Survey Updates for the new Long Term Care Survey Process (LTCSP) starting on November 17, 2017 that was part of survey bootcamp hosted by CHCA (Colorado Health Care Association), Genesis Healthcare, and Vivage Senior Living. The instructors were Kaile Hilliard and Maritza Straub, co-founders of RegsPro. We hope you find this PowerPoint helpful when looking at some major changes to the State Operations Manual.

1. Survey Updates
November 28, 2017
Kaile Hilliard, LCSW, Regulatory Compliance Manager-West Division
RegsPro Co-Founder
Genesis Healthcare
Maritza Straub, CTRS, Quality Improvement Specialist
RegsPro Co-Founder
Vivage Senior Living

2. Survey Process

3. Survey Process Updates
 Survey has a new name
 Long Term Care Survey Process (LTCSP)
 QIS and Standard get combined into one brand new survey process
 LTCSP is a mix of both survey processes
 With focus on:
 Best practices and opportunities for improvement
 Flexibility vs. prescriptiveness
 Computer-aided vs. paper-based
 Conference room vs. “out and about”
 All States will use new computer–based survey process for LTC surveys
 Each survey team member uses a tablet or laptop PC throughout the survey
process to record findings that are synthesized and organized by new software
 The goal for the New LTC Survey Process is to have surveyors out on the floor
most of the first day completing critical observations and interviews
 Surveyors will not have to investigate disaster and emergency preparedness,
oxygen storage, or the generators in an effort to reduce redundancy with Life
Safety

4. Number of Surveyors & Time Onsite
4
 Survey time onsite is expected to be similar to current time spent onsite
 Expect some lengthening while surveyors learn the new process
 Number of surveyors and time onsite also impacted by other factors such as
State licensure, facility history, or complaints
Census Sample Size % of Census # of Surveyors
< 48 < 12 > 25% 2
49 - 95 13 - 19 20% – 27% 3
96 - 174 20 - 34 20% 4
≥ 175 35 < 20% 5

5. Survey Process Overview
Three parts to new Survey Process:
1. Initial pool process
 Sample size based on census:
 70% offsite selected
 30% selected onsite by team:
 Vulnerable
 New Admission
 Complaint
 FRI (Facility Reported Incidents – Federal surveys only)
 Identified concern
2. Sample Selection
Survey team selects sample
3. Investigations & Mandatory tasks
All concerns for sample residents requiring further investigation
Closed records
Facility tasks

6. Information Needed Upon Entrance

7. Entrance Conference
Facility Will Need to Provide
 Documents
 Previous process (e.g., floor plan, CMS 671/672, etc.)
 Policies and Procedures
 New requirements (QAPI plan, Facility Assessment)
 Access to Electronic Health Records

8. New Matrix
Link to the Matrix and Entrance Conference Worksheet
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

9. Initial Entry To Community

10. Sample Selection
 Initial Pool: Conduct interviews, observations, and limited record review
(means confirming observations or other items)
 ~ 8 residents per surveyor- Surveyors will begin observing every resident in their assigned area
 Offsite, preselected residents
 Residents identified onsite as a result of screens (prioritized by new admissions, vulnerable
residents)
 Facility Matrix used to identify other specific concerns (e.g., dialysis, hospice, smoking, ventilator,
infection, etc.)
 Will spend about eight hours completing the observations, interviews and record review for the
residents selected for the initial pool process
 ****All residents will be screened during this process***
 Final Sample:
 Based on facility census (~ 20%)
 70% offsite/30% onsite
 End of day 1/start of day 2

11. Survey Process
 Surveyors get assigned “areas” to go room to room without staff to
identify residents to include in the initial pool.
 It is not possible to complete an observation and interview for every
resident in their assigned area;
 The goal is that each surveyor will include about eight residents in their initial pool although
every resident in their assigned area should be observed/screened to determine if they should
be in the initial pool.
 That is not a fixed requirement, which means a surveyor can include less or more than eight
residents in their initial pool.
 They may have more than eight residents in their assigned area who qualify for inclusion in the
initial pool;
 For example, they may be on a rehabilitation unit and have a high number of new
admissions, or
 Or on a locked Alzheimer’s unit and have a high number of vulnerable residents.
 If this is the case, the surveyor will prioritize residents based on a brief screening.

