Comment Nursing Home Enquiry with airSlate SignNow

Initial nursing home enquiry

so very briefly a little bit of background before we get started as I mentioned earlier the regulations were published in the Federal Register on October 4th of 2016 they're being implemented in three phases phase one went into effect November 28th of 2016 and puts into effect most of the regulations particularly those that continue existing requirements and aleshia view put forward by two slides please Thank You Saints two of the regulations go into effect on November 28th of 2017 and include some of the new requirements such as behavioral health with the implementation of phase 2 CMS is also putting into effect new interpretive guidelines which they're working on now and a new survey process that combines elements of the traditional survey and the QIO survey and then phase 3 which goes into effect on November 28th of 2019 includes implementation of new programs such as copy and compliance and ethics programs you can see a full implementation schedule of each of the sections on the consumer voice website our presenters today have decade's worth of combined experience and expertise on nursing home regulatory and advocacy issues we'll hear first from Erik Carlsson director attorney with justice and aging we'll hear from Toby Edelman senior policy attorney with the Center for Medicare advocacy and also from Robin grant the director of public policy and advocacy with the consumer voice and with that we'll start the presentation Alicia if you could move forward to the next slide I will then turn it over to Eric thanks Laurie and we can move one slide forward please you talked about an assessment in in care planning and just a general comment about the regulations as you'll see I think through each of the presentations that we'll be doing today some has changed but there's a lot of similarities as well it's still of course based on the federal statute which has been effective since 1990 and so there's a there's a lot of similarity there's some changes on the margins and a few more significant changes but if folks on the phone are familiar with the nursing-home rules you'll see a lot of similarities certainly going forward although that being said a lot of provisions that essentially remain the same have been moved from one section to another so they're some of the changes have been new provisions in some of the changes have been a reorganization of existing of existing requirements one of the changes that occurs throughout the regulations is an increased focus on person-centered care or resident centered care and anyone who works in LTSs these days is very familiar with this concept the difficulty is in the execution of course in work there's a lot more talk about person-centered care whether we see a lot of it and in practice is another another question to move things forward CMS now offers this that regulatory definition of person-centered care and you see it's a it's a focus on the resident and that's the basic requirement that the care that's been provided to the extent possible is not based on facility convenience or standard operating procedures the way has always been done but what the resident would need or prefer next slide please and consistent with that is an accommodation regulation that's very similar to the provision that's been in place forever pointing out that residents preferences should be accommodated there needs to be a reasonable accommodation of what a resident wants and you'll see here that the standard is actually very stringent saying that there should be reasonable accommodation except when to do so would endanger the health or safety of the resident or other residents so certainly that's something that residents should be aware of and a facility should not be turning down reasonable requests because they're busy because it's not the way they've ordinarily done it but it because it would be inconvenient inconvenience to staff members and you see here the standard is health and safety of the resident or other residents next slide please and here we'll talk a little more about the care planning requirements care as has always been true is based on assessment followed by care planning one of the critiques about the previous regulatory system was that it allowed facilities to wait an excessively long time for the development of a care plan if the longest possible amount of time was taken it would be possible under the old regulations not to have a care plan in place for up to three weeks after the person's admission to the nursing facility so to address that the current regulations now require but I shouldn't say current regulations that because they're not this provision isn't in effect yet but the regulations are going to require that there be a baseline care plan put in place within 48 hours of admission and you'll see here that this particular provision doesn't become effective until November of this year we called in Laura a couple minutes ago talks about phase 1 and phase 2 in phase 3 of implementation phase 1 of the regulations already in effect that don't reflect any significant changes from the previous regulatory requirements baseline care planning is something that wasn't required before and because of that you know that requirement will come into effect until November of this year but it would certainly facilities would be well advised to start doing that as as early as possible I don't there's no particular reason why you need to wait 12 months I mean certainly and it's certainly a good practice to have some sort of functioning care plan whenever a resident is in the facility you'll note here that there were regulatory requirements are focused on the basics the the goals and the the various orders relevant to the residence care next slide please which moves us into the knots of