Guest Columns

Be proactive with new CMS regulations

Susan LaGrange
Susan LaGrange

Change, change, change — it's the only constant, right? In healthcare, we are ALWAYS navigating change! And with “Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities,” some of us still haven't read the regulations. We must take heed to get our systems and our staff prepared.

To start, if you haven't already, READ, highlight and digest the information. Please send observations for consideration within the 60-day comment period, which is September 14. In the meantime, understand that a good deal of the content makes sense, and you need to proactively get our systems in order.

Here are a few of the changes and comments:

  • We have all seen significant innovation in the care practice, evidence-based standards, QAPI and resident safety; therefore, it is crucial to keep up with our systems.

  • Compliance and ethics programs for facilities: This is a great process when planned and implemented appropriately, as this will help in quality, person-centered care, improve decision making on all ends, and provide a process that reduces confusion and indecisiveness.

  • The majority of us are probably not surprised that requirements for comprehensive, person-centered care planning, QAPI and reporting on the suspicion of a crime are added to the proposed changes. In fact, if you don't already have these systems in place, you are behind the eight ball!

  • Facility-wide assessment

  • Competency-based staff education

If you haven't done so, have a QAA team meeting to split up the document for each respective department. Include the medical director, pharmacy consultant and the entire IDT.

Review and revise your systems:

  • Cross reference current policies, procedures and protocols. Make a copy of the current applicable policies/procedures and protocols to mark up — crossing off the old and adding the new information.

  • For new programs (e.g. compliance and ethics programs), it may be wise to include the facility's legal counsel for advice.

  • Have meetings weekly to specifically review each section and the necessary revisions.

  • Once your system is revised, ensure you have two additional sets of eyes looking at the process—reviewing the proposed rule and the revisions to the system.

  • Have the new policies, procedures and protocols approved by your facility's Quality Assurance Committee.


It is important to plan and deliver education for all staff, including volunteers and contractors.

  • Ensure your system will account for evidence of education and competency by all staff.

  • Identify a person responsible for ensuring documentation.

  • Make sure staff is aware of the location of the Policy and Procedure Manual for reference.

Next, plan and deliver informational sessions to residents and resident representatives.

  • Ensure several sessions at multiple dates and times, to allow for scheduling.

  • Identify a person responsible for documentation of content and attendance.

  • Plan a system for follow-up and questions.

Finally, prepare regulatory-specific audit forms.

  • Include specific changes.

  • Recommend IDT team audits in several departments over time.

  • Utilize the information to identify opportunities for improvement changes by developing an action plan addressing: Concern, Recommended Correction, Date to be Corrected and Person/Position Responsible.

  • Address the results of the audits and Action Plan with the facility Quality Assurance Committee, for further discussion and action.

If you wait to only react to the process, you will have to bite off more than you can chew when the deadlines come. If you start now — one system at a time, in a calculated, organized and planned process — your chances of staff understanding and complying with the updates will be more successful.

Recognize the phenomenal professionals on your team and enlist them in this process! Our industry has made so many changes in the past and overcome many obstacles. LTC professionals are strong and resourceful!

Susan LaGrange, RN, BSN, NHA, CDONA, is the director of education at Pathway Health.






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