12. Survey Process Cont.
 Surveyors will
 Screen every resident in their initial screen of 8
 If the resident is interviewable, they will complete a full interview for the resident,
which takes about 20 minutes..
 For any concern expressed by the resident, they will ask additional questions until they
can determine whether the concern can be ruled out or needs to be investigated
further, which means you think there may be deficient practice.
 For example, if the resident says they had an issue with their roommate but the facility
addressed the concern to their satisfaction, you would not need to investigate further;
conversely, you would want to investigate a concern if the resident says they have lost
weight recently because of their loose dentures unaddressed by the facility.
 They have suggested questions – but not a specific surveyor script
 Must cover all care areas – Rights, Quality of Care (QoC), Quality of Life (QoL)
 For the interview, suggested questions are available; however, they can ask the
questions as you like, such as open-ended or closed or broad or narrow, but all care
areas should be addressed
 Investigate further or determine no issue

13. Non-Interviewable Residents & Limited Record
Review for Certain Conditions
Surveyors need to attempt
at least 3 resident
rep/family interviews
They have the duration of the survey to do so but goal is to do them early in the survey
They should be interviewing people familiar with resident care
They should be using sampled residents if possible
Certain conditions will get
reviewed right away in
limited record review.
Survey team will confirm insulin, anticoagulant, and antipsychotic with a diagnosis of
Alzheimer’s or dementia, and PASARR (Pre-Admission Screening and Resident Review)
The intent of the limited record review is to ensure that the survey team spends the
majority of its time on interview and observation
Please ensure those systems are in place with ongoing monitoring

14. Mandatory Facility Tasks
 Sufficient/Competent Staffing-(new)
 Throughout the survey, surveyors
will be determining if staffing
concerns can be linked to QOL and
QOC concerns
 Infection Control (Some changes)
 Beneficiary Notices (some changes)
 A new pathway has been developed
 List of residents (home and in-
facility)
 Randomly select three
residents
 Community completes new
worksheet
 Review worksheet and notices
 No significant
changes to
categories below.
 Dining Observation
 Medication Storage
 Medication
Administration
 Kitchen Observation
 QAA/QAPI

15. Environment
Investigate specific concerns
Eliminate redundancy with LSC
 Disaster and Emergency Preparedness
 O2 storage
 Generator

16. Dining – First Full Meal
 Dining – observe first full meal
 Cover all dining rooms and room trays
 Observe enough to adequately identify concerns
 If feasible, observe initial pool residents with weight loss
 If concerns identified, observe another meal
 Surveyors will use Appendix PP and CE Pathway for Dining
 The dining task is completed outside any resident specific investigation
into nutrition and/or weight loss
 This is a mandatory task for surveyors

17. Kitchen Observation
 In addition to the brief kitchen observation upon entrance, one
surveyor will conduct a full kitchen investigation
 They will follow Appendix PP and Facility Task Pathway to complete
kitchen investigation

18. Sample Selection – Unnecessary Medication Review
System selects five
residents for full
medication review
Based on
observation,
interview, record
review, and MDS
Broad range of high-
risk medications and
adverse
consequences
Residents may or
may not be in
sample

19. Closed Record Reviews
 Complete timely during the investigation portion of survey
 The system will select the residents for the closed record reviews
 Unexpected death
 The system will select a resident who was not on hospice and died in the last 90 days.
 Hospitalization
 The system will select a resident who went to the hospital and has not returned in the last 90 days
 Community discharge last 90 days
 The system will select a resident who was discharged back to the community in the last 90 days.
 They will use Appendix PP and CE pathways
 Surveyors will either review the resident selected by the system or a discharged
resident selected offsite, if applicable.
 If no residents were selected for one of the closed record areas, they do not have to complete
that review.
 Example: if no residents died within the past 90 days, they do not need to conduct a closed
record review for death.
 They can complete the closed record review any time during their investigation

20. Team Meetings
Brief meeting at the end of each day
Workload
Coverage
Concern
Synchronize/share data (if needed)

21. Infection Control Survey Process
Throughout survey, all
surveyors should
observe for infection
control
Assigned surveyor
coordinates a review of
influenza and
pneumococcal
vaccinations
• complete a review for five
residents
Assigned surveyor
reviews infection
prevention and control,
and antibiotic
stewardship program
In addition, during the
initial pool process and
sample selection, the
team must select a
resident, if in the facility,
who is on transmission-
based precautions.

