to Know
  • Assisted Living Action Plan Response for Adverse Events

    Contains 5 Component(s)

    It is critical to address and mitigate adverse events and potential adverse events. An action plan, otherwise known as a mitigation plan, is a necessary response to adverse events and potential adverse events. For many such events, it is important to respond and start the mitigation process immediately. These tools were initially developed by members of AHCA’s Survey/Regulatory Committee and adapted for assisted living communities to assist providers in addressing adverse events and potential adverse events, documenting and tracking the steps they have taken, and identifying best practices for ongoing improvement. Communities may use different titles or terms than the action plans, such as Director of Health Services instead of Director of Nursing, or service plan instead of care plan. Please adapt the plans to reflect your AL community. Use of these tools does not guarantee regulatory compliance nor mitigate potential liability. Providers should adapt their tools, policies, and processes as needed to ensure compliance with current federal and state requirements and use both professional judgement and the advice of legal counsel in determining whether or how to share these mitigation tools.

    image

    How to Register in ahcancalED 

    Easy as 1, 2, 3 !

    click the image button found in the upper right corner of your screen or follow these three easy steps below! 

     

    Step 1

    image

    Go to the ahcancalED site at https://educate.ahcancal.org/and log in using the orange button in the upper left hand corner.

    Use your usual user name and password that you would use for LTC Trend Tracker or the AHCA NCAL website.  


    Don’t have one or can’t remember?

    Click the log in button and follow the directions found under the search button that reads-“If you need help retrieving your Username or Password, click here”.

    *Please note* you must add your member facility name to your login


    Once you are in and can see your name in the upper left hand corner, you are ready to go.

    Step 2

    image

    From the home page click on a category (Resources, Training, Webinars or Trending Now) For this demonstration, let’s try hovering over Webinars until upcoming webinars displays. 

    Under “upcoming webinars” go to a product in which you are interested. Click on the title.

    You’ll be redirected to the site where you can register for the product. This allows you to view the overview, handouts or resources associated with that product.

    Step 3

    image

    Almost there!

    Click the green register button.

    Fill out the registration details and voila! The products are yours to use indefinitely and can be found in your dashboard.

    FYI: after registering, you will be automatically notified when the recording of the webinar is ready.


    Need further help? Email us at educate@ahca.org

    We’ll walk you through it.

     

    It is critical to address and mitigate adverse events and potential adverse events. An action plan, otherwise known as a mitigation plan, is a necessary response to adverse events and potential adverse events. For many such events, it is important to respond and start the mitigation process immediately.

    Examples of adverse events/potential adverse events include:

    • Falls (not following the care plan, use of gait belt, one vs. two-person transfers)
    •  Falls with a mechanical lift
    •  Elopement
    •  Allegation of abuse or neglect
    •  Water too hot
    •  Smoking (supervised vs. unsupervised, with oxygen, defined smoking area, all about safety)
    •  Bedrails (entrapment, assessment for use)
    •  Significant medication errors such as cardiac medications, chemo, insulin, morphine, Coumadin
    •  Infection Control – outbreaks (e.g. scabies, bedbugs, MRSA, C-Difficile, Noro Virus, Legionella)
    •  Lack of timely or complete evaluation of a change in condition
    •  Pressure ulcer – lack of prevention or following prevention measures
    •  Grievances and resident/tenant council feedback

    Objectives:

    1. Identify adverse events that could potentially have a negative impact on residents/tenants as well as on a community’s regulatory compliance.   
    2.  Establish a routine root cause analysis process to identify the specific/source, root cause or causal factor of the problem.  
    3.  Create a structured process for developing a mitigation plan to address the adverse event/potential adverse event and minimize similar events for all residents/tenants:
      1. Complete the Initial Mitigation Action Plan 
      2. QAPI members complete the formal documentation of the Mitigation Action Plan
    4.  Use information learned by sharing results and Plan with the QAPI committee for continued monitoring.

    Note: These tools were initially developed by members of AHCA’s Survey/Regulatory Committee and adapted for assisted living communities to assist providers in addressing adverse events and potential adverse events, documenting and tracking the steps they have taken, and identifying best practices for ongoing improvement. Communities may use different titles or terms than the action plans, such as Director of Health Services instead of Director of Nursing, or service plan instead of care plan. Please adapt the plans to reflect your AL community. 

    Use of these tools does not guarantee regulatory compliance nor mitigate potential liability. Providers should adapt their tools, policies, and processes as needed to ensure compliance with current federal and state requirements and use both professional judgement and the advice of legal counsel in determining whether or how to share these mitigation tools. 