baseline care plan but a further conversation about the complete care plan has to be done within seven days of assessment it's based as it was before on an interdisciplinary team which should include the extent practicable the resident of the residence representative as you can imagine it would be hard to with a straight face talk about resident centered or person-centered care if the reston wasn't a big part of the service planning process and so to emphasize that further and to make sure that the resident participates when it all possible the regulations now require that if the resident is not participating and that the resident representative is not participating there has to be an explanation which explains why that is you don't want well you just want some assurance that the facility and everyone involved do everything possible to make sure that the resident or the residence representative participates to again guarantee as much as possible that person-centered care is a reality and not just a facade next slide please the interdisciplinary team the participants are similar to where they were before the member of food nutrition staff is a new requirement and also the mention of other staff as requested by the resident next slide please and that brings us into the contents of the the care plan its what the the resident needs to get to the highest practical level of functioning it should as much as possible incorporate particular preferences and should not be limited to quote unquote care its daily life is anyone who is involved with nursing facilities no it's it's not just it's not a health care exclusively health care it's about your life and if you're in a nursing facility 24/7 there's a lot of quality of life issues as scheduling issues and choices and activities and preferences that should be encompassed in a in a care plan one other thing that has increased emphasis and the new regulations is the discharge plan there has to be more of a focus on discharge there shouldn't be an assumption that once a resident is in the facility he or she is going to be there forever there needs to be a look at how the what steps are being taken to prepare for discharge out of the nursing facility next slide please and you'll you'll see that here as well and you don't want to see a decision where it's just assumed that the resident of course will be in the facility forever and because of that the regulations require that if discharge is determined not to be feasible there has to be documentation of why that is and who made that determination next slide please and just to wrap up this topic the same advice that that we've been given for years still is is true that residents need to be active in this process it's not helpful to just go to a care plan meeting and say to the nurse facility well what do you guys think the resident and the residents representative should go in with some sense of what what the resident lost what would be what would be good and - and to push things forward it's a it's a tremendous tool but it needs to be taken advantage of and and those of us who work in this field need to do as much as we can to support residents and residents representative in making this process meaningful so with that let me pass the conversation over to Robin to talk about some nursing services issues thank you Eric so as Eric said I'm going to discuss what's in the revised regulations related to nursing services or we just usually refer to this as staffing and just to clarify I'm sure almost all if not all of you know that when we say nursing services we mean the care that's provided by licensed nurses so that is licensed practical nurses LPNs or in some states they're known as licensed vocational nurses lv end and registered nurses so RN so we've got licensed nurses and also certified nursing assistants who are usually referred to as Nurse Aides in the regulations so I'm going to talk about both sort of staffing levels and numbers as well as training next slide please so from our perspective meaning consumer voice perspective and I would say from the perspective of many other advocates as well we remain very disappointed that there's been no change in the requirements for staffing levels and numbers despite the the work of many advocates we still don't have a required minimum staffing standard nor has there been any required increase in staffing levels so I would just note that that is a huge concern for us and other advocates staffing or lack of staffing remains the biggest problem in nursing homes today we know that that is without doubt the number one complaint we hear from residents and families and tickets and we know there's a relationship between staffing and quality care but the new regulations don't include a minimum staffing standard nor as you'll see in a little bit a requirement for a 24-hour RN so that's what's not in the regs but let's look a little more closely at what is in the regs of next slide so there are some changes in the regulation relating to staffing and I felt it was important for all of you to see the actual regulatory language related to nursing services so here's what the regulation says in forgive me aza as I read this out loud the facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical mental and psychosocial well-being of each resident as determined by resident assessments and individual plans of care and considering the number acuity and diagnosis of the facility's resident population in accordance with the facility assessment required at section 483 point 70 little e so as you've probably figured out by now the parts that in are in red are new language next slide please so I just want to make a few points about this requirement first like the previous regulation the revised regulation continues to require that there be sufficient nursing staff so no change there