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Quickly identifying and communicating relevant changes of condition to clinicians (e.g., physicians, nurse practitioners, or physician assistants) has long been a challenge for many nursing homes. However, timely, efficient notifications are more critical than ever during the ongoing COVID-19 pandemic because directors of nursing services (DNSs) have to guard against potentially catastrophic COVID-19 spread in their buildings in addition to addressing each resident’s individual clinical concerns. The following steps can help DNSs ensure their teams stay on top of changes of condition:
Use a tool that structures the nurse-clinician conversation
Communication between nurses and clinicians can be difficult,” says Joseph Ouslander, MD, professor of geriatric medicine and senior advisor to the Dean for Geriatrics in the Schmidt College of Medicine at Florida Atlantic University in Boca Raton, FL; author of the editorial “Coronavirus Disease19 in Geriatrics and Long-Term Care: An Update” in the Journal of the American Geriatrics Society; and the primary creator of the free INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program. “Sometimes nurses don’t know the resident very well, and sometimes the physician is on call and doesn’t know the nurse, the facility, or the resident very well. There is also a struggle to determine what information is important to communicate to clinicians and what is not important. What are the pertinent negatives that should be communicated? What are the pertinent positives?”
To gather the necessary information, nurses should complete an assessment when staff identify a potential change of condition. In many facilities, this assessment is done using a tool that gathers information using the SBAR (Situation – Background – Assessment – Recommendation) format. The Agency for Healthcare Research and Quality (AHRQ) defines SBAR as follows:
Directors of nursing services (DNSs) and other managers can support and motivate staff in two critical ways: individually and organizationally. Taking the following steps can help staff deal with the anxiety of caring for residents in a pandemic:
Teach staff how to help each other—and themselves
Judy Davidson, DNP, RN, FCCM, FAAN, a nurse scientist at UC San Diego Health and co-chair of the Strength Through Resiliency Task Force at the American Nurses Association, offers the following two stress reduction techniques that DNSs can use themselves and teach staff as well:
* Tap Out and Take a Lap. “If you see someone at work whose anxiety level is rising, you figuratively tap them out and invite them to take a lap of the unit with you. A lap of the unit usually takes about one minute, and that is all it takes to do this stress reduction technique,” says Davidson. “While walking, you coach them through a little breathwork. If they are really panicked, just do four breaths in and four out. Doing that for five cycles will add up to a minute—which is all it takes to break the stress response that the person is under and ground them again so they can get back into the game.”
If the person isn’t totally panicked, “they may be able to tolerate a more complex breathing pattern, four-seven-eight: Breathe in for four, hold for seven, and breathe out for eight. Four to five repetitions of that will give you a minute that you have walked around the unit, and now both you and your colleague are feeling better,” says Davidson. “I recommend anyone to do that for helping out in-the-moment stress.”
In the March 13 revised Quality, Safety, and Oversight (QSO) memo QSO-20-14-NH, the Centers for Medicare & Medicaid Services (CMS) advised nursing homes to restrict all visitors except for compassionate-care situations and to “cancel communal dining and all group activities, such as internal and external group activities.” Adjusting to these changes has been difficult for every nursing home resident, but social distancing is especially hard for residents with dementia who wander and are eased by group activities.
“That’s not who these people are,” acknowledges Teepa Snow, MS, OTR/L, FAOTA, founder and CEO of Positive Approach to Care, a global dementia care services and products company based in Efland, NC. “Nurses are being asked to do the impossible with the inadequate.”
While physicians and physician extenders may be willing to prescribe an antipsychotic medication as an emergency measure in an acute or emergency situation as allowed under F758 (Free From Unnecessary Psychotropic Meds/PRN Use) in Appendix PP of the State Operations Manual, giving residents with dementia antipsychotics to make them immobile not only increases their risk of adverse events, such as cerebrovascular accidents (CVA) and even death, it also increases their risk of respiratory symptoms, including shortness of breath—one of the primary symptoms of COVID-19, points out Snow. “Providers may also consider taking away wheelchairs and other mobility aids. However, doing that puts residents with dementia at greater risk for falls and fall-related injuries, potentially resulting in a trip to the emergency department where they may be exposed to SARS-CoV-2, the virus that causes COVID-19.”
Instead, the goal should be to come up with strategies that make sense, balancing safety and resident needs, says Snow. “Keeping these residents in a small room is highly improbable, so you want to be ready to move forward with some element of safety. You will put residents at risk if you aren’t prepared for the reality that they will come out of their rooms.”
Telehealth has existed for quite a while, and as its use has expanded in recent years, some healthcare groups have even provided the services to their entire network of facilities. These networks often paid for telehealth access out of their own pockets, as accessibility and financial assistance for Medicare beneficiaries has previously been very limited, with coverage only available to facilities in designated rural areas and only for patients who had a previously-established relationship with their doctor. However, on March 6, the $8.3 billion dollar Coronavirus Preparedness and Response Supplemental Appropriations Act was passed, which allowed the Department of Health and Human Services (HHS) “to temporarily waive certain Medicare restrictions and requirements regarding telehealth services during the coronavirus public health emergency.”
