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LIBRARY- Requirements of Participation

Greetings Members:

The library 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, TOOLS, and WEBINARS.

  • COMING SOONTackle Your Top Tags Series
  • ACTION BRIEFS - provide highlights, specific information, tips and resources about a particular topic
  • Tools - are an instrument designed to assist you in implementing the requirement
  • 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.


Action Briefs


Tools

  • Accompanying Residents at Discharge or Transfer §483.15(c)(2)

    Purpose & Intent of §483.15(c)(2): To improve care coordination by providing information to the receiving health care organization and provider that can help them provide quality care to the resident.

  • Admission, Transfer, and Discharge Rights §483.15(c)(1)

    Purpose & Intent: To provide documentation that a physician has determined a discharge or transfer is necessary.

  • AHCA Toolkit: ROP Compliance and Ethics Program

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    How to Register in ahcancalED 

    Easy as 1, 2, 3 !

     

    Step 1

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    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

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    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

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    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.

     

    Starting November 28, 2019, nursing centers must have a Compliance and Ethics Program that meet the standards outlined in the Requirements of Participation. Creating an effective program requires advanced planning to have in place the appropriate staff, training, and policies and procedures. This toolkit is a concise summary of the requirements with helpful, practical tips for implementation. It also pulls in best practices from a variety of sources to support providers in building or improving their program. While we wait for interpretative guidelines to provide additional clarity, the information in this toolkit will help providers plan for phase 3 implementation.

    This toolkit is intended for:

    • All nursing homes that must comply with the requirements of participation

    AHCA contracted with Post and Schell to draft this toolkit. Their attorneys have extensive experience representing governmental, proprietary and not-for-profit post-acute and long-term care clients on matters involving a full scope of operational, regulatory and compliance matters

  • Comprehensive Person-Centered Care Planning §483.21

    Purpose & Intent: To develop a baseline care plan within 48 hours of admission to direct the care team while a comprehensive care plan is developed that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

  • Discharge Planning Process - §483.21(c)(1)_Tool

    Purpose & Intent §483.21(c)(1): To develop a discharge plan to help as many residents who want to return back to the community, to be effectively discharged from the nursing center back to the community.

  • Facility Assessment Elements (Phase II) - § 483.70 Administration_Tool

    Purpose & Intent of § 483.70: Facilities need to know themselves, their staff, and their residents.

  • Infection Prevention & Control § 483.80 _Tool

    Purpose & Intent of § 483.80: Designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

  • Infection Preventionist Role & Competencies Tool

    Purpose & Intent of §483.80: Designated Infection Preventionist (IP) Role & Competencies. 

    CMS requires each center to designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the center’s Infection Prevention and Control Program.** 

    AHCA has outlined information for centers to consider when developing the role of the Infection Preventionist.

  • Integrating the Requirements of Participation into Your Community Morning Meeting/Routine Monitoring Practices/Audits/QAPI Process

    This tool was created by the AHCA Survey & Regulatory Committee, with input from AHCA staff. The intent of this tool is to support Administrators, Directors of Nursing and the Interdisciplinary Team members with integrating the new CMS Requirements of Participation (RoP) into community practices. Although extensive, this checklist can be used to assist a community with RoP compliance, the AHCA Quality Awards journey, and potentially to increase CMS Five-Star ratings.

    For communities with a new Interdisciplinary Team, this tool may be used daily. As the team becomes familiar with the requirements, this tool may be used for auditing purposes and QAPI processes. For example, the Administrator could choose a section to review each day and cycle through it a few times until it becomes routine. Team members would become aware of requirements that are their responsibility and would be able to bring that information to the morning meeting, or to track and trend. Identified areas for improvement may be integrated into the QAPI program. Note that this is not an exhaustive list of requirements but is a guide to support daily operations and longer-term planning within your community.

    This tool can be used for the following:

    • Agenda for Morning Meeting
    • Assign sections to specific members of Interdisciplinary Team to report on
    • Pathway to create auditing tools
    • Review for QAPI Meetings
    • A checklist for survey preparedness
  • Learning from Julie Jones: A Case Study

    Learn from the story of Ms. Julie Jones to gain a better understanding of systems and process improvement, person-centered care and various Phase II requirements. 

    This story is presented in four parts in the PDF document.  Intended approach is to pause after reading each part of the story, discuss what you just read with your team, consider what stands out to you as flags or key information and think about how you would approach each of the areas listed in the bullet points under the story part.  Move on to the next part and repeat process.  Share your thoughts, concerns, ideas with your colleagues and think about how your collective learning from the story of Ms. Julie Jones can inform your own center’s systems and process improvement efforts.

    You can use the PowerPoint slides to supplement this activity and guide discussion. 

  • Member Sharing: Antibiotic Stewardship Program

    Resource shared by Genesis HealthCare that uses the CDC Core Elements of Antibiotic Stewardship for Nursing Homes. 

  • Member Sharing: Legionella Prevention and Water Management

    Legionnaires’ disease is caused by a type of bacterium called Legionella. Those at risk include persons who are at least 50 years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains.

     CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.  There are several resources to support your efforts in developing these prevention and management systems and processes. 

  • Member Sharing: Resident Rights and Facility Obligations in the RoPs

    This is a resource shared by the Pennsylvania Health Care Association outlining resident rights in the RoPs along with corresponding facility obligations in Sections 483.10 and 483.12.