but there are two changes that impact what a facility has to consider in determining staffing so first there's what CMS is calling the competency-based approach and that's a new requirement that nurses and CNAs certified nursing assistants have to have the necessary competencies and skills to keep residents safe and provide the care that they need to reach their highest possible level of well-being so when you put that language together with sufficient you get the requirement that the facility has to have sufficient nursing staff with the appropriate competencies and skill sets so loosely translated there has to be enough staff and that staff have to have the knowledge the abilities and the judgment that are needed to successfully and properly care for the residents in the facility so the question then becomes how does the facility determine how much staff is enough and what the right competencies and skill sets are so the answer to that in the regs is that it does that by conducting a facility assessment so the goal of the assessment is to give the facility a way to determine what resources it needs to competently care for its residence so this assessment is a new element it's found in the rules under the section on administration and CMS is really viewing this assessment as a critical factor in guiding how facility operates and I would note that it's you see reference to the assessment in numerous places in the regulations not just in the part about dressing services next slide please so in mind the elements of facility have to look at to the to develop the assessment are all aspects of its resident population and you can see on the slide on the left side what has to be considered when assessing does the resident population and the facility also has to look at its resources and you can see on the left on the right side this time what those resources are that the facility has to consider so that means that the assessment in essence defined sufficient nursing staff with the appropriate competencies and skill sets it tells the facility the number of staff it needs as well as what competencies and skill sets are needed so this assessment in CMS's words is really about the facility knowing itself knowing its residents and knowing its staff next slide please often this assessment has to be carried out is pretty much left up to the facility with the exception that it has to be reviewed and updated at least annually and whenever there's a significant change so for instance if the facility began omitting residents who needed bariatric care and it hadn't been providing that care in the past it would certainly need to update its assessment because its resident resident population has changed so before I move on I want to point out that the facility assessment requirement doesn't go into effect until Phase two so that's November of this year so because the sufficient nursing staff with the appropriate competencies and skill sets requirement is tied to that facility assessment that whole requirement about you know sufficient nursing staff with the appropriate conferences won't go into effect until Phase two as well so just wanted to point out the the timeframes here next slide please so the second aspect of staffing that I want to briefly highlight is training so for the first time facilities will have to have an ongoing training program for all staff and the regulation specifically says that that includes existing staff new staff and also contract employees and volunteers so of course this applies to all staff but because that includes nurses and CNAs I wanted to specifically point out just training requirement since it applies here next slide please so the rule lists some of the topics that have to be included in training and you can see those topics on this slide they include communication residents rights abuse neglect and exploitation and more so one thing I want to particularly note is the requirement that for the first time all staff will have to be trained in dementia management which from our perspective is is a very good requirement however the regs don't say how much training must be provided that's to be determined by the facility assessment so again just underscore the importance of that assessment this requirement for all staff training on these topics goes into effect in Phase three with the exception of training on abuse neglect and exploitation and that is already in effect it was implemented with phase one next slide please in addition to the training requirement for all staff which obviously includes CNAs the in-service training requirement for Nurse Aides has been revised in a couple of ways so first it includes dementia management training and resident abuse prevention that must be part of nurse aide in-service training so that's new and this part has already gone into effect and second when facilities determine what training what in-service training to provide to address areas of weakness of Nurse Aides they have to look at their facility assessment to get a sense of what areas should be discussed and addressed in that training right in the past they have based training to address areas of weakness solely on there's a performance reviews so now they will they will have to or when this goes into effect with the facility assessment they will have to look not only at the performance reviews but also of what their assessment is telling up next slide please so I think Eric referred to there's some new things there are some old things or something old something new with a lot of old frankly you can see on this slide that the provisions many of them under nursing services have stayed the same such as hiring of Nurse Aides posting of nurse staffing information but one other requirement that from our perspective unfortunately has stayed the same is the requirement for a registered nurse