And now, I would like to introduce our speaker to get us started this morning. 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 of 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 of Western Region, Patient Safety, and Risk Management for the Doctors' Company in Napa, California. In this capacity, Laura provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's 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. Well, welcome, everyone, and I want to thank everyone for joining us today. As Lindsay mentioned, we're talking two special services for acute hospitals, and that is swing bed. Normally, we talk about those for critical access, but CMS has extended that ability for certain acute hospitals to provide swing bed services. And then we're going to go to an entirely different focus, and that's psychiatric hospitals or dedicated psychiatric units. CMS has special requirements for you, those type of providers, for psychiatric hospitals. And to me, there's some a little bit more stringent, a little bit higher level than some of the requirements for a routine acute hospital. For any program, I always have to include my disclaimer, and that this information that I'm providing today is strictly educational. It's informational only. It is not meant to be legal advice, nor establish an attorney-client relationship. So please check with your in-house counsel, your professional legal representative, as it relates to specific advice for your facility, and especially when we're dealing with any specific state laws. I want to do a brief introduction as far as why we are here today. Those of you who have gone through state surveys, you know you don't want to get one of these, and that is when they have found you're not meeting the requirements, there's something that needs to be updated, and short statement of deficiencies. And of course, no facility ever wants to get the notice that they are being terminated from the Medicare-Medicaid agreement. That is such a huge financial impact to a facility, and that's usually after everything fails, where you just haven't been able to come up to the standards of what CMS is requiring. Well, how does this all work? Where did these regulations come from? Well, they first start in the federal register. That's where the regulation starts. Well, then CMS has to publish that into a transmittal, and then they are tasked to develop interpretive guidelines, survey procedures. Those two items are geared to their surveyors. That's what they're meant to do. And they're also required to update the manual here and there on occasion. Now, the last actual update for the acute hospitals came in July of 23. For criticals, we haven't had an update since 2020. I'm really hoping they get one out there because there's still some very vital information that's not in the manuals, but you are still required to meet them. There are three types of surveys. Certification, complaint, which no one wants to get, and a validation survey, where they're going to go back, see how things are doing, how you're progressing. Changes, they do come now and then. Now, the last some of the major changes, again, for acutes, again, was back in 23. Overall, for both types of hospitals, 2020, massive changes at that time. How to keep up? Well, of course, you want to make sure you have the most current manual. It first came out in 86 with multiple updates since then. If there is a new manual, check the transmittal page and the survey and certification site at least monthly. That's where they send the memos to their surveyors. So I've listed the links on that previous slide for you. So just go to there for the red or register, type in your email, and then they will send you the updates. This is how the manual appendix looks. This just lists how all of the responsibilities that CMS has, where they have oversight, which facilities, what type of services. And you can see now hospitals, psychiatric hospitals, you're into one big manual. You just have two separate. Now, back in 2019, they decided, you know, there's so much overlap, we're just going to combine them. And then it continues on all the way down to Z, where it's emergency preparedness. Now, I want to point out one thing, and it's part of the topic we're addressing today. And that is Appendix T. And that says swing bets. That manual does not exist. You cannot find it online. Even though the regulation references it, it is not there. Now you have to go to Appendix A and Appendix W. Appendix A, that's the focus of this discussion today. That is for your acute hospitals. Where you see transmittals, that blue lettering, you can click on that once you're in the manual, and it will take you to that list. And just bear with me, I'm going to explain what does that transmittal mean? Well, this is what that transmittal page looks like for starters. They go down, they start with the most recent and go to the oldest one. But it's a quick way to get to what was changed. Again, major changes in 2020. And this really affected most of the manuals. So what you'll do is you'll click on that, and that will take you to what it looks like. Good way to really have an oversight of what was changed. They'll be revised, deleted, new. Makes it much easier to track those major changes. As far as memos, well, that's what this page happens to look like. And you'll see now, and it used to be, by the way, you had to triple click the posting date. Not anymore. They finally did a major revamp of their overall website last year. And now it starts with the most recent and works its way down. That's an example of what one looks like. We're going to touch upon this very briefly. But you'll see this one happened to do with ligature risk and assessments within hospital. Well, let's talk deficiencies. I mentioned before, no one wants to get that list of, OK, what didn't we quite meet the standards for? Well, the nice thing is, I guess it's nice, we can now access that data. And it's for all hospitals, acute, critical access, long-term, excuse me, short-term hospitals, those type of hospitals. It doesn't have the plan of correction, but you can ask for it. Now, I want to point out something. Even though this is updated quarterly, it used to be this went back to day one. Not anymore. The data is now only available back to 2018. I think it was becoming so burdensome and onerous and really not relevant. Some of those changes that had come along, that they decided to simply delete it. It's gone. You can't access it anymore. So I've included the link here on this slide where you can go access it. This is number 19. And scroll to the bottom where it says full text statement. Again, it is an Excel format. It is massive. But I just showed how you can filter and sort. You can filter and sort by tag numbers. Be aware, you must include the letter and the four digits. If you don't, you will end up in the totally wrong place from where you want to be. I always want to mention this one also. It's hospitalinspections.org. And the Association of Healthcare Journalists, they pull together those deficiencies and publish them and give us much more information. So to get there, I'd like the link there. Go to where it says search your state. You have to put your cursor over your state in order to get to it. And then a list of all your hospitals that come up. And it shows where they are located. How many reports are there? How many missing reports? How many, again, you'll see violations. They call them violations, not deficiencies. But then you can scroll to your particular facility and read the full report. Much more information. Maybe gives you an idea where they're coming from, where they're looking at. No names. It will just be designations of who they talk to. But again, much more information. And it does take more time. That's why if you are going to use this, hone in on what facility you're looking for. Otherwise, you're going to spend a lot of time going back and forth to try and find a particular tag. So as of December of last year, there were a total of 38 deficiencies. The most cited for swing beds happened to be in the activities section, which is really surprising considering back in 2019 with the hospital improvement rule, they took out that requirement for an ongoing program. Now, the information that I'm providing today, the regulation is in your appendix. It's in appendix A. But the interpretive guidelines, the survey procedures, they reflect back to appendix PP. That's the long-term care manual. And that's really where some of the changes they made addressed. So when you're talking to hospital, there are certain things that you're going to see in that long-term care manual that don't apply to you. But just be aware, the one thing that was most cited was activities. Next, dental services. Finally, again, CMS, they don't have any information on why. What was the basis of that deficiency? It just said no information available. It's a little frustrating when you're trying to find out, okay, why did they get cited on this? And there's no information available. Let's go ahead and start with the conditions of participation for swing beds. Again, acute hospitals. You'll see here, you have your own little special spot there. And as we scroll down, I want to point out one thing. The information we're covering, you won't see it listed here. I'm going to back up a slide. This is the only place where it's listed on the actual table of contents for appendix A. You don't see it listed down below as you normally, what, you see psychiatric hospitals, but you don't see swing beds. Now, we're going to talk about that as we go through. So again, it starts on tag 1500 for you. And the, excuse me, the interpretive guidelines, survey procedures, they are in appendix PP. They updated this one also last year, earlier back in February of last year, and added quite a bit of information. But again, we are going to touch on that. So let's go ahead and start with the swing beds conditions of participation. There are several tag numbers. But before we start with that, Lindsay mentioned that there's going to be some questions. And here's the first one. I'll have her put that one up for us. Lindsay. Absolutely. I'm going to read this first part, and then I'll put the polling question up on the screen for you to have the opportunity to select your answer there. So this says hospital R has 110 beds. Over the past three years, it saw an increase in the number of patients needing and requesting swing bed services. The governing body has asked if you, excuse me, has asked you if swing beds are an option for hospital R, increased revenue and census. Okay, and then now the question, let me launch that. Therefore you ask, is hospital R eligible to apply for swing bed status? Yes, no too many beds. Yes, but only if the maintained bed count is reduced. And then while you're taking just a moment to put in your answer there, I see that we've had several people join after our initial introduction. So let me just remind you all that if you have any questions for Laura relating to the material, as we approach these polling questions throughout the webinar, please be typing in any questions that you have for her into the Q&A option found at the bottom of your Zoom window. Or if you don't see that option, you can of course type in your questions into the chat. So we can make sure to address those during the time of these polling questions as well. I did see a couple of questions come in asking for a link to the slides. I'll go ahead and provide that for everyone there again in the chat as well. Okay, we've gotten some good responses here. I'll go ahead and end that and share those results. Okay, so yes, only at the main, all right. So, and by the way, I want to thank everybody who does participate in these questions. It helps me further develop the programs as I go along. But before I really get into the meat, there were four changes back in 19. And I mentioned part of that earlier. First off, any patient, by the way, they call them residents. Because again, this is a long-term care manual. This person has the right to refuse to perform services on behalf of the facility. In other words, let's say you have a person who, you need some things done. Well, they have a right to say, no, I'm not going to go fold sheets or towels. I don't want to do that. Used to be, they didn't have that option. Now, they have, we have to give them that right. Number two, they took away that requirement for an ongoing activity based upon the assessment, a comprehensive assessment. You still have to do something, keep them active. You don't just want to send them there. But we still took away that absolute requirement. They also took the requirement for you to employ a full-time social worker. In a long-term care, yes, they have to have a full-time social worker. And then finally, to help a patient in getting 24-hour dental care or routine care, because the reason they took that out was, wait a minute, this is all part of our normal care. We're not going to change anything. If a person's got an abscess, something's going on. Well, of course, we're going to take care of it. That's why they got rid of it. So