Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director, Facility, Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Judisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing, and she is licensed to practice law in Colorado and in California. Thank you so much for being here with us this morning, Laura, and we invite you to get us started. Okay. Thank you, Lindsay, and welcome, everyone. We're talking about two very specialized services that normally we don't cover during the routine programs throughout the conditions of participation because they are so specialized. And so that's nice that Georgia Hospital Association has provided this for you so that you do have that opportunity if you are a psychiatric hospital, have a unit, or if you provide swing bed services. I always include my reference here that my program today is strictly informational. It is not meant to serve as providing legal advice or establishing an attorney-client relationship. You will have to reach out to your own counsel, whether that's in-house counsel or other legal representative, to give you advice on any particular situation going on within your hospital. So just a really quick introduction on why we're here, that you don't get one of these, that when the state shows up, that they have found deficiencies where you have to do the plan of correction. And no facility wants to get noticed that they have been involuntarily terminated from the Medicare or Medicaid agreement. That usually is the result of multiple repeated deficiencies that aren't corrected, aren't corrected enough, the issue still persists, or that you didn't do any correction. That can also lead to it. The areas we're talking about today within the acute manual are here, number one, the psychiatric unit, what they talk about during that survey. There are more, there is more information as we go through here. I'm going to show you where you will find it in the manual. But starting with, I'm going to start with swing beds, because some of your hospitals now can't qualify in order to be certified to provide swing bed services. As of 2019, CMS did report that roughly 480 acute hospitals within the United States were providing swing bed services. That was 2019, that was pre-COVID. And they don't have those numbers out yet as of now, how many continued, how many still are providing those services, but it is available. By the way, I always include just a quick rundown of some of the deficiencies. I did mention, you know, you don't want to get that notice of deficiencies. As of December 23, there were only 38 deficiencies for acute hospitals on swing bed services. The most cited happened to be activities. And it was interesting, because in 2019, one of the changes CMS made was that they eliminated that requirement for that ongoing established activity programs for those who are in SYNGAPHS. So why that was the leader of the pack, there's no explanation. I'm going to go through here what you do have to provide for patients who are in swing bed. But I was surprised that was the leading deficiencies. Then the next happened to be dental services. Finally, as far as the deficiencies on their site, there's no real information on the basis for those deficiencies. They just listed, here's the swing bed deficiency. There wasn't an explanation as to why. So on the manual, now, what you're going to look for here is go to the bottom. This is the new manual from 2024. And it's way down there, provisions applying to psychiatric hospitals, and then special staff requirements. So we're going to go through all of those areas. And this is one area where they really, especially on staffing requirements, what they expect from you. And you'll notice on here, swing beds are not listed. It's not in there. But yet, they have them in the manual. So the actual listing for swing beds isn't there. But I'm going to show you where to find it. So for swing beds, that's what we're talking about first. It starts at tag 1500. Again, I'm going to back up a slide and show you it's not listed here. You won't see that here. But it's in the manual. And so that's why you have to abide by it. And so that's why they include it. It also references the long-term care manual. Because that's where all of this legislation, all of the rules, everything that you're expected to do and follow, that's where it's located in the long-term care manual. Because what you're doing is you are providing not acute services, but more long-term care services. This is a reimbursement term. It is not a location term. It's a reimbursement term and what you have to follow under those requirements. Lindsay mentioned we have a few questions. So I thought let's go ahead and start off right off the bat with this one. Lindsay, will you start us off, please? I sure will. Okay, hopefully you all now see this question on your screen that 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, Do swing beds are an option for Hospital R for increased revenue and census? 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 here. We'll give you just a couple of seconds. Put in your responses. And just for this question, I always want to start off, because I will explain the answer as we go through. It's not meant to trip you up or catch you on anything. It's just to get you started thinking about, Okay, what do we have in our facility? How many beds? What are we doing? Etc. Okay, we've gotten some varying responses here. Good. All right. And I think while you still put in responses, I'll give you just a second to do that. Okay. There we go. Okay. There are those. Okay. All right. So again, I just want to put this one out for you for just in case. So let's go ahead and start. There are a few changes, though. I do want to start off with back in 2019. It's called the hospital improvement rule. And what they meant to do is kind of decrease some of the redundancy and some of the things that simply didn't apply. And so I got to hand it to them, because that was a very in-depth program that they did to get this thing done. Well, we know that residents, that's how they refer to them. Residents, not necessarily patients, but residents. They can refuse or choose to perform services for the facility. They took out the requirement for that ongoing activity program based upon a comprehensive assessment. That's what I mentioned before. They took out the requirement that you had to employ a full-time social worker and that they took out the requirement they assist residents in getting that 24-hour dental care. Now, some of these were very specifically aimed to critical access hospitals, but they also would apply to you. So overall, if you're looking to do swing beds, or if you have them, you probably know this, you're going to be surveyed during an entire survey of the hospital if you have approval for swing beds. Now, the procedure, the survey procedures do reference Appendix T. It doesn't exist. Appendix T was deleted. So they refer you back to Appendix A. The regulations start at 1500. Here is different than what might be on your slides that you have access to. And that happens to be the page numbers in this updated manual. They are now start on page 414 and go through page 428. It is only the regulation. It is not the interpretive guidelines, nor the survey procedures. Those are in the long-term care manual. And no, there is no crosswalk. I will provide that during this program where it goes back to Appendix PP. By the way, those tag numbers start with the letter F, as in Frank. So here we want to start off with our requirements. First, the patient has to be an inpatient. They are swinging from getting acute care, reimbursement, and services to post-acute, skilled nursing. That's services and reimbursement. One thing they must have is a three-day qualifying stay for that same episode of illness. Now, they don't have to be at your hospital. They can come from a major facility that's across town, and you can take them in. But they do have to participate or be qualified as an acute hospital or critical access hospital. In other words, qualified under CMS. And this only applies to those Medicare beneficiaries who are asking for Medicare coverage for these services. If you have a patient who has Medicare Advantage, those requirements follow what the insurance plan says they have to have. So what we're talking about is traditional Medicare. As a facility, by the way, I include the tag numbers here in the upper right corner. They will always start with the letter A when it's in the acute manual. Number one, you have to have a Medicare provider agreement. You must be in what's considered a rural location. At that hospital, you don't have any waiver for nursing care 24 hours. That's in effect. You haven't had your approval terminated in the previous two years. Your regional office will determine that eligibility, and they're going to look at your Aspen file to make sure that, yes, indeed, you have not had that termination. And then you just meet all the conditions of participation on the bed count. So this goes back to that question. They look at that count during the survey, because what you have to have is fewer than 100 maintained beds. You may have a census of only 25. Great. But if you have 110 beds, as that one hospital did, you do not qualify. It has to be 100 maintained beds, less than 100 beds. What they count is your psych and rehab units. They will do observation, because that's part of your beds. And that's why the moon notice was created, because that's considered outpatient observation. Also, any nursing bed units, swing beds, they take this all into account. And that includes if you have any satellite locations. So if you have a remote or satellite location within your, say, 98-bed hospital, those beds are added into that count. But they don't count newborn beds, trans stretchers, those you have in your ICU, which can be a benefit. That may tip you over if you have five ICU beds, but you only have 96 hospital beds. So that does help. Those, they don't count. And then, of course, procedure tables, exam tables. Your swing beds, they don't have to be in a special location within your hospital. In fact, the patient doesn't even have to change beds if you don't want to. But what you do have to have, they have to be discharged from acute care and then go into swing bed. You can use the same record as long as services are very clearly delineated. Within that record. Now, you still have the old paper record to just put a divider in there. Well, now with our electronic records, there has to be some delineation to know the patient's now in swing bed, not acute. There's no length of stay restriction. This person can stay in there until they have the next level of care. It is intended to be transitional. It is. Because some of the rules that we're going to talk about, they may if they stay longer, say, than 30 days, there are certain things you have to do. And that's on discharge requirements and notice to them. But it is intended to only be transitional. You don't have to