In addition, the rule requires providers to educate staff and residents about vaccines and their potential side effects, as well as document those education efforts and when shots are offered.

The Centers for Medicare & Medicaid Services’ new regulation became effective May 21. The reporting requirements apply to long-term care facilities and intermediate care facilities for individuals with intellectual disabilities.

The agency said the mandate was designed to monitor uptake and help identify facilities that need additional COVID-19 resources. It is also seen as a tool to enhance transparency.

As data becomes available, CMS will post facility-specific vaccination status information on its public-facing COVID-19 Nursing Home Data website.

CMS staffers encouraged providers to submit suggestions for particular cost-cutting methods during an Open Door Forum in late April. The agency’s SNF Prospective Payment System proposed rule for 2022 included plans to recalibrate PDPM’s parity adjustment after the agency found SNF spending under the new model increased by $1.7 billion.

Officials have previously acknowledged the rise could have been driven by COVID-19 and specifically called on providers to consider the pandemic’s impact on the PDPM adjustment. 

In some instances, CMS combined metrics to understand the payment model’s impact, said John Kane, technical advisor and SNF payment team lead for CMS.

“These are the kinds of things that we look at and do help to inform any sort of future policy development,” Kane said. “This is by no means to represent that we are fully done with our analysis of everything in relation to PDPM … But it’s also to indicate that we have done analyses, and that we do have a variety of analytics and metrics that we have been able to look at that have led us to question

A:We literally had staff coming to us conflicted. They wanted to get out there. They wanted to be part of the protests, but yet we were telling them, “It’s COVID. You need to stay safe.” A lot of our [diversity, equity and inclusion] initiatives started because of that. Now we’ve started our leadership program.

Q: How has your board worked to become more diverse and inclusive?

A:It’s an amazing story about being deliberate in this quest. For seven years, we’ve been trying to increase  board diversity. When faced with this issue last summer, we were stuck at a point where we had a full board complement, and we didn’t want to overfill the board. Larry Minnix, former CEO of Leading-Age, volunteered and stepped down [to free up a seat]. It’s a true story of good governance that will filter down.

Q: What’s a good first step for organizations launching their efforts?

A:The reality is we have to encourage diversity in our workplaces. The important thing is to do an organizational assessment. See where your biggest issues are. We may think we have a racist issue. It may be a LGBTQ issue. Or you may have an issue bigger in one department than another.

First of all, always follow your facility’s policies and procedures. Upon your orientation, this should have been reviewed with you.

In 2016, The National Pressure Ulcer Advisory Panel (NPUAP) revised the definition and stages of “pressure injury.” 

The revised staging system uses the term “injury” instead of “ulcer,” and it denotes stages using Arabic numerals rather than Roman numerals. 

Pressure injuries are classified and described through the use of staging systems. You must use the right one.

Only pressure injuries should be staged with the NPUAP Pressure Injury Staging System.

Diabetic foot ulcers use the Wagner Classification System, venous leg ulcers use the Clinical Etiology Anatomy Pathophysiology, skin tears use the International Skin Tear Advisory Panels assessment, adhesive or tape injuries use the Medical Adhesive Related Skin Injury categories (MARS) and burn classifications use total body surface area. It is essential that the intended staging or classification system be used for each type of injury to ensure appropriate treatment.

Since the NPUAP staging system is based on the extent of tissue damage, an understanding of anatomy is essential when evaluating the type of tissue present in the wound. 

In addition, NPUAP states, “In order to perform an accurate visual assessment, pressure injury staging should take place only after the wound bed has been cleansed.” 

Intertrigo is a common skin condition characterized by inflammation between opposing skin surfaces. Fungal skin infections (also known as candidiasis) can develop in areas of intertrigo and are more prevalent in warmer climates and in the summertime. 

Candidiasis often develops in skin folds, particularly under breasts, in the underarm area and in the groin area. These areas are prone to increased sweating and tend to be warm and moist, which encourages growth of candida. Moisture in skin folds also leads to maceration and breakdown of the skin, which can become infected with bacteria.

Patients with advanced age, obesity, diabetes, incontinence, immune disorders or immobility are at increased risk to develop candidiasis. Preventative measures and good skin care can minimize the risk of developing candidiasis.