overall, when you have swing vets, you're going to be surveyed anytime the rest of your hospital is surveyed. They could also, though, come in if there's a complaint. So if it's just in reference to the swing bed services, they may still come in and do a survey, of course. But if they find some overlap in those complaints with what's going on in the acute hospital, they might also decide to survey the rest of the hospital. The procedure does, again, reference Appendix T. Ignore it because it doesn't exist. And I've asked CMS, why wasn't that taken out when you did the 23 update? I didn't get a response on that other than we're working on it. Their pages start from 495 to 515, and that is in the acute manual. And the guidelines, the procedures are in Appendix PP. Is there a cross-reference? No. You do have to go back and forth between the two of them. As far as the patient requirements, where does this start? Well, of course, the patient has to be inpatient somewhere because they're swinging. It's a reimbursement designation. They swing from acute care inpatient services and reimbursement to post-care. That's SNF services and reimbursement. And one thing they do have to have somewhere along the line is a qualifying three-day inpatient stay for this same episode of illness. And they really wanted to clarify that because sometimes patients would be inpatient, say, for two days, and they would be in for, I don't know, say, a total HIP. And then they're sent home. Well, while they're at home, for one reason or another, they get sick. Maybe they develop an ulcer or they have a heart attack. And it's not related to that illness that they were inpatient. Well, the clock starts all over again. That doesn't tack on to it. One thing it doesn't have to be is in the same facility. So I could be admitted to, say, Facility A, and I'm gonna be there for two days, but then I'm transferring to Hospital B because it's still continuing with my inpatient stay from that original stay at Hospital A. It just has to be a hospital that is participating or qualified as a Medicare hospital. They have to be qualified as a critical access hospital if that's going to be the case. And this is only, that three-day stay is for Medicare beneficiaries who want coverage for SNF services under their Medicare Plan A. So those are some of the three requirements. The number of days, it's a qualified hospital, and it's for Medicare beneficiaries. What about your requirements as a hospital? You have to have that agreement with Medicare. And you have to be in a rural area. There is no 24-hour nursing waiver. In effect, some of the rural hospitals have it because of staffing issues. You haven't had your approval terminated in the previous two years. And then you'll meet all the conditions of participation. So in reference to the question that we asked, what about the bed count? It has to be fewer than 100 maintained beds. Now, there are certain ones that are excluded, psych and rehab units are not included in that 100 bed count. And in fact, there is no swing bed services when you're talking psych patients. They are excluded. Also, you do count observation, nursing bed unit, that's really what they're looking at as far as how many beds do you have, your swing beds, and any maintained beds you have at any remote satellite location for your hospital. They come in as far as your total bed count. There are certain items that are not counted as far as a bed or what looks like a bed, carts, let's say transport stretchers, newborn beds, neonatal bassinets, those are not counted. And of course, your exam, they do limit that, that they're not counting those. And if you have beds in your ICU, they don't, for some reason, they don't count those either. Now, swing beds, as far as the location where the patient's going to be, you don't have to be in a special section. Patient doesn't need to change beds. You're going to be inpatient for four days, they can stay in the same bed, and now they're getting swing bed again. It's a reimbursement, it's not a location. There are certain things you do have to have. You have to have a discharge order, and then another readmission order for swing bed status. So it's essentially, they're leaving that type of payment, and now you've got to admit them to this type of payment. You can use the same record as long as the services are clearly delineated within that record. And that can, you might want to work with your IT person on how you're going to do that with an electronic record. Nice thing with swing beds, there's no length of stay restriction. You know, granted, it's to be in between, like going home to a nursing home place, nursing home placement, hospice or respite care, whatever it happens to be. It's intended to be a crossover, just kind of that bridge. You don't have to have any transfer agreement. And it is also, they specifically know, you're not skilled nursing or nursing facility beds. This is totally optional. You don't have to provide it if you do not want to. Now, there are limitations, and again, it talks about what beds can't be used. Those in your exclusive rehab and psych unit, those cannot be used for swing beds. If you have separately certified co-located entities under your hospital purview, for example, you've got a distinct SNF unit within your hospital. Those you cannot use for swing beds. Hospice, inpatient hospice, those cannot be used for swing beds. Psych hospitals, I've already mentioned, you are not allowed to have swing bed approval. They're just, they're not going to permit that. This applies to any patient who's admitted to swing bed. These requirements. Also, you have the rest of your acute care hospital course requirements that you have to meet, infection control, et cetera. What the surveyor is going to do, first they want to look at open records and they're also going to do an environmental assessment. They'll look around and see how it's set up done. Is it clean? They'll talk to patients who are in swing bed because they want to talk about what were you told about your rights, et cetera. They will watch care being provided. And then of course, they're going to review your policy and procedures. They want to see what do you have in place. If you don't have the benefit of two swing bed patients or no swing beds, they'll look at least two closed records that you do have available. A majority of what we're talking about today really revolves around patient rights because you're having to follow up those long-term care manual resident rights. They are extensive. When you think about it, it's probably a vast majority. If you had to separate it out into sections, resident rights takes up the majority of it. Overall, on patient rights, we need to give them prior to they're being admitted when you know they're in inpatient status and they're going to go to swing bed, give them a copy of those rights so they're aware of what those are. In writing, no, the patient doesn't have to accept them. Just document that you did hand it to them. They should acknowledge them. Initialing is fine, but don't be surprised if they don't. Just document again that you provided it to them. When you do this, keep in mind your patient. Do they have a limited English proficiency? What language is their primary language? If so, we have to provide it in their primary language and low health literacy. You read some of the items that we're so used to reading and it makes total sense to us. But when you have, say, an 85-year-old person, they're overwhelmed as it is because they're sick, they're away from home, they're going to go next. We need to make sure it's in a way they can understand it. What if you have that patient who, not quite competent or they're so sick or they've already had this illness? Say they have Alzheimer's or other form of dementia. Well, then you have your representative, of course we know steps into their shoes and exercises their right. If you have a patient that doesn't have a designated representative, maybe that's something you want to look at. And of course, those resident rights for that representative only go as far as the court says they can have them. These are when patients are deemed incompetent by a court. Because if you do have limited authority by that representative, then the patient still, what they want, takes priorities. In other words, if the resident says, I don't want to be resuscitated and they're not incompetent, the court hasn't said they can't make any decisions, then what the representative wants and says, no, no, make them a full coat. The patient still retains that right. Of course, we always want to consider what does the resident want? What's their wishes? What's their preferences? To the extent that we're going to recognize what the representative says. And of course, that's what's practicable. We really need to include the resident and the representative in planning, especially discharge planning, because the representative may have to make arrangements for that individual. Now, if you have a competent resident, that's great, because that's someone who they know what's going on. They understand the risk, the alternatives, and can make those decisions. And to the extent that it's practicable, we need to take that into consideration. And just because you have a representative involved, that doesn't mean that we can just ignore what the patient wants. The staff still has a duty to protect and promote that resident's interest. We may or may not agree with it, but we'd still have to take it into account. So I'm going to put in here, you're going to see a different tag numbers. Normally these would be tag A-1500, et cetera. I've included in here the tag numbers for what's in appendix PP. So it'll help you kind of make that crossover when you're looking at the interpretive guidelines. So those will be in parentheses. So first off, and I mentioned before, we have to make sure we give these patients rights so they understand it in a language that they can understand. And of course we have to tell them, this is what your rights are before we make any changes to where they are or their plan of care. Patient can refuse or even request certain treatment. Of course, we have to give them the option that they can refuse to participate in research. I don't know how many critical, excuse me, not critical, but swing bed patients actually participate in research. And CMS has made that just one of their priorities that, hey, we need to tell them this is what we're doing. And of course they have the right to make advanced directives that if they don't want something done, they have a right to say no. They get to choose who takes care of them. It's just that person, that physician, that attending must be licensed. If that person, if the physician does not either meet the requirements to come into your facility and provide swing bed services or doesn't want to, then you have to help that patient find another physician, another alternate physician to be in charge of their care. We also have to give them information on that physician. How do they reach that person if they need to? What's their name, their contact information? If they're with a group, let's say you have a group of hospitalist or long-term care providers, we have to give them contact information for that group. Not necessarily a specific physician if it's like in a PC, but the group. Somebody's responsible for their care. We also have to tell the patient if their particular physician doesn't meet the requirements or is unwilling to come in and take care of them. We do have to notify them. And how do we find an alternative physician that will honor their preferences? Now, if the resident selects another physician who meets the requirements, then that's who we have to honor. Otherwise, there's a smattering of other rights. And I'm just gonna go through these pretty quickly. One, they can use what they have, their own personal possessions, as long as you have space for it. I have an older sister, she's in respite care now. And one of the items that she wanted was her favorite rocking chair. So that's easy, we can bring that in and she can have it there with her. They can share a room with the spouse, but both must consent to that. You have to be able to give them immediate access to family, other residents, or relatives, excuse me. The resident can deny or withdraw those people from seeing them. They have still that right to do it. Just because Aunt Sally wants to come in and see them, if the resident says, no, I don't wanna see Aunt Sally, then sorry, Aunt Sally, send her a letter. And then access to others who are visiting, of course, if it's safe for them to do it. And likewise, the resident can say, no, I don't want to see that visitor. They're gonna talk to patients. And I must apologize, I'm using patient and resident interchangeably. So I will try to stay with resident. They will interview the resident, the representatives, families, visitors, because what they wanna find out, have you had access to the resident 24 seven, if needed? You may have someone who works an off shift and that's the only time they can come in and say midnight, but the resident's still