In rural Horton, KS, staff at the 45-bed Mission Village Living Center have spent countless hours over the last nine months filtering through the 700-plus pages comprising the new rules of participation for Medicare and Medicaid providers.

Administrator and Chief Executive Officer Patricia Raasch led efforts to update policies and procedures to comply with Phase I requirements. By late this spring, her community was starting the risk assessment process that will underpin facility initiatives and survey success in coming years.

Raasch has arranged additional training for her clinicians, and they’re working in heightened collaboration with their medical director and pharmacy consultant to refine infection control and medication practices.

But Raasch questions whether the ends will justify the means for her faith-based, nonprofit organization, where about 70% of skilled nursing and assisted living residents rely on Medicaid.

“Some of those rules support areas of the country where there are ample resources to utilize, whereas in rural areas, resources are scarce,” she says. “The intent of the rules of participation was to have higher quality of care for our residents. Diverting care away [to devote to more time to compliance] seems contrary to that intention.”

Providers are prepared for some aspects of the rule and panicked about others, depending on which expert weighs in. But the clock is ticking away, with Phase II requirements focusing on infection control and medication management kicking in on Nov. 28. Though Phase III isn’t triggered until late 2019, many facilities also appear to be laying the groundwork now for its stipulations.

“It’s really not that long, looking ahead to November,” says Mary Madison, RN, RAC-CT, CDP an LTC clinical consultant for Briggs Healthcare. “From the top down, leadership has to take these rules of participation and deadlines seriously.”

Briggs took an all-in approach, updating its forms, posters and educational tools for providers for all phases at one time.

But some providers are waiting for the next shoe to drop to determine specific strategies.

Interpretive guidelines that outline details on everything from staff training to acceptable drug regimens— and tell surveyors what to penalize for — aren’t expected until summer.

“We’ve had some early adopters, facilities that see this as a big deal,” says Chad Worz, president of Medication Managers, a consultant pharmacy company serving facilities in more than 30 states. “But other, smaller facilities are busy putting out fires, and will be until Nov. 1 or so. You’ll have that same sort of ‘We’ll get to it when we can’ approach.’”

Full-time attention

To meet Phase I requirements by last November, facilities had to develop their basic infection prevention and control program. 

Now, each building must conduct an annual facility assessment and link it to that program.  The second phase also calls on facilities to adopt antibiotic stewardship programs that look to combat antibiotic resistance and related illnesses.

Now it’s up to facilities to determine where they and their patients are at most risk and set achievable goals for improvement.

“You can’t do everything at once,” says Barbara Connell, vice president of medical affairs for Medline. “You really have to pick the most concerning thing first.”

For those who work in infection control, the news is good.

Despite previous requirements, infection control consultant Deborah Burdsall, Ph.D., RN-BC, CIC, FAPIC, says 39% of long-term care facilities had related F-tag violations in 2016.

She expects pressure to improve that number to rise over the next two years.

Connell likewise views the rule as an opportunity to improve surveillance, dive into the results and make significant improvements in patient care.

That effort starts with the appointment of the preventionist.

“Personally, I think it should be a full-time position,” Connell says. “I’m not sure how they could run a really robust program if they’re wearing multiple hats.”

It’s preventionists who will lead surveillance for patients with healthcare-associated infections, monitor drug-resistant organisms and implement isolation or other precautions to manage outbreaks. The IP also can play a big role in the education of clinicians, physicians and patients on the need to practice antibiotic stewardship, Connell says.

Many corporate-owned facilities have already hired coordinators to lead initiatives system-wide.

The Centers for Medicare & Medicaid Services, however, backed away from draft plans to require a full-time position because independent providers might not be able to dedicate staff. In those cases, Burdsall says, the facility assessment will determine how much time the preventionist needs to spend in that capacity.

In larger post-acute facilities with more high-risk patients — especially those on ventilators or dialysis — Burdsall says more than one full-time employee could be needed.

At Mission Village, Raasch says she tacked the preventionist role onto a nursing position. They’re “just starting” the risk assessment process using a risk management module included in their EHR and will later align QAPI goals with results from that risk assessment.

In all settings, access to education and staff training will be critical.

“People need constant reminders and constant re-education,” Connell says.

APIC offers a long-term care certificate series that includes lessons on microbiology, disinfection and sterilization. The approach incorporates the latest evidence-based training and innovative methods.

Connell says it’s a good idea to offer live staff training as well, as researchers have found that in-person observations on infection control measures like hand-washing resonate best.

