I would like to introduce our speaker to get us started with today's session. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. Laura is a registered nurse and attorney. Laura holds a Bachelor of Science from Reeds University, a Doctor of Jewish Pronouns from Drake University College of Law, and a registered nurse diploma from St. Luke School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura, and we invite you to go ahead and get us started. Okay, and welcome everyone. And for those of you who listened last week, I want to say again, thank you for putting up with my voice. I did have a little bit of a cold. So again, thank you. Today, we are talking about the issue of swing beds, and it's primarily focused to critical access hospitals. Main reason being that it really helps, well, to them actually, it helps keep the patient in their community, as opposed to having to go to a facility away from where they live because of their small hospital, but also provide some financial support for those critical access hospitals who are providing such a great healthcare resource for those individuals. I always include my disclaimer that this program is informational only. It is not meant to be legal advice or provide legal advice or serve as establishing an attorney client relationship. So please consult with your own in-house counsel, legal representative, especially if there's any particular question, as it might relate to your state law. I always like to do a brief introduction on why we are here. Those of you who've gone through surveys, and probably all of you have, you know you don't want to get one of these from CMS, and that is where they found some deficiencies at the condition level, and then you have to do that plan of correction. And no facility, no provider wants to get the notice of an involuntary termination of the agreement with Medicare and Medicaid. Sometimes when the findings are so egregious or their plan of correction didn't meet the needs or they just didn't happen, that CMS would finally say, nope, no more, we're done. How does this all work? Well, the regulation, the rules start within the Federal Register. Then CMS has a couple jobs that they have to do. They have to develop the interpretive guidelines and survey procedures. Those are directed to their surveyors, but we have access to those, and they also have to let them know, and that goes out through the transmittal. They also are responsible to update the manual. There are three types of survey, the certification when you're getting started, the validation if you happen to, they're coming back, or if you are deemed status, they may still want to do that validation survey, and then of course nobody wants to get the complaint survey where they do quite a bit more in depth. How do we keep up with any changes that are coming around? Subscribe to the Federal Register. That's a good way to start, and make sure, of course, you have the most recent manual. It first came out in 86, yours was last updated in 2020 for critical access hospitals. If there is a new manual, check for the transmittal page, because it makes it easier to find out what's changed, and if you're in compliance, you probably already know all of this, but also what's called the survey and certification website. That's where they put the memos, where the new changes are coming out or the new alerts coming out for their surveyors. So today, by the way, CMS is responsible for a host of services that are provided, and one of them, of course, is hospitals, but we're going to focus on critical access hospitals in Appendix W. I will mention some of the references and regulations for Appendix A, but those are very few that happen to have swing bed services. And the operations manual, this happens to be the index for the acutes. Again, you'll see their last update in 24, April of this year, and for criticals, you haven't been updated since 2020. I have been reaching out to CMS to find out, you know, when is this coming around, because there's been some changes that affect you, and they're not in this manual. And so they said, well, we're still working on it, so I'm sorry, I wished I had a better answer for you. That is the answer. That transmittal page that I mentioned, where they give you a clear indication or quick indication of what the changes are, you'll see the blue lettering when you go into the link, and this will pop up. You will see the dates of those revisions and the numbers that do come out. And that's just an example of what one would look like on the transmittal page. Again, revision, new or deleted. And the survey memo site, you'll see it has what was the change, who did it apply to. Those last few letters at the end of those numbers tell you, is it nursing homes, at hospitals, and then the date that it goes into effect. And that's just an example of what one would happen to look like, gives you the date and the number. Well, I want to talk briefly on deficiencies, just very, very quickly. You can access this deficiency data that CMS comes back and posts to their site after they have done their surveys, and it includes all sizes of hospitals. It has the address, the name, the tag number, and it will give you a brief description of what that deficiency happened to be. So to find it, I have the link there for you. This happens to be on slide 18. You will have to copy-paste, because once you get these slides, they don't automatically link to the web. And then scroll to the bottom where it says full-text statements. These are, again, updated quarterly. And this was what will pop up, a huge Excel format, but you can filter and sort. I like doing this if I'm trying to figure out, okay, what are some of the recent deficiencies that CMS has? When it does come up, let me back up a slide. When you go to where it says full-text statement, two Excel formats will come up, two Excel links. Just make sure you get to the right years, because some are like from 2010 to 16, and then it's 2017 to current. So that's why you want to make sure you get the most recent list. Some swing bed deficiencies that I found, some of the recent ones, one, they didn't tell residents that's how they refer to them. Instead of patients, they call them residents. They didn't inform them of their rights, both in oral and in writing format. They didn't have non-English speaking references for those patients who don't have English as their primary language. They didn't allow residents to get copies of their own medical records. That has been a huge focus of some of, not only CMS, but the Office of Civil Rights, of some of their complaints that were just not giving them access. They didn't provide interpreter so that the resident or patient couldn't understand what was going on. Restraints applied without any order or any assessment. They didn't follow their own policy regarding restraints, and specifically how it related to side rails. Side rails are considered a restraint. So that's one thing we have to follow. Restraints were written as a PRN order for any hospital, whether it's acute, critical, even in a swing bed status, that is not permitted. The policy for restraints was inappropriate. It allowed for what they call a trial application, which essentially is a PRN order, and again, not permitted. They didn't monitor patients who were in restraints. They didn't have a plan of care. And then just to wrap up just a few of the deficiencies, nursing wasn't aware there were specific rights for these residents, that they didn't provide medically appropriate social services or do a comprehensive assessment. And then finally, they didn't talk to them about, hey, is it safe to smoke or not? And then the discharge summary. We're going to go through the majority of what these deficiencies encompass as we go through this program. But just to do a quick, brief introduction to swing beds, there were four changes back in November of 2019. It was a hospital improvement rule. Now the majority of these regulations are in Appendix W. There are very few of overall regulations in Appendix A, because it applies to only those hospitals that have 100 beds or less. The interpretive guidelines and survey procedures aren't even in these two manuals. They're in Appendix PP, which happens to be the long-term care manual, because that's where the regulation started, what's in there. Now CMS had thought at one time, why don't we just put them all into there, save people time? And then after reconsideration, they said, nah, we're not going to do that. So unfortunately, you do have to have Appendix PP and Appendix W, if you're a critical access hospital, handy. Now as we go through this program, I have tried to collate those into this together, so you'll get an idea about where they overlap to hopefully make it a little bit more, a little easier for you. There are new tag numbers they put back also in 2020, and there are only 12 tag numbers total, so it's a very short section. But generally, as of January of this year, there are roughly 1,400 critical access hospitals in the U.S. total. Almost all of them do provide swing bed services. And again, the reason is, it really is a way for patients to stay in their community when they need continuing care. And it also helps stabilize the census for those critical access hospitals. Hospitals that do have swing beds, you're reimbursed at the per diem rate as a SNF. And again, that's a huge revenue opportunity for critical access hospitals. So here's just an example. This is from the Rural Health Information Hub, shows you where these are located, a huge amount within the Midwest. But again, they are all over the U.S., so quite a few of them. And what we're talking about today in Appendix W is this area here, 485.4645. And that is for long-term care services, also known as swing bed services. But Appendix PP, again, 800-and-some-odd pages long, and that's why I've tried to do that collation, so you don't have to flip through those overall manual to try and find where does this apply. Okay, swing beds. As Lindsay mentioned, we have four questions. These are totally optional. And some of them are to try and kick off the conversation. And also, the others are to start thinking, hey, is this going on in my facility? So here's my first one, Lindsay. Okay, so this one should now be on your screen. And it says, our critical