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Embrace the Future of Infection Control: Join the National Infection Prevention Forum<p>​<img src="/Articles/PublishingImages/740%20x%20740/0920_News2.jpg" class="ms-rtePosition-1" alt="" style="margin&#58;5px;width&#58;190px;height&#58;190px;" />In today’s rapidly evolving health care landscape, the significance of effective infection prevention in long term care is paramount. Recognizing this, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) launched the <a href="https&#58;//www.ahcancal.org/Quality/Clinical-Practice/Pages/default.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">National Infection Prevention Forum (NIPF)</a> in early 2023, supported by a grant from the Centers for Disease Control (CDC)/Project Firstline. The forum has attracted over 1,100 dedicated infection preventionists from diverse long term care organizations across the United States in its inaugural year, marking a significant stride in our collective journey to elevate health care standards.</p><h3>A Unique Platform for Collaboration and Learning</h3><p>The NIPF distinguishes itself through its collaborative and dynamic nature. It provides a space where infection preventionists in long term care settings can ask critical questions, exchange innovative insights, and learn from both peers and esteemed experts in infection control. Witnessing the rapid, informed responses to inquiries, often bolstered by evidence-based citations, underscores the forum's commitment to factual and practical knowledge-sharing. This vibrant interchange not only provides immediate answers but also fosters an environment for continuous learning and professional development.</p><h3>Expertise and Guidance at Your Service</h3><p>A key feature of the NIPF is the involvement of a rotating panel of infection control experts from the Association for Professionals in Infection Control and Epidemiology (APIC). These seasoned professionals monitor discussions, offering timely assistance and enriching conversations with their expertise. Additionally, the forum provides a unique opportunity to escalate complex queries to CDC experts, ensuring members receive clear advice.</p><h3>Expanding Horizons with New Initiatives in 2024</h3><p>Looking ahead to 2024, the NIPF is excited to introduce several new features designed to further support infection prevention work and offer a robust networking hub for professionals.<br></p><ul><li><strong>Hot Topics&#58;</strong> Stay abreast of current issues with concise one-page briefs, tackling topics like dual vaccine administration and the utilization of vaccine information sheets.</li><li><strong>Clinical-Based Scenarios&#58;</strong> Engage with interactive multiple-choice questions to enhance clinical decision-making skills, complemented by comprehensive insights from subject matter experts.</li><li><strong>Tips to Help You&#58; </strong>Access quick-reference resources designed in response to common citation issues, providing practical tips to elevate care quality and prepare for state surveys.</li></ul><p></p><p></p><h3>Empowering Through Knowledge Sharing and Community Building</h3><p></p><p>In the coming months, NIPF members can anticipate&#58;<br></p><ul><li><strong>Educational Video Interviews&#58;</strong> Gain perspectives from experienced infection preventionists and interdisciplinary team members, showcasing the integral role of infection prevention in team-based, person-centered care practices.</li><li><strong>Ask the CDC Expert Thread&#58;</strong> Utilize this direct line to CDC professionals for clarifications and insights on complex topics.</li></ul><h3>Your Participation Matters</h3><p><img src="/PublishingImages/Headshots/DavidGifford_2022.jpg" alt="David Gifford, MD" class="ms-rtePosition-2" style="margin&#58;5px;" />NIPF is more than a forum. It's a community where every voice is valued, and every question can lead to new understanding and improved practices. We invite you to join this thriving network of infection preventionists committed to advancing infection control in long term care. Whether sharing your expertise, seeking answers, or engaging in rich discussions, your involvement is crucial to our collective success.</p><p>Visit <a href="https&#58;//www.ahcancal.org/NIPF" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">ahcancal.org/NIPF</a> or contact <a href="mailto&#58;ltc-nipfhelp@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">ltc-nipfhelp@ahca.org</a> to learn more about joining. &#160;<br><br><em>David Gifford, M.D., M.P.H., is the chief medical officer of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).</em><br></p>2024-02-29T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/0920_News2.jpg" style="BORDER&#58;0px solid;" />Infection ControlDavid Gifford, M.D., M.P.H.NIPF is more than a forum. It's a community where every voice is valued, and every question can lead to new understanding and improved practices.