  • Mr. McNally Cardset

    A case study about a resident who came into a nursing home for short-term rehab after a stroke. He declined rapidly in ways there were avoidable. Originally developed by B&F Consulting for Improving the Nursing Home Culture Pilot by Quality Partners of Rhode Island. 

  • QAPI Detailed Checklist (Phase 1) - § 483.75

    Purpose & Intent of § 483.75: To develop, implement, and maintain an effective comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care, and quality of life.

  • The Requirements of Participation and Baldrige Connection

    In implementing the Requirements of Participation (RoP), AHCA encourages member providers to take a step back and look at the big picture. At its core, the RoP are tied together by three key themes that focus on knowing your residents, your staff, and your center. Check this resource out to learn more! 

  • The Requirements of Participation and Baldrige Criteria

    This document contains a crosswalk of the Baldrige Criteria and the Requirements of Participation. 

  • Tool: Exercise on QAPI team – hi-low performing team

    Helps you determine the differences between high performing and low performing QI teams. 


Webinars and Presentations

  • What a CEO Needs to Know about the New Regulations

    This three part series is presented by Dr. David Gifford, Senior VP of Quality & Regulatory Affairs of AHCA/NCAL. This series will break down what an owner or CEO needs to know about the new regulations: 

    Part 1: Overview and key themes in the new regulations
    Part 2: Overview of the new survey process that goes into effect in November 2017
    Part 3: Provides key questions you want to ask your management to make sure your organization is ready for the new regulations

    REMINDER: This content is an exclusive member benefit, free to members. Please be sure to login to ahcancalED with your ahca username and password in order to receive access to this series. If you need additional assistance, please email educate@ahca.org

    David Gifford, MD, MPH

    Senior Vice President of Quality and Regulatory Affairs, AHCA

    David Gifford, MD, MPH, is a geriatrician and former medical director of several nursing homes in Rhode Island. He currently serves as the Senior Vice President of Quality and Regulatory Affairs at the American Health Care Association. He helped create the Quality Department at AHCA which assists providers in their quality improvement efforts and works with administration officials on regulations and policies impacting the profession. Dr. Gifford also serves on the Board of the Advancing Excellence in America’s Nursing Homes campaign and the Baldrige Foundation Board. He is a former Director of the Rhode Island State Department of Health, where he received the National Governor’s award for Distinguished Service Award for State Officials. Prior to that he served as Chief Medical Officer for Quality Partners of Rhode Island where he directed CMS’ national nursing home-based quality improvement effort. He also holds a faculty appointment at Brown University Medical School and School of Public Health. He received his medical degree from Case Western Reserve University and conducted his geriatric fellowship at UCLA where he also earned his Master’s in Public Health while a Robert Wood Johnson Clinical Scholar. 

  • Preparing for the New Survey Process and Requirements of Participation Phase 2

    November 28, 2017 is a significant date for all nursing centers. That Tuesday marks (1) the implementation of Phase 2 of the Requirements of Participation, (2) all new F-Tag numbers, (3) new interpretive guidance, and (4) a brand-new annual survey process.  This might result in many providers feeling anxious and overwhelmed. This webinar will provide information on what to expect in the new survey process; updates on materials available from CMS; AHCA tools and resources available to help you understand and implement new Phase 2 requirements such as the Facility Assessment; and guidance on how to access AHCA tools and resources.
     
    Learning Objectives

    1. Participants will review key elements of the new survey process and be prepared for the changes that will be implemented on Nov. 28, 2017.
    2. Participants will recognize tools and materials available from AHCA to help centers implement Phase 2 requirements and will understand how to access AHCA tools and resources on ahcancalED.
    3. Participants will understand the importance of using a framework focused on the intent and purpose of the requirements to help centers navigate successfully through these changes.
  • Staff Competencies and the Facility Assessment for Independent Owners

    The implementation date for the facility assessment requirement in the Requirements of Participation is November 28, 2017. This webinar will provide Independent Owners (IOs) with an overview of the facility assessment and staff competencies requirements and offer suggestions aimed to help IOs get started on these new requirements.  This Phase 2 requirement touches upon many aspects of managing your center, including understanding the care needs of residents based on their acuity, conditions, and other factors, and reviewing your center’s resources including buildings, equipment, and services provided. A key component of the facility assessment is identifying the staff competencies needed to provide the level and types of care to meet the needs of residents in your center.

    Learning Objectives:

    1. Identify the facility assessment and staff competencies provisions in the Requirements of Participation.
    2. Recognize existing data in their nursing center that is applicable for completion of the facility assessment.
    3. Assess and update their center’s staff competency assessment process in accordance with the new requirements.

    Speakers

    Janet Snipes, NHA
    Holly Heights Nursing Center

    Sara Rudow, MPA
    Director of Regulatory Services
    AHCA

  • Requirements of Participation

    Please note, there will be second offering of this program on Wednesday, October 5th from 3-4pm ET if you are unable to attend this program. You may register for the October 5th program here.


    The final rule for the new Requirements of Participation has been released and AHCA will provide a briefing about the changes. This briefing will provide a high-level overview of the more than 700-page final rule. There is a 3 year Phase-In of the requirements and we will focus on the portions of the rule that are in Phase 1. Following our presentation there will be a Question and Answer period.


    Presenters:

    Mark Parkinson
    David Gifford
    Lyn Bentley


AHCA/NCAL Publications

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