Plus, New Regulations for Facility Closures

Quality is job one, as the Ford Motor Company has said. A key touchstone of our profession is patient safety. Such a practical aim suggests goals for us to target. And such goals have been and are set forth by The Joint Commission in the organization’s national patient safety goals. 
 

Background

The Social Security Act (SSA) permits providers and suppliers accredited by a CMS-approved national accreditation organization (AO) to be exempt from routine surveys by state survey agencies to determine compliance with Medicare conditions. Accreditation by an AO is voluntary and is not required for Medicare certification. Such accreditation by an AO is “deemed to meet” CMS regulatory requirements. The provider and/or supplier is said to have “deemed status.”

The requirements for long-term care facilities (LTC) derive from Title XVIII (Health Insurance for the Aged and Disabled), particularly section 1819, and Title XIX (Grants to States for Medical Assistance Programs), particularly section 1919. More detailed regulations are set forth in Title 42, Part 483 (Requirements for States and Long Term Care Facilities) of the Code of Federal Regulations. LTC facilities are referred to as skilled nursing facilities in Medicare and as nursing facilities (NF) in Medicaid. Additionally, states will also have their own LTC laws and regulations.

In 2002, The Joint Commission began its NPSG program, which became effective in 2003. Patient safety goals were designed to address important areas concerning patient safety. Usually, patient safety goals are updated annually by an interdisciplinary committee of experts. This patient safety advisory group seeks input from clinicians, other providers and health-related organizations, the healthcare industry, patients and consumers, and interested parties. The Joint Commission accredits LTC, and it has published LTC patient safety goals.
 

LTC Patient Safety Goals

The current Joint Commission patient safety goals for LTC became effective on January 1, 2011. There are six broad LTC goals:

Goal 1: Improve the accuracy of resident identification.

Goal 3: Improve the safety of using medications.

Goal 7: Reduce the risk of healthcare-associated infections.

Goal 8: Accurately and completely reconcile medications across the continuum of care.

Goal 9: Reduce the risk of resident harm resulting from falls.

Goal 14: Prevent healthcare-associated pressure ulcers (decubitus ulcers).

Some previously published patient safety goals have become standards. Not all healthcare settings (e.g., hospitals, ambulatory surgery centers) have the same number of patient safety goals. But each goal has specific requirements.

NPSG.01.01.01: Use at least two resident identifiers when providing care, treatment and services. This goal further states: At the first encounter, the requirement for two identifiers is appropriate; thereafter, and in any situation of continuing one-on-one care in which the clinician knows the resident, one identifier can be facial recognition. A measure of success (MOS) is required, i.e., monitoring of performance.

As any requirement states a minimum level of performance, other requirements may be more stringent than the Joint Commission’s, such as requirements for administering blood and blood products, and blood sample labeling.

NPSG.03.05.01: Reduce the likelihood of resident harm associated with the use of anticoagulant therapy. This goal further states that: This requirement applies only to organizations that provide anticoagulant therapy and/or long-term anticoagulation prophylaxis where the clinical expectation is that the resident’s laboratory values for coagulation will remain outside normal values. This goal does not apply to routine situations in which short-term prophylactic anticoagulation is used for venous thromboembolism prevention and the clinical expectation is that the resident’s laboratory values for coagulation will remain within, or close to, normal values. MOS and a written policy addressing baseline and ongoing laboratory tests are required.

NPSG.07.01.01: Comply with either the current hand hygiene guidelines from the Centers for Disease Control and Prevention or the World Health Organization.

NPSG.07.04.01: Implement evidence-based practices to prevent central line-associated bloodstream infections. This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines. A standardized protocol to disinfect catheter hubs and injection ports before accessing the ports is required, as are MOS.

NPSG.08.01.01, NPSG.08.02.01, NPSG.08.03.01, NPSG.08.04.01: While this patient safety goal is not in effect, Joint Commission has approved revisions to the reconciling of medication information goal. This new patient safety goal becomes effective July 1, 2011, for LTC, and is renumbered:

NPSG.03.06.01: Maintain and communicate accurate resident medication information. This new NPSG focuses on critical risk points in the medication reconciliation process – name, dose, route, frequency, duration, purpose; updating the information; comparing the information the resident brought to the organization with the medications ordered for the resident by the organization, and clarifying any discrepancies (a qualified individual, specified by the organization, must perform the comparison); providing the resident (or family, as appropriate) with written information regarding his/her medications; and, explaining the importance of the medication information to the resident at discharge.

NPSG.09.02.01: Reduce the risk of falls. MOS are required.

NPSG.14.01.01: Assess and periodically reassess each resident’s risk for developing a pressure ulcer and take action to address any identified risks. A written procedure for the identification of risks for and prevention of decubiti is required, as are MOS.

Clearly, patient safety goals point us to problematic areas in care delivery and focus us on identifying and implementing solutions to these problems. Working together, we can reach toward our main goals of safe and effective patient care.

 

LTC Closure Plans

Section 6113 of the Affordable Care Act ensures that in the case of an LTC facility closure, administrators of a skilled nursing facility or nursing facility provide written notification of the impending closure and a plan for the relocation of residents at least 60 days prior to the impending closure. Or, if the secretary of HHS terminates the facility’s participation in Medicare or Medicaid, the announcement must come no later than the date HHS determines appropriate.

As of March 23, 2011, new federal regulations regarding notice of LTC closures, including penalties for not doing so, are effective.

According to CMS data, as of April 2010, there are more than 15,700 LTC facilities (i.e., nursing homes). For the past decade, CMS’ Online Survey Certification and Reporting (OSCAR) data have shown a decline in the number of nursing homes, from 17,508 in 1999 to 15,713 in 2010. In 2009, there were 231 nursing home closures; 2010 saw 191 closures. LTC facility closures have implications related to access to care, quality of care, availability of services, and overall health of residents.

Currently, in an emergency, states have the authority to transfer Medicaid and Medicare residents to another facility or close the facility and transfer the residents to another facility. If a facility closes permanently due to an emergency, the administrator is required to provide proper notification.

However, if a state temporarily relocates residents during an emergency with the expectation that the residents will return to the facility, such a situation would not be considered a facility closure and would not require the administrator to provide notification. For example if a facility’s air conditioning failed during a heat wave, a state may order the facility to relocate all of its residents while the problem is investigated.

Previously, there were no federal regulations requiring that an LTC facility notify HHS or a state’s LTC ombudsman prior to closure of a LTC facility and there were no federal requirements for submission of a plan for closure of an LTC facility to any individual or entity.

 

Avrum H. Golub, MD, JD, is a consultant for accreditation, regulatory affairs and compliance for institutions, group and individual practitioners, and lawyers, and is former medical director of a multi-centered healthcare system. Email: agolub@optonline.net