access hospital has swing bed patients that may stay for an extended period of time, up to a year on occasion. And your options here, yes, no, or prefer not to answer. And then for those of us who missed the initial introduction of today's presentation, we will have several of these polling questions throughout the webinar. And as we pause for you to put in your answers here, we will also pause to address any questions that you have for Laura up to this point in the presentation. So if you do have any questions at this time, you can type those into the Q&A option, seen there at the bottom of your Zoom window. Or if for some reason you don't see that option, you can, of course, type your questions into the chat as well. Okay, we've gotten some good responses here. Looks like a couple more just coming in. Okay, I'll go ahead and end that here. Great. And while they're answering too, and I put up here into a year, oh, no, okay. I put in here a year because I have, I was surveying one hospital, and there was a patient and I was walking past the room and said, yeah, that's our swing bed areas. And she had everything in that room. She had pictures of family and friends and posters and everything on the wall. And I'm going, well, that's kind of unusual for swing bed. But there was no place for this individual to go. And so based upon that, she had been there for almost a year while they continued to find alternative placement for her. And so that's why I said, does it happen up to a year? And it could, it could. So briefly on Appendix A, just very briefly, you're limited to fewer than 100 beds. It must be in a rural area. For these hospitals, and this is usually 50 beds or less, you cannot have any 24-hour nursing waiver in effect. That means that that waiver says you don't have to have a nurse on duty 24-7. So if that's your size hospital, you can't have that waiver to qualify for swing beds. There has to be an agreement with Medicare already in place and that you haven't had that approval terminated within the previous two years. The regional office will determine eligibility. But otherwise, everything else that we're going to cover today, it all applies to you. The requirements, the guidelines, and survey procedures, they're all in Appendix A. So very basically, first off, to qualify for, as a patient, what they have to do to qualify for swing bed stay, they have to have a three-day inpatient qualifying stay. Observation beds don't count. And that's why they put the moon notice under the Notice Act, that Medicare observation notice that you have to supply to Medicare patients who are in observation. The patient must be admitted to a swing bed within 30 days of discharge from that acute care stay. There has to be benefits under Medicare Part A that the patient still has, that they're still available, and of course, medically necessary. They have to meet that criteria. It just can't be for convenience of the family that, eh, we really don't need so-and-so home, we need a breather. No, there must be a medical necessity for that patient to have that swing bed stay. Otherwise, patient rights really is a huge component of all of the regulation. And so, like any patient in the hospital, we have to give them notice of their patient rights. For swing bed, we should give them prior to they get over there. Now, again, if they've had that three-day inpatient stay, they've already got them. But reiterate that. Make sure they're aware of what those rights are. They must be in writing, and the resident should, should acknowledge receipt. You don't have to force them to sign it. Just document it if they won't sign off that they got them. And of course, keep in mind, when you have those who have limited English proficiency, it's not their primary language, or it's low health literacy. And we have to make these in easy-to-understand terms. What do we have to provide? Well, it's a host of information. Slide 35 just gives you the major components. There's more. Don't get me wrong. We don't have enough slides to fill, to use, or available in time. So, here's just some information we have to give them. Financial obligations. That's a big one. You know, what are you going to have to pay for? HIPAA. That just continues while they're in SNF. Their rights and responsibilities. Yes, the patient has responsibilities. Who do they contact if they want to file a complaint? Whether it's with the hospital, or they also want the state agency at Adminsen notified. Description of what is a swing bed. What does that mean? How do they file a complaint? How do they report abuse, neglect? What happens when it comes time to transferring or discharging them? So, these are just some of the information that has to be provided to a patient once they enter swing bed. So, I'm going to start now with TAG 1600. This is where it is, again, in the Critical Access Hospital Manual. You have to be certified for SNF care if you're going to do this. And the services have to comply with Appendix PP. So, the nice thing is you can use that bed interchangeably for acute care or SNF level. Patient doesn't have to even leave the bed or that room. They don't have to go to another part of the hospital. They can stay there because it's a reimbursement term and a services term. It's not a physical movement within the hospital. They will survey your swing beds during a full survey, or if they happen to get a complaint, or if you're requesting swing bed certification and approval. They will do it at that point in time. So, with the swing bed, they're discharged from acute care to SNF care. So, what does that mean? There must be discharge orders. There must be progress notes to show, okay, what's going on with this patient while they were in acute care. There must be a discharge summary. Yes, we have to do one. And then there has to be subsequent admission orders for when that patient enters swing bed status. And again, if they don't change facilities, you can use the same record. You just have to have some sort of a separator, and that's up to your IT person to help you with that so that they understand, okay, they're done in acute, now they're in this new status. I mentioned the three-day stay. Medicare does require that qualifying stay either in your hospital or another hospital who is also qualified before they're admitted to swing bed. Now, this only applies to Medicare patients, so keep that in mind. You can still have other patients coming in for swing bed if you're qualified to do that. And also, the surveyor, while they're there, they want to see at least two swing bed closed records if you don't have any on site. Otherwise, they're just going to go through those records for swing beds who happen to be on your facility. And the length of stay restriction, they can stay there, like I said, up to a year if that's the case, if that's the issue with getting this patient into a next level of care. But it is to be transitional. While they're recovering, maybe they're going to a nursing home, they're going to get into a placement, or maybe they're going to go to a long-term care hospital, a different situation. Or even home, whatever that happens to be. The nice thing is you don't now have to have a transfer agreement between the nursing home and your hospital in order to accept these patients. Another nice thing they said you don't have to use are what's called the MDS forms. And it's kind of a multiple data sheet to record the assessment. Nursing homes use that. If the patient came from a nursing home and it's still in their record, use it. That's OK. But you don't have to use it if you don't want to. As your eligibility, again, you must be pre-certified as a critical access hospital, or your small rural hospital. As a critical access hospital, no more than 25 inpatient beds. Distinct patient units, your distinct psychiatric units, behavioral health. Your distinct rehab unit beds. Those do not count toward that maximum. But what you do have to do is make sure that the individual is eligible for a swing bed. And again, CMS will determine, the regional office determines if those requirements are met. Next eligibility is you have to comply with the requirements in Appendix PP. Again, this is a host of information that you must comply with, which we are going to go through on these, and especially those that I have listed out here, the rights, nutrition, dental, activities, social services, assessment, et cetera. On patient rights, if the patient is incompetent, then we all know the representative steps into their shoes and acts on their behalf. Otherwise, it's up to the patient. And they have a right to be told what's going on with them, what is their treatment. Of course, in a language they can comprehend and understand. They are informed of any changes to their plan of care. You know, instead of doing PT once a week, we really want to get you back on your feet. So we're going to up to two times a week, or maybe decrease it. They get to choose their physician. That physician has to meet their requirements. In other words, they're licensed to come to the facility. And if they don't have one, then we have to provide them the name and specialty of a person, a physician, who is going to take care of them, and how do they contact them. I just want to give you some quick pointers on here. This is not in the manual. It's not in the requirements. Now, CMS has always said they get to choose their own provider. And so CMS is saying, yep, we're going to follow that. This is a new part. And again, what we have to do now is provide them with a list of providers who are understaffed. again, if they don't have one that goes to SNF or can take care of them. If it happens to be a hospitalist that was taken care of in the hospital and they like them, well, you give them the name of the group, not the name of that individual hospitalist. So you may need to look at your policies and procedures just to make sure it's clear so staff understand this is what the patient, what their rights are to do. If they don't come to the swing bed status or don't treat patients, you can still accept the patient and then, you know, give them that list of those who are accepting and do provide swing bed status. And again, may need to educate our staff. Now, a few folks already probably know this and that's already happening. But again, they