eight hours a day seven days a week we had along with others really advocated for this to be changed to 24 hours a day but that didn't happen and I will say that we continue to be very concerned about the lack of the assessment intervention and treatment skills of a registered nurse and we feel that that really those those skills need to be available round-the-clock and not just eight hours a day seven days a week and that without having an RN 24 hours a day residents really are placed at risk but that is a fight for another day so with that I'm going to turn the program over to Toby who's going to talk with you about unnecessary and antipsychotic drugs so Toby okay Thank You Robin the revised requirements of participation changed the regulations for drugs in some very significant ways some of them are good and some of them are not quite so good until the revision last year the quality of care regulations addressed drugs in a subsection called unnecessary drugs and this section said that residents should be free of unnecessary drugs which is defined as drugs with excessive dose excessive duration without adequate monitoring without adequate indications for use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued a subsection of unnecessary drugs in the quality of care requirements participation was anti-psychotic drugs with two provisions first these drugs shouldn't be given to a resident unless they are necessary to treat a specific medical condition which has been both diagnosed and documented in the medical record and secondly even then even if the drug is appropriate it should be subject to gradual dose reduction next slide please the revised requirements of participation that went into effect largely in November 2016 move these provisions to a different requirement of participation unnecessary drugs and anti-psychotic drugs are now in pharmacy services additions our concern for a number of us because we thought that the standards of care for facilities should in a single place that it makes more sense to have all the standards that facilities need to meet to be in one location so that they could be found easily by residents advocates families and everybody else however CMS chose instead to move these rules to pharmacy services the part of pharmacy services that addresses unnecessary drug prohibitions is identical to the language that we had in the older regulations so again unnecessary drugs are excessive dose excessive duration without adequate monitoring and so on a second big change though is that the new requirements for the first time address four categories of psychotropic drugs not just anti-psychotic drugs which were the focus of the prior regulations but also now for the first time antidepressants anti-anxiety and hypnotics on the one hand it's a good change because we know that facilities believing they couldn't use anti-psychotic drugs shifted residents to different psychotropic drugs and use them for the same inappropriate purpose of sedating residents and making them quiet so that's good to have attention to other psychotropic drugs on the other hand the change is somewhat troubling but because it removes the focus on antipsychotic drugs and we know that these drugs are seriously misused with nursing home residents actually for all older people but we're focused on nursing home residents there have been reports to Congress for decades about the inappropriate use of drugs like this for residents most recently the inspector general's report about six years ago indicated that practically 90 percent if not more of the antipsychotic drugs are prescribed for residents who have dementia not as psychosis the Food and Drug Administration says the use of antipsychotic drugs for residents with dementia can be life-threatening the beers list of inappropriate drugs is that the antipsychotics are inappropriate for all older people and CMS's had a campaign for more than five years on the misuse of antipsychotic drugs so there's some concern that some of us have that broadening the attention to all psychotropic drugs not just antipsychotics is something of a problem this expansion of concern to these four categories of psychotropic drugs doesn't take effect until November of this year but the same rules that were applied solely to anti-psychotic drugs in the past not being given unless they're necessary to treat a specific medical condition and gradual dose reduction those rules in the revised requirements of participation apply to all four categories next slide please the new rules for the first time also addressed PRN or as needed psychotropic drugs but the rules are different for antipsychotics and for the other four categories for the three new categories of psychotropic drugs as needed orders are limited to 14 days although the physician can document in the medical record why a long go a longer order is appropriate but for anti-psychotic drugs an order for more than 14 days of ADD needed as needed antipsychotics is appropriate only if the physician evaluates the resident and in the discussions about the interpretive guidelines that will give further meaning or further explanation of the regulatory language we had a lot of discussion about what evaluation means whether it means an in-person examination by the physician or not we don't know how CMS is going to come down on matters whether an in-person examination is required for those PRN orders for antipsychotics exceeding 14 days the next slide please the preamble gives us some additional information about the public comments that were submitted on the proposed regulations and how CMS responded for example CMS declined to adopt regulations that it had proposed in 90 - but never made final because CMS says now that they're too prescriptive and it also indicates in the preamble that it accepted the public comment to extend the