have any transfer agreement between a nursing home. You don't have to have that. And again, they specifically spell out. It is not skilled nursing nor nursing facility beds. This is just a swing bed service. You just have to abide by their rules. They made that delineation. I can't answer. It is an optional. You don't have to do this if you don't want to. There are certain limitations that you cannot use as a swing bed. Those that are considered to be inpatient prospective payment system, excluded rehab, separately certified in a co-located entity like another hospital. If you have inpatient hospice, you cannot use that bed for swing beds. Psychiatric hospitals are not allowed to have swing bed approval. Now, I want to just clear up something. If you have a unit, a psych unit, they count those beds. But you can't use those beds for swing beds. This applies to any patient going into the swing bed. And acute care hospitals, those requirements apply to you. What the surveyor is going to do, they're going to look at your open records. Because what they want to do is find out what kind of care is this patient getting? They'll do an environmental assessment. They want to make sure it follows all the requirements, a clean, safe environment. They'll talk to your patients who are in swing bed status. Because what they're going to try to find out is, what do you know about your rights as a swing bed patient? They're going to watch care being provided. Then they want to see your policy and procedures. If you don't have any swing beds, they will look at two closed records during their survey. On your services, the majority, actually the majority of the content within these regulations revolve around patient rights, rather than hands-on care. It's about the rights. And that's why you want to have appendix PP handy in your library. Because that's what they're going to look at are those requirements. It is a very long manual. If you have ever looked at it, your current manual is about 440 pages, 60 pages, 460 pages. The long-term care manual is over 900 pages. So this is the bulk of that. You have to give them a notice of their patient rights. If they're in your hospital, it's great because you can give it to them. Hey, we're going to be transferring you. Here's your patient rights. You have to give it in writing. And if possible, have them acknowledge that they've received it. Do you say it's like a sign-off when they get their HIPAA rights? You have them initial it. But keep in mind when you're giving them this information, this written information, don't forget low health literacy and limit English proficiency. So in other words, it has to be in their primary language. And use words they can understand. Look at that sixth grade level of education. One other thing they look at, and now you'll see this is a new tag number, F. This is in the long-term care manual. So if you happen to have someone who is looking at swing back, but they've determined to be incompetent, according to state law, we know then their representative steps into their shoes. And that's why we have to give them a copy of those rights also. If that person's decision-making is limited, then of course your resident, aka patient, and I'm just going to say resident for ease of understanding, they retain that right to make their decisions outside of that person's authority. So I'm going to take example. I have an older sister who we sometimes question her decision-making. So her daughter is her medical durable power of attorney. Now, they were always included. She was always included in any of the decisions that had to be made with my sister. My sister, though, retained the full right, based upon that medical power of attorney, to determine, am I going to have surgery? Am I not going to have surgery? But when it came time to other decisions, and they very clearly spelled this out, as far as where am I going to go live while I'm in the interim? Will I live with my daughter? Will I live independently? Then Carrie, the daughter, was able to make those decisions. And she was good enough. She did consult with my sister at that time. But that was very clearly spelled out. What was the limitation of that authority? Of course, we always have to take into account, what does that resident want? What's their preferences? When we're looking at the exercise of rights by the representative. So to the extent you can, because you may have those residents who've come in and out of competency, include them in that opportunity to participate in that care. So at least you have showed that you've done the best you can. If you're lucky to have all of those residents be competent, they just have to make sure they understand what's going on. What are the risks, the benefits, the alternatives? And to the degree practicable, what is their preference? What do they want to have done? Now, involvement of the representative doesn't relieve our duty to protect that resident's rights. And their interests. Yes, we want to include the representative. But remember, keep that resident's preferences in mind also. Otherwise, they have a right to be informed in a language they can understand in advance of any changes to their plan of career. They can request, refuse, or say, stop treatment. They can do that. They can also say, I'm not going to participate in research. I want to perform or formulate an advanced directive. They can do that. Now, one thing you see on here, again, these are the tag numbers. I've tried to do that cross-reference. So you can go to that tag number and look up what those certain or if any, interpretive guidelines are. They're really clear cut. They've tried to make them as clear with the rights. Resident can choose who takes care of them. That just has to be licensed and come to the facility. Now, if that physician doesn't meet the requirements for your facility, in other words, they're not privileged, they're not credentialed, whatever it happens to be, then help get an alternative physician that this is the person who they are privileged, they are credentialed, maybe that other physician doesn't want to do it, maybe they're of a certain age or distance that isn't practicable for them. And also, if it is another physician, the resident's not familiar with, make sure you have their name, specialty, and contact information, someone who's gonna be actually taken care of, because then the resident and or their representative can reach out and talk to them. We have to also tell the resident if their own choice isn't willing or able to come to your hospital, or meet the requirements for privileging and credentialing, that discuss an alternative physician, honor their preference if you can, the resident's preference, and if they do select another one, then honor that choice, whoever they select. Other rights, they can keep personal possessions as long as space permits, and how long are they going to be there? You may not wanna wheel a grand piano into their room if they're only gonna be there for 10 days. If both spouses consent, they can share a room, but both do have to consent. Give access to their family, other relatives, and of course, the resident can say, I don't wanna see him. Even though that person is pushing to come in and see him, the resident says, no, keep him out, you keep him out. And then others who come in to visit. Now, we always take into account, are there any concerns you have with that person coming in to visit that resident? Are they, are you concerned with maybe abuse, neglect, exploitation by that individual? Maybe this is a person who has a substance use disorder, and you have to take that into consideration. As always, of course, the resident can deny or withdraw their right to have that visitor come in. On your visitors, the surveyor is going to talk to the residents, those who come in and visit. Can they come in 24 seven? And then they'll look at your policy. They wanna see your written visitation policy, and under what circumstances would you restrict access to the patient? So you wanna make sure your policies clearly, to the extent you can, spell that out. In your policy. Other rights they can receive and send mail. And also those delivered to an outside postal service that it's brought in. Communication privacy, so if they're on the phone, don't stand there and hang over them and listen to that conversation. That means they have access to the phone, internet and stationery, postage, writing. Now, postage and stationery, they have to pay for that. You just make sure they have access to that, that postage and or stationery. On billing, and now this talks about Medicaid patients. Make sure that Medicaid eligible residents know in writing when they become eligible for that Medicaid. Also, what services or items are actually included in your services, in your fees. And those are the ones who cannot charge a resident, such as nutritional supplements. Anything else that you can charge and how much it would charge for those services. Like maybe getting your nails done or getting the hair washed by a beautician and having it done professionally. Otherwise, tell them when changes come along to those services that, okay, this had been covered, it is no longer covered. You have to inform this individual before or at the time of admission. If they're there for a long period of time, then go back and revisit it. Services available, what are the charges, those not covered under Medicare and Medicaid. The surveyor will look at records. They want some documentation, legal documentation, if there is a court appointed guardian or somebody keep an eye on this individual and their resources. And they'll also look to see if this person is involved, has been involved in the planning of their care. How is their care being provided? Are you providing some activities to keep this person active? What were their choices and preferences? They will look for documentation if there's a delegated representative. This can be verbal, that's just put into the record. Maybe you have it on your intake form. Is there a representative who is that person? Is it yes, no, and if so, yes, who? They will interview the person, the resident and or representative. What do you know about participating in your care? Were you invited to participate in development of your plan of care? They'll talk to your staff. How did you notify this individual of their rights and their preferences? And then a record review. Was there an assessment done on the resident? And that includes cultural preferences. Over to privacy and confidentiality. I talked about it somewhat about keeping the conversations private, but also just their general person. If they're taking a bath, close the curtain or the door, whatever it is, same if they're on the toilet, make sure there's privacy in that occurring. They mentioned only that staff who is authorized to be directly involved in the care is present when that resident is getting care, absent their consent. In other words, we close the door. Other requirements, that's the