    You are also encouraged to register for the following free resource: 

    Tools to Prevent and Address Resident to Resident Mistreatment

  • Nursing Centers Action Plan Response for Adverse Events

    Contains 5 Component(s)

    It is critical for nursing centers and assisted living communities to address and mitigate adverse events and potential adverse events. An action plan, otherwise known as a mitigation plan, is a necessary response to adverse events and potential adverse events. For many such events, it is important to respond and start the mitigation process immediately. These tools were developed by members of AHCA’s Survey/Regulatory Committee. Use of these tools does not guarantee regulatory compliance; nursing centers should adapt as needed to ensure compliance with current federal and state requirements. They are not intended as legal advice and should not be used or relied upon as legal advice.

    image

    How to Register in ahcancalED 

    Easy as 1, 2, 3 !

    click the image button found in the upper right corner of your screen or follow these three easy steps below! 

     

    Step 1

    image

    Go to the ahcancalED site at https://educate.ahcancal.org/and log in using the orange button in the upper left hand corner.

    Use your usual user name and password that you would use for LTC Trend Tracker or the AHCA NCAL website.  


    Don’t have one or can’t remember?

    Click the log in button and follow the directions found under the search button that reads-“If you need help retrieving your Username or Password, click here”.

    *Please note* you must add your member facility name to your login


    Once you are in and can see your name in the upper left hand corner, you are ready to go.

    Step 2

    image

    From the home page click on a category (Resources, Training, Webinars or Trending Now) For this demonstration, let’s try hovering over Webinars until upcoming webinars displays. 

    Under “upcoming webinars” go to a product in which you are interested. Click on the title.

    You’ll be redirected to the site where you can register for the product. This allows you to view the overview, handouts or resources associated with that product.

    Step 3

    image

    Almost there!

    Click the green register button.

    Fill out the registration details and voila! The products are yours to use indefinitely and can be found in your dashboard.

    FYI: after registering, you will be automatically notified when the recording of the webinar is ready.


    Need further help? Email us at educate@ahca.org

    We’ll walk you through it.

     

    It is critical for nursing centers and assisted living communities to address and mitigate adverse events and potential adverse events. An action plan, otherwise known as a mitigation plan, is a necessary response to adverse events and potential adverse events. For many such events, it is important to respond and start the mitigation process immediately.

    Examples of adverse events/potential adverse events include:

    • Falls (not following the care plan, use of gait belt, one vs. two-person transfers)
    • Falls with a mechanical lift
    • Elopement
    • Allegation of abuse or neglect
    • Water too hot
    • Smoking (supervised vs. unsupervised, with oxygen, defined smoking area, all about safety)
    • Bedrails (entrapment, assessment for use)
    • Significant medication errors such as cardiac medications, chemo, insulin, morphine, Coumadin
    • Served/consumed wrong consistency of food or liquids
    • Infection Control – outbreaks (e.g. scabies, bedbugs, MRSA, C-Difficile, Noro Virus, Legionella)
    • Fluid restriction not managed or monitored by facility, physician parameters not followed
    • Lack of timely or complete assessment of a change in condition
    • Pressure ulcer – lack of prevention or following prevention measures
    • Grievances and resident council feedback

    Objectives:

    1.  Identify adverse events that could potentially have a negative impact on residents as well as on a center’s regulatory compliance.   
    2.  Establish a routine root cause analysis process to identify the specific/source, root cause or causal factor of the problem.  
    3.  Create a structured process for developing a mitigation plan to address the adverse event/potential adverse event and minimize similar events for all residents:
      •  Review the guidance for determination of avoidable versus unavoidable event
      • Complete the Initial Mitigation Action Plan
      • QAPI members complete the formal documentation of the Mitigation Action Plan
    4. Use information learned by sharing results and Plan with the QAPI committee for continued monitoring.

    Note: These tools were developed by members of AHCA’s Survey/Regulatory Committee to assist centers and communities in addressing adverse events and potential adverse events, documenting and tracking the steps they have taken, and identifying best practices for ongoing improvement. Use of these tools does not guarantee regulatory compliance nor mitigate potential liability. Providers should adapt their tools, policies, and processes as needed to ensure compliance with current federal and state requirements and use both professional judgement and the advice of legal counsel in determining whether or how to share these mitigation tools. 

    You are also encouraged to register for the following free resource: 

    Tools to Prevent and Address Resident to Resident Mistreatment

Action Briefs, Tools and Webinars

The library below is a living repository of tools and resources to help you navigate the Requirements of Participation. It contains an array of documents divided into three categories:

  • ACTION BRIEFS - provide highlights, specific information, tips and resources about a particular topic
  • Tools - are an instrument designed to assist you in implementing the requirements
  • Webinars - are an array of communications from AHCA to assist you in learning and mastering the new requirements

The Quality Team has a plan in place to deliver these topics to you in a regular and steady fashion. Be sure to return often to see the newest materials.

AHCA/NCAL Publications

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NCAL AHCA