wanted to reemphasize this. Otherwise, patients can decide they don't want treatment. They can decide to refuse it or discontinue treatment. Of course, never. They don't have to participate in research if they don't want to. They can make advanced directives. They can request certain care. Now, this care that they're requesting, it has to be indicated. It can't be something so off the wall and not medically indicated nor good medical practice. You know, they can request it. You don't have to give it. Again, they can use and keep their personal possessions as long as, of course, space permits. And then we have to give them access, excuse me, to their immediate family, visitors. And like with any inpatient, they can decide I don't want to see anybody. I don't like my Aunt Susie. I don't want to see her. Keep her out of here. They have still those continuing rights. They do say you can have visiting hours or you can loosen those visiting hours for swing bed. Again, these patients aren't so critically ill in swing bed. They're just kind of there waiting to continue recovery. And that can be a very long and boring process. So if you wish to open up your visiting hours, if you already have or don't have those in place, that's fine. And they have found sometimes that does help the patient recover quicker. Now, here's a new one. Here's one where you have maybe there's something going on in your hospital. And you're asking the patient, hey, you want to keep yourself busy? How about if you fold up these towels? Well, we can have patients, we can offer that to them. But they have a right to say, no, I don't want to do that. These are services on the behalf of the facility, not part of their PT, not part of their physical therapy regimen, but it's something extra. You can't require it to do that. Just document if they want to do this. Now, let's say you've got somebody who's a really good pianist. And maybe you provide this social interaction and you need a piano player. And you've got someone who does that, one of your patients. Well, you can do that if they want to do it. You just have to decide, first off, do they want to do it? And do they want to get paid? Or is it going to be voluntary? If you're going to pay them, it's at the prevailing rate. And it has to be in their plan of care, believe it or not. And of course, a policy and procedure on it. Is it going to be paid? Who's going to be responsible to make sure that occurs? How is that going to occur? And all of the other information that comes into it. I had a sister who had to go to respite care, similar to SNF care. And she was a great pianist, and still is, I should say. But she, they had a piano there. And one day, she went out and just started playing just to entertain herself. And then they asked her, would you continue to play for us? And they did have to say, we are willing to pay you. But by her own decision, she said, no, don't pay me. I love playing, and it gives me something to do. And so they had to document that within her plan of care, that it was offered, and it was only voluntary. Otherwise, they get to receive and send out mail. And that means we have to give them access to stationery and postage, but they pay for it. And we have to tell them what's covered by Medicare and Medicaid and what is not. Do it at the time of admission, periodically, if they're going to be there for an extended period of time. And once the patient becomes eligible for Medicaid, we need to notify them of such. Then personal privacy and confidentiality. They're taking a bath, please close the door or close the curtain. Receive communications. Choose their attending. Again, in a language they understand. They can get a copy or refuse release of medical records. I mentioned OCR is really stepping up and starting to find hospitals. This tends to still be one of the issues. There was a system back east that paid almost a million dollars because they didn't give access to the medical records. Another right is they can share a room with their spouse if they want. Both have to consent to that. Maybe they want to be away from each other for a while. But they do have that right. And CMS, as far as the guidelines, survey procedures, they only refer to appendix PP. It's the F standards. And sadly, again, there is no crosswalk. So I've tried to incorporate that into that. So you'll see here where the implementation was in 2020, but they do refer to 483 as far as the interpretive guidelines. So here you'll see an example of where I've tried to do that crosswalk with what does the regulation say in appendix W and then what's in appendix PP, the tag numbers. So very briefly, treated with respect and dignity. To self-determination, that's their advanced directives. Communication with people outside of your facility. Equal access to quality care, whether it's self-pay, no pay, Medicaid, depending on what's their condition and what's their diagnosis. We can't discriminate nor interfere with the patient's exercise of any of these rights. They can dress in their own clothes if that's practicable. In other words, if you have a patient, they're in swing bed and maybe just doing wound care and it's not a good idea to be wearing your shirt from home, maybe it's more practicable for them to be in a gown with just an explanation of why. We also want to promote independence in dining so we can't make them wear a bib and also not stand over them while assisting to eat. What CMS is trying to get across here is we want this interaction. We want them to be treated as an adult and an individual. And so eye level, talking to them. Now, there is not a corresponding section in the critical access manual. This is all in appendix F. Respect their personal space. Maintain eye contact when you're speaking with them. They even put it in appendix F, what's not meeting those rights? Staff talking to each other or on their phones and not really helping the resident when they're helping them with their meal. Restricting that individual from public areas such as you can't go to the lobby, you have to stay over here in this corner. Keeping the catheter bags uncovered, that's a privacy issue. Again, they just gave some examples. In appendix F, they also put out some prohibited acts like retaliation. If a resident wants to have some family members in and we say, no, you can't because of your behavior last week, therefore we're going to punish you, that's a retaliation. You can't prohibit them from being a part of a group activities as a form, again, of either reprisal, in other words, retribution or discrimination. And we can't require them to get approval. If they want to post something on, say, Facebook or Yelp or wherever it happens to be, well, we can't require them to get our okay to do that because that's an imposition of their free speech. On planning and implementing care, we have to, of course, inform them what their care is and that they participate and also in a language they understand as it relates to their condition. They have a right to know who's taking care of them, what type of healthcare provider. Are we talking advanced practice nurse? Are we talking a physician? Who's taking care of them? And then what are the risks and benefits of any proposed care treatment? That's informed consent. It still applies within the long-term care situation. They can administer their own medications if it's appropriate. Now, there is no corresponding section in W for this other than in the medication component. But if you want to do this, that's your choice. If choose they're attending again, we give them that list and the physician has to meet the requirements and agree to come in. Otherwise, just a continuing rights treated with respect and dignity, have their personal possessions, furnishings, and receive services within a reasonable accommodation. That's the one where if they want or they're requesting certain services and it's safe to do so, then okay. But if it's not safe, you can say no. And I bring up the one, there was a culture where they had lit candles around the room for this patient's recovery. That's their culture. Well, of course, the patient's on oxygen and those two don't mix as most of us know. So, that was a danger. So, we had to come up with an alternative that would still meet their cultural requirements and yet be able to keep them safe. Again, share a room with their spouse. By the way, we have to tell them if we're going to be moving them out of a certain room. We have to give them written notice if they're going to be moved out of that room. It could be for a very valid reason, like you've got a water leak. It's like, well, we have to move you out because we've got to go back in and fix the wall. And they can refuse to transfer if it's just for your convenience. Say, nope, I like this room. It's a quiet room. I'm going to stay here. So, here's our second question. Lindsay. Okay, let's get that one up here on your screen. Okay, this question says, Miller Critical Access Hospital has open hours for visitors for swing bed patients but for immediate family only. Miller is due for a state survey. Will this policy be questioned as acceptable? No or yes. Are your options here? And it looks like we do have a couple of questions, Laura. Okay, okay. This first one says, what if you only have one provider and they do not have a choice on selecting a provider? That's a challenge. I will admit to that. If you have only the one provider, you just have to explain it to the patient. I'm just going to say patient for ease. You just have to explain it to them. This is the only one we have. Now, understand those two may not get together and they may not get along and they're going to butt heads. You have to make some arrangement to have another provider come in because that's just not therapeutic. If they're not going to get along, they're arguing back and forth, it's just not going to work. So yeah, unfortunately, you have to have some kind of a backup to do that to take care of them. Okay, and it looks like I don't see any of the responses coming into the polling question here. It says it's popped up on my end, but let me see if I can maybe relaunch that. But there is one other question here while I try to figure that part out. It says, how often does the provider have to document a progress note on swing bed patient? That's