awake. We still have to allow access. Also, they wanna look at your written policies on visitation and then list out when you are going to restrict access, because you can, let's say a patient's ill or the visitor is ill. They come in with a flaming episode of the flu or they're hacking and coughing and say the resident is immunocompromised. You can say, you know what, maybe today isn't the day. And you can deny access, but your policies must specify when you're going to restrict access. Otherwise the resident gets to send and receive mail, privacy of communications. And this is when they're talking with family or on the phone. We have to make sure they have access to telephone, internet, and a way to communicate with the outside world. That could be letter writing material. That doesn't mean you pay for posting. They have to pay for the postage. We just have to be able to supply access so they can get it. Other information is we have to give them billing information. This is from each Medicaid eligible resident. And that's first off, either on admission, that's a good time to do it, or at least when they become eligible for Medicaid. We also have to tell them what items are included in the services that they're not going to be billed for. We can't bill them for medications. We can't bill them for food supplements, but there are certain services, yes, you can charge, and how much it is. Let's say you have, I don't remember, we used to have one in one of my old hospitals. We had a sink for washing hair, just like you would see in a hair salon. And so we would be able to, we'd have to tell the person, you know, we have this service, but you have to pay for it. It's not included as part of your room fee. If there's any changes to those services, and this is before admission, or at least at the time of physician admission, and then periodic through the state. If it's going to be a long stay, make sure they're aware, hey, this is still what it costs to do this, and any charges, especially those not covered under Medicare and Medicaid. The surveyor is going to look at the record. First, they wanna see if there's any documentation court appointed representatives, guardians. They also want to see, has your resident been involved in care planning activities? How would you do that through your documentation? Who was present at this care planning session? RN, LPN, nurses aid, patient representative. They will also watch as you provide care, because what they're looking for, are you really sticking with what the patient wants? What are their goals? Is it to be up an ambulatory and getting back on their feet? Is it to try and be more social interactive? There's getting them out of their room and getting them some environment changes. They will look at the medical records, and what they're looking for is documentation, if that resident has delegated a representative. That's why it's so important, you wanna make sure you document who that person is, and when they are present during care, or when you're giving care to the patient. They'll talk to the resident, and probably their representative also. What's your level of understanding on participating in your care? They wanna talk to your staff also. How did they tell the resident of, hey, this is what we want you to get out of your stay here in swing bed. We want you to be able to go back to being as mobile as possible in your home. We wanna be able to replicate what you have to do at home on any given day, whether that's getting out of bed, going to the bathroom, giving yourself a bath, cooking your meals, maybe going up and down steps. Then again, they will look at the record, because what they're looking for is that assessment of the record. They are also adding in there any cultural preferences. Have we identified those in taking care of this patient? Moving over to privacy and confidentiality, just briefly mentioned that they have a right to personal privacy. And what I mean in person, when they're taking a bath, have we shut the curtains, have we closed the door, giving them the privacy you would expect in your own house. But also in their medical records, who has access to those records? Anybody, only authorized staff who are really taking care of that resident, first off, are really the only ones to be in the room with them, and are the only ones who should have access to the record. Otherwise, you follow HIPAA. There's no difference in confidentiality with a swing bed patient as an inpatient. The surveyor will watch staff. Are they honoring the resident's right to privacy? Are the doors shut? Are the curtains pulled while we're giving them care? And by the way, if they're sitting in a wheelchair, or they're sitting out in the main area, and say their gown kind of dropped open, whatever it is, have we made sure that they're covered? Again, personal privacy. They'll talk to the residents, their visitors. Has staff honored that person's right of privacy? Then they're going to also want to interview, and they may do this once they're off-site or even before, and that's the state's long-term care administration. What they're looking for here, did you allow access to the records with the resident's consent? Now, these folks come in and protect the rights of residents. That's what their responsibility is. So if they come in and say, I'd like to see the records on Laura Dixon, and you say no, then see. To look for other signs, is there care information in view of the rooms? They want to make sure personal information is communicated in such that we're protecting confidentiality to the extent that you can. Now, we do recognize that some folks have a little bit of difficulty with hearing. They're hard of hearing, and that's why we try to make it as confidential. Maybe it's done quietly in front of them so they can know you're talking to them, or it's in their room. We're not yelling across the room, hey, so-and-so, did you happen to have a BM today? That's what you don't really want to be communicating across the room. Another section talks about admissions, transfers, and discharge. Again, we're back to the acute manual. Transfer, when they mean here, that means they're leaving your facility. And what they're doing here, they're really trying to restrict that or make it more tight so there's not dumping when you have those patients who are really high care or difficult residents. And it only, this only applies, this regulation only applies when you are initiating that transfer. If the patient comes to you and says, well, it's been lovely here, but I'm ready to move to another facility, and I want to go somewhere closer to my daughter, then these regulations do not apply. There are certain times you cannot do this, but otherwise, there are certain conditions when, yes, you can transfer, when you have to do this to meet their needs. In other words, what this resident requires, you cannot provide. When they no longer need services, they're at that level of recovery where, no, they're just not, it's not needed here. Maybe you have a resident that is exhibiting behavior that endangers staff or others within the facility, and it's not safe for them to remain there. It's not safe for the others. Maybe it's their health also. Say the person ends up with TB or some other very contagious disease. And of course, they're just the basics, that they're not paying, even after you've given them direct notice, or you've, unfortunately, have to cease to operate. Now, I just want to point out, you see these and you think, how would a hospital in their swing bed cease to operate? Remember, these are geared to the long-term care situation, and so that's why they did want to include those. Otherwise, you can't transfer while you have an appeal pending, unless, again, there's that endangerment factor, whether it's health or safety. And if so, you must clearly document what it is. And it's not just saying, well, this resident is an endanger to the other residents. Be specific. What is it that makes them dangerous? They're walking into other residents' rooms. They're assaulting them. They're stealing or assaulting them and stealing their information. They need specificity. And how did you then, when you observe this behavior, what'd you do to try to meet those needs? It's not working. We've tried to isolate or contain this individual within a certain area. We've had someone with them at all times that are out of their room, but then you run into the issue of privacy. Is that practicable? Does that work? Is it successful? Again, clearly document. If you, again, do initiate transfer or discharge, you must also send this information to the Ombudsman because they do protect the rights of these residents, which brings me to number two. Lindsay. Okay, let me read this first part and then I'll get the question up there on your screen. This question says, hospital C has 90 beds with swing bed certification. Staffing issues has resulted in fewer qualified staff and a noticeable delay in documentation. Patient L is discharged back to his previous nursing home. His record has not had an updated care plan or discharge planning documented for two weeks. And so the question here is, will hospital C be cited? Let's get that up there on your screen. So you should see those options of yes or no, delay unavoidable with staffing challenge. And then Laura, it looks like we do have just a couple of questions here. This first one asks, if the patient has a Medicare Advantage plan and requires an off for skilled nursing, will they have an inpatient stay? Medicare Advantage is so unique. And I'm trying to be politically correct here. See, they don't separate Medicare and Medicare Advantage. Okay, and so they're looking at swing bed, not SNF, but swing bed. That's what they're looking at. So the three day stay is for swing bed status. I think I got the question. So if that is incorrect, please let me know, Lindsay. And if not, I'm happy to follow up with the person later after the program. Yep, sounds great. And then let's see. And it looks like the person who asked this question may possibly have found it. But the question was, where can we locate in the regulation that ICU beds are not included in the 100 bed counts? But then it looks like she may have found that. But if we need to follow up and provide additional information, we're happy to do that. Okay, looks like we've gotten a pretty resounding response here to this polling question. I'll go ahead and end that and share those results. So yes, that'll be. This is kind of an interesting one because we have those fluctuations in staffing. And so it's possible. Yes, they're probably going to be cited. We do have to make sure we have enough. And especially in those states where you have mandatory staffing per patients. Not too many states do, but there are those. As far as documentation, when you are transferring a patient, and I'm using transfer and discharge because discharge is considered a transfer, believe it or not. When you're doing this under any circumstances, make sure that you're sending off enough information when you're transferring them especially so that the next person taking care of them knows what happened. Why were they admitted? What happened when they were in your swing bed status? Why is it that they're being transferred? It has to include why they're doing it, that we can't meet their needs. Again, this is when the resident has not instituted it. And that this is all documented by the physician. So the physician has a hand in this documentation. We need to include information to send to the new practitioner who took care of them while they were at your site, the representative's information. Please send any advanced directives, right? That should just go along with the patient. You don't want to have that patient get there, have a terrible event, if they had advanced directives in place and they resuscitated them not knowing, oops, we weren't supposed to do that. What were the plans for this patient while they were under your care? Any special instructions? Did they have to sit up to eat and remain sitting up for half an hour because of esophageal issues? And what was the discharge summary? Yes, when they are being transferred, we need to do a discharge summary, unfortunately. How do we give notice? How soon do we wanna tell the patient, oh, by the way, you're being transferred? At least 30 days. At least 30 days before this is going to happen. And why? Well, we have to give them a reason for that transfer and discharge. When does it go into effect? Where are they going? We also have to include in there a statement, you have a right to appeal this decision. In doing so, here is the information in order to write or file that appeal, and that's the phone number, the name, the address of the Office of the State Long-Term Care Ombudsman. And that is also spelled out and tagged in the Long-Term Care F-623. What is their rights to appeal this decision? How do they obtain the form? You may have to help them fill out that form depending on their level of awareness. Again, notice is not required. You don't have to do any of this if the patient starts this process. There are certain