duration of PRN orders for psychotropic drugs from 48 hours which is what CMS had proposed to 14 days because some facilities focus or at least there were enough a number of public comment saying it was burdensome to have only a 48-hour period next slide please a second part of the the drug regulation is drug regimen review and as before a licensed pharmacist must review each residents drug regimen each month next slide please what's new is first beginning in 2017 the pharmacists must look at the medical record as part of drug regimen review that's a good change of course and it should improve pharmacist ability to evaluate the appropriateness of drugs that are prescribed a second new change is that the pharmacist must advise the medical director of any irregularities that are found in the residents drugs until these rules the pharmacist was required to inform only the attending physician and the director of nursing so this is a good change if the medical director is actually an independent person and not the attending physician for all of the residents in which case it would just be a redundant requirement but the third change that's also quite important is that the physician must document that he or she reviewed the pharmacists report and made the changes that were recommended or explained the rationale for not making changes and in the past I think physicians could ignore the pharmacist recommendation without explaining why so this could also be a very important change next slide please another new requirement is that facilities must have policies and procedures for drug regimen review next slide please and the preamble gives some additional information or understanding about what CMS thought and the decisions that it made so one concern we had was that CMS declined to require the independence of the consultant pharmacist which it had proposed back in 2011 but declined to make final in 2012 saying it would look for additional information some of us hoped that in these new requirements of participation the independence of the consultant pharmacists would be confirmed but that did not happen so I think there are some very important changes here but it's also important for residents and their families and representatives and advocates to be vigilant and to use the tools we have it's important to stay involved in the drug prescribing because as I mentioned we know antipsychotics are inappropriate for most residents so unless a resident has a long-standing psychosis and the anti-psychotic drugs are medically appropriate for that individual it's important to question if a resident suddenly gets antipsychotics prescribed or suddenly as we've heard happening and seen in survey reports present suddenly gets a new diagnosis of psychosis to justify use of an anti-psychotic drug so it's important to stay on top of these issues secondly even though the regulations on drugs don't explicitly say that residents have the right to give informed consent to specific drugs the rules and the preamble make very clear throughout that residents have choice and control over their health care all aspects of their health care and aspects of their lives and this of course includes drugs so finally we would encourage people to make sure that assessment and care planning includes discussion of drugs residents and their families and advocates should not hesitate to use the process as Eric described at the beginning of this webinar to understand the drugs that are being prescribed to question the appropriateness of these drugs and to say no to drugs that should not be prescribed so Eric back to you for a transfer and discharge now thanks Toby let's start with the six reasons for transfer discharge these are familiar to anyone who's done nursing facility work the read language here indicates some changes that are made some standard six reasons that everyone's are familiar with the first change noted here is that the safety of others is purportedly limited by the requirements that this applies only when this endangerment is due to the clinical beat or behavioral status of the resident although I've got a note here that I don't know how much limiting that actually does that in most cases when supposedly the safety of others in the facility is is endangered the allegations relate to the clinical or behavioral status of the resident the second change is likely more useful this is a provision that in the past was in the surveyors guidelines and now has been upgraded to the regulations and it states that there can't be non paint there can't be involuntary transfer discharge for non-payment if the resident has submitted the necessary paperwork to a third party payor and this most frequently comes up in situations where there's a pending Medicaid application and when that happens the facility cannot move to force the resident out for for non-payment the Medicaid application has to the processing has to be allowed to go on to its go on to its conclusion which of course is completely fair to them to the resident in that situation next slide please this is something that's new and is likely to be useful I think a lot of times you see allegations by facilities that they can no longer meet than the residents needs and in my experience in my opinion is oftentimes cited in situations where the facility really could the resident may be difficult to raise there may be heavy care there may be there may be some complications and in providing care but there's nothing about that resident that says his or her needs cannot be met the nursing facility in a practice you I think you see that demonstrated all the time because nursing facility a will propose transferring the resident to nursing facility B and so then the argument to the first nursing facility always goes well if the second nursing facility can deal with this person why can't you and