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1, 2, 3 … The Final
Phase is Near
Lisa Thomson
Chief Strategy and Marketing Officer
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Disclosure of Commercial Interests
I have commercial interests in the following organization(s): Pathway Health Services
List the Name of Your Employer: -Lisa Thomson -Pathway Health Services
Pathway Health is a professional management and consulting organization serving clients in the long-term and post-acute care industry.
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Objectives
▪ Identify skilled nursing facility requirements of participation for Phase 3
▪ Understand necessary training for Phase 3 for direct caregivers and management
▪ Apply concepts learned and individualize sample resources provided to aid in the development of necessary policies, training, and tools
▪ Develop a plan for the next year to fully implement Phase 3
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Background Where it all began
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Implementation
Phase lll
11/28/19
Phase ll
11/28/17
Phase l 11/28/16
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Ph
ase
1 Resident Rights
Facility Responsibilities
Abuse
Advance Directives
Admission, Transfer Discharge
Grievance
Resident Assessment
Care Planning – Person Centered
Physician Services
Nursing Services - Staffing
Pharmacy Services
Dental
Lab, diagnostics
Food and Nutrition
Specialized rehabilitation
QAPI Committee
Infection Control – Program
Physical Environment
Ph
ase
2 Resident Rights - Contacts
Abuse - Reporting Crimes
Transfer/Discharge Documentation
Base Line Care Plan
Nursing staffing and FA
Facility Resource Assessment
Competencies and Skills
Behavioral Health Services
Pharmacy – Chart review
Dental – Dentures
Food and Nutrition – Link to FA, RD, DSM
Ethnic, Cultural and Religious preferences
Antibiotic Stewardship
QAPI Pan
Smoking
Ph
ase
3 Care Plan – cultural competent and
TI
Cultural Competence
Trauma Informed Care
Sufficient and Competent Staff – FA
Governing Body
QAPI – full implementation
Infection Preventionist
Compliance and Ethics
Physical Environment – Call Light
Training Requirements
Facility Training Program
Full Implementation
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(QCOR) Quality, Certification, and
Oversight Reports (as of 2-2019) https://qcor.cms.gov/report_select.jsp?which=0
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Phase 3Prepare Plan Implement
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Phase 3 Intent
Completes the final phase implementation of the RoP for Skilled Nursing Facilities/NFs
Updates and reorganization of the new requirements are viewed as necessary to reflect current standards of practice
Goal is to improve care and reduce negative outcomes
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F659: Comprehensive Care Plans that are culturally-competent and trauma-informed
F699: Trauma-informed Care
F741: Sufficient and Competent Staff, FWRA, PTSD and/or trauma
F837: Governing Body-QAPI
F865: QAPI implementation
F866: QAPI Program Feedback, Data Systems and Monitoring
F867: QAPI Program Systematic Analysis and Systemic Action
F868: Infection Preventionist involvement in the QAA
F882: Requirements for the Infection Preventionist
F895: Compliance and Ethics Program
F919: Resident Call System
F926, F940, F941, F942, F944, F945, F947, F949: Training Requirements
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F 659Care Planning
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Care Planning
F659 – Comprehensive Resident Centered Care Plans
• (ii) Be provided by qualified persons in accordance with each resident's written plan of care.
• (b)(iii) Be culturally-competent and trauma-informed
Guidance
• The facility must ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity. This includes proper licensure or certification, if required.
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Care Planning
Phase 3 Expectations
• Comprehensive Resident Centered Care Plans must be
• Culturally Competent
• Trauma Informed
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Definitions
Competency
“A measurable pattern of knowledge, skills, abilities, behaviors and other characteristics needed to perform work roles or occupational functions successfully”
Cultural Competency
“ helps staff communicate effectively with residents and their families; helps provide care that is appropriate to the culture and the individual; also known as cultural responsiveness, awareness and sensitivity… it is a set of behaviors and attitudes held by clinicians allowing effective communication with various cultures and backgrounds”
Care that is appropriate to the culture and the person!
