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Maintaining Compliance under PDPM by Rhiannon Hunter, VP of Compliance and Denials

Now that the Patient Driven Payment Model (PDPM) is here, you might be asking yourself how this change in reimbursement will affect the requirements of participation as a Medicaid/Medicare provider. The good news is this: NONE. Really?? Really!!! PDPM is a change in the Medicare reimbursement model, not the rules and regulations required to maintain compliance. Oh, CMS, if it were only that simple….

Our industry is almost three years into the Mega-Rule Requirements of Participation for Medicaid and Medicare, with the third (and final stage) being implemented next month. Before you worry about this third stage, let’s ensure you’ve implemented the first two stages. Survey results continue to vary, but industry leaders report the following examples as top citations from the first two stages:


· (F610)-Facilities are failing to investigate patient allegations of abuse and/or neglect.


· (F-757)-Facilities are failing to have an appropriate diagnosis documented with orders for antibiotics, without monitoring side effects.


· (F-758)-Facilities are failing to document non-medication interventions before providing PRN psychotropic medications secondary to behaviors. This includes hospice use.


· (F-689)-TOP CITATION!!! This citation covers a multitude of potential tags; not following care plan, failing to complete a full assessment following a fall, or leaving a medication cart open and unattended.


· (F-881)-Facilities are failing to monitor antibiotic use, log infections that require antibiotics, follow criteria for infection determination and/or failing to include the antibiotics stewardship outcomes in their facility QAPI program.


So what can we expect from Stage 3? Let’s take a look!


QAPI Plans: All subparts, including your process improvement plan (PIP) are due. Your facility must have designed program feedback, data systems and monitoring programs with written QAPI policies to support each of these areas reported in your PIP.


Infection Preventionist: Your facility should have assigned this role to act as a designated active participant on your quality assurance committee. This individual must have specific qualifications as outlined in the Rules of Participation which includes specialized training in infection control and prevention practices.


Trauma-Informed Care: Your facility must ensure that residents who are trauma survivors receive culturally competent trauma informed care that is in accordance with professional standards of practice. This must be a person-centered care plan with interventions that meet the residents’ need to continue to reduce trauma or other traumatic stressors. Your facility must have documentation and sufficient training in place targeting staff competency in this area.


Compliance and Ethics: Written procedures and training of staff to reasonably reduce the prospect of criminal, civil and administrative violations and promote quality of care must be in place.


Centralized Call System: A resident call system must be placed by the residents’ bedside that goes directly to a staff member or to a centralized call system.


Training Requirements: Ongoing training is KEY. This training must be provided for new and existing staff, volunteers, as well as contracted staff. Training should include effective communication strategies, resident right training, QAPI, infection control, new compliance and ethics and performance evaluations and competencies.


At Turning-Point, we understand the time constraints of implementing these requirements while running the day to day operations of your facilities. However, these are mandatory to maintain your licensure and must be made top priority. Make sure that you are equipped to maintain these regulatory compliance measures or talk to someone who can help you! Your patients and operating licenses depend on it!


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