Cleansing the skin with a pH-balanced skin cleanser (not antibacterial soap), careful drying (blotting) after bathing, and routine application of an emollient barrier cream, zinc oxide or talcum powder can help. Avoidance of unnecessary antibiotics also helps protect the skin’s normal bacteria, which normally prevents candida overgrowth. 

People prone to candidiasis may benefit from regular use of an antifungal powder or cream in affected areas. Skin folds can be separated by absorbent cotton fabrics but check regularly to prevent oversaturation. Keeping room temperatures comfortable and ensuring adequate air flow can decrease excessive sweating. Avoidance of tight clothing and synthetic fabrics and frequent incontinence brief changes also help. 

Candidiasis that persists after these preventative measures may need to be treated with an oral antifungal medication. People who have resistant candidiasis may require prolonged treatment.

— Answered by Mary P. Evans

On March 30, the SNF PEPPER Users Guide, Ninth Edition, was released, and it’s evident that SNF PEPPER target areas and supplemental reports will be changing over time to provide information related to potential vulnerabilities of the Patient Driven Payment Model, rather than the billing patterns that were vulnerable under the RUG system. 

SNFs were able to obtain their PEPPER on or about April 5, and new, PDPM-related target areas include:

• PDPM High Utilization codes — Claims where the first digit of the Health Insurance Prospective Payment System (HIPPS) code, representing the PT and OT component, is C, D, G, H, K, L, O or P. 

• 20-Day Episodes of Care 

• 90+ Day Episodes of Care 

• 3-5 Day Readmission (new in July 2020) — Readmissions to the same SNF for the same beneficiary

Are you an outlier? Relax! A high target area percent does not necessarily indicate the presence of improper payment or that the provider is doing anything wrong; however, you may want to review medical record documentation to ensure the services beneficiaries receive are appropriate and necessary, and to ensure documentation supports the care and services CMS reimbursed. 

Don’t forget to focus on appropriate diagnosis coding for I0020B and accurate assessment and reporting of Section GG items, as well as discharge planning to facilitate safe transitions, support appropriate lengths of stay, and avoid rehospitalizations. 

SNF PEPPER is available to CEOs, administrators, controllers and other executives through a secure portal at pepper.cbrpepper.org. 

The question is not will you be sued but will you be liable for damages. If an organization serving seniors follows all guidelines and procedures established by federal and state authorities to protect residents from contracting COVID, then the organization should not be liable for damages if sued by a family member. Showing that you complied with government-recommended procedures should lead to a court finding of no liability. Thus, if you followed all policies and procedures, you should be less likely to be sued and more likely to prevail if you are sued. 

A few residents recently believed they were missing money or jewelry from their rooms. I hate to say it, but some of our newer employees might be capable of pinching things. How can we tactfully (and legally) search their lockers and question them? No one wants to cast aspersions, but we also cannot let our reputation fly out the window.

An employee handbook should set forth all policies and procedures that apply to employees. That handbook would state that employees cannot steal from residents and that stealing will result in discipline, including termination.

The handbook also should expressly reserve to the employer the right to search the employee or the employee locker for any stolen or other inappropriate materials (such as drugs). If the search finds identifiable resident money or other resident property, then the employer, under the handbook, will have the right to discipline or discharge the employee. 

Many facilities have experienced census declines. Fewer elective surgeries means fewer admissions for post-operative care. That, coupled with concerns about facility-transmitted COVID-19, has dissuaded many who otherwise would have sought skilled nursing care. Here are four ways the nursing department can help rebuild the census:

Prioritize infection control. Educate on proper infection control and track improvements. After providing training on infection control precautions, monitor performance and use the data to demonstrate specific improvements to referral sources. For example, track staff compliance with proper donning and doffing of personal protective equipment (PPE) and highlight improvements post-education. 

Reduce facility-acquired infections. Sepsis remains a top reason for hospital readmissions. Facilities that demonstrate low or no infections are more attractive partners in the value-based care landscape. To achieve this, you must make accurate and timely assessment a priority. 