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf
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Care Plan Example
• Adapting Care to patients cultural needs and preferences:
• Cultural assessment forms care plan foundation
• Cultural beliefs
• Values
• Practices
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Care Plan Example
Muslim resident
• Islamic faith and beliefs
• Need for modesty and privacy
• Appropriate use of touch
• Respect for personal space
• Dietary requirements
• Medication use
• Treatment requirements and wishes
• Refusal of care guidelines
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Quality of Care
F699 – Trauma Informed Care
• Residents who are trauma survivors receive culturally competent, trauma-informed care
• Professional standards of practice
• Eliminate or mitigate triggers that may cause re-traumatization of the resident.
https://www.samhsa.gov/
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Trauma Informed
Care
• Mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment
• 11/28/19
https://www.samhsa.gov/
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Care Planning
Trauma Informed Approach to Care Planning
• Trauma screening and assessment
• Trauma specific interventions
• If not available within the organization, have an effective referral system to connect individuals and families with appropriate treatment
• Evidence based
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Trauma Informed Care Additional insight
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Trauma
Trauma is:
• Widespread
• Harmful
• Costly
• Public Health Problem
Results from:
• Abuse
• Neglect
• Loss
• Disaster
• War
• Other harmful experiences
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Concepts of Trauma
Individual trauma results from:
• an event
• a series of events
• a set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being
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Principles of Trauma Informed Care
SafetyTrustworthy and
Transparency Peer Support and Mutual Self-Help
Collaboration and Mutuality
Empowerment
Voice
Choice
Cultural
Historical
Gender issues
https://www.samhsa.gov/
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Trauma Informed Care
It is common, 50% of people report a history of trauma!
❑ First screen to determine if the person has a history of trauma
❑If yes, do they have trauma-related symptoms?
❑ A positive screen only indicates that further evaluation is warranted
❑ Positive screen does not indicate a disorder actually exists
❑ Negative screens do not necessarily mean there are no symptoms
❑ Why we screen
▪To identify stress symptoms
▪Prevents misdiagnosis
▪Prevents inappropriate treatment planning
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Domains to
Screen
➢ Trauma-related symptoms
➢ Depressive or dissociative symptoms
➢ Sleep disturbances
➢ Intrusive experiences
➢ Past and present mental health disorders
➢ Severity or characteristics of a specific trauma
➢ Substance Use
➢ Social support and coping styles
➢ Availability of resources
➢ Risk for self-harm, suicide, and violence
➢ Health screenings
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Leaders Guide
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Cultural Competence
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What is Culture?
Ethnicity Life
Experiences
Religion
AgeParent
s
Sexual Orientati
on
Gender
Identity
Race
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Having Cultural Competence
• Have an awareness of one’s own cultural identity
and views about difference
• The ability to learn and build on varying cultural
and community norms
• The ability to interact effectively with people of
different cultures
• To be respectful and responsive to health beliefs
and practices
• Understand cultural and linguistic needs of diverse
population groups.
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Increasing Cultural Competence
1. Recognize that culture extends beyond skin color
2. Find out each resident’s cultural background
3. Determine your cultural effectiveness
4. Make your residents feel “at home”
5. Conduct culturally sensitive evaluations
6. Elicit resident expectations and preferences
7. Understand your cultural identity
https://www.mdedge.com/psychiatry/article/59732/7-ways-improve-cultural-competence
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Core Competency Development
Self-Awareness
Cross-Culture Knowledge
Health Literacy
Delivery of Care
Advocacy
2/28/2019 https://shafiamonroe.com/cultural-competency
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CompetencyNursing Services
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F726 –Competent
Nursing Staff
INTENT
Nursing staff possess:
Competencies
Skill sets necessary
Sufficient Staff
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F726 –Competent Nursing Staff
DEFINITIONS
“Competency” is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.
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Competency
The facility must ensure that licensed nurses have the specific
competencies and skill sets necessary to care for residents’
needs, as identified through resident assessments, and
described in the plan of care.
Providing care includes but is not limited to assessing, evaluating,
planning and implementing resident care plans and responding
to resident’s needs.
The facility must ensure that nurse aides are able to demonstrate
competency in skills and techniques necessary to care for
residents’ needs, as identified through resident assessments, and
described in the plan of care.