Madison says education also must involve families, whose acceptance of limited antibiotic use will be critical to meeting new standards.

“Every person needs to have training,” she says. “And we’ve got to have some of the infection control experts swing the binoculars around to look at LTC. A lot of the current education is geared toward the acute phases.”

Medication management

Burdsall has been telling providers not to reinvent the wheel to adapt to new rules.

Resources including the QAPI toolkit and the CDC Core Elements for Antibiotic Stewardship for Nursing Homes can be invaluable. Burdsall recommends providers set up the facility assessment and antibiotic stewardship components as QAPI performance projects, meaning they have an accessible and likely familiar framework. 

Providers also are strengthening partnerships that can help them better manage and keep track of medication use.

Since the Final Rule was announced, Worz has been training his pharmacists and adding services to meet the expanded needs of his long-term care clients.

Some of his consultants are essentially managing antibiotic programs for long-term care clients, an add-on to the already required monthly medication reviews. In some cases, they can spot antibiotics being prescribed earlier than necessary or when other treatments might work better. 

As a benefit of beefing up admission reviews — and serving as a liaison between hospitals and skilled nursing — Worz says they also can help avoid redundancies and recommend less expensive antibiotics if they are necessary.

“To be able to say there’s a possible cost-saving component makes it more palatable,” Worz says. His consultants also emphasize the need for vaccinations and looking for residents who are due to help cut infection rates.

All of this makes sense to Joan Baird, director of education and clinical affairs for the American Society of Consultant Pharmacists. She’s seen some panic among providers about meeting all requirements of the rule.

But she expects challenges will lead to opportunities for better-informed clinicians, and better treatment for patients. The focus on multidisciplinary solutions should ultimately protect providers, too.

“Most surveyors are not pharmacists, and most are not nurses. They may be coming in seeing things in black and white, and there are still gray areas,” says Baird, who was part of the group that reviewed the interpretive guidelines. “Consultant pharmacists and medical directors provide checks and balances. We’re not at the facilities putting in catheters or starting an IV, but advice is something we can and do give.”

That advice comes face-to-face during QA meetings, or in notes on charts that advise clinical staff on psychotropic drugs to avoid or reduce.

Baird says while the use of antipsychotic drugs is now widely viewed as a negative in long-term care, many facilities remain uncertain about identifying psychotropics. As examples, Baird says she’s recently fielded questions about the use of melatonin as a sleep aid and a new treatment for Parkinson’s and dementia that needs to be provided at the same dosage consistently.

That’s one area where guidelines may provide more clarity.

Technology upgrades also could help facilities get the most out of partnerships.

“A lot of nursing homes, especially those that are unaffiliated, still don’t have EMRs or other systems that allow you to document medicine use,” says Connell, who predicts the rules will spur new tech investment.

If providers want to show they’re hitting targets for reducing antibiotic use or other unnecessary prescriptions, they’ll need data. Similarly, easy access to lab results can speed responses.

EHR systems that provide alerts also can help staff tackle infections and outbreaks in real time, Burdsall adds. 

Online training empowers nurses as antimicrobial stewards

Nurses who receive online training are uniquely positioned to serve as antimicrobial stewards in long-term care settings, according to a study published by the American Journal of Infection Control.

Researchers from Case Western Reserve University and a Veterans Affairs medical center in Ohio created an online version of a course intended to help VA nurses improve the care of residents with possible infections. The 103 nurses who completed surveys after completing the six-module course had a greater awareness of their role in limiting use of antimicrobials.

About 10% of the nation’s 1.4 million nursing home residents receive antimicrobials each day, up to 75% of them unnecessarily.

The researchers reported RNs and LPNs in long-term care have a stronger influence on the use of antimicrobial products and antibiotic prescribing than those in acute settings. That’s because they function as frontline clinicians in nursing homes, caring for patients and communicating about their status with prescribers, family members and residents themselves.

“As nursing homes prepare to meet policy changes proposed by [the Centers for Medicare & Medicaid Services] and The Joint Commission that call for antibiotic stewardship programs, nurses will likely become integral members of interdisciplinary antimicrobial stewardship teams,” wrote Brigid M. Wilson, Ph.D., with the VA’s Geriatric Research Education and Clinical Center in Cleveland. “Education may increase nurses’ confidence, empower them to help effect changes … and improve the overall care and safety of nursing home residents.”

The free course is available at

— Kimberly Marselas