Specialize. While this may require infrastructure changes, facilities that provide high-quality care in a specific area are valuable to discharging entities. Some ideas include stroke care, respiratory care or other medically complex specialties that offer value. 

Don’t hold patients who are ready for the next discharge level. When census is low, there is incentive to keep patients, but this is unattractive to insurers and health systems using alternative payment models. Extending patient stays also hinders SNF quality measures. Instead, plan for discharge from admission and don’t let the overall census number alter the plan. 

“Keeping the brain and body engaged as much and for as long as possible is the best medication to combat use of psychoactive medications,” said Lori Newcomb, RPh, BCGP, geriatric pharmacist consultant at Guardian Pharmacy of Atlanta. 

iN2L CEO Lisa Taylor agreed.

“Connecting residents to meaningful experiences has been proven to engage and calm them, creating a positive intervention in situations where PRN medication might otherwise be used,” she said. 

Kim Blackmon, Pharm.D., a consultant pharmacist for Turenne PharMedCo, said confining resident activities to smaller “pods,” or groups should help residents ease back into routines safely, calmly and purposefully.

2. Tap into the vast array of non-pharmacologic therapies that stimulate the senses.

Chad Worz, PharmD, BCGP, chief executive officer of the American Society of Consultant Pharmacists, said sensory activities, such as watching movies, or tactile activities, including art therapy or gardening, can sometimes be more beneficial.

“If symptoms become harmful, these approaches may only serve to help alongside medications,” Worz added. 

Erin Foti, PharmD, BCGP, director of consulting services for Remedi SeniorCare, relies strongly on consultant pharmacists to reduce unnecessary medications. As “deprescribing advocates,” her pharmacists “look for non-pharmacological interventions.”

“While it is always important to consult with a medical professional, there is a growing body of research for herbs and their use in stress management,” said Joe Kramer, vice president of sales, Geri-Care Pharmaceuticals Corp.  These can include ashwagandha (Withania somnifera) and melatonin (for sleep).

3. COVID has required special considerations in seniors when dosing antipsychotics, according to experts.

“The decision to prescribe antipsychotic drugs needs to be considered with extreme caution, especially for residents residing in memory care,” said Justin Williams, OTD, CDP, HealthPRO Heritage vice president of clinical strategies. “Those with Alzheimer’s disease and dementia who take these types of medications are at an increased risk for stroke and even death.”

Worz stressed the adage of “start low and go slow.”

“It’s important to recognize that it takes six to eight weeks to see the full effect of many medications used in these situations,” he said.

4. Pharmacists roundly defend what they see as a judicious and prudent use of higher levels of antipsychotics during the pandemic.

“The pandemic stressed the long-term care industry to the max and long-term caregivers were heroic in many ways. Often, use of an antipsychotic is necessary to prevent harm,” said PharMerica’s Marti Wdowicki, PharmD, director of clinical operations-South.

Wdowicki added that engaging in alternative analysis with a multi-disciplinary team would be helpful. Crisis management protocols with respect to antipsychotic prescribing could include specific criteria for appropriate use and a method for tapering and discontinuation post crisis.

As the environment returns to pre-pandemic, Wdowicki said providers need to re-visit and re-evaluate their medication regimens and “set a specific cadence” for potential tapering and discontinuation.

“A ‘set it and forget it’ mindset is the nemesis of antipsychotic medication management best practice,” she said.

“It comes down to clear diagnosis,” said Worz. “People with dementia and behavioral issues can be pleasant and non-threatening, but they can also progress to be harmful.

“There are a number of nonpharmacologic approaches that can be tried. The key is to be very patient-centric in these approaches as there are no non-pharmacologic approaches that work for everyone.”

5. Going forward, the lessons of the pandemic should provide evidence that prescribers approached the use of psychotropic medications with the same prudence and caution they began with.

“I don’t think anyone was ready for the isolation and the length of time people would be isolated and restricted from visitors,” said Worz. “That said, we should be more experienced going forward and work to learn what things did work during the pandemic and what we could have done sooner to reduce the negative consequences of those kinds of strategies.”

“When looking back to help drive psychotropic medication reduction efforts, it’s incumbent for the LTC community staff to stay engaged with the pharmacy that serves their residents,” added Newcomb.