same, HIPAA, protected health information. The survey, again, is gonna watch the staff. Are they keeping an eye on this person's privacy? They'll talk to residents and representatives. Did the staff do so? Did they close the door when the physician came in and talked, if that's an option? They'll talk to the representative for the long-term care admin center also. Did the facility allow them access to the record of the resident? Of course, with their consent, if they were coming in to investigate a complaint. They'll look for signs, care information in rooms. Personal information is communicated in such that we're protecting their confidentiality. So they are really concerned about this. I was really surprised when they go out and talked to the admin center. So they do some outside checking along with what occurs within your facility. So I do wanna talk about now admission, transfer, and discharge. They clump this into one tag number in the acute manual. So physically leaving your facility, they're going away. And the purpose of this regulation was so that we don't dump high care need patients, that that is not occurring. It only applies, these rules that I'm gonna cover, it only applies when you initiate this transfer or discharge. Not when the resident says, I'm ready to go home, I'd like to leave now. Here's things you cannot do with discharge or transfer unless. So there's this caveat. You can do this if you have to meet their welfare. In other words, you can't take care of this patient in that facility. Maybe your facility doesn't have the ability for a Whirlpool and another one does. Maybe they just don't need these services anymore. It's time for them to go. Safety, where the resident or others would be endangered because of this person's behavior, whether it's clinical or behavioral. The health of others would be endangered. Maybe this person has TB and you have the setup that you can't take care of them. Then they haven't paid after they've given notice and given notice, hey, you need to pay up or you do close your facility, that you're shutting down and that's the end of the services. On transfers, the patient can appeal a transfer. And if that's the case, then you can't do it until while that appeal is pending, unless again, there's the endangerment. And you have to document what is that endangerment. Be specific in that endangerment. This patient is getting up and wandering to the point where we can't keep track of them with our staffing and the physical abilities of this patient that they're going into other people's rooms and they're physically harming them. They're stealing things. And that's why you have to have that specific documentation to include what did you do to try to take care of that patient? What is the basis of that transfer also? Again, the safety and health of others. Again, if you start this transfer or discharge, you have to send notice to the state admin. You as a hospital have to send it out to tell them we're transferring this patient and here's the basis of that transfer. Because then they want to come out and just they may come out and do an inspection or they may get ahold of the records, talk to the resident, whoever it is. And that brings me to question two, Lindsay. Okay, let's get this one up here on your screen. Okay, hopefully you now can all see this question that says that hospital C has 90 beds with swing bed certification. Their staffing issues have 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. Will hospital C be cited? Yes or no delay unavoidable with staffing challenge. A couple of seconds here. And if you have any questions for Laura, just as a reminder, go ahead and be typing those into the Q&A option there at the bottom of your Zoom window. Or if you don't see that, you can of course type in your questions into the chat and we'll make sure that we're addressing those as we go throughout the program today as well. Okay, we've got an unanimous response here. That's what I like. And on my screen, it comes up as yes, and you are absolutely correct. Yes, indeed, hospital C is gonna have a little bit of an issue. Staffing won't cut it. That's not an excuse. Documentation, so when you are sending this patient on, under any circumstance, doesn't matter why, make sure the information is in there and then we can send it on to the next person taking care of them. And it must include why are they being transferred or discharged, that you can't meet these needs even after you've tried, but that receiving hospital or facility can. And this has been documented by a physician. So keep in mind, these requirements have to be documented by the physician. What do you send off? Well, contact of who took care of them, who's responsible for their care at your facility. The representative's information, how do you get ahold of them? If there are advanced directives, please forward those. Care plan goals, instructions for care ongoing and the discharge summary. Yes, they have to have a discharge summary. So regardless of where they're going, going home to another facility, they still have to have that summary. Now there's certain notice you have to give to this resident. At the time of transfer, before, I'm sorry, before discharge or transfer. They say 30 days at least, okay? Why this is happening, when it goes into effect, where they're going, transferred or discharged. That we include the statement of their appeal rights and the phone number and the name, address and contact number for the state long-term care admin. That is also in the long-term care manual. That notice also has to have the statement of what are their appeal rights? Who does that? Who's to get this information? How do you get that form? And you may have to help them fill out that hearing request form in doing so. The name, address and phone number of the admin. And again, if the patient initiates discharge or transfer, you don't have to do this. Now there's one other thing. Again, if this person is there 30 days or longer, you know they're going to be there that long. You have to do this because swing bed again is to be transient. It was not intended to be longer than 30 days, but hey, sometimes that happens. You can't find a facility or they're just not ready for discharge and there's no place to put them. So they may stay there longer. So if it's a reasonable assumption that they're going to be there longer than 30 days, give them this notice. If something crops up during their swing bed and they end up with a reasonable probability they're going to stay, I would give them the notice. Even if it ends up only being 28 days, I would still give them that notice. Cover yourself in that respect. You don't want to have a surveyor going through and finding, wow, this was pretty close. Why didn't you do it? Just take that extra step to give them this notice. If you have those residents who have maybe intellectual developmental disabilities or mental health disorder, there are certain services, certain agencies within states that cover their rights also. So you may have to also give them that notice. So not only long-term care, but perhaps the agency for disabled adults, whatever it happens to be, the same contact. If you're going to close, try and give them as much notice in advance and help them get ready for this transfer or discharge. If you're just simply changing a room in a distinct part, keep them within that building, unless of course the resident agrees to the change. So you want to sit down and chat with them and say, hey, we're going to be repainting this entire segment. We're going to be redoing this entire wing. There is another wing that is open and the plan is to move you over there. So if the resident goes, okay, cool, good. I'm good with it. Then you're fine. The interpretive guidelines or procedure, they always reference CMS in the manual. They talk about appendix PP. So those are the tag numbers I've listed if you want to look at that. And then we get into something that it's a little sad that we have to put this in here, but freedom from abuse, neglect, and exploitation. Now, this is out of order. This particular tag number in your manual is out of order from what's in the interpretive guidelines and survey procedures and the actual regulation in the long-term care manual. But I did want to bring it up just to keep going in order for your acute manual. It follows the patient rights section. So that means we cannot use this abuse, whether it's physical, sexual, mental, verbal abuse toward any resident. We don't put them in restraint as a form of punishment. We don't put them in involuntary seclusion, again, as a form of punishment. We simply cannot do that. Restraints, both physical and chemical. And that's when it's used for convenience or disciplined, not to treat a symptom. If you do have to use those restraints, use the least restrictive for the shortest amount of time and document why you're having to use them. That may mean constant re-evaluations of that resident. This is a very long and descriptive section. It is very similar to the patient rights section that we talked about last week. That's in Appendix A. It is very, very similar. Or even employ any individual found guilty of abuse, neglect, exploitation, mistreatment, misappropriation of property, in short, theft. There is an entry in the Nurse Aid Registry. Some of your nursing boards will also have these entries that list those individuals who have been found guilty. A NOLA contendere, a plea of NOLA contendere is considered a guilty plea. So if they say, yeah, but I pled NOLA contendere, sorry, that's a guilty plea. So these are just my notes. Just, you don't have to do this. Look at your policies and procedures so that you include that information and that staff know what are the requirements for reporting abuse and neglect. That is through annual education. Give examples of what might be seen as abuse and neglect. Speaking of reporting, we do have to report to the Nurse Aid Registry or other licensing authority. If you have knowledge of a court action against that person, that would mean they're unfit to be a staff member. That could be, maybe they have, excuse me, been convicted of substance use, illicit substance abuse or use. Hey, that's not the person you want on your staff. Or they have a long past history of theft. That's, you know, again, just kind of take that into consideration. Something that might not make them fit to be taking care of people. Put them in your written policy and procedures so that we know that we're prohibiting not only mistreatment, but theft. How are you also going to investigate those allegations? Who's going to do it? What will be involved in it? What's going to happen to the staff member while this investigation is ongoing? On reporting abuse, of course, timely. You have no more than 24 hours after an allegation to report it. However, if it is serious bodily injury, you've got two hours to do that. You report to the administrator, your state survey agency and Adult Protective if that's within your jurisdiction. Now, if