this requirement addresses that if a facility alleges that it can meet the residents need the records got to include the specific need that purportedly cannot be met has to be documentation of attempts by the nursing facility to meet the residents needs and a listing of the services available at the receiving facility nursing facility number two that allows that facility purportedly to meet the residence needs I'll note another regulatory requirement here there's a separate provision of the regulations that admission requires the nursing facility to provide notice of quote the special characteristics or service limitations I know that that language didn't seem seemed a little dangerous to me and others that do this kind of advocacy because it seemed to to give the facility some encouragement to supposedly limit the services in it that it provides possibly below that from what should be required by law but in this particular circumstance it might be sited useful by residents if a facility is arguing it can meet the residents needs one argument by the by the resident the resident representative could be look you didn't say that an admission we would have no way of knowing that you supposedly cannot meet this particular need you we're required to give us notice at the front end of any service limitations you have and you fail to do so next slide please some some new protections the first one I think was the way it usually worked in any case so it should have worked in any case that people weren't shouldn't have been transferred out while their appeal is is pending and the regulations now explicitly say that they're skipping down to the third bullet point there the facility has to assist the resident in completing the form so not to prosecute the appeal of course because the facility can be argued against itself but just to provide logistical assistance in getting the transfer discharged appeal file and then finally going back to the middle bullet point the facility now is required to send a copy of the transfer discharge notice to the long-term care Ombudsman program and this does not require the residents consent the facility should just be doing it in every instance and the idea being that residents needs some support and they need some information and too frequently residents when they get a notice they don't they're scared they don't know particularly what to do they're intimidated by the whole process and they just pack up and move away if the notice on the other hand grows the nurse into the Ombudsman program the Ombudsman program can speak to them counsel them give them some suggestions give them some support and help them through this process there's been a fair amount of conversation I think prompted by this requirement looking into when notice has to be required I've had I get an inquiry about this just within the last hour and a half and or two hours and and I think that because of this requirement there's been some concern that option programs will get bare and all these notices and that facilities have to notices every single time a resident ever leaves a facility whether it's involved moves out of the facility whether that's involuntary or not and that's that's never been true in my experience there when are their facilities have never been giving these kind of transfer discharge notices when a person just chooses to to go back home or to to move elsewhere the operative provision which is still operative it's a provision in the interpretive guidelines it says that the involuntary transfer discharge rules apply quote to transfers or discharges that are initiated by the facility not by the resident whether or not a resident agrees that with to the facilities decision these requirements apply whenever a facility initiates the transfer discharge so that has been the standard in the past it remains the standard so if and you know if a facility initiates the transfer discharge if they give out a transfer just the notices as you have to get out or if they say look you have to to get out or if they say your your your Medicare stay here is ending we you don't have a right to stay here anymore because we only want you're under Medicare whatever it is whatever whenever it's being initiated by the facility then the facility has to give that notice it appropriately has to then include that notice to the ombudsman program if on the other hand if the move is from the residence initiative then it's not an involuntary transfer discharge and this process is not initiated next slide please there's some improvements here on the returning to the facility after a hospitalization for example that as has always been true the facility has to give notice of a bed hold policy also as has always been true if the residue it is medicaid-eligible the resident has a right to return to the next available room in the nursing facility regardless of the the length of the hospitalization and regardless of whether there's been a bed hold so if I'm in a hospital for six weeks and I want to get back to nursing facilities the Medicaid program hasn't paid for an empty room for six weeks but I'm entitled to get back to the next available space and if my old room is available at that point I have to be allowed to move back there next slide please and then there's some good language I think in in most situations about preventing this resident dumping where the resident goes to the hospital and the facility says we don't want to we don't want to take you back it's essentially a lockout and in most advocates opinions an evasion of the transfer discharge rules rather than going by following the process the facility just says we're not taking you back which puts an incredible burden on them on the resident who's likely in the hospital that doesn't intend to retain him or her for more than another day or two so that the languages