Deadline Looming for Mandatory Nursing Home Compliance Programs

Skilled Nursing Facilities have until November 28, 2019 to adopt and implement a compliance program that meets the elements set out by the Center for Medicare and Medicaid Services (CMS). Beginning on that date, state survey agencies will start assessing nursing homes’ compliance programs as an additional condition of participation in Medicare and Medicaid. Issued in 2016 as part of CMS’s revised Part 483 of Title 42 (“Requirements for States and Long Term Care Facilities”), the CMS compliance program elements are functionally identical to those from the Office of Inspector General for Health and Human Services (OIG).¹ Already the standard for effective compliance programs, the OIG elements are used to measure an organization’s culpability when federal fraud and abuse laws are violated. Specifically, the OIG considers “the existence of an effective compliance program that pre-dated any governmental investigation when addressing the appropriateness of administrative sanctions.”

Western clinicians are beginning to embrace Eastern healing modalities more than ever, especially in regard to patients with unrelieved pain. According to Maureen Foye, an RN, employed at the in-patient pain management program at Spaulding Rehabilitation Hospital in Boston, “Many people don’t understand the role that Eastern healing can play in the management of pain.” Foye began working with patients in severe pain after being exposed to the principles of therapeutic touch. She has now come full circle by instructing other practitioners in the value of these principles with plans to conduct further research into the clinical effectiveness of energy healing and therapeutic touch associated with the field of pain management.

Many patients with chronic pain tend to isolate themselves. A major focus of the program is to therefore, create community among her patients.

Ageism and Aging are stereotyping and discriminating against individuals or groups on the basis of their age. The term was coined in 1971 by Robert Butler to describe discrimination against seniors, and patterned on sexism and racism. Butler defined “ageism” as a combination of three connected elements. They are prejudicial attitudes toward older people, old age, and the aging process. There are also other discriminatory practices against older people, such as institutional practices and policies that perpetuate stereotypes about older people.

Contrary to common and more obvious forms of stereotyping such as racism and sexism, ageism is more resistant to change. For instance, if a child believes in an ageist idea against the elderly with few people correcting him, then as a result, he will continue to grow into an adult believing in ageist ideas. In other words, ageism can become a self-fulfilling prophecy.

In almost every book or article on aging, one idea continues to be stressed: longevity is desirable if accompanied by a life of high quality. But, I continue to ask, what makes for such a good life? Most of us want love, meaningful work, safety and security, energy and health, and to varying degrees, power, fame, freedom and wealth, and we want to live in a society that supports these goals.

How can we measure quality of life? There is no simple answer. It is an amorphous concept, constantly changing with the historical period and one’s culture, personal background, stage of life, and socioeconomic status. A person’s definition of quality of life is and should be highly individualized and objective.

Earlier this month, the Center for Medicare and Medicaid Services (“CMS”) issued a final rule repealing its’ prior rule prohibiting long-term care providers (“LTC”) from entering into pre-dispute, binding arbitration agreements with their residents. This change takes effect September 16, 2019 and comes after years of protracted rule-making efforts, public comment, and litigation that began in October 2016 when CMS issued a final rule prohibiting the agreements in nursing facilities and ended up in the U.S. Supreme Court in May 2017.

This new final rule represents a win, albeit a limited one, for the long-term care industry. On one hand, the ability to pursue arbitration represents a real opportunity for facilities to reduce liability and minimize the costs of potential litigation with residents by eliminating discovery, attorneys’ fees, and other related litigation expenses. On the other hand, the final rule contains a number of provisions, intended to protect nursing home residents, which may cause providers concern as they evaluate the benefit of adding these provisions to their Admission Agreements.

Changes Made to Compliance and Ethics Programs and Quality Assurance and Performance Improvement Programs

On July 16, 2019, the Centers for Medicare & Medicaid Services (“CMS”) released a pre-publication copy of the revisions (“Proposed Rule”) to Part 483 to Title 42 of the Code of Federal Regulations the Requirements for States and Long-Term Care Facilities (“RoPs”). CMS stated that it identified a number of existing skilled nursing facility requirements that could reduce unnecessary burdens on facilities if they were simplified or eliminated.

The Proposed Rule would alter a over dozen sections of the RoPs, including: (1) resident rights; (2) admissions transfers and discharges; (3) quality of care; (4) nursing services; (5) behavioral health; (6) pharmacy services; (7) food and nutrition services; (8) facility assessments; (9) physical environment; (10) compliance and ethics programs; (11) Quality Assurance and Performance Improvement (“QAPI”) programs; and (12) infection control. The Proposed Rule also proposes to delay implementation to some of these Phase 3 provisions until one year following the effective date of the Proposed Rule.

An old woman has been admitted to an institution with a probable diagnosis of dementia and uncommunicative. She doesn’t speak nor appear to understand. However, it soon becomes clear that she can speak and understand.

Silence is, however, her way of punishing the family whom she regards as insensitive to her needs. “They are all living in my house and they treat me like a poor relation. Boss me around all the time!”

There can be much satisfaction in sharing with an elderly person his reflections on the past. Directly or indirectly, it is part of our history as well. Apart from the facts we could glean, it deepens our understanding of life’s experiences. Together with the old person, we feel the transformation from child to youth to adult and beyond.

In this way, an old person who opens his mind and feelings to us is a unique text on human development and aging.

The elderly are often less vulnerable than they appear. They may attribute their health to exercise, religion and a positive attitude. It is well known that genetics, good health practices and a certain degree of luck are involved. The very process of enduring beyond the average life span indicates personal survival capacities beyond those of the ordinary person.

