On Nov. 28, 2019, Phase Three of the Centers for Medicare & Medicaid Services’ (CMS’) Final Requirements of Participation (ROP) for long-term care facilities went into effect. By failing to comply with these rules, skilled nursing facilities (SNFs) not only jeopardize the well-being of those in their care, but also risk their accreditation and/or financial penalties.

There are several areas SNFs must take into consideration to ensure they don’t run afoul of the new regulations. These include:

1. Cultural Competence

Cultural competencies help staff communicate effectively with residents and their families and help provide care that is appropriate to the culture and the individual. The term “cultural competence” refers to a person’s ability to interact effectively with persons of cultures different from his/her own. Cultural competence is a set of behaviors and attitudes held by clinicians that allows them to communicate effectively with individuals of various cultural backgrounds and to plan for and provide care that is appropriate to the culture and to the individual.

2. Trauma-Informed Care Planning

Caring for residents with trauma and/or post-traumatic stress disorder is a specific requirement for Phase 3. Trauma survivors must receive culturally competent, trauma-informed care in accordance with professional standards of practice, accounting for residents’ experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. Trauma-informed care in long-term care settings helps residents feel safe, and empowers them to make their own care decisions.

Facilities must have sufficient staff who provide direct services to residents with the appropriate competencies and skill sets that include knowledge of and appropriate training and supervision for caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment.

3. Change in Condition

Facilities are responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being meet each resident’s needs and include individualized approaches to care. A key component of competency is a nurse’s (CNA, LPN, RN) ability to identify and address a resident’s change in condition. Facility staff should be aware of each resident’s current health status and regular activity, and be able to promptly identify changes that may indicate a change in health status. Once identified, staff should demonstrate effective actions to address a change in condition, which may vary depending on the staff involved.

Facilities should consider these three areas when determining training and competency assessment needs for their staff.

Following a recent webinar on the critical role of Infection preventionists in long-term care, we received several additional questions regarding infection control, prevention programs, and the new role required by the CMS in Phase 3. Some of the most frequently asked questions included:

For the “part-time at facility” requirement, can a nurse that works full time also have the infection preventionist (IP) title and be IP as needed? Or do they need to spend the “part time” amount as IP?

The guideline on this does not have a specific stated number of hours the IP must work in the facility. However, the idea behind the regulation is that CMS wants someone with “boots on the ground” in the facility to be able to make observations as well as perform ongoing infection control interventions. CMS is trying to avoid someone doing off-site oversight of the infection control program for the facility.

A good infection control program requires someone with specialized infection control training to be inside the facility. If this full-time RN can perform ongoing infection control tasks as part of the day’s job duties on top of other tasks of caring for residents, that would qualify. For example, IP tasks would include overseeing daily monitoring of isolation of residents including signage, personal protective equipment, hand hygiene observations, ensuring compliance with infection control policies, etc. That being said, the infection control officer needs dedicated time each week to do tasks, such as surveillance, that cannot be performed at the same time as patient care.

Does this person have to be an RN?

No, they do not have to be an RN. The regulation states that primary training can be in nursing medical technology, microbiology, epidemiology, or another related field. A primary training in nursing is also acceptable, so an LPN should meet the regulation as well.

Can the IP also be the director of nursing (DON) of the facility?

In long-term care, it is common that some people must fill the job duties of several titles. There is no language within the regulation specifically prohibiting this scenario. However, a surveyor is likely to frown on this arrangement unless it is in a very small facility (for example 25 beds or smaller), and would be looking very closely during survey to ensure that the DON is also able to perform all the duties of the infection prevention and control officer.

For the new F-tag of infection preventionist, if I have had previous training from the California Department of Public Health (CDPH) basic boot camps and also a paid two-day course is that suitable for the F-tag? Or should I be on the safe side and do the CDC TRAIN course?

The requirement states that you must have state-sponsored training or training from approved nationally-recognized agencies such as SHEA or the Association for Professionals in Infection Control and Epidemiology (APIC).  If the CDPH boot camp was a state-sponsored infection control training, it may meet the requirement. However, to be on the safe side, it would not hurt to do the free training through the CDC TRAIN website.

For more information on the upcoming implementation of the final phase of the ROP, Relias has two recently completed webinars, focusing on an overview of Phase 3 of the requirements of participation and the competency requirements.

Corinne Epton, MA, MHA, CHC, is senior regulatory officer at Relias, where she provides regulatory compliance and training guidance to our clients. She is certified in healthcare compliance (CHC) and holds MHA and MA degrees.

Amanda Thornton, RN, MSN, CIC, clinical science liaison, joins PDI from Kindred Hospital, where she was chief clinical officer, Infection Control; employee health nurse; and West Region Resource ICP for eight years. She utilized her skills in epidemiology and clinical management to reduce healthcare associated infections and increase patient safety.