LeadingAge New York Adviser Adviser LeadingAge NewYork Spring 2019 final - Page 28

An Overview of the Requirements of Participation Phase 3 LeadingAge New York ProCare’s Mary Wassel and Elliott Frost spoke of the upcoming third phase of the nursing facility Requirements of Participation (RoP) that will take effect Nov. 28, 2019. The presentation was a high-level discussion about the RoP Phase 3 and highlighted key changes to provide an overview of the programmatic and systematic revisions that require training of staff. Trauma-informed care is a significant addition under the new requirements. Under F659, the services provided by the facility, as outlined by the comprehensive care plan, must be culturally competent and trauma-informed. The facility must ensure that services provided are delivered by individuals who have the skills, experience and knowledge to do a particular task. F699 details Trauma-Informed Care, namely that the facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. Behavioral health is another focus. The intent of F741, Competencies, is to ensure that the facility has sufficient staff members who possess the basic competencies and skill sets to meet the behavioral health needs of residents for whom the facility has assessed and developed care plans. The facility must consider the acuity of the population and its assessment. Additions to the Quality Assurance and Performance Improvement (QAPI) oversight regulation are also noteworthy. Although the QAPI/Quality Assessment and Assurance (QAA) improvement plan was implemented in Phase 1, Phase 3 requires facilities to develop and implement written policies and procedures that establish coordination with the QAPI program to monitor and review incidents (trends, patterns, etc.) indicating abuse, neglect, misappropriation and exploitation. Another revision to the QAPI regulation is that the governing body is responsible and accountable for the QAPI program (F837). This regulation is intended to ensure that the facility has an active, engaged and involved governing body that is responsible for establishing and implementing policies regarding the management of the facility. Moreover, the governing body and/or the executive leadership team will have to adopt policies and practices to document that they are meeting this oversight requirement. The requirements under F865 are intended to ensure that facilities develop a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Another significant addition is the inclusion of Infection Preventionist requirements. The facility must designate one or more individuals as the Infection Preventionist, who is responsible for the facility’s Infection Prevention and Control Program (IPCP). Further, this role must be included on the QAA committee. Compliance and Ethics (F895) is another new regulation. The facility must establish written compliance and ethics standards policies and must include individuals who have substantial control over the operating organization or who have a substantial role in the making of policy within the operating organization. There are further requirements for oversight for an organization with five or more entities. One noted environmental addition is the inclusion of the facility’s Resident Call System. The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or centralized staff work area from each resident’s bedside. Continued on page 28 27 Adviser a publication of LeadingAge New York | Spring 2019