Then, on March 13, President Trump declared the COVID-19 outbreak a national emergency. And thus, we received the 1135 waiver, which expanded telehealth services:
Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
On April 10, the Centers for Medicare & Medicaid Services (CMS) released for public inspection the Fiscal Year (FY) 2021 Proposed Rule for the Skilled Nursing Facility Prospective Payment System (SNF PPS) and Consolidated Billing (CMS-1737-P) as required by law. In a major break from recent years, CMS offers no proposals for updating the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and only what the agency describes as “minor administrative proposals” related to the SNF Value-Based Purchasing (VBP) program.
However, CMS does propose several other revisions in addition to the required Medicare Part A payment rate update. These include:
Multiple changes to the ICD-10-CM code mappings used for case-mix classification in the Patient-Driven Payment Model (PDPM);
Technical changes to the regulatory language in the Code of Federal Regulations, including a proposed change that will clarify the “practical matter” criterion of a Part A skilled level of care by removing an outdated example that referred to the repealed Part B therapy cap provision; and
Changes to how SNFs are identified as rural or urban for wage index classification, as well as a proposal to cap wage index decreases from FY 2020 to FY 2021 as a transition measure.
As COVID-19 spreads and the demand for personal protective equipment (PPE) increases, nursing homes across the country are experiencing or preparing for shortages of PPE. To help providers prioritize and make difficult but critical decisions about PPE use, the Centers for Disease Control and Prevention (CDC) has developed a framework, COVID-19: Strategies to Optimize the Supply of PPE and Equipment, which CDC officials discussed at the March 25 Clinician Outreach and Communication Activity (COCA) call, COVID-19 Update: Optimization Strategies for Healthcare PPE. Options for prioritizing and extending existing PPE supplies include the following:
Utilize engineering and administrative controls
Facilities should be maximizing their use of administrative and engineering controls to reduce exposures and help extend their PPE supplies, says David Kuhar, MD, the lead for the CDC’s COVID-19 Hospital Infection Prevention Team.
Engineering controls include “maximizing use of physical barriers (e.g., glass or plastic windows) that can potentially eliminate the need for PPE use in selected situations,” says Kuhar. Additional engineering controls include closing the curtains between residents and maintaining ventilation systems. Ventilation systems should provide air movement from a clean to contaminated flow direction.
Driven by the ongoing opioid crisis, drug diversion among healthcare workers remains a significant, often underrecognized problem, creating significant risk for long-term care facilities in addition to the individual risks for addicted staff or even residents’ family members and the harm to residents from inadequately managed pain. F-tags that could come into play as a result of drug diversion include:
F602 (Free From Misappropriation/Exploitation),
F608 (Reporting of Reasonable Suspicion of a Crime),
F697 (Pain Management),
F755 (Pharmacy Services/Procedures/Pharmacist/Records), and
F761 (Label/Store Drugs and Biologicals).
Surveyors also may refer providers to the Drug Enforcement Administration (DEA), local law enforcement, State Boards of Nursing, Pharmacy, and Nursing Home Administrators, and/or other agencies as required by state law, according to Additional Investigatory Activities Related to Allegations of Drug Diversion in F602 in Appendix PP, “Guidance to Surveyors for Long-Term Care Facilities,” of the State Operations Manual.
Implementing the following seven steps can help directors of nursing services (DNSs) reduce the risk of drug diversion:
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease (2019-nCoV or COVID-19), is spreading rapidly in nursing homes across the country. On March 23, the Centers for Medicare & Medicaid Services (CMS) announced that 147 nursing homes across 27 states have at least one resident with COVID-19, according to data from the Centers for Disease Control and Prevention (CDC). The number of providers with internal spread is increasing as well. For example, on March 25, news reports indicated that at least 16 residents and four staff members tested positive for COVID-19 in a West Virginia nursing home. Nursing homes that do not yet have COVID-19 in their facility should be actively working to mitigate the risk to residents and staff. Implementing the following strategies can assist in this effort:
Constantly monitor key infection prevention practices
Infection prevention auditing should highlight two areas:
* Hand hygiene. “From a self-inoculation perspective, the hands are the key,” stresses Michael Bell, MD, deputy director of the Division of Healthcare Quality Promotion at the CDC. “If you were to touch a soiled surface, you could end up with infectious material on your hands. If you then touch your eyes, nose, or mouth without washing your hands first, then you could deliver the infectious materials to yourself. Hand hygiene either in the form of alcohol-based hand gel or soap and water is the key to breaking that transmission. Simply walking into a room that might have something on the surface is not associated with any recognized risk of transmission.”
On a day-to-day basis, the DNS can become so busy with staff and resident care that they completely lose track of employee files. However, the DNS is often either directly responsible for or works with human resources to manage employee files. Compiling and maintaining these files needs to be a priority in order to stay in compliance with survey requirements, avoid legal hurdles, and have a reference of past behavior when it’s time to evaluate or promote staff.
To keep these important documents up to date, here’s what the DNS should know about employee files:
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