other situations where certain notice needs to be provided, and that's usually to the agency. If you have intellectual or developmental disabilities or even a mental health disorder, there is certain agencies that you also have to give notice to. So if you have, let's say, an elderly person who also has some developmental issues, you may have to send it to two agencies, the Long-Term Care Ombudsman and the state agency that has oversight for the care and treatment of those individuals. And then just generally facility closing or you're changing the rooms. We still have to give the person advanced notice if you're closing your facility. So we get them ready for this transfer or if they are to that level, they can't eventually go home. Now, room changes. If you're gonna move the patient around, it has to be at a distinct part within a particular building unless the patient goes to, agrees to that move. So let's say you happen to have a floor where you have all your swing beds and that's normally where they would go. Well, let's say there's another room in a different part of your hospital, say it's quieter or more secure for other reasons, just let the patient know this is why we wanna move you to a different part and just document patient's agreement to it. Now, interpretive guidelines, they do reference appendix PP and I've listed the tag numbers there for you so you can see what they are referencing. I wanna move on to one that I still find a little sad that we have to reference this and that's abuse, neglect and exploitation. Now, this is out of order. This tag number I'm covering right now, it's out of order when you look in the manual. So that's why I've included the actual tag number in the long-term care manual because you start reading the long-term care manual and you're not gonna find it as you go down it. This follows the patient's rights section within the long-term care and again, we can't use verbal, mental, sexual, physical abuse as a form of punishment. We can't do involuntary seclusion, again, as a form of punishment. This includes physical and chemical restraints. Now, they specifically talk about restraints in this area. We don't use it for convenience. Oh, they keep getting up at night, I'm gonna put them in a vest and be done with it, I'm tired of having to go chase them down. We can't do that. And when we're talking medications, when we use the medication outside of what it's normally used for, Phenergan, for example, really good sedative. We used to call it vitamin P, but we're using it to keep the patient quiet. That's not what it's used for. Phenergan's used for nausea. If you must use restraints, the least restrictive for the least amount of time and document ongoing reevaluations of the resident. Look at their skin, how was their mentation? Are they starting to withdraw? What is it that we had to use a restraint and now we can take it off? This is a very long descriptive section and it's very similar. If you've listened to any of the other programs, it's very long and similar to what's in the patient rights section of appendix A that starts at tag 113. So very long, they're very serious when it comes time to the use of restraints and proper use of restraints. Still along with patient rights and protection are employees. We cannot employ or hire those folks who have been found guilty of those items, misappropriation of property, in other words, theft, mistreatment, neglect, exploitation, abuse. And you wanna check your state nurse aid registry on such for the nurse's aid. RNs, this will be in your RN registry. Update your policy and procedures to include it. This is not in the requirements. That's just my suggestion. And make sure staff know that everybody has a right, has a responsibility to keep patients and residents safe from abuse and neglect. Put this in your annual education. Give them scenarios, give them situations. Make it up if you have to. But so that they understand the vital, because if they know this occurs and they don't act on it, they themselves could also face any action by their licensing board. My Colorado Board of Nursing is very strict on this. And they don't take, oh, they didn't mean to hurt them. They don't take that lightly. And so please make sure that you're including that in your policy because you have to report. As an employer, you must report to your nurse aid registry or licensing authority when you have knowledge, any knowledge of action that could harm a patient or if there's been an action by a court against an employee, which means, hey, they're not fit to be a person. They're not fit to be here. We had a family friend who, they had a son who had substance use issues and he was working as a nurse's aid in one of the long-term care. And he got released from there. And we're going, how do you get fired from working in a nursing home? Then we found out he'd been stealing. And so that made him unfit now to ever work in any kind of a healthcare setting ever again. That's why you must, this is one thing you have to do. You must develop policy and procedures that spell out prohibiting and how you're going to prevent mistreatment and theft. How are you going to investigate these allegations? This is some of the policies and procedures you must have. You also have a timeline to report mistreatment to the residents. You have to do it timely. Usually it's 24 hours after an allegation is made. So if you have a nurse who comes to you, you're the administrator, the risk manager, whatever it is, and they come to you and say, I am really worried this nurse aid here, I saw him slap the patient on the hand. That's abuse, believe it or not. It is abuse. And they told you nine o'clock Saturday morning, you have until nine o'clock the next morning, Sunday morning to report that. There's no day of the week. You have to do it within 24 hours. If this caused serious bodily injury to that resident, you have two hours to do it. Where do you do it? The administrator of the facility, your state survey agency. And if your state law gives jurisdiction to say adult protective services, that's who you report it to also. Now, while you haven't reported it, you still have to investigate it. You must keep evidence that you have done this investigation. Keep that documentation, put it in a separate file, whatever your legal counsel tells you to do, wherever they want you to store it. Then of course take steps so it doesn't happen again. That may mean you're going to put that person on leave. Maybe you're gonna move the patient to a different floor, different area, or put that individual employee onto a different area. Again, you have to report it to the state survey agency within five working days. Your investigation, yes, I've done it. This is what we found. And if it is a verified allegation, you have to act on it. You just cannot say, oh, they didn't mean it. We'll talk to them and be done with it. No, they want to see some corrective action. And again, the interpretive guidelines here are under text F608-610. Now here's again, just some of my notes on it. They have revised the definitions on abuse reporting. Administrator, within 24 hours, if it does not result in serious bodily injury. If it is serious injury, two hours. And then check any state-specific reporting requirements. You certainly don't want to get in trouble for not reporting it. We've seen some issues and situations where they just didn't report it. And the state came in just really, it was not pretty, needless to say. Write your policy and procedures if you need to. Evidence, keep evidence that you did that evaluation and investigation. And make sure those who are in charge know their requirements, their notification requirements in particular. Whether that's a charge nurse, your supervisor, whoever it is, they need to know what their responsibilities are. We'll on to something a little bit more cheerful and that's social services. You have to provide medically related services so that we keep this person functioning where they're supposed to be. The requirement for that full-time qualified social worker does not apply. That's only, only if you have more than 120 beds. But keep in mind, you can only have 100 beds or less. So it doesn't apply. The requirement, really what we're trying to do is help this resident keep going on what their activities was. What did they do? What were they involved in? Were they still active? We need to keep this mind working for them. And we just, again, supporting that physical, mental wellbeing and encourage their independence and interaction. There's one thing called a comprehensive assessment. So when you're reading the long-term care manual, you're gonna see this a lot. You might wanna think about using that in a care plan when you're looking at what activities are you going to offer to this individual to do. And that comprehensive assessment really takes into account the patient, the resident's behavior, their actions, so that we can really incorporate what they've done in the past and doing this plan for them to keep them active, keep them independent to the extent that they can. Then onto the discharge summary, we have to have it when you are anticipating that discharge of the resident. What happened while they were there? Did they have anything, any additional x-rays or pertinent labs? Summary of their status, any medications, including over-the-counter, please do that reconciliation. And what was their discharge plan after they left you? That you worked with the family or the resident in getting this done so that they can adjust to where they're going to end up. That could just simply be, tell me the setup at your house. How many stairs do you have to get into your house? Do you have to go to the basement? Do you have to go upstairs? How many stairs? Do you have a railing? What's in your shower? Do you have a grab bar in your shower? Where is your shower located? You know, just some of the simple questions you have in what happens on a day-to-day basis. Make sure one is done when they are discharged from swing bed. Make sure a copy is sent if they're going to another facility and indicate if you simply couldn't meet their needs. Look at the charts, go back and do an audit on your own charts. Make sure it's in that summary. That's why you wanna have a list of those audit questions and just say, hey, how are we doing on this? As far as discharge planning, we do have to coordinate an assessment. Now there's called the PASAR. Now you can use this if you want. You're not required because this is really for those individuals who've come to your hospital and they happen to have one if they had like a serious mental disorder or an intellectual disability. So they will have one when they come to your facility. You can use it if you want, if it avoids any of that duplicative testing and effort. Document that, by the way, you've talked over with the representative and the resident, their discharge plan and what care is needed. That could be non-medical care. Where are they going? Are they going to hospice, assisted living? They're gonna go back home. I wanna talk about one of the memos that came out June of last year. I've got the link there for you on where to find it and it applied to all hospitals. And it really talked about that discharge planning process because what they were finding was some of the information was missing when they were doing surveys. Well, we know we have to send them where it's safe, where it's applicable, but we have to send along all that necessary information. I've already covered those. What was their course of illness? What's their goals and treatment preferences? But they found a lot of information was missing. And these are the post-acute care providers. And they did this because we just wanna reiterate the need for good discharge planning so patients aren't coming back because it wasn't done sufficiently, wasn't done, period. Because when this information is missing, especially when they're going to a PAC, those folks aren't ready to take care of them. They don't know what they need or weren't prepared for what they needed. And they did reference the state agencies, accrediting organizations. They want them to be on the lookout for some of these issues. How you do this, how you're going to meet the requirements, that's up to you. You develop your own policy and procedures, but six major areas that they found of concern. Again, medications, no reconciliation had been done. Patients were getting double-dosed on the same classification of drugs or they were simply missed. They weren't there anymore. Durable medical equipment wasn't available or wasn't the right type. Even the skin condition of the patient, the resident hadn't been documented. Oh yeah, by the way, he's got a stage one D cube in the center of his back and this is what we've been doing to treat it. And then those who happen to have serious mental issues, SUDs, what information was communicated, what did the patient or the resident want and then any communication on what was needed at home. So that was one of the memos that came up in reference to discharge planning. Again, for dental services, they removed that you have to