you have a minor, you might need to report to the Child Protective Services. That is where your in-house counsel needs to advise you on do we also report it to them? Have evidence that you have thoroughly investigated this. In other words, keep your documentation, keep it separate. Your risk manager or again, your in-house counsel, whoever that is, your legal representative, let them tell you where those need to be stored. Avoid any further mistreatment while this is occurring. Again, you may need to put that alleged perpetrator on another unit or put them on paid leave, whatever it is. You have, again, to report to the state survey agency within five working days. And if it is verified, take action. You have to do that. And again, they talk on there, the regulation refers to Appendix PP. I have the tag numbers for you there. Just here's some other notes from mine. Now, the definitions have been revised for abuse reporting. Again, administrative within 24 hours if no serious bodily injury, otherwise you have two hours. State law may have specific reporting requirements. I don't know those. You will have to check with your council. Have evidence, you've done your evaluation, your investigation. That may mean you have to go back and look at your policy and procedures again. By the way, make sure those who are in charge, charge nurses, a shift supervisor, your chief nursing officer, they need to know what those reporting requirements are. The surveyor may ask them during it. Have you ever had an incident of abuse? Well, yeah. Well, when did you report it? I don't know. That's what they're going to be asking those folks in charge. Let's move on to some a little bit more lively or lighthearted social services. Now again, that requirement to have that full-time employed qualified social worker does not apply, because that's for those who have 120 beds or more. You can't if you're going to be doing swing bed. And to do this, you have to at least provide something to keep these folks active, keep them alert, keep them engaged to maintain or attain some wellbeing, psychosocial. We don't want them sitting in their room, twiddling their thumbs all day. They need to be out and involved. So the requirement for this ongoing program was removed. But again, something for them to do, meet those needs, keep them involved, encourage that independence and interaction within the community. I always like to bring up my sister because she's kind of stubborn and she's a little older. She lives alone in this very remote farming community. And she had an incident where she had to go to some extended care. And it was wonderful because she was finally around other individuals, her own age group. And they were very good. They got her involved. They went out. She was in the area and she loved it. And so she eventually made the determination after she was ready to go back, I like being around people. It keeps me engaged. And we could even tell improvement in her attitude that she was much more engaged, talkative and just seemed happier. So that was the purpose behind this. Before we do anything, keep an eye on this comprehensive assessment because what you wanna do is find out what does this person need? What do they have? What abilities do they have to participate? So look at their actions. Incorporate maybe some of their hobbies. Get my sister played piano. She was a concert pianist. She was up for being a concert pianist. And so they got her involved in playing piano for the residents there. Maybe cultural preferences that you can incorporate to keep this wellbeing and independence going. On the discharge summary, again, when you anticipate it that they're gonna be leaving, what was the summary of their stay from their diagnosis to any lab results that came around? What was the final status? Medication reconciliation, including OTCs, please. That's been some areas that we found on readmissions that that wasn't done. And then what was their plan of care after they left your facility? Work with the resident, their family because they may be taking care of this person. Help them adjust to that new environment. Make sure the discharge summary is done when they leave swing bed and that a copy goes with them if they're going to another facility. Also indicate if you can't meet those needs that is a requirement when you send them off. Look at your charts. Do an audit to make sure that information is in the summary. Have a list of what you expect to see during this audit so that those who are doing it can have a reference and you might get some really good feedback on, hey, we're not seeing this being done that we need to go back. Discharge planning. We have to coordinate that assessment with our discharge planning. This is for those, by the way, it's called the PSAR, the pre-admission screening resident review process. This is usually from those who have mental disorders, intellectual disabilities, something related. You can incorporate it because it will help in your discharge planning and maybe prevent some duplicative testing that had to be done. You don't have to, but it's always good to coordinate your assessment in doing so. Document that you have that plan. It's been talked over with the resident and of course their representative and include any follow-up care that needs to be done. Medical, non-medical, where are they going? Are they going home? They're going to hospice, assisted living. Is there anything that needs to go with them? Because in June of 23, a memo came out from CMS where they found in some of these surveys, some of this stuff wasn't given, wasn't being done. And they found that those hospitals that did have a really good discharge planning process, the pre-admissions were cut down and things went much more smoother. We know we have to send them where it's applicable, that is it going home or is it going to go to a long-term care facility? And of course all the information has to go with them. What happened to this person? There were areas that weren't found. When they did these reviews, a lot of this stuff was missing and that's why those post-acute care providers couldn't take care of them. And so when they found that when we did include it, readmissions were back down. Adverse events post-discharge went down. Also, by the way, they included in this memo any accrediting organization there to be on alert for some of these common issues like joint commission, if you're deemed status. You have the discretion to, of course, develop your own policy and procedures to meet these areas and the requirements. There were six areas of concern. So you can see here, medications was leading the pack at number one. Durable medical equipment, was it there? Was it available? Was it put together? Was it functioning? Did they know how to use it? Then patient care, were there any skin tears that we needed to be aware of or breakdown in the skin like the start of it, acubitus? Communications with those caregivers, what did they need at home that wasn't done? Those who happened to have substance use or behavioral health issues, those weren't addressed. And then finally, just what was the patient's goals? What did they want to have done that wasn't addressed? So those were the six areas in your discharge planning you really want to pay attention to. Now, moving on to dental. Again, they took out the requirement that you had to help them get 24 hour routine because it's part of their overall care. If you've got a resident who has poor dentition, that's part of a routine care of a resident. So they took out the requirement, it was duplicative. They did mention it because it's still important. Medicare, you can still charge that resident for any dental services that have to happen, whether it's routine or an emergency. Have a policy so that if we lose their dentures or their partials, it's our responsibility. What are we going to do to take care of that patient and also make sure they're eating and that we don't charge the resident for that? If necessary, help them make appointments to get that outside care. Maybe that's transportation. If we've lost their dentures or damaged them to the point they're unusable, we have to get that resident over within three days. And if no referral within three days, then of course, in other words, they can't get in within the three days, keep an eye on what they're eating and drinking so that we make sure, yes, indeed, they are eating. Now on top of specialized rehab, these are the services that you, through your plan of care and your assessment, know they need this, PT, OT, speech. Maybe it's rehab for mental health disorders. You have to provide it internally, but you can contract for the services to come in. It does require an order and of course, make sure they are done by qualified personnel. Overall, the goals, and I've just included them here because that's the same tag number, help them maintain and restore their level of functioning for those with any intellectual or other medical disabilities. Make sure those services look at that PSAR to see what they actually need. The guidelines specifically mentioned restorative services. That is not specialized rehab services. And restorative, that's nursing interventions that help them adjust to living independently and as safely as possible. So again, that's not necessarily PT, restorative. Those are specialized services. So I'm gonna show you just a few resources before I now move on to site, but there is a worksheet and it does have the crosswalk for Appendix A and W. Use it if you're gonna do a gap analysis because some of the things in this worksheet were in those old regulations. They're still being assessed even though the tag numbers no longer exist. So just keep that in mind. If you wanna do a gap analysis, you'll see these are the old tag numbers, especially for critical access. They're still being assessed on them. There is also a fact sheet that is available on Swingbeds if you're considering it. It's under what's called the Medicare Learning Network. Talks about requirements, payments, and also references the Rural Health Office. So here's what that fact sheet would look like. And I always try to include the links there for you. Yes, you have to copy paste, sorry. And then just some other manuals for Swingbed. All right, before I move over to psychiatric, is there any questions, Lindsay, you would like me to answer or address? Yep, it looks like one has come in that says, I know that you talked about this a little bit earlier, but regarding the long-term care ombudsman, this is intended for those who are at a facility for 30 days or more and should be issued 30 days prior to the transfer. Yeah. Okay, so for the notice, again, this is when you as the hospital are transferring or discharging the patient. So if it comes along and say, hey, patient, we've done all we can, and say, yep, I'm ready to go home. You don't have to do that. This is when for that notice for the appeal rights in particular. So if they are there, I would say give it to them no matter