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Competencies listed in SOM
• Preventing and reporting abuse, neglect, and exploitation
• Dementia management
• Infection Control
• Competencies related to an approved nurse aide training and evaluation program
• Medication management
• Change in condition
• Resident rights
• Person-centered care
• Communication
• Basic nursing skills
• Basic restorative services
• Skin and wound care
• Pain management
• Cultural competency
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Change in Condition
• Competency is a nurse’s ability to identify and address a resident’s change in condition
• Promptly identify changes
• Effective interventions to address
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http://www.pathway-interact.com/
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Available Tools
Detecting and communicating a change in condition
AHRQ – Agency for Health Care Research and Quality
https://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/ltcmodule1.html
INTERACT®
http://www.pathway-interact.com/
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Individual
Professional
Resident
Outcomes
Organization Outcomes
Mandatory
▪ Identify Gaps▪ Determine Competencies
Needed▪ Develop Education ▪ Evaluate
Competency
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Competent and Sufficient Staff
• Leadership Strategies:
• Monthly Staff Deployment Meeting
• Review the overall staffing
• Behavioral Health
• Dietary
• Nursing
• Attendees
• Potential Subjects
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Governing BodyAdministration
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Governing Body INTENT
Active (engaged and involved) governing body
Responsible for establishing and implementing policies regarding the management of the facility.
DEFINITIONS
“Governing body” refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility.
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It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities.
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AdministrationThe facility must have a governing body, or designated persons functioning as a governing body, legally responsible for establishing and implementing policies regarding the management and operation of the facility.
The governing body appoints the administrator who is—
• Licensed by the State, where licensing is required
• Responsible for management of the facility
• Reports to and is accountable to the governing body
• The governing body is responsible and accountable for the QAPI program
• Governing body responsibility of QAPI program will be implemented beginning November 28, 2019 (Phase 3)
F837 – Governing Body
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Governing Body
Facility must determine:
• NHA reports and reporting to Governing Body
• Method of Communication
• NHA Accountability
• NHA and GB involvement in Facility Assessment
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Quality Assurance Performance
Improvement
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Consulting | Talent | Training | Resources
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QAPI
The chart was adapted from the Health Resources
and Services Administration (HRSA)1
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F865 – QAPI Program/Plan, Disclosure,
Good Faith Attempt
INTENT
Describes the process for conducting
QAPI/QAA activities, such as identifying and
correcting quality deficiencies as well as
opportunities for improvement
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QAPI - F865
Disclosure of Information and Good Faith Attempts
• The survey process - objective assessment of
facility compliance with the requirements of
participation
• Guided by facility performance and outcomes
• The surveyor task - review the QAPI Plan and QAA
• Occur at the end of the survey
• Ensure that concerns are identified by the survey
team independent of the QAPI Plan and QAA
review.
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F866 –QAPI/QAA Data Collection and Monitoring
•Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment and including how such information will be used to develop and monitor performance indicators.
•Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.
•Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.
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QAPI - F867
F867 - Program systematic analysis and systemic action
• Policies and procedures
• Actions aimed at performance improvement
• Implement corrective actions
• Measure success
• Track performance
• System wide action
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Infection ControlPhase 3
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F882 – Infection Preventionist
Infection Preventionist
• IP Requirements:
• Professional background
• Qualifications
• Work (PTE)
• Specialized training
• QAA Committee
• Report to Committee
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Compliance and Ethics Phase 3
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Compliance & Ethics
• The operating organization must develop, implement, and maintain an effective compliance and ethics program that contains, at a minimum, the following components:
• Established written compliance and ethics standards, policies, and procedures
• The designation of an appropriate compliance and ethics program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously
• Disciplinary standards that set out the consequences for committing violations for the operating organization's entire staff; individuals providing services under a contractual arrangement; and volunteers, consistent with the volunteers' expected roles.
• Annual Review
F895 –Compliance and Ethics Program
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Purpose
Reduce the prospect of violations
Criminal Civil Administrative
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Consulting | Talent | Training | Resources
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Other F Tags
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F919 – Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area
• Each resident’s bedside
• Toilet and bathing facilities
https://www.ahrq.gov/patient-safety/index.html
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Training Requirements
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General Training Requirements
F 940
To ensure any training needs are met for:
• New Staff
• Existing Staff
• Individuals providing services under a contractual arrangement
• Volunteers
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Training Requirements
F941 – Communication Training
• Mandatory training for direct care staff
F942 – Resident Rights Training
• Rights of the resident
• Facility responsibilities
• Staff responsibilities
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Training Requirements
F944 – QAPI Training
A facility must include as part of its QAPI program mandatory training that outlines and
informs staff of the elements and goals of the facility's QAPI program
• Five Elements
• Facility QAPI Implementation Plan
F945 – Infection Control Training
A facility must include as part of its infection prevention and control program mandatory
training that includes the written standards, policies, and procedures for the program
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Training Requirements
F946 – Compliance and Ethics Training
Mandatory Training
• Communicate the program’s standards, policies
• Annual training
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Training Requirements
F949 – Behavioral Health Training
A facility must provide behavioral health training consistent with the
requirements and as determined by the facility assessment
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Facility Training
Program
• Consistent with their expected job
roles
• What policies are required
• Review job descriptions
• Do they meet professional
standards of practice?