provide that emergency care. It's all part of your routine care. So they said, why bother? Why make it duplicative? You can charge a resident if they do have to have some dental care. If they have to go to the dentist, okay, you can charge for that. Just have a policy that if they have to go because it's something that happened under our care. In other words, we lost our dentures. Okay, replace them. And you can't charge a resident when it's our responsibility. So staff being well-meaning, dropped the dentures and broke them. We can't charge a resident to replace those. That's on us. If necessary, we can help the patient, the resident make those appointments, get transportation. But if they are lost or damaged dentures, then we have to refer within three days. If you can't, just make sure that you're documenting their I's and O's. How are they eating? So that we can maintain their nutritional status. And then if you do have any specialized rehab services that are required as part of their care plan, make sure it's included. That could be PT, could be rehab for mental disorders. He can provide internally or work with an outside source. But it does require a physician's order and has to be of course given by somebody who's qualified to provide it. So the interpretive guidelines, pretty much the same thing. Help that person get back to where they were. And for those who have a mental disability or an intellectual disability, those would be determined by the PSARF. The guidelines mentioned restorative services are not considered specialized rehab services, restorative. That means what you do from a nursing intervention that helps that person adapt and adjust to living independently and safely as possible. Now I do just wanna point out a few of the resources available for Swingbed before I go into psychiatric. There is the worksheet if you wanna use it. The surveyors use this. You have access. So if you're looking at a gap analysis, how are we doing? What's going on? You can tap into it. I've got the link there for you here. Excuse me, on slide 94. It does include the cross references on your tag numbers. Hospital, you're gonna have the A section. There's also the Medicare Learning Network. They have a fact sheet on Swingbed. So if you're looking to do this, okay, where do we get started? And there's also the Regional Office for Rural Health Coordinators. Again, I just wanna put these resources out for you. They're directly from CMS. All right, so let's go ahead now and switch gears and over to psychiatric. Before I leave Swingbed, Lindsay, are there any other questions that you'd like me to address? I don't see any pending at this time. Perfect. Okay, now we're going to have a little change here. That's our first question, Lindsay. Okay, let's get that one popped up here on your screen. Okay, you should see this as your options here. And it says, our hospital, and you can check all that apply here, accepts patients only from our community, accepts patients from across the state, has patients of all ages, only accepts patients over the age of 18, is limited to child and adolescent ages, and or has a large population of patients with dementia. I know we just paused to address any questions, but if you have any up to this point, please go ahead and be typing those into the Q&A option at the bottom of your Zoom window, or of course, there in the chat, so we can make sure to alert Laura of any questions that you have. Let's see, some of you are still putting in some responses. Here, I'll give you just another second. Okay, I think we've gotten some good varying answers here. Okay, wow, patients, wonderful, wonderful, wonderful. Okay, so it looks like we have all over, a good host of providers. So this is the section that we're talking about now. Now, there's two areas you need to be aware of within the manual, and I've got those highlighted here. First, of course, is your hospital, psychiatric hospital survey. And then when you have a year, hospital, psychiatric hospital survey, and then when you have a unit within a general hospital. So two different survey areas for you. And then the absolute conditions. There is separate, it starts on page 24. And again, it mentions hospitals and units, but the actual regulation, the conditions, they start way down, like tag 1600, page 515 in appendix A. As for deficiency, there were only 470, believe it or not. Now, then this is taken from 2018 going forward. That's not many deficiencies. Really, when you think about it, that's pretty good in the overall scheme of things. Section 1640 had the most, and I'll touch on that once we get there. Well, first off, I do wanna talk about the survey team because it is different than for what a routine general hospital would be facing. So as far as the survey team for a psychiatric hospital or unit, they have to have expertise in behavioral health. At least, at least master's prepared. Psych nurse are in with inpatient experience. So they really want their surveyors to know and be very versed on what to look for. The focus of the survey is on the outcome experienced by the patient and how you put together a plan of care to meet that. That's not how it normally is. It's what they're looking for is the care, but here they're looking for the outcome by the resident. The surveyor has quite a bit to do in this one. They have seven overall tasks. They're gonna look at a sample of patients. They're gonna look at their records. They'll look at other records too, by the way, not just patient records. They'll watch patient care. They're gonna interview people. They're going to do visits to the units. And then what's the assessment of your overall compliance? If you have a unit within your hospital, a psych unit, then they will also... ...in time. They will count as annual validation compliance if you have self-attestation with you have an excluded unit requirement. Exclusion, oh, that's it, simply in a reimbursement term. That's all it is. You're reimbursed at the psych unit, excluded rate versus the hospital inpatient. That's all they mean by excluded. And the rate is per day versus per cost. So it's a little bit different. There are certain areas as far as determining compliance, again, should be done by an RN. They'll look at 10% of your average daily census, at least two patients. That's at least what they're gonna look at. If you don't have any, they'll go back and look at closed records for six months. Should be conducted with a hospital survey. And there's what's called form 437 to verify whether or not. Now, these are the essential forms, 437 and 724. One's a unit, one is the hospital. I've got those in the appendix, what they look like for you and how to get to them. I've just listed out a few other optional forms you might wanna keep on hand. The psychiatric review, do special conditions, there's a nursing compliment, death record. Those items are optional, but it's helpful to have, especially if you're going to be anticipating a survey and getting ready for that survey. But overall, what do you have to do to meet the requirements? You have to be primarily engaged in providing psychiatric services. And that's not only for treatment, for diagnosis of this person. And that has to be under the supervision of a physician, whether it's MD or DO. And one of the things you must meet all of the other conditions of participation in A, except for the medical record section. You have your own requirements and I'll touch on those when I get to 620. So briefly, you have to maintain records on all patients. You have to meet staffing requirements. And they do talk about nursing and mental health care staff. As far as records, your records must be able to show that you have determined the degree and intensity of treatment that you're going to provide to your patients. That should at least include, why is the person there? What are the treatment goals? Any changes in the status of treatment? Don't forget discharge planning. You still have to do that. You have to account for follow-up that must be in the records. And what did the patient experience? What outcomes did they have? It has to have enough information to show that you know your patient and that you have also, how are you going to intervene if this patient starts to decompensate? If they start to go downhill? Also, did you put those interventions into place? And really it's that intervention that is the function of the patient is experiencing. That's what they're going to ask the patient. You have to be able to identify using interviews. They will do that through staff and patients and of course observation. Did that de-escalation that they were able to observe your staff instituting help bring this patient down and get them to an area for further treatment? And I've just got an example what the progress note would look like. Again, just an example where it talks about the mental status. As far as the assessment data, they really have to stress the psychiatric components and the history of findings and treatments. So I've just put an example in here what some of the documentation might look like. And by the way, this came from an actual record. Patient B admitted for paranoid ideation. And this was the person's statement. The CIA put a chip in my neck so they can track me and this individual went on to describe what was going on. This started at a very young age. So this is very specific documentation. What were they saying? How soon did it start? And how are we going to treat this individual? Now surprisingly they put in here, the identification data has to include their legal status according to what the state says. And it's really, when can the patient be admitted or treated, whether it's voluntary or involuntary? Or when were they admitted by the court so that we can evaluate and maybe recertify according to what the state says so we can continue their inpatient hospitalization. Your surveyors are going to talk to your staff. Do they understand that terminology of legal status? Is there any documentation? Do you have court orders from included into this patient's record? Are there any changes? And if so, when did that change occur with that status? Each one, each patient has to have a provisional or admitting diagnosis once they hit your doors and any other intercurrent diseases. Maybe they have high blood pressure. They want to make sure that's also listed. Now the guidelines do refer to several resources for admission or working diagnosis. I begin, the asterisk means I have that in the appendix for you. The international classification of diseases is another one. But this is made and put into each patient's record at the time you're doing your admission exam. Now, of course we know the final diagnosis could be something different. If further observation or evaluation makes that determination. If there is no diagnosis, there has to be really good justification in the record why it's not there. Maybe the patient is so psychotic and there's no one around that can help identify what was this patient like before they got to you? Then it has to be clarified. That has to be documented in the record. Other diagnosis, again, documented when you make them. Maybe it's apparent on admission or there's other records that happen to come in from an inpatient stay. Surveyors, they are really to look at the physical exam notes and determine, is this reflected by the diagnosis? And these are your intercurrent illnesses. But it could also be substance use. Maybe they're using lab tests also to determine let's say their kidney function or liver function is so bad that's causing part of their behavioral health issues. Do the labs reflect that? Categories, they should include physical illnesses when of course we have them. We have to have clear documentation of why this patient is there. Could be what the patient says or those who are really close to that patient. We wanna have that understanding why did the patient come in? And what's their response to being there? There was one, it was a young lady. She was unfortunately a victim of child abuse at a very young age. I think it started around three or four. And it continued until finally the state stepped in. Well, this young thing did end up having a baby. And at one point in her illness, she started to become paranoid and schizophrenic where she stopped taking her medication and she tried to kill her baby. And so the reason that she had to come into the hospital is because she tried to kill the patient, or baby, excuse me. And that's what they had to start with was that she became so paranoid, so ill that she became a hazard to others. And she accepted that, yes, I need to be here. I'm not safe. Other examples, I wanna, in my life, and there's say cutting marks, self-mutilation marks on their forearms, or let's say the family mentions, we're real concerned about this person. They won't eat. They won't leave their room. They're admitted. The patient, the family has some documentation, say from the PCP, they weighed one weight and now they're down 20 pounds. So these are some of the examples of what you wanna document. You wanna also have statements or other reasons, maybe the family or a friend. If