what, because even if they're there for 15 days and the patient said, I'm not ready to go, I don't wanna go, you have to do it. You have to give them that information so they know with whom to file the appeal. Otherwise, if they're there or anticipated 30 days or longer, it's a done deal. Most hospitals now that I've talked to, especially the criticals, they say, you know what? We're just saving ourselves the headache and giving them this information so they know who they can contact if they so wish to. But if you are discharging and transferring, you do need to send the notice to the oddments that we're doing this, it's time for the patient to go. Perfect. And if you have additional questions after, or more specific, send them to Lindsey and she'll put them over to me. Absolutely. Great. Okay. Question coming from Morgan, just let me know if you have any additional questions. And another question asks, Laura, can bed alarms be used on swing bed patients? Oh, absolutely. Absolutely. No reason not to. Yep. Okay, I think that's it. Great. And actually that may help get the patient home sooner. Okay, I'm gonna switch over now to the behavioral health unit. These are the psychiatric hospitals and units within a hospital. You may not have one. So again, that's what this is referencing. So they used to have their own separate manual. They are now incorporated into Appendix A. So our third question, Lindsey. Okay, let's get this one up here on your screen. All right, this question says, our behavioral health hospital, and you can check all that apply here to your organization, 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. And this is just informational for me to try and get an idea how many of our facilities now have these options available. We know that it's becoming decreasingly available in a lot of states. In fact, one of ours on the Western Slope in Colorado, they had to close because of funding and a lot of the non-compliance with the conditions of participation that they were cited so many times, they lost their Medicare funding. Okay, we've gotten a good number of results here. Okay, all right. All patients grade across over 18. Okay, so yeah, we've got a good population here. That's very interesting. Okay, so here's where we're looking at Appendix A. Again, there is the survey model, whether it's a hospital or unit, and then the specific references below that were on page two. Now, there are a few tag numbers that do talk about specialized rehab services for psych that was tried to be covered under swing beds, like PT, OT, dental services. That's when you have that resident who is in your behavioral health unit who might need these specialized services. So just keep an eye on that. So psychiatric hospitals, separate survey information, and the regulations conditions, they start way down at the bottom at tag 1600. And that's page, by the way, that is now page 414, not 431. So I apologize. Again, I'm gonna get Lindsay the updated slides just so these new page numbers will be available to you if you'd like to see those. Deficiencies, only 40, 470 deficiencies. Now, I only say only, that does seem like a lot, but obviously behavioral health units are doing something right in that they don't have the massive numbers of deficiencies that a lot of the routine med-surg hospitals have. So they're doing something right in that respect. 1640, I'll talk about that. That had the most of all 470 of only 73. So on the survey team, they just don't let any survey team come in and do these. They want these individuals to have expertise. At least masters prepared psychiatric nurse are in with inpatient care experience. So they want somebody who knows what to look at and what is deemed to be good care. The focus on this whole survey is the outcome experience of the patient. How did you implement that plan of care to meet these? The surveyor has seven jobs. They'll look at a sample of patients and review their records. They'll do other record reviews in addition to it. They'll watch care being provided. They will talk to patients and staff. They'll go visit the units. And then they'll also look at a team assessment on your units. When a hospital has a unit, they're gonna follow the same survey process. It will count as annual validation compliance with a hospital self-attestation when you have excluded units. And that exclusion, that's a reimbursement term. They're reimbursed at a psychiatric unit rate versus the hospital rate. And that is a per day versus a per cost. So that's what they're talking about. So again, in determining compliance, the surveyor is supposed to be an RN. They will look at 10% of the units, average daily census, a minimum of two patients. If you don't have any, they're gonna go back six months and look at your closed records. It should be conducted when they're doing your hospital survey. And there's a form 437 to verify if the requirements are met. There are other forms. I have these links in the appendix for you. 437, I mentioned that. What is the worksheet, the data sheet, other optional forms that they will have that you might wanna download and have available. So overall, your main job, primarily engaged in providing psychiatric service. That's for diagnosis and treatment. It has to be under the supervision of a physician, an MD or a DO. They meet all of the requirements of Appendix A except medical records. You have your own specialized section for medical record. And I'm gonna cover that as I go through here. For criticals, and I'm only bringing this up because if you happen to have a critical access hospital in your system, and they have a dedicated unit for behavioral health, they are surveyed under A, not W. So keep that in mind. For records and staffing, of course, we keep a record for all patients and you have to meet staffing requirements. The medical records, so here it is. The records have to show that what you're doing is providing to the degree and intensity of those treatment for those who are getting care in your institution. It has to have information of why are they there? Why were they admitted? And the treatment, what were the goals of that treatment? How did they improve? Or maybe a change in status. Maybe they didn't improve, maybe they slid back a bit. Always include discharge planning, just like with any other patient. Follow-up and outcomes. And follow-up is the follow-up of the treatment. Outcomes that this person experienced from their stay. There has to be enough in there so that you know the status of this patient, that you have a way to intervene if you need to. Enough evidence for the effectiveness of that intervention. Is it working? Because that's going to serve as a function of the outcomes experience. You have to be able to identify through interviews with staff, and maybe patients and observation in what they're hearing. So here's an example, just as an FYI. What did you find, the mental status, what were their diagnoses? Maybe got some test results, don't forget that. We may have to do some clinical test results for them. The records have to have a psychiatric component to that assessment. And any history of findings, what treatment was provided. So here's just an example. We have a patient admitted for paranoid ideation. C-I-A implanted a chip in my neck to track me. They know I have special powers. They're trying to follow me and what I do. Now this patient, needless to say, they found has a very long history of paranoia. Began about age six, according to his mother. So the treatment will include, and then what is your treatment going to include? So that's the assessment data. That's kind of what they're looking for. And by the way, this was an actual patient that I was working with the hospital on. What do we have to document in here on this? And they took his word, his verbatim words, on what he said was going on. We have to include their legal status according to what your state statute spells out. In other words, when can they be treated or admitted involuntarily? Maybe court committal, how long? What do you have to do for an evaluation and recertification according to those requirements to keep them inpatient? They will talk to staff. What does that terminology mean? What is their legal status? They're here voluntarily, they're here involuntarily. Is there documentation to support that status? Have there been any changes in that legal status? And when did that occur? You know, they may have been there voluntarily, but during their stay and getting ready for discharge, there were some events going on, interpersonal events, maybe between family and this patient that the family said he's not safe to come home or she's not there yet to come home. And they had to go and get involuntary admission to that status. Of course, everyone has to have a diagnosis, a provisional or admitting diagnosis. That's on admission. And any incurrent diseases, like do they have diabetes, high blood pressure, anything else that goes along with it. The guidelines will refer to professional resources. They don't do that. They leave it to you folks, those with the expertise in the field. American Psychiatric Association or the DSM manual, international classification of disease as ICD numbers. The diagnosis is made and put into each record at the time of admission. And we know that could change, be a completely different diagnosis at the time of discharge based upon what is your evaluation observation say. If there is no diagnosis, there has to be some justification for why there isn't one. Maybe they were so psychotic on admission, no one was there to help, which could help confer what was going on at the time of admission. Intercurtain, in other words, other than psychiatric, they have to be documented. The surveyors are directed to pay attention to the physical exam. Is it reflected in that also the diagnosis and the documentation, allergies, substance use? Maybe there's a lab test with an abnormal result, no medical conditions. Diagnostic categories, they should always include when a physical illness is a common with that admission. But of course we have to document why is the person there clearly documented, whether it's stated by the patient or whoever brought them in. Because that's going to give us the understanding of why they came to the hospital and how are they going to respond to admission. Maybe here you've got that patient, I don't want to end my life, my family would be better off without me. And your diagnosis and your documentation shows that there are visible healing scars on their arms or legs that were perhaps as a result of intentional self-cutting. Or the family, we're concerned, this person hasn't eaten, they won't leave their room. And they've had a 20 pound weight loss in two weeks, not two months, but two weeks. You want to record, of course, anything the person or those around them say as far as admission. Verbatim is best, they know that. We have to identify who is making that statement and include those in various areas of the record. Avoid any ill-defined