22. Med Administration & Med Storage
Recommend nurse or pharmacist
Include sample residents, if opportunity presents itself
Reconcile controlled medications if observed during
medication administration
Observe different routes, units, and shifts
Observe 25 medication opportunities
Med Administration
Observe half of medication storage rooms and half of
medication carts
If issues, expand medication room/cart
Med Storage

23. Group Interview

24. Complaints & Facility Reported Incidents (FRI)
2
4
 Issue:
 Balancing efficiency and protecting the integrity of the process
 Analysis:
 ~ 30% of standard surveys included complaints
 Of surveys with complaints, 94% included no more than five complaint
residents
 CMS Policy:
 States may add up to five residents associated with a complaint or FRI
 If more than five residents are added to the sample, team size or survey
time is extended

25. Phase II Changes – How do They Affect Me?
 Phase II changes must be
implement by November 28,
2017
 New Long Term Care Survey
Process (LTCSP)
 New Regulations
 F550 – F949
 Providers must be in
compliance with Phase 2
regulations
 All States will use new
computer–based survey
process for LTC surveys
 Phase II Changes:
 Behavioral Health Services
 Quality Assurance and Performance
Improvements (QAPI Plan Only)
 Infection Control and Antibiotic
Stewardship
 Physical Environment – smoking
policies
 Resident Rights and Facility
Responsibilities – Required Contact
Information-
 Freedom from Abuse, Neglect, and
Exploitation – 1150B
 Admission, Transfer, and Discharge
Rights – Transfer/Discharge
Documentation
 Comprehensive Person-Centered Care
Planning
 Pharmacy Services – psychotropic
medications
 Dental Services – replacing dentures
 Administration – Facility Assessment

26. Interpretive Guidance/ROP Changes
(AKA Reg/Tag Changes)
Tag numbers changed to F540-F949
 Tags were broken out into individual tags instead of catch-all
tags such as F309.
Revised format with consistent sections (e.g., Key
elements of Non-Compliance)
Most of the Interpretive Guidelines have not been
changed per CMS
Revisions for phase 1 & 2 tags, and some existing tags
where improvements were needed
Revised CE pathways based on lessons learned (e.g., MDS
focused surveys)

27. Understanding Tag Specifics
Categories of tags were
adjusted
Additional tags can now
lead to substandard of
quality of care if cited
at an F or above.
Many tags were
updated with deficiency
categorizations from 1-
4 to provide guidance
to surveyors.

28. Notable Tag Changes

29. New Ftag Categories
https://www.cms.gov/Medicare/Provider-
Enrollment-and-
Certification/GuidanceforLawsAndRegulations
/Downloads/List-of-Revised-FTags.pdf

30. Ftag Renumbering
The image above is the F Tag Crosswalk showing:
 The original regulatory grouping and the new associated grouping
 The original regulation number and the new associated regulation
number
 The original F Tag and the associated new F Tag

31. F-Tag Crosswalk
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/F-Tag-Crosswalk.xlsx
31

32. Resident Rights Updates
F575 - Required Postings - We must post:
 (i) A list of names, addresses (mailing and email), and telephone numbers of all
pertinent State agencies and advocacy groups, such as the State Survey Agency, the
State licensure office, adult protective services where state law provides for
jurisdiction in long-term care facilities, the Office of the State Long-Term Care
Ombudsman program, the protection and advocacy network, home and community
based service programs, and the Medicaid Fraud Control Unit; and
 (ii) A statement that the resident may file a complaint with the State Survey Agency
concerning any suspected violation of state or federal nursing facility regulation,
including but not limited to resident abuse, neglect, exploitation, misappropriation of
resident property in the facility, and non-compliance with the advanced directives
requirements (42 CFR part 489 subpart I) and requests for information regarding
returning to the community.