a good question. That's a very good question. Of course, that's going to depend on what's going on with that resident patient. There we go again with the patient. You know, do they have to come in? They don't say how often. It may be once a week to go in and see what's going on with them. That's where your medical staff bylaws have to determine. CMS doesn't say that. I mean, in a nursing home, they want them there once a month for them to come in and evaluate them. But what is good SNF services, skilled nursing services say that a physician needs to come in and document, see them or document on them and who can provide those services. Now they have a PA. You might want to see if your state law permits a PA to come in and do that, to make those change or to do that assessment and to document on that swing bed patient. But usually it's whatever the patient's condition warrants it. They may want them in there once a week. It doesn't otherwise say how frequent the physician has to document. Okay. It looks like the survey or the polling question is now working. I mean, one other question has come up here that says for the three-day inpatient requirement, what if the patient has UnitedHealthcare or Humana Medicare Advantage plan that says it is not required? Well, I would be very careful on that one. There has been some, I want to say confusion or professional disagreement between UnitedHealthcare Humana and the Medicare Advantage plans and the three-day stay. But until CMS gives us further direction, I would go with that three-day inpatient stay just to be on the safe side until CMS can work it out with their own plan and these Advantage plans because they say it's not required. Remember that's an insurance plan. That's not Medicare, straight Medicare. It's just not. That's just the optional plan that the patient can have. So yeah, it is a headache. And that's why I'm wondering if some of these hospitals haven't dropped accepting Medicare Advantage because there's that conflict that's going on and they just don't, okay, who do we abide by? Because we don't want to put that patient in the situation of, oh, you've only been here one day and the Medicare Advantage has said, yeah, it's okay. And we switch you to swing bed and they get tapped for a huge bill. That's what we don't want that to happen. And then it looks like one final question in the Q&A says, speaking of the residents that stayed one year, how does that happen when SNF days being 20 over 80? Right. That's what you have to find out because again, under Medicare, there is no length of stay limitation for swing bed. The idea is it is transitional for that patient who stayed a year. That was a very extreme rare condition where they just couldn't find a place to put her. They just, there was nothing. And for the care that she was going to require long-term, there were no beds that they could take this patient. Now, I found that a little odd, but that's how they explained it to me. And in looking in the records, like, yep, there's just no place that could take her. It was, and I don't know if she ever got out of there, to be honest. I didn't follow up with the hospital after that. There are the results of that question. Okay. So we'll let me say, okay, very good. Let's go and talk about visitation. All right. Of course, they get a right to receive visitors of who they want to see and that's immediate access. In other words, now if the patient's sleeping or if there is some treatment they're undergoing, you can ask them, hey, your sister's here. Do you want her to wait or you want, is it okay to bring her in? Otherwise, you have to give them access. And, of course, tell them of their visitation rights. Now, I want to put in here that visitation rights are also in tags 1054 and 1058. So it is even before we get to the swing bed status for visitation. We get to the swing bed status for visitation. And then for that hospital, limited to family, yeah, because that was too much of a restriction and for no apparent reason. They can choose to work or not. Is it paid, volunteered? Now, as far as being in the plan of care, now they said they took this out that was deleted for critical access hospitals. I would leave it in because it is in the conditions and the requirements in the long-term care manual. So I would still keep that in there. Manage their own affairs, that they can decide who gets paid or what. Now, again, depending on what their cognition level and their ability and who is their representative, just they still have that right. Speaking of bills and charging for items, we can't charge them if Medicare or Medicaid cover that, like meals, dietary supplements. Other things, yes, flowers, cosmetics, a TV or phone, clothing, if they require outside clothing from what you normally would provide, hospital, private duty nurses, and then flowers, plants, that is some of the things you can charge. Postage, you can charge them for postage if they want to send a letter. But then we tell them their rights orally and in writing and access to records upon request. Now, this says within two working days. That's a lot shorter or longer, excuse me, than access to records. Now, the new laws, you probably heard about this in the past, there are some new laws, we have to give them access to their records as soon as practicable. In other words, if I'm in your SNF, or I'm sorry, in your swing bed, and I want to get a copy or look at my records, as soon as practicable, get me access to my records. This is access, not just copies. Otherwise, you can charge for copies of records, as long as it meets what your state said. And the couple dollars that they had listed on there, that's not a cap. That's just a starting point. Then they get notices in writing and orally in a language they understand. Don't forget, there may need Braille, if that's how they understand or an interpreter. A list of required notices, we have to give them that, that how do they file a complaint, whether it's with the hospital or the state agency. We have to give them names, phone numbers, addresses of where how they file these complaints. And we may have to help them file that complaint also. In other words, send this complaint on to the state agency. Access used to the phone, receive mail, get calls without being overheard. Make a request, advance directives, participate in not only care, but then refusal to participate in care and research. And then how do they apply for Medicare when they become eligible? We have to inform the physician or representative if something happens to our person while they're under our care. And that's especially when there's an injury, or if something's going on with their mental status, their psychosocial status, and of course their medical physical condition. And if you're going to transfer this patient, and of course discharge, please do that discharge timely. A day's notice is not timely. And a right to privacy and confidentiality. There are other areas we have to keep in mind, and I do want to talk about the environment and the grievances. We have to give them a clean environment. When was the last time their linens were changed? Do they have adequate lighting in that room? What about the temperature? Now in the appendix PP, they talk about a comfortable temperature of 71 to 81. That's just a range. You of course can modify that based upon what the patient needs. Now 81 might be a little toasty for some patients, and 71 too cold. So that's where we kind of moderate it. Private closet. Each one has to have a private closet for their belongings. Grievances, how do they file one? We have to tell them how to do that. Who do they do that? That means you have to have a grievance officer. At your hospital, you probably already have one. It can be the same person. It doesn't have to be a separate person. And the same steps. Look at it, investigate it, and resolve it promptly. And you also have to give written information back to them. This is the decision and what we found from our investigation of your grievance or complaint. If you're going to transfer, that means they're leaving your facility. And what they were doing here with also discharges and transfers is to prevent dumping. In other words, they put this regulation and giving them notice so that we're not transferring them, transferring patients to another level of care where they can go. And that we're preventing that dumping of those high level care or those difficult residents. You have them, You know who those patients are. Now these rules that I'm going to cover only apply when the facility is initiating that transfer or discharge, not the patient. So if the patient is getting ready for discharge, we have to tell them, you know, you're stable enough and we're ready to send you home. That's fine. But if the patient is in there and they're at that point in time where it's like, you know, I'm done, I'm ready to go home, or I'd really like to go to that other facility, I'm at that level, I want a little bit more interaction with my old buds who used to be there, and they can, that's fine. Then what I'm going to cover is not applicable when the patient initiates it. So you can do this when it's necessary to meet their care. Now if you can't do it in your facility, they don't need the services, they're at that level of recovery. The resident, other people who are in your hospital, or others, that means your staff, would be endangered due to their clinical or behavioral status. This can be visitors also, so keep that in mind. Health of individuals in the facility would be endangered. And then the basic ones, the person isn't paying after we're giving them reasonable notice, or you close, you cease to operate. So what do we have to do? We have to do this as soon as possible, once we come notice, once we become aware of it. They recommend 30 days before this happens. Now that may not be practicable, but as soon as you know, get that patient notice, they're going to be going. What do you have to include? Why? Why are they being transferred or discharged? When is that taking effect? Where are they going if transferred or discharged? Their appeal rights, and how do they exercise those rights, and the phone number, plus the name address of the state long-term care adminsem. Now the adminsem, that's, they're there to protect the rights of that