Evan Shulman
Evan Shulman

Organizers of the first national meeting of the new American Association of Directors of Nursing Services timed their event just right. On Thursday, members became the first group of long-term care providers to learn of a new survey process that will start next year as a consequence of the new federal nursing home participation rule that was released late Wednesday.

The survey announcement came during a presentation from a Centers for Medicare & Medicaid Services official that clearly surprised the crowd of nurses attending the Baltimore event.

The 713-page rule will have three phases, explained Evan Shulman, CMS Deputy Director in the Division of Nursing Homes, Survey and Certification Group. The new survey process will start with the second phase.

The first phase, which will become effective Nov. 28, is reasonably straightforward in addressing either minor changes or existing requirements, Shulman said. The second phase will hit in November 2017, and the third phase two years thereafter.

The decision to put requirements in phases was made due to feedback from commenters on the proposed rule, who asked for intervals everywhere from 1 year to 10 years.

“There are a lot of new requirements, but most of the regulations are not new,” Shulman noted.

Certain areas, such as infection control, have different requirements within the phases. For example, existing infection control requirements are effective in 60 days, but the requirement to have an infection preventionist is in three years.

Speakers at the inaugural AADNS meeting and expo, including Shulman and Jillene Snow, the SVP of Compliance and Clinical Information at Ethica Health & Retirement Communities, encouraged the directors of nursing to remain calm about the rule.

“First of all, deep breath everyone,” Shulman said. “[If] I’m a director of nursing, what have I got to do?”

The answer, more or less, is to look at implementation guidelines and make a plan, including preparing for a different survey system. Surveyors will be trained on their new survey process, which is currently nameless, in July 2017.

Currently, half the country uses a Quality Indicator Survey and the other half uses the traditional survey, Shulman said. There are positives and negatives to both, he said: The QIS is computer-based, and as such can seem too regimented or inflexible. The traditional process allows the surveyor “a little more flexibility.”

“The new survey process leverages best practices of both,” he said. It will be computer-based. “It’s time to stop carrying around a thick binder.”

New F-tags will be effective in November 2017, along with changes in the State Operations Manual. 

Surveyors’ updated job “will include surveying facilities for everything in phase 1 and phase 2 of the final regulation. It will also include new F-tags. If any of you spent time memorizing the 500 F tags, I’m sorry,” Shulman said.

Dementia care surveys are scheduled to continue, he said, in response to a question.

“Dementia care will continue to be a focus of our organization. We are continuing the focused surveys and identifying facilities that have aberrant rates of antipsychotics,” he explained.

Shulman notes that while providers are to be commended for lowering off-label use of antipsychotics for residents with dementia, CMS has found some “unintended consequences,” specifically higher rates of reported schizophrenia. That’s one of the excluded illnesses, along with Tourette’s syndrome and Huntington’s disease.

“You all would know more about this than me, but it’s typically uncommon for a 90-year-old to have sudden onset schizophrenia,” Shulman said, to laughter.

Conference attendees also posed several questions about Section GG, which will need to be filled out in the MDS starting Saturday. Section GG is focused on data collection, not penalties, related to best practices in therapy, reminded Tara McMullen, Ph.D., Quality Measures and Health Assessment Group, Center for Clinical Standards and Quality at CMS.

“We are trying to see a person’s status at baseline,” she said. “The point at discharge is to see the effect of care. There are best practices within facilities, and we want to show the benefits of that care.”

Her response to a question about auditing the MDS or record for accuracy was succinct: “Section GG is not in that sort of audit. Section GG is leveraged for assessment.”

With regards to providers who may seem overwhelmed by the plethora of requirements and regulations, Shulman said to remember that much of the new rule includes best practices reflecting culture change and high-quality work.

“Many facilities are doing many of these things already,” he said.

The AADNS conference concludes today, with plans for another national meeting in the spring, organizers said.