is better in this case it makes it clear that if a facility makes a claim like that the facility has to comply with the transfer discharge regulations and and I would suggest that that means that when you've got this these kind of situations and the facility claims that it can no longer meet the person's needs or whether or there's non-payment or whatever the reason is and those allegations are made regarding a resident who's currently hospitalized the obligation of the facility is to readmit the to accept the return of the resident and continue with the with the process that's what this says and also you recall that regulatory provision we talked about a couple minutes ago that says there there can't be transfer discharge carried out until the appeal process is complete all that is basic fairness to the residence suggests that if there's allegations by the facility the facility cannot take advantage of a hospitalization and instead has to give the proper notice and allow the residents return and to follow whatever appeal processes that may be available to him or her next slide please just very quick rules these are the same tips I would have given six months or a year ago don't move out if you can't tell you how many times residents panic move out and then call up and say oh I think that was that was inappropriate that's a little late at that point people need to to hang in there and go through the appeal process the law is actually very good the administrative hearing officers may vary in their inclinations from state to state or county to county but the law is really strong and in favor of of residents and it's appropriate to look at what the facility needs to do go back and look at that care planning process you shouldn't be blaming a resident with dementia for behaving in certain ways when the that kind of behavior is just I expected a completely normal way of behaving if you if you have Alzheimer's or some other dementia there should be some burden on the facility to care plan for that rather than claim that that they're incapable of providing the appropriate services for some reason or another so with that why don't I pass the program back to to Laurie you will address maybe another issue or two and field some questions thanks Eric and thanks also to Obi and Robin for your excellent and informative presentations this afternoon we've gotten a number of questions in and as we're getting those ready to ask I want to just take a moment to update those of you on the phone with some Torn events that have put these regulations which are the quality standards the nursing homes at risk so first Congress and the new administration are using the congressional review act to attempt to roll back regulations that were published in the 60 legislative days prior to the end of the last Congress and there are already at least 10 congressional review act bills that are moving through the House and Senate most of them are on different issues like environmental issues and things like that but the revised nursing home regulations do fall within that window for possible repeal and some in the nursing home industry have actively been promoting that they be rolled back so obviously that's a great concern to us because as you heard from our speakers today there are some really positive improvements in these regulations some updating that was needing to take place and we would not support having memoral back at this point in addition Congress has also indicated its intent to block grant or impose per-capita caps on Medicaid which will not only result in serious cuts to Medicaid affecting access and eligibility for nursing home care but they're also intended to give States flexibility that could really seriously undermine or even eliminate the nursing home quality standards so each of our organizations has been issuing and sharing information about these concerns along with things that you can do to help protect these important programs Action Alerts information about calling your members of Congress and different types of activities that you can do to support these programs and so we would encourage each of you to look for and subscribe to our action lists and to take action yourselves by contacting your members of Congress when asked because it certainly is important that quality standards be maintained in the current standard that they are now so right now though we're going to continue on with questions about these regulations and what we are being told from CMS is that until they have been directed to change direction they are moving forward full steam ahead with implementing these regulations and so we have been also continuing our work in advocacy around providing issue briefs and training and additional things to advocates and consumers about these regulations so let's now turn to some questions because lots have been coming in so there were a number of questions related to transfer and discharge issues particularly around the ombudsman program notifications and Eric did address that some and I guess the other thing we'll say about that as CMS is very aware of some of the challenges that are being addressed with that issue right now and is working on its guidance and are looking to actually send out the guidance fairly quickly since they know that Ombudsman programs are being inundated with notifications and there's confusion among facilities and also programs as to what needs to be sent to the Ombudsman so okay let's go to a couple other of these questions so one question relates to whether sorry about that one question with respect to antipsychotics and psychotropic medications is around whether whether the rules reply to antipsychotics for hospice patients and I don't believe the rules specifically talk about that but does anyone want to address that question I don't think there's any this is Toby