individual. That's who they're there for. They come in and they investigate complaints of, you know, early discharge, early transfer, not taking care of them. That's what they are there to do. Otherwise, we also have to include in that notice that, hey, you're going. What are their appeal rights? How do they obtain an appeal form? You may even have to help them either complete or submit a hearing request for that early discharge. Again, it is not required if the patient initiates the transfer or discharge. And then just some basics. We can't transfer them while that appeal is pending, again, unless there's an endangerment issue, but there has to be some really clear documentation of that endangerment. As far as specific documentation, what have you done? How have you tried to meet this person's needs? And you can't. And therefore, here's the basis for that discharge or transfer. And again, if you initiate it, this notice, by the way, has to go also to the adminsem. So it's not only to the patient, you have to send that notice to the adminsem. Documentation, if you're discharging them or transferring for any reason, make sure that where they're going, if it's to another facility, that this information goes with them. If they're going home, make sure that it is somehow getting to their provider, their PCP after care. And it must include why, the basis for transfer or discharge. You can't meet the needs in your facility after you've tried to, but the new place can. Now, this is documented by the physician, not just the nurse. The physicians need to be involved in this documentation because they write that transfer and discharge order. For disability, if you have a patient with intellectual developmental delays or disabilities or a mental health disorder, you may need to send the information on to other agencies. Those who are responsible for taking an oversight of care and services provided to those. And so that's the address, the email, a phone number for them to contact. If you close or you happen to be just changing the room, give it in advance of closing and enough so that they can get oriented that, hey, I'm leaving here and I have to go elsewhere. Now, room changes in a distinct part. You have to limit them to moving within a particular building. So if I'm in floor three of your building and I'm on the west side, that's where you have to move me. Now, unless something's going on so bad on third floor west side that, hey, we need to move you for your safety and others, that's fine. Just make sure that you've gotten the resident's input and buy-in into that move because everybody's getting moved, not just that particular patient. Again, they will mention that the interpretive guidelines, the survey procedures are in appendix PP. I wish they had made it a little bit clearer for you so it was easier for you to find that reference real quickly. So when you do move them, what information do we have to give to that person taking over their care? Well, first off, what's the contact information for the person who took care of them in your facility? Their representative's information. Send their advance directives, please. What was the goals while they were in your care, their care plan goals? Any instructions for ongoing care? Do they need wound care? Maybe they have a feeding tube or catheter or perhaps some other like a central line that they have to have taken care of. And yes, they have to have a discharge summary done. Now, again, just some of my comments here. Give a copy. Give them the resident's notice to the state oddmentson at the time of transfer and discharge. Again, send notice to that oddmentson unless the patient activates this. Again, they're an advocate for the resident. And again, the physician is the one to document this pertinent information. It's not just up to the nurses. The physicians have to be involved in this. So under Appendix PP for transfers and discharge, same thing. We can't transfer or discharge unless we have to. It's for their welfare. And maybe they're done with what's going on in your hospital, so they no longer need services. Safety of others are endangered due to the behavior of the resident. Or you close or they're not paying their bill. And document. Also, information that was provided by that physician. What you send off, contact information of those who took care of them, the representative's contact information, advanced directives, ongoing care needs, care plan goals, copy of the discharge summary, and anything else that might be involved in there. So not only advanced directives, maybe there's something else that's in there. They don't explain what other necessary documents, but it could see something such as PT notes that should be part of the record anyway. Perhaps there was some stress testing that was completed. Maybe they want a copy of that. So any other necessary documents. And then written notice. You can use a universal form. You can use electronic summary, whatever fits into your facility. But do it before the transfer. We send that again, that written notice you're being transferred to the oddmentson. Why they're being transferred, that must be in the record. Timing of the notice. When did you give them notice? And the reasons, the date, their appeal rights, et cetera, et cetera. And again, this is when you initiate it, not the patient. So the next tag number, this is in appendix W, freedom from abuse and neglect. And it's unfortunate that we still have to include this, but it's part of our patient rights that they are free from abuse, neglect, and exploitation. We can't use any types of abuse, no verbal, no mental, no physical. And that means we're not stealing their property. We're not doing any restraint or seclusion, including chemical restraints. That is not necessary. We can't use restraints to discipline them. And of course, convenience. And if we do use them, they must be the least restrictive way to do it. Freedom from chemical restraints also for, again, convenience or discipline. These are not the ones we are using to treat their conditions. These are not the ones we're using to treat their behavioral conditions. This is over and above that. And if we do use them, the least restrictive. And then we, of course, have to document our ongoing re-evaluations of that resident, especially when they're in those physical restraints, the hands, the feet, whatever it happens to be. So here's third question, Lindsay. Okay, let's get that one pulled up here. Okay, so I hope you all can now see this one on your screen that says, our facility has difficulty employing sufficient and qualified staff. As a result, our process for background checks is not as complete as it has been in the past. Yes, no, or prefer not to answer. We have a couple of questions here as well, Laura. Very good. Okay, let's see. How do we enforce the inpatient stay requirement when the Advantage plans are approving them for swing bed? We are primarily ortho, and the majority of our procedures are outpatient. However, many of our patients request swing bed and are approved when they meet medical necessity. Wow. And that's Medicare Advantage? And that could be how that's, again, that's, I think that's still untested under CMS. I know that sounds like a kind of a lame way to explain it. But I have not seen any of the CMS, they have a website that they pull up with some of their investigations that they do. I haven't seen that come up yet for when they're saying no swing bed. Because again, who's paying the bill? And if it's Medicare Advantage, then if maybe that's how they're getting around that, that they're saying, hey, they're eligible, and we're going to pay for it, then I can't argue with their decision making. Okay, and yeah, she clarified it. Yes, Medicare Advantage. Okay, and the next question is, are we allowed to use bed alarms on swing bed patients? Sure, absolutely. Absolutely. Sure, you can. That's a good fall. It's one of the fall prevention. It's only good as it's only as effective as we know how well it used and how well we respond. But absolutely, you can use those alarms. Okay, and then does the grievance officer have to be designated in writing? Yes. Yes. Sorry. Yeah, because I did. I actually went back to CMS. Because the concern with some retaliation against the grievance officer, and they said to have their name and how to contact them can pose them or put them in, expose them, that's the word, expose them to perhaps retaliation by the family, etc. And the response back from CMS wasn't quite as what I'd hoped to get. But it's like, short answer, yes, you must provide the name and contact information for the grievance officer. Okay, and then regarding notifying the ombudsman, on all discharged, do we have to do this? No, only on those that you initiate. So if you're sending the patient home, and maybe the patient isn't quite agreeing with this, that's the one you have to notify him. If you go in and say, you know, here's where you are in your care. We think you're ready for discharge basis. Yep, I'm ready for discharge. I want out of here. You don't have to do that. It's only on those you initiate, not the ones that the patient are in on or agree to. And, and yep, I want to go home. Okay. And then let's see, there's one more here that says, okay, does the, and this is an acronym, I believe, IRIS, cover for access to medical records? Would you repeat that, Marnie? Yeah, yeah. And I did ask for some clarification on that. So I'm going to make sure I did. I'm not sure if you would have everything you need to answer that question. But does the, and it's IRIS, I-R-I-S, in quotes here, account cover for access to medical records. I'm wondering if they're talking about patient portal. Just make sure they know how to get on to their records and nothing is being withheld or blocked. Because I can go on to my medical record with my healthcare provider. Everything's in there. Everything. I mean, every visit's in there. All of my labs are in there. And they just tell me, hey, here's your new information if you want to go in and look at it. And I have access to it. You just have to make sure that if, let's say, they're in your facility, do they first off have a computer? Can they get access to it? Through the patient portal, then that's how you would do it. Give them access to it. It's when we say, no, we're not