33. Freedom from Abuse, Neglect, and Exploitation
 *F600 - Free from Abuse and Neglect - Abuse and neglect are
combined into a single tag. The regulatory language changed some of
the distinction between abuse and neglect around the area of
withholding services. Instead of making a fine distinction about what
in withholding services is abuse vs. what in withholding services is
neglect, CMS put it together to encompass the full range of abuse and
neglect related areas within the tag. CMS also added guidance about
what constitutes abuse and neglect, including staff-to-resident abuse,
resident-to-resident abuse, and issues related to assessing consent for
sexual activity.
 *F602 - Free from Misappropriation/Exploitation - The regulation
includes a new definition for exploitation: … taking advantage of a
resident for personal gain through the use of manipulation,
intimidation, threats, or coercion.
 *F603 - Free from Involuntary Seclusion - CMS added new guidance
around what involuntary seclusion means and areas that surveyors will
look at related to involuntary seclusion

34. Freedom from Abuse, Neglect, and Exploitation
*F604 - Right to be Free from Chemical Restraints –
The regulation states that the resident has the right to
be free from chemical restraints not required to treat
the resident’s medical symptoms. By treating a
medical symptom, this means the medication has a
clinical indication for use. If the survey team identifies
that the medication is not being used to treat a
medical symptom, then the team must determine
whether the facility is using the medication as a
chemical restraint if the medication restricts the
resident’s movement or cognition, or sedates or
subdues the resident.

35. Freedom from Abuse, Neglect, and Exploitation
 *F605 - Right to be Free from Physical Restraints - The revised interpretive
guidance for physical restraints explains that “physical restraints can take
many forms, and practices or devices that would not be restraints for some
residents … would be restraints for other residents.”
 The resident’s physical condition and his or her cognitive status can impact a
resident’s ability to remove a restraint.
 In addition, position change alarms have been included in the physical
restraints guidance. Per CMS, position change alarms don’t physically stop
residents from moving, but the sounds they emit can have a psychological
impact on some residents that has the same effect as if they were being
physically restrained. Under some circumstances, position change alarms can
be physical restraints, and surveyors need to ensure that they are medically
indicated—and also the least restrictive alternative for the least amount of
time used

36. Freedom from Abuse, Neglect, and Exploitation
*F606 - Not Employ/Engage Staff With Adverse Actions -
 The facility must not employ or otherwise engage individuals who
—
 Have been found guilty of abuse, neglect, exploitation, misappropriation
of property, or mistreatment by a court of law;
 Have had a finding entered into the State nurse aide registry concerning
abuse, neglect, exploitation, mistreatment of residents or
misappropriation of their property; or
 Have a disciplinary action in effect against his or her professional license
by a state licensure body as a result of a finding of abuse, neglect,
exploitation, mistreatment of residents or misappropriation of resident
property.
 Report to the State nurse aide registry or licensing authorities any
knowledge it has of actions by a court of law against an employee, which
would indicate unfitness for service as a nurse aide or other facility staff.

37. Freedom from Abuse, Neglect, and Exploitation
*F607 - Develop/Implement Abuse/Neglect, etc. Policies -
The facility must develop and implement written policies
and procedures that:
 Prohibit and prevent abuse, neglect, and exploitation of
residents and misappropriation of resident property,
 Establish policies and procedures to investigate any such
allegations, and
 Include training as required at paragraph §483.95 - Training
(F942 and F946), (Effective November 28, 2017)
 Establish coordination with the QAPI program required under
§483.75.
 [Will be implemented beginning November 28, 2019 (Phase 3)]