they're going to say, I want them in here, or they need to be in here, or I'm concerned because, put it verbatim if you can. Make sure you're identifying that informant. That has to be documented. Mother says, family friend, Alice says this. You wanna avoid those vague statements. And especially if they come from unknown sources because really we need to record who, what, when, where, why. I know that sounds very superfluous, but really that's what we need to have in the record. This is what the surveyor is going to look for when they're looking at the records. Can the patient describe what was going on with them before? Is that documented? And do they still exist? Is it still there for them? Who is giving you this information? Did they witness the behavior? Okay, no. Well, then how do you know this behavior occurred? Did the staff, did they document or actually see the behavior in this person? Were there any interruptions in their medications? Again, with that patient I just mentioned, the young girl, she stopped taking her medication because she said, oh, I wanna see what I feel like. Any other thing that's going on in the environment? Maybe there was a loss of a parent or a loved one or loss of a job. What happened? Is there anything else that triggered this patient? So moving on, just briefly on social services records, they have to provide what's going on at home. What's the setup? What's a family attitude with the patient? Are there any resources within the community, social history? Because really what they're trying to do is assess this entire person to get them home, get them back into their safe environment. So there may be interviews that include family and friends and others. The assessment will be done. First up, they wanna look at the current baseline. What are their strengths once they leave here or once they're coming in? Where do they need to work on? Again, we're looking at this discharge plan and the overall scheme. The length of stay, that's going to be affected with your documentation policy. When do you expect documentation done? Are they there for a week? Well, then it's gonna be a shorter timeframe. Is it going to be, we expect or anticipate they're going to be here for a month? Again, how often you're documenting is gonna be influenced by that. Each patient though must have a completed psychosocial history and assessment. Each patient has to have it. There are three key components of this assessment. First off, of course, you're going to start with what's the background information? What's the historical information? Nine components to this one. Why are they there? What happened? What's the past functioning that they had? What's going on in their personal life, family, marital history? Are there any religious or cultural factors? Any abuse, whether it's physical, sexual, emotional? Other significant factors. What is their abuse history, psychiatric history? What's their education, their vocation, their employment status? Are there any resources? Again, previously used treatment resource. Did they have a community resource center they could go to? And identification of their present factors. So one was historical. Now what's going on right now? Then we have the second component. There's two components to this factor. What are their strengths and deficits? And any risk, high risk issues that really we need to jump on this fast. Maybe there's kids unattended at home. There's no one else there. Patient was brought in by law enforcement. Do we need to know about noncompliance with treatment? Maybe there's obstacles for this person to get in that we just weren't aware of that we need to jump on now. And then three, again, all part of the assessment. What are the conclusions? What'd you come up with from your assessment of one and two? And what are your recommendation? Four areas on this. What necessary steps do you have to occur for discharge? If we have a high risk patient or family dynamics what do we need to put into place quick so we can get those in place? This is regardless of what the anticipated length of stay is. Any resources, support systems. Maybe it's housing help. They were initially unhoused living on the streets. Is there anything we can get them into short-term housing until we can get them stabilized? And then what is the anticipation of the social worker's role in getting this discharge planning going? In other words, what are the resources that this social worker may know? As far as the survey procedure on the assessment, is there a clear indication of who's giving this information? Is it the patient? Is it the family member? Is it considered reliable? Did the patient participate to the level they could in that assessment? Was there an integration of that data to the plan? And that may mean those high risk issues with that patient. Perhaps it's drug use that is a high risk issue. How did you make sure that what they're saying is actually correct? Excuse me. Now we're gonna go to the neurological exam. There may be times you have to do a neurological exam. That you have to do this at the time of admission. Thorough history and physical, all labs included, because what we're trying to do, is there anything functional going on with this patient? Is it a metabolic disorder? Is it something structural? Have they had head trauma that's resulting in some of this behavior? Thorough history. Do they have any seizures or loss of consciousness? Headaches. Maybe they're exposed to toxic substance in their work environment. I've already talked to head trauma, but also substance use issues. Maybe they're just sick, and it happens to be an infection that's causing the psychological disorder. What we wanna do, why are they, the rationale for doing the history, of course. We wanna make sure the physician's aware that maybe there's some other pathology that's going on. But that may be significant and pertinent to what's going on currently. And of course, other signs of illnesses. It could be just a general medical condition that's doing this. I remember taking care of a patient, she was in ICU, and she would be very pleasant and fine. I shouldn't say normal, but cognizant, alert, oriented. And then in a heartbeat, start screaming and became very paranoid. Thinking the television was a camera that was spying on her. I mean, it was a heartbeat changes. And what we identified was she was having spasms, cerebral spasms that were causing this to occur. And so that's why these items are so important to have done. Now, CMS does recognize from a neuro exam, they do know there's not a precise definition, but really what they're trying to do is what is the gross function of the central nervous system? And how do you do the gross versus the fine? They want gross testing of cranial nerves two through 12. That should be a part of it. To simply say it's intact, nope, they're not gonna accept that. They need to see that this is what you have looked at to say, yes, they're intact. And if it comes up positive, then start doing a deep dive. That may be a consultation. That complete exam includes looking at their current history, doing that exam, looking at their psychiatric evaluation too. It's a very detailed orderly survey of what's going on with that nervous system. So here's just an example. They're looking at their psych, what's their acuity? Then doing the fundoscopic exam. For the motor system, grouping those muscle groups within arms and legs, how strong are they? They also test the head, the neck and the trunk. Smaller muscles, individual muscles may also be tested. So they're really looking at that neuro exam to be very, very thorough. Psychiatric evaluation. Now, of course, every patient has to have one. Why are they there? What's their diagnosis? And also what treatment is indicated. It's a total appraisal of this person's illness that the physician assessment, have they identified any contributing factors or forces that led to the patient? Now, this also includes the patient's perception of the illness. So during the exam, the physician is gonna ask them by a lot biographical historical perspective of their personality. They're trying to see how did this person develop to where they are now. They're seen as really a dynamic individual with a past, a present and a potential future. With some threat of logical continuity. Here's just some of the areas that they're going to be touching on when they're doing this evaluation. What is their basic personality structure? Where are they in their development? Do they have a value system? Any past medical history? Past psychological trauma? Did they witness say a horrific crime, a family or friend that can impact them? Do they have any defense mechanisms? How do they react when this happens? Do they have a support system? Do they have people there to say, hey, we're here to help you? Are there precipitating factors that led to this particular event? Again, evaluation enough information to justify their diagnosis and treatment. There has to be a physician signature on this. Now, if part of the exam, part of that status is done by a non-physician, then that person has to be credentialed by the hospital. They have to be authorized by the state to do that function. And if it is required by the state and the policy, then the physician has to sign off on it. They have to review it and countersign it. So you may have a PA who's doing this. You may have a nurse practitioner. That's fine as long as the state says they can do it within their scope of practice and your policy permits it. Surveyors going to look at the records. They wanna make sure the chief complaint has been recorded and in their own words, if possible. Why is the patient there? Was it their idea? Are they there against their will? Who decided? Why? Is this an M1 hold or is it court ordered? Is there any history of psychiatric treatment or problems? Are they chronically ill? How severe is this patient? Did the treatment interfere with their ability to adjust? Any persistent behaviors that are going on? Social, family history. Again, are these all documented? Are they employed? What's their educational level? Are they getting along with people? Are they isolated? Do they have friends and family? And I think this will be one of our last questions, Lindsey. Well, while I'm waiting for Lindsay to come on, I'll go ahead and I'm sorry, double muted Laura I was just reading away and double muted I'm so sorry about that. Okay, so this question here says Creekside Hospital provides inpatient psychiatric care to all ages. Over the past nine months and due to a decrease in payments, a reduction in force occurred. Current staff includes RNs, LPNs and a few technicians. As a result, admission assessments have been delayed for up to four days and were completed by the technicians. Will Creekside be cited? And then here are your options. No, it is an unavoidable staffing issue. Yes, assessment is not timely or possibly and it looks like I think we have one question here. So this says since swing beds is a skilled nursing facility level of care in a hospital, are we supposed to fingerprint our staff? We do a criminal records check as part of the hiring process, but currently in the hospital, no fingerprints. But I know nursing homes had to also start this a couple years back. Yes, you're right. Yeah. And that's a very good question because in most states, they do have to fingerprint in the nursing homes. I guess I'm going to leave that to your policies. Again, you are following the interpretive guidelines. And that's the level of care you're given. But if I guess you have to decide what kind of staff do you have, are these staff are already in the hospital, then you would follow those hospitals. They don't specify that you have to fingerprint. CMS does not specify that in the regulations. You just have to do your background checks. You have to make sure these folks are safe. They do not say you have to fingerprint them. You might want to check with your state, see if there's any special requirements for those who provide skilled nursing facilities. It just might be a good overlap just to make sure that if you do have different staff levels in your swing bed than what's in your acute, it might not be a bad idea. But CMS does not require that at this time. Perfect. Okay. I don't see any other questions. Let me end this poll and share that result there. Okay. Yes. Assessment is not timely. Cool. Okay. So assessment, the evaluation has to be done within 60 hours of admission, 60 hours. You have to have a medical history, what's going on, past surgeries, the usual that you would have, any physical disabilities, anything that's going to contribute to their condition. You have to have a record of their mental status. How do they appear? How are they responding? What's their thought content? Can they carry on a thought conversation and keep it lucid? Are they all over the place? Cognition. Now, this is two ways. One is how the patient is reporting it. What do you think is going on here? And what the examiner also notes. So here's just some examples. During the patient interview, they are able to say, hey, that's your name. After they hear it