NEW ORLEANS — Nursing home operators can expect long-awaited final guidance on Phase 3 Requirements of Participation “very, very soon,” the federal government’s top skilled nursing official said Tuesday.
The release of detailed rules covering the mandatory use of infection control preventionists and Quality Assurance and Performance Improvement (QAPI) programs will be among the new material, said Evan Shulman, director of the nursing home division at the Centers for Medicare & Medicaid Services. He spoke live by remote video to attendees at the 35th national NADONA conference in New Orleans.
New Phase 3 guidance, which has been on delayed implementation since late 2019, also will dictate actions concerning involuntary discharges, trauma-informed care, arbitration agreements, abuse allegations, mental health and the inappropriate use of antipsychotics.
Shulman returned often to the theme of trying to get back to “normal” after contending with the height of pandemic conditions.
“We are very, very close to releasing this guidance. Very close,” he told his audience of nursing directors. “Even though we haven’t released guidance on [infection preventionists] yet, everyone in that room should have an infection preventionist in their facility.”
“We’re going to go into more detail in the guidance to make sure that everyone knows how to make sure the infection preventionist has all the tools they need to ensure your facility has an effective infection prevention and control program, which is your responsibility,” he added. “But you should all have an infection preventionist working with your staff right now.”
In 2017, providers were required to have a QAPI plan in place under Phase 2 of the sweeping new Requirements of Participation (ROP), which dictate conditions for receiving federal reimbursements. Phase 1 stipulations of ROP were put into play in 2016.
In 2019, Phase 3, which called for actual QAPI implementation among other provisions, was delayed. It has been on hold since, pending CMS’s final release of updated guidance.
Other parts of Phase 3 also have received significant attention over the last several years and figure to reignite interest again.
One of them is the issue of arbitration agreements in resident admissions agreements. Shulman didn’t go into great detail about what new guidance would highlight, but he reminded Tuesday’s crowde that “arbitration agreements can be offered, but they cannot be offered as a condition of admission or as a condition to receive care at a facility.”
He next noted that involuntary discharges will be addressed in the upcoming guidance. They are the “No. 1 complaint” the agency hears from state ombudsmen.
“And it’s not No. 1 by a little bit,” he said. “It’s also something that the Inspector General of the GAO (General Accounting Office) holds us responsible for taking a closer look at. We’re not saying you can’t discharge but there are requirements that need to be followed for a safe and orderly discharge in order to be compliant.”
Mental health, substance abuse get focus
Shulman said that every year his staff learns of more residents being admitted with mental health and substance abuse issues.
“We hear all sorts of things about residents hiding things (drugs) and what do you do if they’re hiding things or leave (the facility) and come back. These are things we’re hoping to address in the guidance … about how to navigate these situations.”
He implored providers accepting mental health and substance abuse residents to have staff fully trained on things such as identifying signs and symptoms of substance use and abuse.
“I feel the pandemic has shined a bit of a spotlight on mental health and substance abuse disorders. I wonder if there’s a little bit of a silver lining in there that the broader light shined on this issue will have the community at large take more action and help all of us address this critical issue.”
Dementia care draws scrutiny
Dementia care, and specifically “reducing unnecessary care and antipsychotics” will be another high-focus area, Shulman said.
“We are concerned because we saw a backslide during the pandemic. We saw the rates kick up just a bit, so we are very concerned that residents are not on these dangerous drugs,” he explained.
He emphasized that regulators are not intent on “second-guessing a clinician’s judgment after a comprehensive clinical assessment.”
“This is about clear and inappropriate diagnosis without a clinical assessment,” he explained. “People who are 80 don’t generally develop schizophrenia. And … it’s not contagious. These antipsychotics are very dangerous. Labeling someone as having schizophrenia to justify these drugs is simply unacceptable. So we’re going to continue to look at this.”
He said public pressure about how to identify and report abuse allegations, and how states should investigate, has led to another point of emphasis in upcoming rules.
“When we release guidance, we’re going to be focusing on providing a lot more guidance on how to report this, and give some examples,” he said.
Shulman alternatingly complimented providers on their diligence, especially under stressful pandemic conditions, and informed them that noticeable shifts toward creating more “normal” conditions again are ahead.
“There is a lot more in it. There’s a lot coming,” he said. ”But we want to implement these changes in a realistic manner so we will not expect providers to implement this new information overnight. You may recall in 2017 we gave providers and surveyors several months … We want to make sure you have time and training to put this new guidance into effect.”
