On July 16, 2015, the Federal Register published Centers for Medicare and Medicaid Services' (CMS) proposed rule to reform the requirements for Long Term Care Facilities participating in Medicare and Medicaid. CMS will be accepting comments to the proposed rules for 60-days. The 400-page proposed rule recommends the biggest overhaul to nursing home requirements since 1991.
This alert is the second in a series of four communications regarding the proposed rule reform for long term care facilities. Long term care providers and other interested entities should carefully review the proposed rule reform and submit any comments to the proposed rule to CMS/HHS by 5:00 pm EST on September 14, 2015.
To see a copy of the proposed rule, click here.
Summary of Proposed Changes to Clinical Requirements for Long Term Care Facilities
The proposed rule introduces a number of revisions and new sections relating to the clinical requirements in Long Term Care Facilities. The following is an overview of the changes to the clinical requirements proposed by CMS:
• Admissions. CMS is proposing to modify the "Admission, Transfer and Discharge Rights" section of the current regulation, replacing it with a new "Transitions of Care" section. The new section includes the following proposed provisions:
- A requirement that the facility establish an admissions policy;
- A prohibition against the facility requesting or requiring residents to waive their rights to Medicare, Medicaid, or other government benefits;
- A prohibition against the facility requesting or requiring residents to waive any potential facility liability for losses of personal property; and
- A requirement that the facility disclose to residents, prior to the time of admission, notice of any special characteristics or service limitations of the facility.
• Resident Assessments. Through the new rules, CMS desires to clarify that resident assessments are not only for the purpose of understanding a resident's needs, but also to understand a resident's strengths, goals, life history, and preferences. Moreover, CMS intends to help facilitate appropriate coordination of a resident's assessment with the PASARR program under Medicaid.
• Resident Care Planning. CMS is proposing a major overhaul to resident care planning. Specifically, CMS proposes to require what it has termed "Comprehensive Person-Centered Care Planning". If adopted, facilities would be required to develop a baseline interim care plan for each resident within 48 hours of their admission. However, if a facility chooses, it could complete a comprehensive care plan within 48 hours and not have to complete both a baseline interim care plan and a comprehensive care plan. Any specialized services or specialized rehabilitation services the facility provides as a result of PASARR recommendations would need to be included in the care plan under the proposed rules. A nurse aide, member of the food and nutrition services staff, and a social worker would be required members of the interdisciplinary team charged with developing the care plan. Facilities will be required to provide a written explanation in the medical chart if the participation of resident and their resident representative is determined to not be practicable for the development of the resident's care plan.
• Discharge Planning. CMS is proposing changes to discharge planning requirements for facilities. Under the new rules, facilities would be required to document in the resident's care plan the resident's goals for admission, to assess the resident's potential for future discharge, and to include discharge planning in the comprehensive care plan, as appropriate. A new provision would require that the resident's discharge summary include a reconciliation of all discharge medications with the resident's pre-admission medications. The new rules would also require that the discharge plan of care include the arrangements made for the resident's follow-up care and any post-discharge medical and non-medical services. Finally, the post-discharge plan would be developed with the participation of the resident and his or her representative.
• Resident Quality of Care and Quality of Life. CMS' proposed changes would add new requirements for resident quality of care and quality of life. Updated Activities of Daily Living are being suggested by CMS. A new section titled "Special Care Issues", which would add requirements for specific special concerns, including bed rails, restraints, and pain management, is being proposed as well.
• Physician and Nursing Services. CMS is also proposing changes to physician and nursing services. The new regulations would require an in-person evaluation of a resident by a physician, a physician assistant, nurse practitioner, or clinical nurse specialist before an unscheduled transfer to a hospital. Also, physicians would be permitted to delegate dietary orders to dietitians and therapy orders to therapists. CMS is also proposing to add a competency requirement for determining sufficient nursing staff based on a facility assessment.
• Behavioral Health Services. One of the biggest changes in the proposed rule is to add a new section for behavioral health services. Under this rule, facilities would be required to determine residents' care staff needs and to ensure staff has the appropriate competencies to provide behavioral health care and services.
• Pharmacist Review. CMS is proposing a rule that would require a pharmacist to review a resident's medical chart under certain circumstances. The pharmacist would be required to document in a written report any irregularities noted during the drug regimen review. Additional rules will be required relating specifically to the use of psychotropic drugs, including implementing "medically necessary" requirements and dose reductions.
• Dental Services. Changes to dental services provided in long term care facilities are also being proposed. SNFs would no longer be able to charge a Medicare resident for the loss or damage of dentures, and Nursing Facilities would be permitted to assist residents who are eligible to apply for reimbursement of dental services as an incurred medical expense under Medicaid.
• Food and Nutrition. CMS' proposed changes also include changes to the food and nutrition services provided at long term care facilities. CMS' proposed rules would require facilities to employ sufficient staff with appropriate competencies to carry out functions of dietary service and would change the certification requirements for a facility's Dietician and the Director of Food Service. CMS also proposes adding a requirement that menus reflect the religious, cultural, and ethnic needs of the residents and that food and drink take into consideration residents' allergies, intolerances, and preferences and ensure hydration. Finally, under the proposed rules, facilities would be required to document the clinical need of a feeding assistant and the extent to which dining assistance is needed in each resident's comprehensive care plan.
• Respiratory Services. Lastly, respiratory services will be added to those services identified as specialized rehabilitative services in order to reflect current needs of facility residents. CMS is also proposing to establish new health and safety standards for facilities choosing to provide outpatient rehabilitative therapy services.
Upcoming Information for You
This alert is the second in a series of four communications regarding the proposed rule reform for long term care facilities. Additional information outlining proposed revisions for Facility Administration will be provided in upcoming communications.
What You Should Do
Long term care providers and other interested entities should review the upcoming e-alerts, carefully review the proposed rule and submit any comments to the proposed rule to CMS/HHS by 5:00 pm EST on September 14, 2015. Comments may be submitted electronically here or by regular mail to CMS/HHS, Attn: CMS-3620-P, P.O. Box 8010, Baltimore, MD 21244.
For More Information
If you have questions regarding the proposed rule or how it may affect your long term care facility, please contact:
- Matt J. Murer | 312.873.3603 | Email
- Meredith A. Duncan | 312.873.3602 | Email
- Jason T. Lundy | 312.873.3604 | Email
- Charles P. Sheets | 312.873.3605 | Email
- Kathryn M. Stalmack | 312.873.3608 | Email
- Mary Beth Blake | 816.360.4284 | Email
- Dayna C. LaPlante | 312.463.6348 | Email
- Hannah L. Neshek | 312.873.3671 | Email