once, they can characterize their present illness. I've been having issues of depression. Now here's one thing you want to document. They believe the pre-admission insomnia or anorexia and weight loss over four months, well, that's fine, but that's because I was very sexually promiscuous 15 years ago. Nothing to do with their current and daily use of amphetamines. So that's one thing you want to document. Is this person, are they really on a cognitive plane? You just want to document it. And that's how you would assess their mental status. In the event of illnesses, what led to their admission? The surveyor will ask or look into how long was the patient ill? Was this a sudden overnight thing or has it been coming on for years, decades? Is it a reoccurrence? Were there any precipitating factors in this patient's current illness? What signs, behaviors that made their hospitalization necessary? Any medications that they were taking at home, whether they should have been or could have been taking? What attitudes and behaviors did they exist? That could be difficulties also in their relationships. Those that really, you got to have active treatment so that we can get them back to where they were. And then an estimate of their intellectual functioning. How oriented are they? How good is their memory? I want you to look at an inventory of their assets, indescriptive, not interpretive, okay? These are those that describe their personal factors on which you can base your treatment. Strengths such as their knowledge, their interests, their skills, personal experiences, what are their education, their talents, their employees, employment status. Here's what is not considered. These are what they would consider interpretive. They have a car, okay? Big deal. You have a car. Youth on their side, they're young, they'll be okay. These are just some of the interpretive ones. Now, they do mention social security income, their own social security income, okay? How does that affect their mental status? Really it doesn't. That's more interpretive. They want descriptive. Has a high school education or maybe their college graduate program study. That's what they're looking for. They want those specifics. And really that's done to help develop their plan because each patient has to have that individualized comprehensive plan based upon that inventory. What are their strengths? What are their disabilities? What are their disadvantages? And it's really what this is the plan that you are going to follow. The facility you decide how you're going to do it, how you're going to develop the plan, what format, electronic, paper, and any updates. A surveyor will watch the patient and staff during meeting in various settings. They will observe treatment during those who are involved. So in other words, they're going to listen perhaps during a group session. They'll look at the program that you have in place. Is it going to be family therapy, individual therapy? They will also listen and attend multidisciplinary planning meetings. So when your RNs, your aides, your physicians are all together, they're going to listen in. And then of course review the records. Really do you have enough information so that you can develop that individualized treatment plan for the patient? They're also looking for evidence that you've really evaluated the patient's response. Is it working? Because they want to make sure that you're continuing with the goals and the approaches. If they're not working, you're going back and revising the plan. So maybe there will be more success. What are the interval reviews? That's up to you. Did you accomplish your goals or is the patient failing to progress? And you really, you may need to really push a patient to attend and also other participants to attend the meetings. I know that can be challenging if you're short staffed. Making sure your staff is there because they know and see and observe the patient. They do have five written plan requirements. Of course, we have the substantiated diagnosis. Rule out alone isn't enough. You have to have something in there. They want data substantiated and the plan has to identify and really describe those behaviors. Alteration in thought process, that's okay. To say they're paranoid, not enough. What is the alteration? That's okay to say. Two, what are your goals, short term and long term? What are the dates for expected achievement? Both really, they have to be expected behavioral outcomes as it relates to the problem. These are written as observable and measurable. So let's say I am in because I have decided to isolate and not interact and I've had that weight loss. The family is concerned with me. Okay. So my goal is that I will be out, I will be interacting with others. I will be out of my room one hour every four hours. I will participate and contribute during my group sessions. And that overall, I am now able to be, I want to be out of my room two hours out of four. Three hours out of four, again, measurable. And what discharge criteria will be there? For me to be able to go home, this is what we want to observe. Three, modalities that you have used. And that's all active treatment measures. Who and what did you do? Include the focus of the treatment and described so that really there's a consistency in approach. Simply naming a modality, that's not going to be enough. Or the approaches. We're going to set limits. They're going to participate in group therapy. They need much more. That's what they're really looking for, specificity. This procedure here, do you have qualified staff? Can staff explain what is the focus of a particular modality? Why do you want them out of their room at that hour or at that time of day for that length of time? Do you have all discipline involved in the plan? It's a patient included to the extent that they can participate, that they're able to participate. And does the patient get to know what their treatment regimen is? Again, a lot more that goes into this procedure. And then number four, what is the responsibility of those who are involved in the treatment? There's no specific number that's really what's going on with the patient. What are the goals? Each person, though, on that team, they are responsible to comply with that aspect as identified. In other words, so-and-so in PT is going to take the patient for a walk, using a walker to increase their physical strength. They have to be identified. But you can also include others, friends, family. And then five, enough documentation. So again, we have the diagnosis to support it and the treatment that it's been carried out. The treatment notes, it has to be related to the plan. The surveyor is going to look at the notes. Do the notes, are they reflective and relative to the program? Are they indicative of how the patient's responding? Do they relate to that specific patient's program and progress? And the documentation, of course, we have to document what we did and that how did the patient respond and a chronological of their progress, hopefully progress, to those goals. Because again, the focus of this survey is the outcome experienced by the patient. As far as recording, it has to be done by someone who's responsible for that care, whether it's a nurse or a physician. You can have others involved. Maybe PT is going to be involved or social worker, whoever it is. The guidelines say we have to give a chronological picture of this person's progress. It's not okay to say, no complaints, slept well. That's not sufficient. They want to know, you know, they want to, you know, patient reports that they slept five hours. They want to observe snoring, whatever it happens to be, dated and signed. The frequency, that's not going to determine the adequacy of the notes. You know, it could chart every hour on the hour. If it's nothing there, it's not going to determine the adequacy. Surveyor wants that documentation, especially by the physicians who are involved in their active treatment. Is there a clear picture of their progress? Are nurses, are they also involved in the, if they're involved, are they documenting? And the same for everybody else. Again, frequency determined by the condition. What they're saying here in tag 1660 is it must be weekly for the first two months and then monthly. Include the recommendations for any revision of the plan and how you're going to assess this person's progress. And of course, then discharge planning. Just like with a normal admission, it's a recapitulation of what happened during their stay. It's part of how we're going to consider, is there anything else that we can do for this person once they leave? Did we meet their goals? There is service recommendations for aftercare, a description of those arrangements with those resources, maybe their medication regimen, dates, who's going to do that, community, housing services that are there. Include in there, what is their financial status? Are they going to be supported by family, friends? Perhaps they can get A&D or Medicaid. Any other resources that they can participate in and family, who's going to be helping them with them. And then finally, we have to talk about what's their condition on discharge. And include in there any anticipated post-discharge issues. And how are we going to intervene? There is some studies out there that, especially if you have a patient who did not have a complete suicide attempt, once they leave the inpatient environment, some studies show that potential for them to complete a suicide increases exponentially when they're gone home, they're out of that secure environment, that safe environment. Sometimes that rises if they don't have these support systems. There is not follow-up with them. Keep that in mind, depending, again, what is the person's ability to participate in those plans? Okay. Briefly on staffing, they really specify here, they're very sticky on staffing for behavioral health patients. Of course, we have to have adequate numbers and they have to be qualified. Not just the professional staff, but the supportive staff. If they support staff, sometimes they interact with the patient a lot more in-depth than a professional staff. There has to be written, comprehensive plans, and they have to be able to provide treatment measures. And they're engaged in a discharge planning. So no matter what level you are, they're very involved. The surveyors, they're not going to look strictly at your numbers. What they're looking for is not only structured sections in an unstructured situation, but really what they're saying here is, is somebody sitting with this patient just out in the lobby having that good interaction with them? And great, how are you going to organize that and make sure that gets documented and done? They will talk to patients, those who can, and staff. Did we get it timely? They'll look at records for the assessment. And they want to review any restraint and seclusion, incident reports, and specific to that restraint and or seclusion. Medication errors, did staffing contribute to any of those outcomes or those results? Overall, you have to employ or at least have adequate number of qualified staff. Whether it's professional, technical, consultative. So that you can evaluate them, prepare their plans, provide treatment and then help with the discharge planning. Active treatment measures. What that means is that they're receiving, the patients receiving interventions under the direction of a physician that's really applicable to them, their strengths, their disabilities. And we're giving it according to the standards of practice. It must be observable and evident in daily practice. It must be identified in documentation. Now the patient, they can direct their own activities if it's appropriate and that's for a period of time. The surveyor, it's very extensive by the way. I'm just listing out some key points here. Because when I mean it's extensive, this thing goes on for about a page and a half. Do you have enough staff? If they're absence, okay, you're missing staff, you got the flu going through, whatever it is. Did that impact patients getting active treatment? If patients are not involved, is it because staff had to attend to other duties? Is there regular review of your quality assessment data? Were there serious incidents on a particular day or shift? These are just some of the things you wanna look at. That's what the surveyor is gonna look at. And can the staff describe to the surveyor how what they do related to the patient's treatment objectives? Again, many, many more. I just wanted to hit some of the highlights. For your director of inpatient services, the services have to be under the supervision of a director, a service chief, the equivalent, however you identify them. They have to be qualified to give this leadership for intensive treatment programs because they're ultimately responsible for the care that's provided. So look at your QI programs, make sure that you're monitoring all patient care that's being provided and education for the staff. That's one thing this person also has to do. They have to provide education for all staff levels. As far as numbers, while numbers and qualified of the