Surviving the Financial Whirlpool<p>​<img src="/Articles/PublishingImages/740%20x%20740/whirlpool.jpg" class="ms-rtePosition-2" alt="" style="margin&#58;5px;width&#58;200px;height&#58;200px;" />​The most effective way to survive a whirlpool is to not get caught in the whirlpool in the first place. The mistake that kayakers and canoers make is that they believe that they can pass over the edge of vortex and not get pulled in.&#160;</p><p>But it happens so quickly that you can’t escape. It’s hard to say where the outer edge of the current is. If we use the whirlpool analogy, in the senior care river, the general edge is a financial one. It is the energy drain that pulls you under.</p><p>The financial strains will generally impact staffing and safety in quick succession. In response, institutions will do all they can to reduce the largest single financial variable&#58; payroll.&#160;</p><p><strong>The Constant Spinning of the Revolving Door of the Employee Entrance Starts the Whirlpool.</strong> While a quick fix is reducing the headcount, this rarely can be a sustainable strategy. Running the smallest possible staffing model results in shift fatigue, which then shows up as work injuries and burn-out. In dementia care units, residents who are faced with a new caretaker on a constant basis are more likely to display aggressive behaviors putting the replacement caretaker at an increased risk of resident violence-based injury.</p><p>How can you tell if this is happening at your facility? The information is tracked by your workers’ compensation carrier or third-party administrator can give you the answer. Your broker can also give you insights as to whether the number of assaults at your facilities outpaces the industry.</p><p>What about your turnover rate? When someone quits, what does it cost in overtime costs? How about the costs associated with finding a replacement employee and training that employee? Is your organization developing a reputation as a place skilled professionals should avoid? The revolving door to the employee’s entrance creates the swirl that starts the whirlpool that ends with a reputation that begs for investigations by state and federal authorities and litigation by families of those in the facility.</p><p>The speed of the downward pull of employee attrition is further accelerated by minimizing safety initiatives. Staff shortages too often result in a lack of time resources to require and provide anything beyond the minimal safety training. This in turn brings the employees back around the downward whirlpool where the lack of training results in injuries, that results in shortages in headcount, that results in burnout.&#160;</p><p><strong>The Heaviest Object Sinks the Fastest and Creates the Greatest Downward Pull.</strong> When I perform risk assessments at a care facility, I am not privy to the organization’s finances. I do not have to be. Just as someone can look at all the dents on a car to determine that the driver is probably unsafe, care facilities have their telltale signs. Signs might include an inadequate number of Hoyer and bariatric patient lifts on each floor, hallways lined with lifts and beds with signs stating that the equipment is out of service awaiting repair, or a storage area littered with broken equipment. About now, employee exhaustion is setting in, and the fight to get out of swirling water is starting to fail.&#160;</p><p><strong>The Smallest, Deepest Swirls Are the Most Powerful Killers.</strong> The deeper you are drawn into a whirlpool, the less your chances of survival. Perhaps it is the additional financial strain of increased insurance costs due to the claim history from too many work-related injuries or slip-and-fall claims due to inadequate maintenance of the facility. Perhaps it is the nonrenewal of your malpractice coverage (errors and omissions) that is proving to be the tight swirl of water. Perhaps it is the state regulatory body or the Centers for Medicare &amp; Medicaid Services showing up at your door due to a complaint. Maybe it is the sheriff serving you with a lawsuit or possibly being the lead story on the nightly news.&#160;</p><p><a href="http&#58;//www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/SNF%20Survey%20Mid-Year%202023.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">The 2023 AHCA Mid-Year State of the Nursing Home Industry report</a> highlights that the two stressors for nursing homes are staffing and financial pressures. New proposed federal mandates will add to the downward pressure, which already has many nursing homes fearing for their ability to survive at the current pace.