In our era, however, this is complicated by the fact that many would have died of various disorders, having now been kept alive through sophisticated medical technology. Therefore, among the oldest-old we find two distinct groups: those hardy souls genetically meant to endure for a century, and the extreme frail who walk a “tightrope” between survival and death.

A resident in a facility where I was the Director of Nursing, claimed the reason he and his wife got married while in their late eighties, was the following,” It was a marriage of convenience. Rather than using a cane or a walker, we can lean on each other.”

Mobility is the capacity one has for movement. In infancy, it is a major mode of learning and interacting with the environment. Throughout life, it remains a significant means of contact, sensation, exploration, pleasure, and control. In old age one moves more slowly and purposefully, sometimes with more caution.

Social media is great for spreading humorous articles of all kinds, but there is a danger that some folks may take what is intended as humor and digest it as fact. A recent Facebook post by a fellow from Oklahoma was actually picked up by several news stations including at least one overseas. In it he details why it would be cheaper to live out his final years at a Holiday Inn rather than a nursing home. I’m sure that you may have also seen, at least once, a similar comparison to a cruise ship.

Can we dispense once and for all with the silly notion that living on a cruise ship or at the Holiday Inn is a viable alternative to being in a nursing home? While the premise might make for an amusing Facebook post, in reality, nothing could be further from the truth.

The old person is largely responsible for his own place in society. What is experienced as rejection or exclusion by one person may be a welcome opportunity to shed responsibility by another. One individual’s lifestyle may keep him closely linked with society, while that of another individual may encourage an earlier withdrawal.

The reality of individual differences is well illustrated in several studies in the field of aging. As an example, researchers in their studies among men, have identified five types of personality.

Today, in general, Americans are living longer than their predecessors. Yet those who make policy have been slow to recognize the implications of this unprecedented increase in longevity. As a result, social institutions (i.e.: educational organizations, healthcare providers and work settings) have not fully adapted to the challenges and opportunities posed by America’s aging population.

It has been projected by 2030, the U.S. will experience accelerated growth in its aging population. It has also been projected that by 2050, the number of U.S. citizens 65 and older, will reach 88.5 million. That’s more than double the 40 plus million that was originally reported in a federal document on “aging in society.”

Some elderly people contribute to their own isolation by boring people with tales that are more than twice told. This is one of the most common characteristics complained of by people who say they do not like to be with the aged, although old people by no means have the patent on repetitious speech.

But there is more purpose to this replaying of the past than might fall upon the bored ear. Notice that the scenes retold are very selective. Often these prove to have an integrating function for the individual. They serve to give the person something to organize himself around.  Furthermore, replaying can be the effect as well as the cause of social isolation in a deprived, alien, unwelcoming environment. The old person may have little other choice to call upon his own memory repertoire if he has to have any company at all. This is akin to the effect that sensory deprivation has on a person of any age; the mind takes over and furnishes the stimulation which is absent in the environment.

The shape of memory changes for many people in later life. If our typical old person has one real complaint about his own mental functioning, it is likely to concern his memory for recent events. A word, a name or a fact, just doesn’t come to mind when he wants it. What happened in the distant past is likely to be clear and precise in his mind. He can accurately recall events that occurred 60 or 70 years ago, but may draw a blank for what happened a week ago last Monday.

The picture is even more complex than this. The research shows that another type of memory also must be distinguished (i.e. recall for immediate events). The old person in good health does not appear to suffer any particular problems in this regard. He can remember what has just happened, can remember very well what happened decades ago, but has difficulty with the time in between long ago and a moment ago.

No single principle of mental health can guarantee that a person will pass through the challenges and perils of a long life without experiencing distress, loss, suffering, and human error that are part of most lives. However, it is within our abilities to reduce the depth and frequency of suffering and to help each other when our own resources are temporarily overrun.

In old age, distress can be more acute since immediate problems bring to mind earlier difficulties. The old person may be haunted by memories of stressful events and relationships as far back as early childhood. Tormented by both past and present, they may feel helpless. At the same time, there may be fewer resources available to cope with problems in the immediate situation, fewer people to share experiences with, less physical and financial control over the environment and so on.

Care is at the heart of your mission and our nurses know too well the struggles of preserving a culture committed to caregivers. It isn't just about staffing—it’s about supporting. From our nurses to yours a series dedicated to compassionate care.

Life review is an examination of one’s total life experiences as we enter that period we tend to call old age. It’s a time to set what is known as “our house in order.”

The outcome of an older person’s life review is by no means guaranteed. Like all of the other ways of using the past, it can have either favorable or unfavorable consequences. If the elderly person is hard on himself, he views his life as a string of failures and missed opportunities. He may dwell on his shortcomings as a child, a spouse, or a parent and perhaps brand himself guilty of some obscure transgression that has not been forgiven. At the same time he may feel powerless to make amends and face the prospect ahead with trepidation and dread.

Three new items have been added to Section N of the MDS, that will have a major impact on the policies and processes you have used in the past regarding medication reconciliation and administration.

• N2001: Drug Regimen Review (Assessed on Admission)
• N2003: Medication Follow-up (Assessed on Admission)
• N2005: Medication Intervention (Assessed on Discharge)

Although this new item may seem to be commonplace in your facility already, there are scenarios which frequently arise, that may interfere and render your processes inadequate. These fundamental concepts will be required for Medicare Part A covered residents but are considered a best practice for any payer source.

Greetings, ACHCA colleagues!

I sincerely hope your summer has been an enjoyable time for you and your communities; it seems like just yesterday that we were gathering in Orlando for the ACHCA Convocation! Although roughly four months have elapsed since that time, much has been happening with your association.