reports of unknown source. Well, they seem depressed, or their cousin told me that they seem depressed. That's not going to do it. They need something of more substantial definition or description of this person. The who, the what, the where, the why, the when. That's what they're looking for. The surveyor is going to look for, well, first off, can the patient describe what's going on with you? What happened before hospitalization? I was under a lot of stress at work, or there were a lot of things happening in my life. Do they still exist? Who is the informant? Who's giving the information to these care providers? Did this informant actually witness those behaviors? If no, then how did they know this occurred? Has a staff elicited that behavior or similar behavior? Okay, what was different? What was different that led to the hospitalization? Has there been any change in their medication? Because that may have been a huge factor in that hospitalization. Oh, the medication really caused me to be very tired, so I stopped taking it. Any other events that's going on that might have contributed? Loss of job, loss of home, a death of someone close. So that's what their surveyor is going to look for. How about I switch over to social service records? That's the next one in line. Here you have to have social service records. That's an assessment of what the home plans are. Is there family around? How do they feel about this person coming back? Are there any other resources within the community? What's their social history? Have they been actively employed? Are there hobbies that this person participates in? And of course, we learn that from the patient, the family, friends, or visitors who come in and see them. So the assessment, this is what, on admission, it's a baseline for their social functioning. What are their strengths? Where do they need help? And that's how we then plan our interventions. Length of stay is a key factor in that documentation, like the completion timeframe, filling out that assessment and the plan of care in the record. Each patient has to have a completed psychosocial history and assessment. There are three components of this. Number one, what is the factual and history information that you're being given? There are nine components to it. The reason for admission, what is their past and present biopsychosocial functioning, any other history, family, marital history, significant others, religious or cultural factors, any issues of abuse, whether it's physical, emotional, or sexual. These are just still that component of their historical background. Others, significant aspects of their medical, psychological, substance abuse history, education, vocation, employment, or military history, identification of those resources. What have you used in your community to get you through this? Any other environmental and financial needs. So that's just the first component. The second major component is in the social evaluation. There are two segments to this. What are their strengths and weaknesses or deficits? And what are the issues that require, hey, we got to get on this now, early treatment and planning. Maybe there's kids at home or an elderly individual, at home that could affect them. Have they been compliant with these treatments? Are there any obstacles to the current treatment or discharge planning that's taking care, that's impacting it? And then thirdly, any conclusions, recommendations. So really what you find out in part one and two will help you develop this one. And there are four components, any necessary steps for discharge that you anticipate that have to occur. Do you have a high risk issues coming up, whether it's family or patient that have to have early treatment and discharge planning, regardless of how long they've been there. Community resources and what is the role of the social worker and social work and the treatment and discharge planning. The survey procedure, they look a lot at the assessment. Is there a clear indication of who gave you this information? Where did it come from? Is it considered reliable? You know, if you have a past behavioral health provider, you can pretty much guarantee they're gonna be fairly, very reliable. But you have a family member, maybe they didn't get along with this family member. There's some dynamics going on. Is that person really reliable? Did the patient participate to what they can in giving the data and also helping with discharge planning? Integration of this data, including any high risk issues that came into the treatment plan. And how did you make sure the information was reliable? What did you do to make sure it was there? So let's say you just have a friend or family member that was at home, got into an argument with this person. Can you substantiate that conversation or that interaction to make sure, yes, indeed, that was a reliable source of information. We also have to do a neuro exam. That cannot be admitted. When it is indicated, that must be done at the time of admission and when you do your physical exam. They should have a thorough course history in physical and in the labs that went along with it. So maybe there's structure or some functional or metabolic disorder going on that could contribute it. So that's why our thorough history is so critical. Any disorders, head trauma, other accidents, maybe there was a history of severe headaches or seizures. A toxic agent, any past history of tumors, infections. I would also include in here as far as any traumas, PTSD. Did this person have any other traumas that could have elicit what's going on right now with the person? Because what this has done is to help that physician look at any contributing pathology outside of a psychiatric disorder. And are there other signs of illnesses that are getting worse? It could just be related to substance use or just an underlying medical condition. So they understand as far as a screening exam, the neuroscreening exam, there's no definition. So at least CMS recognizes that. Do that gross function of your central nervous system, like actual testing of cranial nerves through 12. Make sure that's included. To simply say cranial nerves two through 12 intact, that's not acceptable. They need to see various areas of that exam, not just thrown in together. And if anything comes up positive, then yes, you have to do more detailed examination. That may be a consultation to a neurologist to make sure what's going on. The comprehensive exam. The neuro exam includes a look at their history, the physical exam, and a review of their psychiatric evaluation. It's a very detailed orderly survey of the sections of the nervous system. So here's an example of what a complete neuro exam might have. The site they might test for visual acuity, fundoscopy, a motor one, what's the muscle groups, arms and legs, everything's still strength is the same. Smaller muscles, you can test that, like can they grip your hand? So that's part of it. The psychiatric evaluation, now we're getting into some of the meat of it. We always have to have one because what we're trying to do is get a diagnosis and treatment plan identified and started because that's what you have to justify. Why are they there and the treatment they're getting? It is a total appraisal of their illness. And it's a physician assessment of contributing factors and forces in the evolution. It includes patient, what do you think's going on? What is your perception of what your illness happens to be? So during this, the physician is trying to get enough history of this patient's personality to determine what's going on with the goal to see them as an entire dynamic person. They have a past, they have a present and a potential future and that there's some logical continuity to this individual. Here are the items that are covered when they're doing this evaluation so they get an understanding of the interplay, their personality structure, what's their basic personality structure, their development period, where are they? Are they consistent? Is this 20-year-old consistent with what you would see with another 20-year-old in their development? What is their value system? Any past medical history, surgeries, procedures, traumas, psychological traumas, how they supported themselves, what is their defense mechanism in handling these issues? Support systems, who's out there to help them? And any precipitating factors that might've led to this. Did they observe an event that might trigger their response? Enough information to justify their diagnosis and treatment. There has to be a physician signature. Where the mental status part is done by a non-physician, they can do that. You can have others participate in this evaluation or their status. Evidence that they're, of course, credentialed. They're legally authorized to do it. And if required by the state and your own policy, the physician reviews and countersigns it. You're talking your advanced practice providers here, your PAs, your nurse practitioners. In the survey, they wanna look at the record. Is the chief complaint and the reaction documented? In their own words, of course, if possible. Why are they there? Was it their own idea? Are they there involuntarily? And who decided it and why? Was it court or was it their parent that said, they're 15 and they're out of control and this is what they're doing? Who made that decision? Is there any history of past psychiatric illnesses and treatment or is it chronically ill? The surveyor wants to know also how severe is this patient? Did treatment interfere with their development or adjustment? Is there anything persistent going on that maybe can be addressed for a better outcome? What's their social and family history? Social means educational level. Are they employed? What kind of jobs have they held? Do they get along with others? Do they have friends? Is there anyone else they can interact with? So here's our third question. Lindsay, I'll leave it up to you if you feel we have enough time. I believe we do. We have about only 40 more pages so I can get through those in the next 15 minutes. No problem, I'll go ahead and put this one up here on the screen. And so this says that 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 who are not licensed or certified psychiatric technicians. As a result, admission assessments have been delayed for up to four days and were completed by those technicians. So will Creekside be cited here? No, it is an unavoidable staffing issue. Yes, the assessment is not timely or possibly. And if you do have any questions for Laura as we're getting a little bit closer to the end of the presentation, make sure that you are putting those into the Q&A or the chat and we'll make sure that we're addressing those as well. Okay, I see a pretty unanimous response here. I'll go ahead and end that one and share those results. Perfect, yes. Yes, everybody who said yes, you're right. They're gonna be cited. Here's the evaluation requirements. 