going to let you see that, that's blocking. You better have a really good reason for it. Yeah. And they clarified, yes, the patient portal. Perfect. Okay. I'm going to go ahead and end this poll and share those results here. All right. No, already. Okay. Good. Glad that's not happening. Okay. So, employees, we cannot employ or hire those who are found guilty. Abuse, neglect, exploitation, mistreatment, misappropriation. In other words, theft. Now, they're in our state nurse aid registries. There is an entry where you can go find this. There's also most of the nursing boards I believe now have it too. My state has it where I can go in and look up my license and it will tell me what's been going on. Now, these are found guilty. A nolo contendere. In other words, I'm not going to contest that charge. That's a guilty. That is a guilty plea. So, if that's what they're saying, well, I only pled nolo contendere. That's guilty. Update your policies to include that. Make sure that the staff know. These are the requirements that we have to make sure our residents are safe. That we're not going to be stealing their property. We're not going to be hunting them in the process. We've done our background checks. We've done what we're supposed to do. Another thing we're required to do is report when there is issues of abuse or mistreatment. And that goes, of course, to the licensing authority for your state that you have to report it. Now, this is just that component. Not the police. If there's an injury as far as you may need to take that a step up. And, of course, if you have knowledge of actions against an employee in a court where they've been found guilty, you want to make sure that they're part of that when you're hiring them. You may want to do this when you're doing your annual reviews to make sure something didn't slip through the cracks. Anything that would show this person is not safe. They're not fit to be taking care of patients. So, have that policy written, policy and procedure that spells out you're prohibiting and taking steps to prevent mistreatment and theft and how you're going to investigate these allegations. Not necessarily, you know, it's been proven, but these allegations, how do you as a facilitator, how are you going to do that? You have to report abuse timely. No later than 24 hours after an allegation. But if there is serious bodily injury, you have two hours to do that. You report it to the administrator of your facility, the state survey agency, and you may also have to report it, say, adult protective. You may have to do it to child protective services if the state gives them jurisdiction when you have that minor who happens to be involved. There has to be evidence. You have to keep evidence that you investigated this thing. In other words, documentation. Where you keep it, that's up to you. Your in-house counsel may want to keep it. They'll tell you or should direct you the best place. It doesn't go into the medical record. Not normally. The investigation, that's like investigating a sentinel event. That usually does not go into the medical record. And of course, you want to make sure that patient is still safe while the investigation is ongoing. That means you may have to move that employee to another floor. You may want to get them off duty completely. That they're going to stay at home. Whether you pay them, that's up to you while this investigation is ongoing. And of course, if it is true, you verified this happened and that person did it, then you have to step up and take that action. CMS in this particular area, in this tag number, they do talk about tag F610 when it talks about that. So here are just some of my notes on reporting abuse. Definitions have been revised. If you're working off one of the older manuals, just be aware it has been revised. If no serious bodily injury, you got 24 hours to do it. If there is serious bodily injury, two hours. Any state law reporting requirement, keep up to breast of those. Have evidence you've done your investigation. And maybe look at your policies and make sure those who are on duty and in charge are aware of these requirements. Charge nurse, evening supervisor, night supervisor. Administrators, maybe it's, you know, maybe they're over the, you've got the risk manager, perhaps that's the person you want to notify. But they need to be aware of those reporting requirements. Just one person has to do it. But we need to know who is that individual. And then they've just reiterated these rights. No right. Freedom from abuse and neglect. Not having things stolen. Abuse. Now these tag numbers have definitions of each. So just take and use those definitions in your policy. And how you investigate it. Who's going to do that? By the way, chronic staff problems could be a signal of burnout that could lead to abuse. It gets short-tempered. We get tired. We get fatigued. So if you're having staffing issues, which some of you probably are, just be aware that could be a good sign of it. Negative attitudes. In the interpretive guidelines in appendix F, excuse me, PP, they've talked about what some of these things are. Negative attitudes. Talking over, making jokes about a resident. That's all forms of abuse. Otherwise, freedom from restraint and seclusion. Not employing those who are guilty of those felonies. And policies on how you prevent and investigate. Now an investigation. Determine who you want to do this. Is it going to be someone from another floor? Are you going to have an RN? Maybe a PA? Who is going to investigate it? And how are they going to report on it? Who do they report to? Because you don't want somebody's best buddy going in and doing that investigation. Maybe it's someone who totally, like I said, different area to come and say, would you take a look at this and tell us your opinion with the course of confidentiality being totally maintained. All right. Moving on to something different. Social services. Now, it used to be that in appendix W, if you had swing bed patients, there were patient activities and requirements that you had to do. But they decided, you know what, they're here for short term. That's a lot of involvement. So they took it out. The requirement. But you must still provide medically related social services. And the reason they left that in is so that we get this person back doing things that they're normally doing. They have to be doing something. You don't want them sitting there twiddling their thumbs all the time. Get them involved. Keep them active. Keep them engaged. And so that's why we still have to have them have things to be able to do. We still have to do an assessment. That's a comprehensive assessment. We still have to do care plans. And yes, discharge planning. Now, the one thing you're not required to use is what's called the resident assessment instrument. This is, again, something they probably came in from a nursing home with. You don't have to use it. And you're not required to comply with the frequency, the scope, and number of reassessments. But you still have to do an assessment of this individual. Who are they? What have I got? And where do we need to be? And there are certain required elements of this assessment that did not change. The next couple slides will have these elements. For example, their demographic information, you know, the normal. But then something new. What do you normally do on a day-to-day basis? Of course, we want to look at their cognition. How alert and oriented are they? What's their mood? What's their behavior pattern? Can they talk to us? Can they communicate? How do they communicate? Can they see? Do they require glasses? How about their psychosocial well-being? Are they withdrawn? What's their physical functioning? Any structural issues that we have to be aware of? Are they incontinent? How is their skin condition? What is their dental and nutritional status? Can they eat? Do they require soft food or maybe liquid diet because no teeth? Any special treatment or procedures? And also, another thing you wanna do is document their participation in that assessment. Now, are they communicating with you? Can they move when you say that? Are they cooperative in participating with that assessment? Or do they curl up in a fetal position and say, leave me alone? And then of course, we have to do this also for discharge planning. We have to include in there a summary of information in that additional assessment, the minimum data sheets. Again, you don't have to use these, but make sure there's some summary that is available. And I did mention include their participation in the assessment. But do that direct observation also. How are they responding? Do they have good eye contact? Are they slow to respond? Do they constantly look to their representative or their family member to answer? Is their family member answering when you wanna get the information from the patient? All that's part of your direct observation. The idea behind here is we wanna do this information to develop that care plan. Now, it used to be there wasn't a timeframe. You have to do this full assessment within 14 days after admission. It doesn't apply to you, because again, it's to be transitional, but you must do it timely. Of course, reassess if we have significant changes, they're declining, huge improvement in their status. These are things that normally don't resolve itself without further interventions. And it will impact on one area of their overall status. It may require interdisciplinary review and revision of those care plans. By the way, you still have to have a nursing care plan, even if you have an interdisciplinary care plan. Because the idea overall is you're trying to develop this comprehensive care plan. Measurable objectives to meet their needs. And again, if the patient is going to refuse treatment, document that. There are specialized services. These are for those individuals who have mental illness, developmental disabilities, and it's called the PSAR. It's a pre-admission screening resident review process. Now, if you disagree with what's in that assessment, that's okay, your physician can do that. They just have to document it. Why they disagree with the recommendations from that PSAR with that review. Otherwise, the care plan has to include the goals. What are their desired outcomes? What are their preferences? And