38. Freedom from Abuse, Neglect, and Exploitation
*F608 - Reporting of Reasonable Suspicion of a Crime
 The facility must develop and implement written policies and procedures
that:
 Ensure reporting of crimes occurring in federally-funded long-term care facilities in
accordance with section 1150B of the Act.
 The policies and procedures must include but are not limited to the following elements.
 (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of
that individual’s obligation to comply with the following reporting requirements.
 (A) Each covered individual shall report to the State Agency and one or more law
enforcement entities for the political subdivision in which the facility is located any
reasonable suspicion of a crime against any individual who is a resident of, or is
receiving care from, the facility.
 (B) Each covered individual shall report immediately, but not later than 2 hours after
forming the suspicion, if the events that cause the suspicion result in serious bodily
injury, or not later than 24 hours if the events that cause the suspicion do not result in
serious bodily injury.
 (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the
Act.
 (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the
Act
For the abuse tags, these are the requirements that are going into effect in Phase II

39. Freedom from Abuse, Neglect, and Exploitation
*F609 - Reporting of Alleged Violations
 In response to allegations of abuse, neglect, exploitation, or
mistreatment, the facility must:
 Ensure that all alleged violations involving abuse, neglect, exploitation or
mistreatment, including injuries of unknown source and misappropriation of
resident property, are reported immediately, but not later than 2 hours after the
allegation is made, if the events that cause the allegation involve abuse or result
in serious bodily injury, or not later than 24 hours if the events that cause the
allegation do not involve abuse and do not result in serious bodily injury, to the
administrator of the facility and to other officials (including to the State Survey
Agency and adult protective services where state law provides for jurisdiction in
long-term care facilities) in accordance with State law through established
procedures.
 Report the results of all investigations to the administrator or his or her
designated representative and to other officials in accordance with State law,
including to the State Survey Agency, within 5 working days of the incident, and if
the alleged violation is verified appropriate corrective action must be taken.
For the abuse tags, these are the requirements that are going into effect in Phase II

40. Abuse/Reporting
F600-F610 Freedom
from Abuse, Neglect,
and Exploitation
What are the Different
Requirements for Reporting of
Suspected Crimes v. Alleged
Violations?

41. Freedom from Abuse, Neglect, and Exploitation
*F610 - Investigate/Prevent/Correct Alleged Violations
In response to allegations of abuse, neglect, exploitation, or
mistreatment, the facility must:
 Have evidence that all alleged violations are thoroughly investigated.
 Prevent further potential abuse, neglect, exploitation, or
mistreatment while the investigation is in progress.
 Report the results of all investigations to the administrator or his or
her designated representative and to other officials in accordance
with State law, including to the State Survey Agency, within 5
working days of the incident, and if the alleged violation is verified
appropriate corrective action must be taken.

42. Admission, Transfer, and Discharge
F620 - Admissions Policy - The facility must establish and implement an admissions policy and
the community must not request or require residents or potential residents to waive potential
facility liability for losses of personal property.
F621 - Equal Practices Regardless of Payment Source - Room changes must be limited to moves
within the particular building in which the resident resides, unless the resident voluntarily
agrees to move to another location.
F622 - Transfer and Discharge Requirements - The documentation is what really changed in
Phase II

43. Admission, Transfer, and Discharge
F622 - Transfer and Discharge Requirements
•Transfer/Discharge Documentation
•Documentation in the resident’s medical record must include:
•(A) The basis for the transfer
•(B) In the case of inability to meet needs; we must specify the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available
at the receiving facility to meet the need(s).
•The documentation required must be made by —
•(A) The resident’s physician when transfer or discharge is non emergent; and
•(B) A physician when transfer or discharge is necessary emergently
•Information provided to the receiving provider must include a minimum of the following:
•(A) Contact information of the practitioner responsible for the care of the resident
•(B) Resident representative information including contact information.
•(C) Advance Directive information.
•(D) All special instructions or precautions for ongoing care, as appropriate.
•(E) Comprehensive care plan goals,
•(F) All other necessary information, including a copy of the residents discharge summary, as applicable, and any other documentation, as applicable, to ensure a safe and
effective transition of care.