physicians, that's so we have enough psychiatric services. How many admits are you having? What's your hospital size? What's your proximity of the wards and units? What's the physician coverage on and off shifts? What about psychiatrists that can consult about medication regimens if you don't have a psychiatrist on there? And the physician to participate in planning and consultation on issues. The director, they have to meet training and experience requirements for board certification. They will review personnel files. Are you certified? American Board of Psychiatry. Do you have other equivalent training? Where'd you go to medical school? What's your residency? How long have you been employed? How long have you been at this position? And they're very specific when it comes time to the directors for the psychiatric units and hospitals. They had duties, they have to monitor and evaluate the care provided by all the psychiatrists. They will evaluate the care provided by all the staff. They will ask, what do you use to monitor and evaluate? Do you look at incident reports only? Any other quality improvement reports? How do you identify problems? How do you correct those problems? Do you have notes, reports that are provided to you as the director and medication? They wanna make sure we're using those appropriate. The physician, other personnel, professional personnel, they have to be able to provide other services. This could be a PA. Don't just rule out your advanced practice providers. Now, if you don't have medical surgical diagnostic services available, in other words, you don't have an X-ray, maybe lab services, you just have to have an agreement so that it's done. Maybe you need to transfer a patient to a general hospital for say an X-ray, CT, whatever it happens to be. Switching to nursing, you have to have a qualified director of psychiatric services. You have to have enough staff, that's RNs, LPNs, mental health workers, so that you can provide enough care based upon the patient's treatment plan. And keep your progress note. The surveyors want to see evidence of the orientation program. They wanna make sure there is continuing programs for LPN and mental health care workers. I see I have a typo on that page, excuse me for that. And also that you have a qualified director of nursing. This person has to be able to provide leadership, supervision of the whole department. Here's their qualifications. This is the director, the nursing director. Have to be an RN with master's degree. They have to come from an accredited school of nursing or they're qualified by education and experience in mental care. They will ask about what's your background. They will also, are you determining nursing assessments are being completed? Are they being evaluated by an RN? And personnel that relate, are they relating to the patient in a therapeutic manner? And I'm not a psychiatric nurse. And I must say that requires a really special talent by nurses to be able to relate to behavioral health patients in a therapeutic manner. That's what they're trying to find out. They also have to be able to demonstrate competence that they are participating in interdisciplinary plans, that they are giving skilled nursing care. They are directing and monitoring what care is being provided. They will ask your director, how did you put together your QAPI program? What did you do on orientation? What continuing ed are you giving to your personnel? Don't forget CPR and management of violence, workplace violence. Overall staffing, you have to make sure there is at least an RN available 24 seven. I'm going to point out, this is the same for any acute hospital. There must be an RN on site and available to provide care 24 seven. You also have to have enough staff, RNs, LPNs, mental health workers to provide care for that person. Here are just some of the considerations. Given the time, I'm not going to go through all of them, but just some considerations. How many suicide or assault patients do you have? We have to have, you know, some sometimes hefty personnel to help manage them. How many admissions are you having or discharges? Because that takes a lot of work going through that paperwork. What's your average length of stay? Do you have to use pool nurses? Okay, just have to make sure they're qualified to provide care. And then what's the availability of those nurses to intervene when necessary, interact and supervise? I'm going to talk about psychological services real briefly, it's very similar. The hospital, you have to be able to provide services to meet the needs of your patients and to be able to provide therapies according to what they need. This may mean participating in multidisciplinary conferences, or it may be individual. You have to have another full-time, part-time consultive psychologist to provide these services. Again, it can be contracted. Social services, very similar. You have to have a director of services to monitor and evaluate quality of those services that you are furnishing. And according to the scope of practice, these may mean doing intake screenings, psychological assessments on new admissions. What are the high-risk care for certain patients? Contact with family, advocacy, community liaison. The director of your social services has to have a master's degree. Again, or qualified, somebody who has experience in meeting these services. They're really looking for the master's. That's what they're really looking for. If they don't have it, then at least someone on the staff must have a master's degree. So if your director doesn't have that benefit, but is still highly qualified, then someone else has to have that master's level. The duties, the responsibilities, clearly identify those in your policy and procedures. Staff, they have to participate in planning, arrange for follow-up care, have a way so we can exchange information with outside sources. Maybe that's family services. Contact family with others as soon as possible after admission. Discharge planning follow-up based upon what their treatment plan and goals are. You also have to provide therapeutic activities so that we meet the needs of the patient. What they're trying to do, just like with swing beds, get them back to where they were, at least some functioning. You have to have a number of qualified therapists to make sure we're meeting those needs so that it's based upon their program. And then here's our final question. I'll go ahead and read it and then I'll have Lindsay put up the options. We have a Mason Hospital. They provide inpatient psychiatric care, adolescents and adults, usually those who are over 30 for adults. We have a patient, 17, admitted for paranoid delusional behavior, violent outburst. And given the degree of the behavior at home, the family said, not coming back here, not safe. So what does the hospital do now? Do they review the home situation? Look to any other, maybe there's another family member who can take CB, interim housing that can take this person, anything else that you can suggest to perhaps help with CB's support. They had younger kids at home and they were very, very concerned for the safety of those younger children with CB's violent outburst. This was a really very scary situation if that person did end up going home. And so I see Lindsay's put up the questions. Thank you. You can choose more than one and I'll turn it back to you, Lindsay, see if we have any more questions. Perfect. Thank you so much, Laura. I don't see any other pending questions at this time. I do see several folks still responding to the final discussion question here. So I'll give you just a couple of more seconds here to do that. And then if you do have any last minute questions related to the material that Laura presented today, please go ahead and be typing those into the Q&A. Or if you don't see that, you can of course type those into the chat. And while they're going through those- And while you are doing that, I'll go ahead and post them. Yep. Okay, go ahead. And then I do wanna just see if my computer's gonna work for me. There we go. The appendix, as I mentioned, I do include some of the sites here for you. There were some updates in the DSM update, the supplement to it. They did some text revisions and then the forms that identified. If you can't find it through the links, just go through CMS form, and that will pull it up for you. So I've got the forms 726 through 729 in there for you. That's what would happen when they come in and do the survey. Great way to do a gap analysis if that's what you're looking for. So Lindsay, I'll wait to see what were the responses for what poor Mason Hospital can do. Yeah. Yeah, I would review the home situation. Could be, that's a good one because maybe there's something else going on. Support system. Maybe there is another family member. Like those are all great ideas. Interim housing. You know, we do have the younger population who is facing unhoused situations. You know, 16, 15, 14 year olds who are living out on the streets. And that's, that's just scary because they're such a target. And so hopefully we could eventually get this person under control. They also did look at some of the youth services through the churches, see if there was any available resources that perhaps they knew of. Now the family wasn't ultra religious but there was a couple of the, one or two of the religious organizations that stepped up and says, you know, we can't help this person but we know of this one that could. And there was an option even to have CB go out of state to another long-term adolescent resident situation where it would have to be private pay but they felt perhaps in this situation it was the best for the patient given how bad it was. Unfortunately, it didn't turn out too well. They ended up being incarcerated because of a very violent act that they did happen. So unfortunately it didn't turn out the way they wanted. And so with that, Lindsay, I'm gonna go ahead and close. I'm finished. I will go ahead and see if there's any final questions. I will send the page number to you, Lindsay, in the manual that identifies what counts and what doesn't count for beds in swing bed counting. Okay. So that that individual, if they want that additional information, then go back and check it directly. Otherwise, thank you everyone. And I'll turn it back to you, Lindsay. Wonderful. Thank you so much, Laura. I did just post that additional information there for you all in the chat. If you have not joined us for a webinar previously, just note that you will receive an email tomorrow morning, and that does come from educationnoreplyatzoom.us. And so because it comes from that Zoom email address, they do seem to often get caught up in spam or possibly quarantine or junk folders. So if you don't see that in your inbox in the morning, I would suggest checking those additional folders. And then if you still don't see the email and you would like to go back and access the recording, you can always use the same Zoom link that you used to join us for the live presentation today to also access the recording. And then just remember that the recording will be available for 60 days. And we do have an additional security measure in place where you will just need to click on that Zoom link, type in your information, and that will prompt an email to come to us for approval. And then once you receive that email, we typically approve those requests very quickly, but we ask that you give us one business day to grant access to the recording. And then again, you'll have full access for 60 days from today's date. And then also included in that email will be a link to the slides that Laura presented today. But I did go ahead and provide that link there for you in the chat to have as a resource now as well. And then if you are joining us as a member of the Georgia Hospital Association, please pay also special attention to the link to the survey that will be included in that email tomorrow morning. And that link is where you will find the continuing education information. And then of course, obtain your certificate of attendance. If you're joining us as a member of a partner state hospital association, I encourage you to reach out to your contact with that association to obtain any further information regarding CEs from your state as well. And then if we can be of any further assistance or answer any questions that you have that we may not have gotten to today, please don't hesitate to reach out to us at education at gha.org. We'll be happy to get your questions over to Laura. And we're just so thankful for her being so thorough in her timely responses. And again, we thank you so much for joining us today. We hope you have a wonderful afternoon. Thank you always, Laura, for your time and the information that you shared with us. And we look forward to having you back with us soon. Have a great day. Thank you, Laura. Thank you, everyone.

patient safety

risk management

healthcare facilities

CMS regulations

swing bed services

psychiatric hospitals

training

surveys

compliance

patient rights

abuse reporting

discharge planning

assessments

staffing requirements

behavioral health issues