</p><p>The most common approach to survival seems to be reducing the number of beds or services. In doing so, does it successfully reduce the expenses, or does it have an equal or greater reduction in cashflow? H.L. Menken observed that, “for every complex problem there is an answer that is clear, simple, and wrong.” As we look at the current crisis in the industry, a solution that screams out is reducing the bed count. By doing so, you can reduce the headcount. Since workers’ compensation is based in part on payroll, the reduction in payroll will result in a reduction in premiums.</p><p>Clear, simple, and wrong.</p><p>If the reduction in payroll results in a straining of the workforce, the increase in the frequency and severity of your work-related claims history will increase the insurance rate, the amount paid per $100 of payroll. Your savings may not be proportionate to the payroll savings. A reduction in the bed count may reduce the number of people visiting the facility daily, but you still have to provide the same number of slip mats, the same number of housekeepers, and the same expenses of security, fire, and property maintenance activities. Even if you close off a wing or two of your facilities, you will still have to maintain them and, frankly, you will not see much, if any, savings in property insurance without expert guidance.</p><p><img src="/Articles/PublishingImages/2024/Jeff-Marshall.jpg" alt="Jeff Marshall" class="ms-rtePosition-2" style="margin&#58;5px;" />In kayaking and canoeing we learn that the three best ways to avoid death by whirlpool is to, first and foremost, avoid the whirlpool. Second, keep your boat from capsizing, and third, always wear your personal flotation device. For our industry, little is different. Perform real root-cause analysis to identify those issues that are pulling you into the whirlpool so that you can avoid them. Understand the forces that are trying to capsize your vessel and provide everyone in the boat with proper safety equipment and training.<br><br><em>Jeff Marshall is a kayaker and a risk and claims consultant for care providers, carriers, and third-party administrators focusing on nursing homes and assisted living facilities. He can be reached at <a href="mailto&#58;IManageRisk4U@gmail.com" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">IManageRisk4U@gmail.com</a>.</em><br></p>2024-02-27T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/whirlpool.jpg" style="BORDER&#58;0px solid;" />CaregivingJeff MarshallThe best ways to avoid death by whirlpool is to perform real root-cause analysis to identify those issues that are pulling you into the whirlpool so that you can avoid them. Understand the forces that are trying to capsize your vessel and provide everyone in the boat with proper safety equipment and training.
Deficiencies at F742: Emerging Trends in the Enforcement of New Regulations<p>​In our <a href="/Articles/Pages/Deficiencies-at-F699-Emerging-Trends-in-the-Enforcement-of-New-Regulations.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">last article,</a> we explored emerging patterns in deficiencies at F699. In this article, we explore trends in deficiencies at F742. The relationship between citations at F699 and F742 is important because many of the citations given at F699 could have resulted in additional citations at F742. Recall that guidelines at F699 instruct surveyors to explore additional F-tags if concerns are found at F699, including tag F742. Identifying a deficiency at F699 may be related to being cited at F742. In fact, if a facility is cited at F699, there is roughly a 41 percent chance that the facility will also be cited at F742. Hence the importance of considering emerging trends in deficiencies at F742.</p><p>Like the <a href="/Articles/Pages/Deficiencies-at-F699-Emerging-Trends-in-the-Enforcement-of-New-Regulations.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">first article</a> in this series, we will discuss deficiencies obtained by SNFs in the CMS database in general terms, and specific deficiency instances with precise details (as outlined in the facility’s CMS-2567) will not be used/described as this could inadvertently lead to the identification of the facilities that received deficiencies. As the intention of this article is to learn about deficiency patterns and develop strategies to achieve and maintain compliance, the more general approach was felt to be the most useful. Again, for those readers who would like greater details, download <em>Full Texts of 2567 Statements of Deficiencies</em> directly from the CMS website and feel free to explore deficiencies in your area of interest. &#160;</p><h3>F742&#58; Treatment/Services for Mental/Psychosocial Concerns</h3><p>This regulation, along with its investigative protocol and