Navigating the New Rule: Changes to Quality of Care Regulations

Dr. Andy Kramer
Provider Magazine – June 2017

At the core of changes to the quality of care regulations are two central themes: 1.) the need to care for more severely ill and frail elders, either during the post-acute period or during long term stays in nursing centers; and 2.) the Centers for Medicare & Medicaid Services (CMS) strategic shift toward person-centered care that explicitly weighs residents’ choices and preferences in all care decisions.

The revised regulations articulate a higher level of clinical competence and service and a more person-centered emphasis, reflecting how the role of nursing centers has evolved and is expected to continue evolving.

The overall Quality of Care domain (regulation 42 CFR §483.25) applies to all treatment and services provided to nursing center residents. The new regulations, however, have been enriched with greater specificity and rigor for all clinical services, with definite updates in the following areas:

(a) Vision and hearing

(b) Skin integrity

(1) Pressure ulcers

(2) Foot care

(c) Mobility

(d) Accidents

(e) Incontinence

(f) Colostomy, ureterostomy, or ileostomy care

(g) Assisted nutrition and hydration

(h) Parenteral fluids

(i) Respiratory care, including tracheostomy care and tracheal suctioning

(j) Prostheses

(k) Pain management

(l) Dialysis

(m) Trauma-informed care

(n) Bed rails

There are three central themes that appear throughout the revised Quality of Care regulation and the related Interpretive Guidance published by CMS. Treatment and care must be based on the following: professional standards of practice; the comprehensive, person centered care plan; and residents’ choices.

This balancing of professional standards with resident perspectives from the person-centered care plan and resident choices acknowledges the focus on individuals and their preferences.

The concept of providing care in accordance with professional standards of practice is nothing new. However, balancing this with a comprehensive and person-centered care plan and ongoing resident’s choices requires all nursing center staff to ask and learn more about each person and the care decisions they would make in different circumstances.

Truly understanding a resident’s choices requires a more intimate level of communication than some providers may be used to.

For example, most providers understand the importance of conducting pain assessments to identify and minimize a patient’s pain and discomfort. But what about understanding whether a resident’s goals for pain management are being met? From the resident’s perspective, do the benefits of the pain treatment outweigh any side effects he or she may be experiencing, such as sedation? Some residents may choose to live with more pain in exchange for greater alertness, or avoidance of other side effects. Others may wish to consider alternative treatment options.

As mentioned in the February 2017 Quality Forum on person-centered care, applying a person-centered philosophy requires a take-charge approach to eliciting resident (or resident representative) input and concerns at every stage of care. This extends to each of the Quality of Care areas listed above. For each of those areas, a question to consider is whether the resident is truly empowered and engaged as an active partner in his or her care.