I don't think there's anything separate in the regulations that says Hospice residents who are in hospice either do or don't get antipsychotics I don't think there's anything separate in there maybe something will come up in the in the guidance documents but I don't think in the regulations does anybody else think the regulations have something to say about that not that I'm aware of no I don't think so either okay another question is how does a resident challenged the assertion that their condition or behavior presents a danger to others as we think about the reasons for a transfer or discharge well this is Eric nothing's changed there that you just poop you put out evidence that the person is not a danger or maybe flip it in and demand that the facility presents their evidence that supposedly shows that the person is a danger in my experience a lot of these are overblown that you've got it's a resident with who's physically frail with Alzheimer's that it lashes and swings his or her arms around a little bit I may be that sort of thing I think the point is to put the onus back on the facility to back up these allegations to emphasize that facilities are set up or should be set up to care for for people with with dementia and also to look back on the care planning process that often times over there's a deficit there the first response in all these situations should be care planning to try to figure out to find solutions and facility instead move to involuntary transfer discharge first that's getting things back backwards uh-huh thanks Eric there's been a couple of attention oh go ahead Robin I was just going to add that the requirements for training around dementia well the phrase it as dementia management I think should help in defending some of these proposed transfer discharges so hopefully that's another term will that people think is good right thanks Robin there have been a couple questions about the assessment and care planning process around residents rights to exercise preferences whether it be the right to refuse treatment or also prep answers that the facility does not agree with such as maybe diet or smoking or or other types of references so would any of you want to address that question around referent resident preferences this is Eric I think the residents right still are in play so I I know that I decided the language is said that there doesn't have to be a reasonable accommodation if there is a endangerment risk but that that doesn't change the right of the resident to refuse treatment so that so and now with Trump in that situation that's that that's the right that would take precedence in in that situation and regarding some of the other situations it is reasonable accommodation and when you talk about what's reasonable there's some balancing there but in in general its if the resident has a right to to do things and if the only negative consequences are to that resident that should be within the residence control not the facilities now if the residence choices affect other residents negatively or an undue burden on the facility in some way that's something else but if the purportedly negative consequences fall only on that particular resident in general that's a decision that the resident can make thanks Eric there have been a couple questions also about the question of discharge for non-payment and how it applies to a resident who is competent and takes care of their own finances and just refuses to pay their share of their bill well if you refuse to pay you lose that definitely sure the short answer and yeah that's it that if you if you don't pay it's non-payment yeah the question about the issue related to hospital dumping there have been a couple questions about facilities that refuse to accept a resident back from a hospital stay yeah this is Eric agenda the difficulty here is in the mechanics because if the rest is in the hospital that the clock starts ticking and if the licensing agency isn't prepared to take quick aggressive steps then things are very difficult for the resident there's a handful of states California is actually one of them that specifically have administrative hearing procedures to deal with this situation it really expedited procedures but in the absence of that it is can be difficult for residents and their advocates and you need to hustle and complain and agitate and get the licensing agency on your side or file a lawsuit and get a temporary restraining order or enlist the hospitals to push back against this and you know object to essentially being a dumping ground or some combination of all those things but that being said I think we all recognize that the logistics of it are are difficult the regulation is not self-enforcing we've got more tools than we then we had six months ago but it still really takes some work when you've got these situations uh-huh thanks Eric so we are at the end of our hour for today I will say that for the topics that we cover today issue briefs have been prepared by our three organizations they've been loaded into your control panels for the webinar and can be downloaded from there but we'll also send around and to all participants links to the issue briefs as well as the recording of today's presentation and the PowerPoint that's available for today and hopefully the issue briefs will address a number of the questions that have come up feel free to call or email us directly with your questions and we'll be happy to try and help you as best we can and will be continuing also to release additional resources and information over the next few months on different areas of the regulation and different topics so with that we'll close for today I'd like to thank Eric Toby and Robin for your excellent presentations and we'll look forward to talking with you next time so with that we'll close today's today's call and Chloe