deficiency categorization (guidance to surveyors on how to cite deficiencies), which became effective in October 2022, requires that&#58;</p><ul><li>§483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that—§483.40(b)(1) A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being.1</li></ul><h3>Patterns and Causes of Deficiencies at F742</h3><p>From 2022 and 2023, Missouri skilled nursing facilities received the highest number of deficiency citations at F742 (57 facilities in the state received deficiency citations), followed by Ohio (41 citations), Illinois (31 citations), Colorado (30 citations), and Pennsylvania (25 citations). It is unknown why these state facilities received the most deficiencies. More time is needed to learn about the reasons for these patterns of deficiency.&#160;</p><p>Vicarious learning is useful when it comes to survey deficiencies—that is, learning about the reasons for deficiencies in other facilities enables us to examine the practices, polices, and procedures in our own facility. <br><a href="/Articles/Documents/2024/Table%201%20Deficiencies-F7422.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank"><img class="ms-asset-icon ms-rtePosition-4" src="/_layouts/images/icpdf.png" alt="" />Table 1</a> lists a broad description of issues that were identified on the CMS 2567 for each facility that received deficiencies at F742, along with some thoughts about potential ways to prevent deficiencies. </p><h3 style="text-align&#58;center;"><img src="/Articles/PublishingImages/2024/Table%201%20Deficiencies-F742.jpg" alt="" style="margin&#58;5px;" /><img src="/Articles/PublishingImages/2024/Table%201%20Deficiencies-F7422.jpg" alt="" style="margin&#58;5px;" /><br></h3><h3>Implications for Older Adults with Mental Health Issues</h3><p><span><em><img src="/Articles/PublishingImages/2024/Timothy-Legg.jpg" class="ms-rtePosition-2" alt="" style="margin&#58;5px;" /></em></span>The emerging patterns of deficiencies for both 699 and F742 are resulting in conversations among some owners/operators of skilled nursing facilities considering whether they will admit residents with histories of trauma or mental health needs, especially those facilities in mental health provider deserts (defined as geographic locations where there is a paucity of mental health providers). Still, other high-performing nursing homes may decide not to admit residents with behavioral health issues because of the potential impact on survey outcomes and the Five-Star Quality Rating System. While this may sound far-fetched, a 2018 study concluded just that—residents who had been diagnosed with depression or anxiety had lower access to five-star nursing homes when compared to no behavioral health diagnoses.2 These disparities were not limited to patients with serious mental illness but were also associated with patients who had substance abuse—a problem that continues to worsen in America.&#160; <em><br></em></p><p><em>Timothy Legg is a board-certified gerontological and psychiatric/mental health nurse practitioner, licensed psychologist, licensed professional counselor, and state-licensed/nationally certified nursing home administrator. In addition to his private practice, he provides direct care and services to older adults in nursing homes as well as consultative services to nursing homes in Pennsylvania. Legg is an approved directed in-service provider by the Pennsylvania Department of Health. </em><br></p><div class="ms-rteElement-QuoteSpeaker">References<br>1.&#160;&#160; &#160;United States Department of Health and Human Services. (2023). Revisions to State Operations Manual (SOM), Appendix PP. <a href="https&#58;//www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R211SOMA.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https&#58;//www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R211SOMA.pdf</a> <br>2.&#160;&#160; &#160;Temkin-Greener, H., Campbell, L., Cai, X., Hasselberg, M. J., &amp; Li, Y. (2018). Are post-acute patients with behavioral health disorders admitted to lower-quality nursing homes? American Journal of Geriatric Psychiatry, 26(6), 643-654. <br>3.&#160;&#160; &#160;Stahl, S. (2021a). <em>Stahl’s essential psychopharmacology (5th ed).</em> Cambridge. <br>4.&#160;&#160; &#160;Stahl, S. (2021b). <em>Stahl’s essential psychopharmacology prescriber’s guide (7th ed.). </em>Cambridge. <br></div>2024-02-15T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/computer.jpg" style="BORDER&#58;0px solid;" />ClinicalTimothy LeggVicarious learning is useful when it comes to survey deficiencies—that is, learning about the reasons for deficiencies in other facilities enables us to examine the practices, polices, and procedures in our own facility.