60 hours of admission. It has to be done within that timeframe. And that includes a medical history of any disabilities, the treatment, past surgeries, and did that contribute to what's going on with this individual? A record of their mental status, a description of how do they look? What's their appearance, their behavior? Are they crying? Can they communicate with you? What's their thought content? Does it follow or track or are they shooting off to various areas? Cognition. In other words, do they seem with it? Here's an example. Now, this is just an example. During the interview, they stated the name, accurately described their history. However, they believe their pre-admission insomnia, anorexia, 35 pound weight loss over four months is due to because I was sexually promiscuous 15 years ago. Nothing to do, no, no, my daily amphetamine use, not a note as it doesn't contribute. So that's an example of what they wanna see. Do they have a good perception and an understanding of what's going on with them? We also have to include when did this illness start and what led to it? The surveyor will ask how long has this patient been ill? Was it a gradual or just an all of a sudden trip? They said an onset. Is it a recurring issue? Were there precipitating factors? What were their signs or behavior that made hospitalization necessary? Any medication that they have? What were their attitudes? How were their behaviors? Was there a change that maybe this patient needs a more restrictive or less restrictive environment? That could be difficulties in relationships, those that require active treatment so that we can get them back to that level of functioning. An estimate of their intellectual function, memory, and orientation. And then an assessment of their own assets, indescriptive and not interpretive. This is their personal factors that you can use to help them take care of themselves essentially. What are their strengths? In other words, what is their interest, their skills, their aptitudes, their talents? Perhaps they have a special talent. And it's not enough to say, well, they have youth on their side or they're on social security income. They have a car. You can include that, but that is not what they're looking for in these elements. That's just, that's an aside. What they're looking for, what can they do? They can carry on a conversation. They can make change. They can carry on their own financial businesses, et cetera. Of course, every patient has to have an individualized treatment plan that's based upon their strengths and their disabilities. It's an outline of what you're going to do. This is your commitment to take care of this patient. And you decide the format, any updates that need to happen. The surveyor is going to probably sit in on your staff meetings and your meetings with the patient in various settings, whether it's group setting. They'll talk to the patient, the family, those who are involved in their care. They will look at that treatment program. What is the schedule of that? And any multidisciplinary planning meetings, of course, they'll look at the records. The idea here is they want, has all this information that you've collected, has that been used to create that individualized plan? They're also going to look to see if there's periodic reviews of this patient. How are they progressing? Are they meeting their goals? It has to justify continuing goals and approaches and going back and visiting the plan again. Intervals between it, that's up to you. How often are you going to go back and reevaluate the plan? Because are you really meeting their goals? Has the patient progressed or regressed? And maybe you need to look at more aggressive needs. In other words, more team meetings, more plans, more goal meetings. There are five written plan requirements. Substantiated diagnosis, that has to be documented. Rule out alone is not enough. Data to substantiate, the treatment plan identifies and precisely describes the problem behaviors, alteration in thought processes. That's what they're, you know, something like that. Not they're depressed. No, they need more. Number two, short and long term goals. What are the dates that you want them to meet this? Both have to be stated as expected for outcomes related to the problems that you've identified and written as observable and measurable. And you can include discharge criteria as one of your long goals. So that's short and long term. Number three, treatment modalities. What did you do for this patient? These are all active treatment measures. Who and what provided them? What was the focus of the treatment? And specifically describe so we can have consistency in the approach. This is what we did for this patient. Naming modalities, group or individual therapy is not enough. Or approaches, we're going to set limits, encourage socialization. They, CMS does not find that to be enough information on what you want in that plan. The patient will interact with their care provider at least 30 minutes every other hour, something specific as to that. And then of course, we have to make sure that we have enough qualified staff, that they're following those methods and approaches and taking care of these patients. Can the staff explain why you are doing that modality? What do you expect to get out of it? Are treatment methods from all disciplines in the plan? Is the patient included in that planning? How did they get to know their regimen? There's a lot that goes into covering this. There's a lot of those requirements. So I just wanted to include the survey for those three. But there's still a couple more plan requirements, two more in fact. Number four, each member of the team has to have their responsibility in that plan. There's no correct number, that's up to you. The disciplines, that depends on what you're trying to treat. And each person on that team is responsible for compliance with that aspect. They have to record in a way so that we know who did it and what did they do. And that may be including patient and family in that. Now they don't have to document, but again, those who are responsible on your team and the staff have to document it. And then number five, finally, enough documentation to justify the diagnosis and treatment. The notes have to have something that relates, can show the treatment plan. The surveyor will look at your notes. And do they show the patient responses? And do they also relate to a specific program or their progress? Treatment included has to document everything they've done actively. It's a record of care you provide and a chronological picture of their progress. We have to document their progress. Whether it's the physician, the psychologist, anybody else licensed, social worker, those who are significantly involved in treatment modalities. So pretty much those who are involved in the care have to document. The guidelines, what they're looking for is a chronological picture of this progress or lack. It's not enough to say, well, they slept okay. No complaints. Frequency alone doesn't determine the adequacy, the frequency. It's what's in it. And then date it, of course, signed. Surveyor is going to look for that documentation of progress notes by the physicians. They also want to make sure the notes give a clear picture of this progress or lack. Nurses, those who are significantly involved, are they documenting the progress? Same for others, like rehab, social work. The frequency is determined by the condition. They do note weekly for the first few months of admission and then monthly and include any recommendations for revisions. What is the precise assessment of that progress that you are looking at from where they came until they are now? Of course, we have to do discharge planning for each patient. And that's part of the planning anyway. What are the alternatives to treatment and what goals were met through that plan? They talk about a service recommendation, discharge summary, follow up and after care. What's going to happen with this patient when they leave your secure location? Medical, physical, any appointment dates, community or housing, where are they going to end up back on the street? Or is there some interval housing they can go to? What resources are available to them? How about their financial status, family, significant others who will be involved in that? And then, of course, what is their condition on discharge? That has to be in there. Any problems you anticipate and then intervention for that. Is there a support system? Do you have that hotline number that they can call if they get into trouble? You don't have to have one, but give them the number of the local one. I do want to talk staffing because they're very specific on their staffing requirements. You have to have enough of qualified professional and supportive staff to not only evaluate and prepare plans and carry out the measures, but also to take care of the patient. The surveyor is just not going to look at numbers. They're looking for that structured sessions in unstructured settings so that these resources are available. They'll talk to patients and staff. Were they able to get these services timely? Yes, they look at the records. They also look for any records of restraint and seclusion, incident reports surrounding them, any medication errors. Did the staffing levels contribute to those? As with anything, you employ or have enough adequate numbers of qualified personnel to evaluate, do the plan, provide the treatment, and engage in discharge planning. Active treatment, this is when they actually get those interventions. These are under the direction of a physician specific to what the patient needs. That has to be observable and evident in daily practice and in your documentation. Now, the patient can direct their own activities if it's appropriate. They can do that. This survey is a very long procedure. Here's just some of the key areas. Did you have enough staff to meet the needs? In absences, what did that prevent the patient from getting the care they needed? Those patients not engaged, were they there while the staff had to do administrative tasks? In other words, did the patient's care lack because of other duties from this person? They'll look at quality improvement, quality assessment data, any serious incidents, and can the staff describe how their activities relate to the treatment objectives? This is some of the other staffing requirements. Inpatient psychiatric services must be under the direction, supervision of a director, a service chief, or something of the equivalent, somebody who's qualified to give leadership that's required for such an intensive program. The ultimate responsibility should be determined through your QI programs and also any education programs for all staff. If your QI program has identified some laxes in your restraint and seclusion, what you have to do, that's what your education programs have to come into play. The numbers and qualifications of your physicians have to be enough to give basic essential services. How many admins do you have? How many discharge? How many patients are currently