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Consulting | Talent | Training | Resources
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Competency Based
Training Program
• Evaluates current staff training program to ensure
competencies
• Identifies gaps in education that may contribute to poor
outcomes
• Outlines what education is needed based on resident
population
• Delineates what specific training is needed based on
facility assessment
• Details the tracking system used to ensure
competency program is assessing, planning,
implementing, and evaluating effectiveness of training
• Ensures the competency training is not limited to
online computer based but also test for critical thinking
skills as well as the ability to manage care in complex
environments with multiple interruptions
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https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
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Consulting | Talent | Training | Resources
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Knowledge Check Leaders
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Leadership Knowledge Check
• Phase 3 – Understanding and Overview
• Key process and system changes
• Professional development plan for management
• Cultural competency
• Trauma Informed Care
• Governing Body
• Role and Responsibility
• Training
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Consulting | Talent | Training | Resources
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Leadership Knowledge Check
• QAPI – full implementation
• Infection Control and Prevention Program
• Program and Facility Assessment
• Staff Competency –required and based upon FA
• Preventionist role
• Compliance and Ethics
• Training Requirements -required and based upon FA
• Facility Training Program
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LeadershipImplementation Strategies
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Checklist – Handout
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Consulting | Talent | Training | Resources
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Strategies
• Review each of the F-tags in the Requirements of Participation for Phase III in the CMS State Operations Manual, Guidance to Surveyors for Long Term Care Facilities, Appendix PP
• Develop an Interdisciplinary Team
• Educate the Team that will be developing your systems to meet the new requirements
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Consulting | Talent | Training | Resources
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Strategies
• Develop Policies, Procedures and Systems using best practices and compliance resources
• Educate your entire team including verification of competency
• Audit your systems for compliance and quality
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Consulting | Talent | Training | Resources
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Strategies
• Coordinate Abuse/Neglect efforts with QAPI Committee
• Prepare for care planning for trauma informed care
• Explore training for trauma informed care
• Pay attention to staff competencies for Phase 3
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Consulting | Talent | Training | Resources
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Strategies
• Sufficient staffing may be observed for behavioral health
• Define Governing Body
• Ramp up QAPI
• Begin working on Compliance and Ethics
• Evaluate and update training programs
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Prepare Plan Implement
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Resources
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Resources
F-Tagshttps://www.cms.gov/Medicare/Provider-Enrollment-and.../F-Tag-Crosswalk.xlsx
(RoP) State Operations Manual https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf
The New Survey Process
http://surveyor-training-docs2.s3.amazonaws.com/LTCSurveyProcess/11.4TrainingSlideswithSpeakerNotes.pdf
http://surveyor-training-docs2.s3.amazonaws.com/LTCSurveyProcess/LongTermCareSurveyProcess_LTCSP_ProcedureGuide.pdf
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Consulting | Talent | Training | Resources
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Resources
The National Center for Cultural Competency
https://nccc.georgetown.edu/index.html
Substance Abuse and Mental Health Services Administration
https://www.samhsa.gov/
State Operations Manual – Appendix PP
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf
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Consulting | Talent | Training | Resources
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Resources
(QCOR) Quality, Certification, and Oversight Reports (as of 2-2019) https://qcor.cms.gov/report_select.jsp?which=0
The National Center for Cultural Competency
https://nccc.georgetown.edu/index.html
The National Standards for Culturally and Linguistically appropriate Services in Health and Health Care (developed by the Office of Minority Health in HHS)
https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf
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Consulting | Talent | Training | Resources
1, 2, 3 … The Final
Phase is Near
Lisa Thomson
Chief Strategy and Marketing Officer
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Disclaimer
“This presentation provided is copyrighted information of Pathway
Health. Please note the presentation date on the title page in relation to
the need to verify any new updates and resources that were listed in this
presentation. This presentation is intended to be informational. The
information does not constitute either legal or professional
consultation. This presentation is not to be sold or reused without written
authorization of Pathway Health.”
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