Deficiencies at F699: Emerging Trends in the Enforcement of New Regulations<p><img src="/Articles/PublishingImages/740%20x%20740/senior_man_nurse.jpg" class="ms-rtePosition-2" alt="" style="margin&#58;5px;width&#58;260px;height&#58;184px;" />​Revisions to the state operations manual, appendix PP (guidance to surveyors), were promulgated in 2016 and ultimately scheduled for implementation in 2017 and 2019. However, the pandemic delayed the implementation of these revisions. The revisions were implemented in three phases, with the most recent revision to phase 3 implementations occurring in February 2023.<sup>1</sup> One of the major changes in the revised regulations included tags for which many skilled nursing facilities were not adequately prepared to address, specifically F699, which addresses the provision of “trauma-informed care.”</p><p>While some advocacy groups have pointed out that skilled nursing facilities have had six years to prepare for the implementation of these regulations, the reality is that meeting these new regulatory requirements has been far from easy. The revised regulations require skill sets not ordinarily found among skilled nursing facility employees for various reasons. Procuring the necessary specialty services to address the requirements of these regulations is particularly problematic not only because America is amid a mental health provider shortage<sup>2, 3</sup> but also because mental health issues among nursing home residents are increasing, placing an even greater burden on an already stressed mental health system. Behavioral health disorders are estimated to impact between 65 to 90 percent of nursing home residents.<sup>4</sup><br></p><p>In this first article of a two-part series, we will review the requirements at F699, what is known about the emerging patterns of deficiencies being cited under this regulation, and, most importantly, consider strategies skilled nursing facilities can use to achieve compliance with the requirements of F699. In the exploration and presentation of publicly available CMS data for preparing these articles, deficiencies were “generalized” without providing specific details (as outlined in the facility’s CMS-2567), as this could inadvertently lead to the identification of the facilities that received deficiencies. While this information is certainly available in the public domain, the intention of these articles is educational—to learn about deficiency patterns at F699 and not single out any facility. Readers wanting more specific details about these citations can download <em>Full Texts of 2567 Statements of Deficiencies</em> directly from the CMS website.</p><h3>Trauma-Informed Care and the Difficulty in Providing It</h3><p>The regulation at §483.25(m) F699 requires that the facility “ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.”<sup>5</sup><br></p><p>While the text of the regulation appears straightforward, it fails to account for the many intricacies involved in the competent provision of trauma-informed care. For instance, how to assess trauma, how to develop trauma-informed treatment plans, treating trauma which depends on the availability of mental health providers within the facility to provide care and services to residents with a history of trauma. Although requirements at F850 demand qualified social workers in a facility that has 120 beds or more<sup>6</sup> (although state laws may be more stringent), there are no requirements for social workers in facilities with fewer than 120 residents. Additionally, coursework in undergraduate social work programs may not adequately address the intricacies of psychological trauma and its treatment. Similarly, nursing education programs require only brief experiences in dealing with individuals with diagnosed mental illness, typically through clinical rotations at inpatient psychiatric units, and as such, do not adequately address psychological trauma. The absence of these educational experiences results in facilities that are challenged regarding “who” can adequately address resident needs.</p><p>In addition to the paucity of staff in the nursing facility skilled in providing trauma-informed care, nurse aide training program curricula typically do not address trauma. A recent survey that I undertook of several nurse aide textbooks failed to reveal any content related to trauma-informed care. While it is tempting to say that this content requires the intervention of the staff development professional, nursing home professionals employed in staff development are typically registered nurses (who, again, have not received training in trauma-informed care). The inadequacy of behavior health (BH) education and psychiatric training of nursing home staff is “associated with subpart provision of BH services in this care setting.”<sup>7</sup></p><p>Facilities are limited in terms of their knowledge, skills, and abilities to provide trauma-informed care despite regulations requiring it. Exploration of evolving trends in deficiencies received at F699 through available CMS survey data shows that the number of deficiencies at F699 has increased from 11 in 2022 to 145 in 2023. <br></p><h3>States Most Frequency Cited and What Deficient Practices Were Found</h3><p>From 2022 to 2023, Pennsylvania facilities received the most deficiencies at F699 (33 different facilities in the state received deficiency citations), followed by Michigan (14 different facilities in the state received deficiency citations), Massachusetts (12 different facilities in the state received deficiency citations), and Minnesota (11 different facilities in the state received deficiency citations). The scope and severity of deficiencies at F699 across all states ranged from levels “D” through “L,” with most deficiencies in 2023 at the “D” level.