44. Admission, Transfer, and Discharge
Definitions
Facility-initiated transfer or discharge:
A transfer or discharge which the resident objects to, did not originate through a resident’s verbal or written request, and/or
is not in alignment with the resident’s stated goals for care and preferences
Resident-initiated transfer or discharge:
Means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the
facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents
with cognitive impairment)
Paperwork
Sending copy of transfer/discharge notice to ombudsman:
Applies to facility-initiated discharges
For emergency room transfers, may send notice to ombudsman when practicable such as in a list of residents on a monthly
basis
Notice of transfer or discharge not required for resident-initiated discharges

45. Admission, Transfer, and Discharge & Bed Hold
Policy
For a transfer or discharge to be
considered resident-initiated:
“The medical record should
contain documentation or
evidence of the resident’s or
resident representative’s verbal or
written notice of intent to leave
the facility, a discharge care plan,
and documented discussions with
the resident or, if appropriate,
his/her representative, containing
details of discharge planning and
arrangements for post-discharge
care.” (F623 guidance)
F625 Bed Hold Policy
Written Bed Hold policy info has
to be provided to the resident or
representative BEFORE the
transfer.

46. F655-F661
Care Plans
§483.21 Comprehensive Resident Centered Care Plans
F655 Initial Baseline Care Plan (BCP) to be developed within 48
hours
How can providers meet the 48 hour requirement if admission
occurs on the weekend?
The regulations do not specify how to create the Baseline Care
Plan (BCP);
Facilities will have to devise a process that ensures new
admissions have their BCP done within the required 48 hours.
It may be necessary for BCP to be developed over the course
of several shifts
E.G., New admission at 11:40 pm on Friday –BCP complete by
11:40 pm on Sunday.

47. What needs to be Included in a Baseline Care plan
(BCP) F655
(ii) Include
the minimum
healthcare
information
necessary to
properly care
for a resident
including, but
not limited to
–
(A) Initial
goals based
on
admission
orders
(B)
Physician
orders
(C) Dietary
orders
(D) Therapy
services
(E) Social
services
(F) PASARR
recommendatio
n, if applicable”
It is expected
that the
admission
orders will be
used, along
with
information
gathered by
the admitting
nurse, which
will include
input from
the resident
or
representativ
e
The guidance at F655 states, “The facility must
provide the resident and the representative, if
applicable, with a written summary of the baseline
care plan…
483.21(a) states, “…The BCP must—
*It may be possible to begin development of parts of the BCP before
the actual admission based on information received from the
transferring provider, however, the information must be verified by the
admission orders and admitting nurse’s observation and interview of
the resident

48. *F678 - Cardio-Pulmonary Resuscitation (CPR)
 To ensure that each facility is able to and does provide emergency
basic life support immediately when needed, including
cardiopulmonary resuscitation (CPR), to any resident requiring such
care prior to the arrival of emergency medical personnel in
accordance with related physician's orders, such as DNRs, and the
resident’s advance directives.
 AS A REMINDER ONLINE CPR TRAINING IS NOT SUFFICIENT. NEED TO HAVE TRACKING OF
CPR CERTIFICATION. MOST FORMS SHOULD BE AUDITED AGAINST ORDERS AT LEAST
QUARTERLY

49. *687 – Foot Care
 To ensure that residents receive proper treatment and care to
maintain mobility and good foot health, the facility must:
 Provide foot care and treatment, in accordance with professional standards of
practice, including to prevent complications from the resident’s medical
condition(s)
 If necessary, assist the resident in making appointments with a qualified
person, and arranging for transportation to and from such appointments
 Facilities are responsible for providing the necessary treatment and foot care to
residents. Treatment also includes preventive care to avoid podiatric
complications in residents with diabetes and circulatory disorders who are
prone to developing foot problems. Foot care that is provided in the facility,
such as toe nail clipping for residents without complicating disease processes,
must be provided by staff who have received education and training to provide
this service within professional standards of practice.

50. F696 Prostheses
§483.25(j) Prostheses
The facility must ensure that a resident who has a
prosthesis is provided care and assistance, consistent with
professional standards of practice, the comprehensive
person-centered care plan, the residents’ goals and
preferences, to wear and be able to use the prosthetic
device.