the potential for discharge. Do they want to go back to that community area where they were before? Then it must be developed. The plan has to be developed within seven days after you've done that assessment. But again, doesn't apply to criticals, you just get it done as soon as possible. Have that appropriate timeframe. If I'm coming into your swing bed status and my anticipated length of time is going to be two weeks, that assessment needs to be done fairly quick after I'm there and the plan developed really quickly. On day 13, it's too late. So again, within appropriate timeframe. But then overall, just to just correspond with what's in appendix PP, do that assessment, again, the slides. I won't repeat those slides. That's the still same information, the 17 items. It must accurately reflect the resident's status. RN has to do this assessment and then have others involved as appropriate. Maybe it's PT. Dietary wants to be involved in that. The care plan section in for appendix PP start at tag S655. And then back to our critical access 620, interdisciplinary team should develop the objectives. In other words, where do we want this resident or patient to be in their care? That could be the physician, could be a nurse's aide who does a lot of the care. RN, who is responsible, the resident or patient and their representative, that's huge because we need their input. Maybe there's other staff that are important to be a part of this interdisciplinary team. And we wanna consult the resident and their representative. Where do you wanna be? What do you wanna get out of this admission? Try and schedule it when it's convenient, not only for the team, but the person also. That could be at four in the afternoon and maybe bedside conferences, if appropriate. And if they're in sharing a room with a stranger, probably not the time to do it, but where it is appropriate. And then of course we have to review and revise our care plan after each assessment. And that's those who are provided. By the way, the staff who provides the care, we have to make sure they're qualified, it's culturally competent care, and they meet the standards for that quality of care. Qualified means it's an RN, it's an LP, and whoever happens to be able to have to do that particular care. And then in the FTAGSA care plan, we still have to develop a comprehensive care plan to meet those objectives and where they wanna go. And the timing, the revision, same thing, make sure it's appropriate and they meet professional standards by qualified individuals. Where it has to do a baseline plan of care in the F standards within 48 hours, excuse me. If you can do the care plan, if it's done within a reasonable amount of time, that includes information for the care of the resident, their goals, any orders that have to come along, whether it's OT, PT, dietary, social services. They always talk again about the PSAR and that RAI, it's never been required to use them, but if they have it incorporated, it may save you some time. And that the physician has to document that they've also communicated this information to where this patient is gonna end up going. And especially if they're going to a new physician, a facility. They specifically talk about trauma patients. And because we have special considerations for those who are recovering from such and include that in the plan of care. Our care must be culturally competent and trauma-informed. What is trauma-informed care? Well, it's a couple of things. One, you have to make sure those who are survivors do receive care that the staff is aware this occurred to them. Account for what the patient, the resident has gone through. We wanna eliminate if possible, or at least mitigate any triggers that could re-traumatize our person. There's treatment or services for mental psychosocial concern. It is based upon that comprehensive assessment. So that those who do have perhaps behavioral health issues, PTSD or history of trauma, they get the appropriate services. And that we're assessing this problem. We're trying to get them back to the highest level. So that's why it is patient-centered with individual attention. Ensure that the team, interdisciplinary care team develop those approaches to help with this issue with the patient. Any distress, maybe they're not improving. Maybe they've slid back in their progress. Document that and get ahold of it as quickly as possible. As far as reasonable attempts, we're trying to get them that autonomy, get that control back under their being. That may mean we involve other resources, whether it's church, cultural heritage, friends, something within their community that could help bring them back to where they were before. So what we need to do is, we need to look at your assessment tool. Did we take into account that this person was the victim of say an assault in a battery? Educate your staff on what the requirements are and that trauma-informed care. That is a framework that involves understanding, recognizing, responding to all types of care. It is quite a culture shift. Or it used to be, okay, they've had this, so I need to take care of this physical component. And we inadvertently forget to include the psychosocial and the psychiatric psychological care that they may need. We're trying to build that sense of control and empowerment. There is, through SAMHSA, they have the National Center for Trauma-Informed Care. I have more resources in the appendix for you on this one. And then just routinely participate in their own plan of care. They participate in establishing goals and the list of services. They get a right to know, hey, what were you providing to me? They must include the resident and the representative in the treatment and the plan of care so that it is culturally competent. Maybe there are certain preferences that we have to include in developing that plan of care. It could be a dietary cultural issue that we need to take into account. And that's why it's helpful to have that meeting with them to recovering all of our bases. And then our discharge summary. They have to have that discharge summary, which is just like in the hospital. It's the summation of what happened while they were there. What was their diagnosis? What was their course of treatment? And here's what we found. Medication reconciliation. Don't forget that. We still continue to have that problem, whether it's in swing bed, acute care, that tends to still be an issue that patients are being brought back in because medication reconciliation didn't occur. And then the discharge plan of care that we're using the patient, especially if they're gonna go home. Who's gonna be taking care of them when they're there? Or maybe we're gonna help them adjust to that new living situation. Always make sure it's done when that discharge summary is when they are discharged. Send a copy when they go to that new facility. And if you couldn't meet their needs, don't forget that has a requirement. We need to include that in our discharge summary. To find out how well you're doing, you may wanna do a chart audit to just go back. Is everything in there? Did we include it so that they're not having to be readmitted? And then again, that the document, the plan of care was discussed with them, with their representative. And again, where are they going? Are they going home? They're going to assisted living or maybe hospice. And then rehab services. This is the special services that we have to include in that plan of care that normally you would have for a patient who just comes in for that short-term care. That could be mental health rehab services or respiratory care. Are they going to need certain respiratory care while they're in swing bed services? Do they provide it? Or are you going to contract to having come out? Overall, we have to have an order for that to occur. Dental services, they did include this and I've got a couple more that they included as swing beds because it used to be very involved in that what we had to do. Well, we still have to help them get routine and 24-hour emergency care if it happens. So if they're eating a chip of tooth or perhaps their dentures are lost, that's fine. How do we take care, make sure their dietary needs are taken care of? And also that we're taking care of this dental issue. You have to have a policy that tells the staff what's going to take care of this if loss or damage to those dentures occur on our watch so that we're not charging that person. When they're left on the tray, we take the tray and it walks away. We have to refer them within three days for any lost or damaged dentures, document their nutritional intake. And they do refer to several tag numbers in appendix PP for what we have to watch. But for nutrition and especially assisted nutrition, your G-tubes, this includes those percutaneous endotubes or enteral feedings. This is all based on that assessment. Remember, what kind of a patient do we have? What is their status? Make sure they're maintaining their body weight and their electrolyte imbalance and make sure they're taking in enough fluids. Document how much they eat, INOs, that's a good way to keep an eye on how their hydration is. And of course, staff have to know what is dehydration? How do they exhibit it? And just they listed out some of those examples or signs and symptoms of dehydration. Of course, dry mouth, but dark urine, maybe they get a headache, irritable, more than normal. Confusion, the vital signs are a little off, low pressure, high heart rate. And then our labs, that's a good way also. Elevated BUN, which is not normal for that individual. High potassium, that can have some other consequences. And they also give us some parameters for weight loss. And they're talking significant and severe. And this is how we can do to evaluate unplanned or undesired weight loss, whether it's a month or six months. Again, these are in the long-term care manual, but this will give you an idea what their percentage of weight loss would be. So just some resources very quickly for you before we get to the final discussion. Medicare Learning Network, it's a great resource. Lots of good information is in there. They actually have a fact sheet for you. It talks about what are the requirements, the payment information, very helpful. Also a website for the rural office on the regional health coordinators that you can tap into. Also it talks about just general services, what the background are. And then for those of you who are going to be the providers. The other additional resources, if you scroll down from that previous page, I'm going to back up on the screen. 