</p><p style="text-align&#58;left;">Examination of the circumstances that led to deficiencies at F699 is useful as it will provide your team with information that they can use to assess practices at your facility. <a href="/Articles/Documents/2024/Table%201%20Deficiencies.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank" title="Deficiencies at F699 and Strategies to Prevent These Types of Deficiencies in Your Facility"><img class="ms-asset-icon ms-rtePosition-4" src="/_layouts/images/icpdf.png" alt="" />Table 1</a> represents an amalgamation of the issues that were identified on the CMS 2567 for each facility that received deficiencies at F699. They are reported as broad themes, along with suggestions for preventing deficiencies. </p><h3 style="text-align&#58;center;"><img src="/Articles/PublishingImages/2024/Table%201%20Deficiencies.jpg" alt="" style="margin&#58;5px;width&#58;672px;" /><br></h3><h3>Mental Health Provider Shortage and F699</h3><p>Nearly half of all Americans will have a mental health (including substance use) disorder in their lifetime.<sup>8</sup> Behavioral health disorders impact between 65–90 percent of nursing home (NH) residents.<sup>9</sup> Approximately 45 percent of Americans (approximately 150 million people) live in a mental health shortage area.<sup>10</sup> These figures do not take into consideration the fact that the population of older adults with Alzheimer’s disease is projected to rise to 13.8 million by 2060 from the current estimated rate of 6.7 million.<sup>11</sup> Data specific to the number of nursing homes in mental health shortage areas is not available; however, facilities that I have provided consultation to in Pennsylvania and New York have reported multiple challenges with finding mental health providers.</p><p>The number of professionals willing to provide care in nursing homes is problematic. Psychiatrists, for instance, are the “least likely” medical specialty willing to accept Medicare because of inadequate reimbursement.<sup>12</sup> Between 2011 and 2019, the number of psychiatric/mental health nurse practitioners willing to treat Medicare patients increased by 160 percent.<sup>13</sup> Unfortunately, their use in many nursing homes is limited by restrictive state laws governing the independent practice of nurse practitioners and CMS restrictions on “non-physician practitioners.” Specific to the psychotherapy services that can mitigate mental health issues, until 2023, only licensed psychologists, clinical nurse specialists, and licensed social workers were able to provide services to Medicare recipients.</p><p><span><em><img src="/Articles/PublishingImages/2024/Timothy-Legg.jpg" alt="Timothy Legg" class="ms-rtePosition-2" style="margin&#58;5px;" /></em></span>However, effective January 1, 2024, both licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) will be covered by Medicare Part B to receive reimbursement for providing care to Medicare recipients.<sup>14</sup> This new infusion of therapists eligible for reimbursement for services can potentially increase the number of mental health professionals available to help both residents and facilities and may be able to help prevent deficiencies at F699. <br><br><em>Timothy Legg is a board-certified gerontological and psychiatric/mental health nurse practitioner, licensed psychologist, licensed professional counselor, and state-licensed/nationally certified nursing home administrator. In addition to his private practice, he provides direct care and services to older adults in nursing homes as well as consultative services to nursing homes in Pennsylvania. He is an approved directed in-service provider by the Pennsylvania Department of Health. <br></em></p><p><em><br></em></p><div class="ms-rteElement-QuoteSpeaker"><span class="ms-rteFontSize-2">References</span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">1.&#160;&#160; &#160;United States Department of Health and Human Services. (2023). Revisions to State Operations Manual (SOM), Appendix PP. <a href="https&#58;//www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R211SOMA.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https&#58;//www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R211SOMA.pdf</a> </span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">2.&#160;&#160; &#160;The Commonwealth Fund. (2023). Understanding the U.S. Behavioral Health Workforce Shortage. <a href="https&#58;//www.commonwealthfund.org/publications/explainer/2023/may/understanding-us-behavioral-health-workforce-shortage" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https&#58;//www.commonwealthfund.org/publications/explainer/2023/may/understanding-us-behavioral-health-workforce-shortage</a></span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">3.&#160;&#160; &#160;Tampi, R. R. (2023). Geriatric psychiatry in the US. <em>Psychiatric Times,</em> 40(12), 20.</span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">4.&#160;&#160; &#160;Orth, J., Li, Y., Simning, A., Temkin-Greener, H. (2019). Providing behavioral health services in nursing homes is difficult&#58; Findings from a national survey. <em>Journal of the American Geriatrics Society,</em> 67(8), 1713-1717. doi&#58; 10.1111/jgs.16017. </span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">5.