51. F698 Dialysis
§483.25(l) Dialysis. The facility must ensure that residents who require dialysis
receive such services, consistent with professional standards of practice, the
comprehensive person-centered care plan, and the residents’ goals and
preferences.
INTENT: §483.25(l)
The intent of this requirement is that the facility assures that each resident receives care and services for
the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice
including the:
Ongoing assessment of the resident’s condition and monitoring for complications before and after
dialysis treatments received at a certified dialysis facility;
Safe administration of hemodialysis at the bedside and/or peritoneal dialysis in the nursing home
provided by qualified trained staff/caregivers, in accordance with State and Federal laws and
regulations;
Ongoing assessment and oversight of the resident before, during and after dialysis treatments,
including monitoring the resident’s condition during treatments, monitoring for complications,
implementing appropriate interventions, and using appropriate infection control practices; and
Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

52. F700 Side Rails
§483.25(n) Bed
Rails. The facility
must attempt to
use appropriate
alternatives prior
to installing a side
or bed rail. If a bed
or side rail is used,
the facility must
ensure correct
installation, use,
and maintenance
of bed rails,
including but not
limited to the
following
elements.
§483.25(n)(1) Assess the resident for risk of entrapment from
bed rails prior to installation.
§483.25(n)(2) Review the risks and benefits of bed rails with
the resident or resident representative and obtain informed
consent prior to installation.
§483.25(n)(3) Ensure that the bed’s dimensions are appropriate
for the resident’s size and weight.
§483.25(n)(4) Follow the manufacturers’ recommendations
and specifications for installing and maintaining bed rails.

53. F726 – Competent Nursing Staff
 The facility must have sufficient nursing staff with the appropriate
competencies and skills sets to provide nursing and related services to
assure resident safety and attain or maintain the highest practicable
physical, mental, and psychosocial well-being of each resident, as
determined by resident assessments and individual plans of care and
considering the number, acuity and diagnoses of the facility’s resident
population in accordance with the facility assessment.
 The facility must ensure that licensed nurses have the specific
competencies and skill sets necessary to care for residents’ needs, as
identified through resident assessments, and described in the plan of care.
 Providing care includes but is not limited to assessing, evaluating, planning
and implementing resident care plans and responding to resident’s needs.

54. Behavioral Health F740-F745
Behavioral Health Services
 Must have sufficient number of staff and
competent staff
 Example
 Dementia patients - must have
communication competencies related to
dementia

55. Unnecessary Drugs F758/F759
Psychotropic medications
Anti-depressant
Anti-anxiety
Hypnotic
Anti-psychotic medications only
Two separate requirements for PRN (as needed) orders for:
The attending physician or prescribing practitioner must directly examine the resident and assess the
resident’s current condition and progress to determine if the PRN antipsychotic medication is still needed
The attending physician or prescribing practitioner should, at a minimum, determine and document the
following in the resident’s medical record:
Is the antipsychotic medication still needed on a PRN basis?
What is the benefit of the medication to the resident?
Have the resident’s expressions or indications of distress improved as a result of the PRN medication?
Evaluation of resident before writing a new PRN order for antipsychotic medication:

56. PRNORDEREXPECTATIONS

57. F791 Routine/Emergency Dental Services
The facility must promptly
within 3 days refer residents
with lost or damaged dentures
for dental services.
If the referral doesn’t happen
within 3 days the facility must
provide documentation of what
they did to ensure the resident
could still eat and drink
adequately while awaiting
dental services
And document extenuating
circumstances that led to the
delay.

58. F800-F814 Food and Nutrition Services
A Qualified Dietician
 A qualified dietitian or other clinically qualified nutrition professional is one who—
Holds a bachelor’s or higher degree;
 Completed at least 900 hours of supervised dietetics practice;
 Is licensed or certified as a dietitian or nutrition professional by the State; and
 Meets the requirements of education and experience of §483.60(a)(1)(i) and (ii).
 Note: If you were hired before Nov 28, 2016, you have 5 years to meet these
requirements.
 483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition
professional is not employed full-time, the facility must designate a
person to serve as the director of food and nutrition services
 Designated persons include: A certified dietary manager (or)
 A certified food service manager (or)
 Someone who has similar national certification for food service management and
safety from a national certifying body (or)
 Someone who has an associate’s or higher degree in food service management or
in hospitality, if the course study includes food services or restaurant management,
from an accredited institution of higher learning.
 Note: These designees must receive frequent scheduled consultations from a qualified
dietitian or other qualified nutritional professional.