on there? How big are you? What's your proximity to other units? Physician coverage when they're off. Psychiatrists to consult about medication regimens. Maybe you don't have an actual psychiatrist who is giving this care, but a psychiatrist to consult. Maybe another physician to participate in planning and consultation. The director has to have training and expertise for board certification, and they're going to look at their folder, or they'll actually talk to the director. Are they certified to the American Board of Psychiatry? Any other equivalent training? Where do they go to med school? What about their residency? How long have they been there? What is their position? The director has to monitor and evaluate the care that is being provided by the medical staff. They will ask, okay, what mechanisms are you using to determine this? Are you looking at incident reports? QI reports? How do you discover and take care of problems? Are there service notes? Are they done timely? And medications, are they appropriate for that diagnosis? You have to have enough medical personnel, whether it's a physician or advanced practice providers, to give any medical surgical diagnostic treatment. Now, this is usually above and beyond your psychiatrist. If you have these services, or don't have these services available, excuse me, you have to have something in agreement with an outside source to make sure they're immediately available. Like, let's say you're strictly an emergency psychiatric hospital. What if this patient develops, say, a hot appendix? Well, you have to get them to a hospital that can provide that surgical intervention to them. Nursing. You have to have a qualified director of nursing psychiatric services, and then an adequate number of other services, whether it's an RN, LPN, or mental health workers. These are the folks providing actual nursing care based upon the program. The surveyors want to see evidence of an orientation program for your nursing staff, ongoing education, and also, they will confirm there's a qualified director. This person provides leadership and supervision of the department. This is for the nursing director's qualifications. RN with a master's in psychiatric, or an equivalent from an accredited school of nursing, and they either qualify by education experience in mental health, and they'll ask about their educational background. They will determine if nursing assessments are done on all patients, it's evaluated by an RN, and the personnel relating to patients therapeutically, is that being done? They have to demonstrate competency to participate in interdisciplinary formulation of the plan, give skilled nursing care and therapy, direct monitor and evaluation of nursing care by others. They will ask this director about the implementation of their QAPI program. Yes, they have to participate. What did they do for orientation and continuing ed? That could be CPR. Of course, you have to make sure there's an RN available 24-7, and then enough of other staffs that may be, again, RNs, LPNs, or other qualified mental health workers, because they have to be able to provide that care. Here's just some staffing considerations in the interest of time. I'm not going to go through all of these, but what are you providing? What's your length of stay? How sick are your patients? How many are suicidal? Are you using restraints and seclusion? These are just some of the considerations. For those of you just listening, that happens to be slide 160. Then just briefly on psychological services, you have to provide or have available to meet the needs of the patient. That means testing and formulations of a plan. That could be multidisciplinary treatment. You have to have a full-time, part-time, consulting psychologist to provide these services. You can do it by employing them, or you can do it by contract. You have to have social services and a director. This person monitors and evaluates the quality of social services provided according to standards of practice. These functions may include intake and admission screening, those psychosocial assessments, high social risk care factors that are there, contact with family and others, advocacy, community liaisons, so that when this person leaves, what's out there for them? They have to have a master's from an accredited school social worker or be qualified through education and experience in social services of the mentally ill. If the director doesn't have a master's, at least someone on staff must. They're very serious about this. If it's not master's trained social, somebody who's on staff has to have that master's level. These duties and responsibilities must be clearly documented in the policy and procedures. The staff has to participate in discharge planning, arrange for follow-up care, have a way to exchange information with those outside resources, contact with the family and others as soon as possible, discharge planning and follow-up based upon what their treatment goals are, and then, of course, a therapeutic activities program. So, just like almost swing beds, something that meets the needs and interests of the patient. It's trying to get them back to that optimal level of functioning. That means we have enough qualified therapists and personnel to take care of these folks. So, I know we're a little bit over. I'll leave it up to you, Lindsay, if you want me to go through this. Otherwise, we can go ahead and close it out, and I'll take any follow-up questions. I think you have time to go ahead and go through this real quickly. Okay. We got a hospital. They provide inpatient psychiatric care. This is to adolescents and adults under the age of 30. That's a really focused area. So, we have a patient, 17, admitted for paranoid delusional behavior, very violent outburst. Given the degree of their behavior, the family refuses to have this person come back home. So, we don't, nope, can't come back home. We've got too many others at home, too much of a danger of threat. What do they do? What do they do now? Do they look at the home situation? Look at any other family members that maybe can take this person? Maybe interim housing? Anything else that you could offer up to them that perhaps could help when CB is ready to go home? Eventually, this patient will go home, but not right now. And again, the home, they don't want her back. What can they do? Because these are events that could come up. They were not declared to be emancipated. And so, while you're thinking about your options, I think if I flip through the slides, I should still be able to see them, Lindsay. Okay. So, just a couple resources. I have roughly only 15 pages of them. The memos that I did mention, I did put in here how you can access the deficiencies if you are interested. And by the way, that's what one looks like. When you open up that Excel document, that's what it looks like. Otherwise, just some of your professionals, like the APA website, and then the updates talk about that DSMR. That form 437, I wanted to include that unit criteria worksheet if you were interested in having it. So, just some of those other forms. I did a screenshot of what they did look like. So, with that, what can we do for Mason Hospital? There are those results. Okay. Oh, there we go. Support, yeah, the other family, interim housing, that's essentially what they ended up doing for her, trying to find some interim housing for her. She was inpatient for a very long period of time, given her outburst and her behavior, how they were trying to get her refigured. And part of the problem was she was very noncompliant in her medication regimen. And so, that's where they were having, you know, as long as she was very committed to her medication, she was okay. She was functioning. She could keep a very part-time job. She ended up going on disability because otherwise she couldn't function. And there was nowhere else for her to stay. So, they were able to, they did eventually, unfortunately, lose track of her. So, they never did find out. I mean, this was sometime after, but they did lose track of her. She was stable, did go to the interim, but then they found out, I don't know how many years after that, but they did lose track of where she ended up. So, Lindsay, thank you for everyone. Thank you for your understanding. I think I went over a bit. And again, if you have a question, please get those to Lindsay and she'll get them over to me and I'll respond back. Yes, absolutely. Thank you so much, Laura. I did just post some final comments there for you all in the chat. Just a reminder that you should receive an email tomorrow morning, but just note that it will come from educationnoreplyatzoom.us. And so, because it comes from that Zoom email domain, it very well may get caught in your spam or your quarantine folder. So, if you don't see it in your inbox in the morning, first, I would encourage you just to check those additional folders. But if it's still not there and you'd like to access the recording of today's session, you can utilize the same Zoom link that you used to join us for the live presentation today to also go back and access that recording. And just remember that the recording is available via Zoom for 60 days from today's date. And when you click on that Zoom link, it will ask you to enter your information. That will prompt an email to come to us for approval of that recording access request. We typically do approve those requests very quickly, but we ask that you just give us one business day to grant those approvals. And then if you are a member of the Georgia Hospital Association, please do pay special attention to that final link that will be in that email tomorrow morning. That will be a link that will take you to the new GHA Learning Academy, where you'll log in using your GHA website credentials. And that will give you full access to the course today, including the slides, the recording, and a link to the evaluation, where you may obtain your certificate of attendance and other continuing education credit information. And if you're joining us as a member of a partner state hospital association, I encourage you to reach out to your contact within your association to obtain any information that they have for you regarding continuing education credits as well. And as Laura mentioned, if you do have any follow-up questions, don't hesitate to reach out to us at education at gha.org. And I'm happy to get those questions over to Laura and then follow back up with you with her response as well. Okay, I don't see any pending questions at this time. Laura, thank you so much as always for your time and information that you shared with us. I hope you all have a wonderful afternoon. We look forward to having you back with us for future sessions. Thank you, Laura. Thank you, everyone. Thank you, Lindsay.

Laura Dixon

healthcare professional

acute care facilities

psychiatric units

swing bed services

compliance

Medicare

Medicaid

patient management

regulatory compliance

patient safety

risk management

specialized training