&#160;&#160; &#160;United States Department of Health and Human Services. (2023). Revisions to State Operations Manual (SOM), Appendix PP. <a href="https&#58;//www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R211SOMA.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https&#58;//www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R211SOMA.pdf </a></span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">6.&#160;&#160; &#160;United States Department of Health and Human Services. (2023). Revisions to State Operations Manual (SOM), Appendix PP. <a href="https&#58;//www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R211SOMA.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https&#58;//www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R211SOMA.pdf </a></span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">7.&#160;&#160; &#160;Orth, J., Li, Y., Simning, A., Temkin-Greener, H. (2019). Providing behavioral health services in nursing homes is difficult&#58; Findings from a national survey. <em>J</em><em>ournal of the American Geriatrics Society,</em> 67(8), 1713-1717. doi&#58; 10.1111/jgs.16017. </span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">8.&#160;&#160; &#160;The Commonwealth Fund. (2023). Understanding the U.S. Behavioral Health Workforce Shortage. <a href="https&#58;//www.commonwealthfund.org/publications/explainer/2023/may/understanding-us-behavioral-health-workforce-shortage" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https&#58;//www.commonwealthfund.org/publications/explainer/2023/may/understanding-us-behavioral-health-workforce-shortage</a></span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">9.&#160;&#160; &#160;Orth, J., Li, Y., Simning, A., Temkin-Greener, H. (2019). Providing behavioral health services in nursing homes is difficult&#58; Findings from a national survey. J<em>ournal of the American Geriatrics Society,</em> 67(8), 1713-1717. doi&#58; 10.1111/jgs.16017. </span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">10.&#160;&#160; &#160;Kaiser Permanente, Institute for Health Policy. (2023). Addressing the Mental Health Workforce Shortage. <a href="https&#58;//www.kpihp.org/blog/addressing-the-mental-health-workforce-shortage/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https&#58;//www.kpihp.org/blog/addressing-the-mental-health-workforce-shortage/ </a></span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">11.&#160;&#160; &#160;Tampi, R. R. (2023). Geriatric psychiatry in the US. <em>Psychiatric Times,</em> 40(12), 20.</span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">12.&#160;&#160; &#160;Bishop, T. F., Press, M. J., Keyhani, S., &amp; Pincus, H. A. (2014). Acceptance of insurance by psychiatrists and the implications for access to mental health care. <em>JAMA Psychiatry,</em> 71(2), 176-181.</span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">13.&#160;&#160; &#160;Gerlach, L. B. &amp; Maust, D. T. (2023). Falling off a cliff&#58; Psychiatric care of nursing home residents. <em>Journal of the American Geriatrics Society,</em> 71(4), 1014-1016.</span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">14.&#160;&#160; &#160;Department of Health and Human Services. (2023). 2 CFR Parts 405, 410, 411, 414, 415, 418, 422, 423, 424, 425, 455, 489, 491, 495, 498, and 600 CMS-1784-F RIN 0938-AV07 Medicare and Medicaid Programs; CY 2024 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program. Retrieved from <a href="https&#58;//public-inspection.federalregister.gov/2023-24184.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https&#58;//public-inspection.federalregister.gov/2023-24184.pdf</a> </span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">15.&#160;&#160; &#160;Stahl, S. (2021a). <em>Stahl’s essential psychopharmacology</em> (5th ed). Cambridge. </span><br class="ms-rteFontSize-2"><span class="ms-rteFontSize-2">16.&#160;&#160; &#160;Stahl, S. (2021b). <em>Stahl’s essential psychopharmacology prescriber’s guide</em> (7th ed.). Cambridge. <br></span></div><div class="ms-rteElement-QuoteSpeaker"><span class="ms-rteFontSize-2"><br></span></div><div class="ms-rteElement-QuoteSpeaker" style="text-align&#58;center;"><span class="ms-rteFontSize-2"><strong class="ms-rteForeColor-2">More Information&#58;</strong><br></span></div><div class="ms-rteElement-QuoteSpeaker" style="text-align&#58;center;"><span class="ms-rteFontSize-2"><a href="https&#58;//ahcapublications.org/products/ready-for-preorde-the-long-term-care-survey-phase-3-second-edition" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank"><img src="/Articles/PublishingImages/2024/LTCSurvey_300x250.png" alt="" style="margin&#58;5px;width&#58;200px;height&#58;167px;" /></a>&#160; &#160; &#160; &#160; &#160; &#160; <a href="https&#58;//educate.ahcancal.org/products/trauma-informed-care-training#tab-product_tab_overview" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank"><img src="/Articles/PublishingImages/2024/ahcancalED_TIC_banner_300x250.png" alt="" style="margin&#58;5px;width&#58;200px;height&#58;167px;" /></a><br></span></div>2024-02-13T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_man_nurse.jpg" style="BORDER&#58;0px solid;" />ClinicalTimothy LeggOne of the major changes in the revised regulations included tags for which many skilled nursing facilities were not adequately prepared to address, specifically F699, which addresses the provision of “trauma-informed care.”

 

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