59. F880
Infection
Control
(Used to be
F441)
F880 – Infection Prevention and Control
• Systems in place for each section:
Preventing
• Identifying
• Reporting
• Investigation
• Controlling
F881 Antibiotic Stewardship Program
• Antibiotic Stewardship applies to all formulations of antibiotics (e.g., ophthalmic
antibiotics, topical antibiotics)
{Phase 3} F882 Infection Preventionist Qualifications/Role
• The role and qualifications of the IP are effective November 28, 2019
The IP must be qualified by education, training, experience or certification
F883 *Influenza and Pneumococcal Immunizations
• Based on Facility Assessment
Covers all residents/patients/staff/volunteers, visitors and other individuals
Follows accepted national standards
Resources available in Interpretive Guidelines

60. F865-F868
QAPI
What
needs
to be
in
place
now?
A QAA committee
which –Is composed
of:
Director of Nurses;
Medical Director (or designee); and
3 other staff, one of which must be
Administrator, owner, board member or
other individual in leadership role.
Infection Control & Prevention Officer -
effective 11/28/19
Meets at least
quarterly and as
needed to:
Identify which QAA activities are necessary,
and
Develop & implement appropriate plans of
action to correct identified quality
deficiencies.
As of November 28,
2017 the facility
must present QAPI
plan to state or
federal surveyors
A QAPI Plan describes the process for
conducting QAPI/QAA activities such as
identifying and correcting quality
deficiencies and opportunities for
improvement
The QAPI plan should be tailored to reflect
the specific units, programs, departments,
and unique population each facility services

61. Enforcement
 Phase II Enforcement:
 Focus on education for phase II requirements
(e.g., facility assessment, antibiotic
stewardship, bx health, base care plan etc.)
 Directed Plan of Correction, directed in-service
training
 Enforcement of Phase I requirements remains
unchanged

62. Current Enforcement Possibilities
An enforcement action is the process of imposing one or more of the
following remedies in accordance with 42 CFR §488.406:
 Termination of the provider agreement;
 Temporary management;
 Denial of payment for all Medicare and/or Medicaid individuals by CMS;
 Denial of payment for all new Medicare and/or Medicaid admissions;
 Civil money penalties;
 State monitoring;
 Transfer of residents;
 Transfer of residents with closure of facility;
 Directed plan of correction;
 Directed in-service training; and
 Alternative or additional State remedies approved by CMS.
 In all cases of immediate jeopardy, the provider agreement must be
terminated by CMS or State Medicaid Agency no later than 23 calendar days
from the last day of the survey if the immediate jeopardy is not removed.

63. Five Star Implications
Five Star Quality Rating System:
Surveys conducted using the new survey process
not included in five star quality rating system for
12 months.
Transparency and user-friendliness to
consumers
 (See S&C 17-36-NH)

64. Resources
 Emergency Preparedness Manual
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-
17-29.pdf
 State Operations Manual - Advanced Copy - November 28, 2017 Tags
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf
 November 28, 2017 - New Federal FTag Groupings and Numbers
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/List-of-Revised-FTags.pdf
 CMS Surveyor/Provider Training Website
https://surveyortraining.cms.hhs.gov/

65. Resources
 LTCSP Procedure Guide
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/LTCSP-Procedure-
Guide.pdf
 LTCSP Initial Pool Areas
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/LTCSP-Initial-Pool-Care-
Areas.zip
 LTCSP Critical Element Pathways
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/LTC-Survey-Pathways.zip

66. Resources
 LTC Survey Entrance Conference and Provider Matrix
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/LTC-Survey-
Entrance-Conference-Provider-Matrix.zip
 FTag Crosswalk
F-Tag Crosswalk [XLSX, 495KB] - CMS.gov
 Adverse Event Trigger Tool
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/Downloads/Adverse-Drug-Event-Trigger-Tool.pdf