128, if you scroll down there, it will give you all of these links. Now, some of them have been archived, but if you just want to get some basic history, that's where you would find it. So before I move on to my last discussion, are there any questions you want me to answer, Lindsay? There are a few that have come in here. Okay, this first one says, does the, oh my goodness, Oddmentson, that person. That person. Requirements apply to critical access hospital swing bed transfers that are considered emergent. Usually that is when we transfer people out to the ED before their treatment plan is completed. Probably not because that's a medical necessity where like you need to do something for them. That is more of a transition of care. I wouldn't think you would have to, if they have to go like to ED or back to acute care. But that's a good question. I'm happy to follow up with CMS on that one to clarify that rule. If they have to go back to inpatient status or to ED. Now, if it's a temporary to ED, they have to go over there for something they're coming back to swing bed status now. But that's a good question. I want to follow up with that one from CMS directly. Perfect. Dana, I see that question came in from you. So if you wouldn't mind sending an email over to education at gha.org, you can just send that same question over to us. And then that way I can get that to Lauren and she can follow up and we can get the information back to you. Okay. And this next question is, if a patient appeals their discharge and it is denied, do we still have to notify the ombudsman? Yeah. Yes. Okay. And then for dental services, does a dentist with whom the facility has a contract for swing bed patients have to be on the medical staff? Not necessarily. No. No. That's up to you if you want to allow that dentist to come on site and take care of your patients. Most of them do. They want them to be a part of the medical staff, just so they have some, a little bit of oversight with that dentist. And by the way, just because you have a contract with that particular dentist doesn't mean the patient has to use them. They may have their own dentist that they want to go to. Just keep that in mind also. And then know that that dentist does not have to be on medical staff. I don't see any other questions at this time. Okay. Excellent. Okay. So here's our last one. We have an 85 year old, lives alone in a remote area. Independent, ADLs, continues to drive, very active in his communities. During his daily walk, slipped on a patch of ice and of course went down and broke the left hip. Admitted to the local critical access for an ORIF, that's open reduction internal fixation. Four days, he's ready for discharge. But given where he lives and the arrangements, plus limited resources, they want him to go to swing bed for further assessment and rehab. Now swing beds, they're 25% of the total bed count. Nursing care is provided by LPNs, CNAs, and there of course is an RN that is supervising all this care. The patient is ordered for PT. Outside vendor comes in and does that. And nursing care, which also includes some agency personnel from a regional office staff. And this is all okay. Under CMS, that's all okay. Well, given the living arrangements, they want him to stay in swing bed until home health or visiting nurses can be set up. Well, after the second week, it was noted that his upper set of dentures weren't there. And of course they look all over and nothing. They can't find him anywhere. So here's what's going on. Oh, let me back up. He's a very small eater. He's normally low weight anyway. That was where he started from their overall assessment. He was low normal weight, but then still acceptable, but kind of down there. So now what do you want to do with this person? What would you recommend they do regarding the dentures, the nutritional status, where they're located? Because replacement could take three to four weeks to get them done, to get these things replaced. Do they put him on a soft diet? Do they put him on a high calorie liquid diet? Bring in the family. Maybe they can get them done sooner in a larger city. How are they going to replace him? Who's going to pay for that? Maybe a dietician come in and meet with them. Anything else to discuss what they can do for this individual? And by the way, just because he's on and is not a big eater, we could even consider having family bring in his favorite meals if it comports with his dietary regimen, with the dietician saying, yeah, it's all okay. And the physician, of course, saying it's all okay. Anything else you can suggest? These are not all inclusive by any means. And while they're waiting, I guess I'll wait because I think I might lose the polling questions if I flip through some of the resources for you. So I'll just wait and see if there's any other questions also. Yeah. Yeah, I don't see any other questions at this time. So if you do have any final questions for Laura, go ahead and be typing those into the Q&A option or of course they're in the chat and we'll give you just another couple of seconds here on this final discussion question. I see some responses still coming in. And then if you have any other suggestions, you can of course type those into the chat as well. Okay, I think we've gotten some good responses here. Good. Yeah, I'll definitely have the dietician, yes. Those are all great ideas. Great ideas. Liquid diet. I don't know if any of you have ever done a liquid diet before, but I understand that having a friend do it, it was horrible. She had to have her jaw wired because of an auto accident. And she said, it's the most horrible thing. Flavors were quite off and you missed the chewing aspect of it. So I see nobody said a liquid diet. So that's good. Again, these are only suppers that were missing. And so they did all of those. As far as who's gonna pay for them, we had to. That was our loss. Somewhere along the line, because there were no visitors who came in and accidentally grabbed them, we lost them. So they did opt to go ahead and replace at least the uppers. So just some quick resources. I have multiple websites. Some of these won't apply to you, but if you just like CDC, the Food and Drug, AHRQ, some of these are just routine ones that you might wanna keep in your bevy of resources for websites. For critical access hospital, I always like to give you the information on the Rural Health Information Hub. It is great. A lot of good information on funding and models. And they also have the state flex programs where you can talk about core competencies for your staff. I did mention the critical access handbook or booklet with other resources, and then the general website. So I'm not gonna make anyone too dizzy watching that, but there. we have to notify the oddments. And I have a feeling now that if it's necessary for their ongoing medical care, that we can do this. I think we lost a couple of seconds there, Laura, but I got the end of that for you. No, it was just that I will follow up with CMS regarding that question on transfer and a notification to the oddments. Perfect, perfect. Okay, and I'm gonna post some additional information there for y'all in the chat now. Just as a quick reminder, you will receive an email tomorrow morning as a follow-up from today's session. Just note that it does come from educationnoreplyatzoom.us. And we have often seen that these emails coming from Zoom get caught in your spam, quarantine, junk folders. So if you don't see that email in your inbox in the morning, possibly just check those additional folders. And then if it's still not there, and you would just like to go back and access the recording, we actually record these webinars as on-demand, meaning that you can use the same Zoom link that you're using to join us for the live presentation to also access the recording. But we do have an additional security measure in place to protect Laura's intellectual property here, where you'll have to click on that Zoom link and type in your information, and that will prompt an email to come to us for approval of that recording access request. We do approve those very quickly, but we ask that you give us one business day. And then once we do approve that, you'll receive a follow-up email from Zoom that will include the final link into that recording. And the recording link is available for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura presented. And of course, that will also include all of the resources that she just went over with you all. But I did provide that link to the slides there for you in the chat now as well. And then if you are joining us as a member of the Georgia Hospital Association, please pay special attention to that last link that will be included in that email tomorrow. And that is a link to the survey. You'll need to complete that in order to obtain your certificate of attendance and any continuing education credit information. If you're joining us from a partner state hospital association, I would encourage you to reach out to your contact there at the hospital association to obtain any information that they are offering for today's session regarding continuing education credits, as GHA is only able to provide CEs to GHA members. And I don't see any other pending questions, but if you do have any questions, possibly after going back and watching the recording or just thinking of something later, you can always reach us at education at gha.org. We'll be happy to get those questions over to Laura. And she's also very timely in her response and very thorough. And we are always so thankful for her for going above and beyond in that regard. Okay, thank you all so much for joining us today. Laura, thank you as always for your time and the wonderful information that you've shared with us. I hope you all have a wonderful afternoon. Thank you so much.

Laura Dixon

risk management

patient safety

swing beds

critical access hospitals

CMS guidelines

patient rights

care planning

interdisciplinary teams

regulatory compliance

Medicare

patient assessments

discharge procedures