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DON’T STOP BELIEVINGDenise Spihlman, LCSW, PRSD, CDP

Outcome Services of I l l inois

denise@outcomeservices.com618-210-7469

THANK YOU FOR BEING A HEALTHCARE HERO TO SO MANY

PEOPLE!

Thank you for your hard work, your dedication, and putting the needs of others in front of your

own!

YOU ARE AMAZING ! ! !

“It is during our darkest moments we must focus to see the light”

- Aristotle

This session is about you and what have you been doing through this past year and a half

It is about your value to the industry (residents, families, staff need you)

It is about meeting the emotional needs of residents

It is about sorting through the ever-changing regulations

It is about figuring out what to focus on in our jobs

It is about what surveyors have looked at

It is about finding hope in what we are doing

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“You are only given a little spark of madness. You mustn’t lose it.”

- Robin Williams

Who would have predicted what we went through the past year and a half?Do you wish you could wake up and this would be a bad dream?

We have been battered with negative publicity, the most restrictive of regulations, and taking care of the most vulnerable population.

We are drowning in these regulations and faced, many of us, with serious staffing issues.

We were stretched, as social services staff, beyond our limits before COVID

And resident rights – what are those?

“The best and most beautiful things in the world cannot be seen or even touched. They must be felt with the heart.”

- Helen Keller

As an industry, we have been battered from all sides

Anyone who does not work in the industry will not have the slightest idea of what you have been through and what your residents and staff have been through

Some of you are exhausted, have gone numb and dread (because you are here) what you will face when you get back

The emotional toll on you – for those who have been here through COVID – can’t be measured, can’t be explained and can’t be willed away. We are different people today because of it

We have got to find moments of joy – reasons for hope to keep going and doing what we are doing

Let’s talk about the Elephant in the Room

◦ We have all experienced the spectrum of emotions

◦ Many of you are beyond emotionally and physically exhausted

◦ You try so hard to help as many people as you can, but at the end of the day, you still feel it’s not enough

◦ Windex has not taken away the pain

◦ You are a one-person show in many cases, trying to stretch in too many ways

◦ As an industry, we are faced with a growing divide between two camps, vaccinated versus unvaccinated – when the emphasis should be on these residents and their care

◦ As much as you have tried to protect your residents from the virus – it has been just as hard to protect them from despair, loneliness, fear, boredom, anger, and helplessness.

◦ We all know what they need and in some cases what they needed – but we don’t have a magic wand to fix it all

◦ We have to find a way to balance all of these responsibilities we are faced with

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“You must strive to find your own voice, because the longer you wait to begin, the less likely you are to find it at all” –

Robin Williams

Current regulations are asking us to do the opposite of what is human decency –

• We have all been morally and ethically at odds with the regulations that tell us to follow the 6 ft. distance between people, to not allow people who love each other to touch each other (This has been a factor throughout COVID – depending on if there are cases in the facility)

• We have to choose between being a decent human being or following a regulation.

• Who wants to work in this environment or live in this environment?

• We have to tell family members they cannot be with their dying loved ones or they have to choose who can be (When the facility is in the middle of an outbreak)

• In an outbreak, we have to keep family members from visiting.

“I alone cannot change the

world, but I can cast a stone

across the water to spread many

ripples”

- Mother Theresa

Yes, assume your residents are depressed, are

lonely, or have psychosocial needs (especially

after you have been able to open up – then

close again due to an outbreak)–

Open up discussion on ways to improve resident

moods, address psychosocial needs with the IDT,

getting their feedback – you can’t do this alone

Factors to identify residents with psychosocial needs:

• Look at PHQ9 scores (Especially 10 or more)• Have any residents had recent psychotropic medication increases

or started on a psychotropic medication

• Who has had recent UTIs, recent falls, etc.

• Weight loss

• Decline in functioning, cognition

Make a list of items staff can watch for as indicators of depression

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“Be the beacon of

light in someone’s darkness”

Emphasis has been on infection control and keeping COVID out of our facilities

Emphasis has been on keeping our distance from our residents and them from each other

Resident rights and resident choice feels like something in our past

Now is the time to fight for our residents and find moments of joy for them.

Yes, we are crippled by regulations that are strangling the life out of people and driving away staff who are overwhelmed.

“Everyone you meet is fighting a battle you know nothing about. Be Kind Always.”

- Robin WilliamsWays to help residents in these times and what to do

• Can do the Cornell Depression Scale• Reach out to family – arrange ways to maintain contact• Decorate resident rooms with items from home • If resident is a member of a church, offer to contact to arrange phone call, window, or

what type of visit is allowed• Work with activities on what resident can participate in• Include on care plan• Spend 1:1 visits with residents• This is also important due to behavioral health regulations

“Breathe, darling, this is a chapter, not your whole story.

- S. C. Lourie

Current COVID regulations

impacting social services

• POLST

• Infection Control

• Visitation

• Mental Health needs

• Reopening guidelines after an outbreak

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Strength grows in the moments you think you can’t go on, but keep going anyway

Include visitation policy in your admission packet

Review policy in-depth with family and resident

Working with families on what can occur with visits and where

Educating residents and families on visitation requirements based on

COVID outbreaks

Reviewing regulations pertaining to vaccination and resident contact

“The time is always right to do what is right”- Martin Luther King, Jr.

• POLST – Cornerstone to direction of care• If resident is able, review with resident• POLST forms need to be complete and accurate• Code status should be in place at admission• Doctor’s order needs to match POLST. Include Section B on

the doctor’s order.• Care planning (include both A & B from the POLST)• POLST addendum• Advance Directive Policy• Healthcare Power of Attorney/Healthcare Surrogate

Advance Directives

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“Try not to be a man of success, rather become a man of value”

- Albert Einstein

• Use your RAI manual guidance for interviews – important to do within ARP

• We are more involved with nursing/therapy with assessing cognitive status

• BIMS needs to be done for reimbursement

• Complete within ARD

• Try to do interview at a time to best capture cognitive status

• Some facilities are doing at admission – in case the resident goes to the hospital

• Some facilities are having more than one discipline doing the BIMS• Have discharge planning meeting - Discharge planning is interdisciplinary and starts at the time of

admission to facility

• Document all arrangements for discharge planning made at the time made

• Review discharge documentation with resident and give a copy

PDPM - What Social Services needs to keep in mind with PDPM

“To handle yourself,

use your head; to handle others, use your heart”

- Eleanor Roosevelt

Important items to remember with interviews C & D of the MDS

• Review MDS before interviews to see if there is documentation about cognition and mood (so you can compare)

• Look at Section B on MDS – this tells you hearing, vision, and communication

• Talk with other members of team to compare cognitive status observations and PHQ9 findings

• Make sure your approaches on the care plan match the cognitive ability of resident – surveyors are looking closely at this

• If resident’s cognitive status fluctuates throughout the day, reflect in your note

• If resident’s mood fluctuates day to day, document this.

“Don’t count the days; make the days count.”- Muhammed Ali

◦ Establish discharge plan at time of admission (talk with resident and document)

◦ Build relationship with resident from admission on

◦ 72-hour meeting is to get all members of team, resident, and family on the same page (Baseline care plan)

◦ Accurate interviews – (reflecting cognitive ability)

◦ Document as you arrange services

◦ Discharge Care Plan – include what all of the departments are working on in order for discharge to occur

◦ Discharge care plan meeting

◦ Review discharge documentation with resident at time of discharge

◦ Give a copy of discharge information to the resident/representative after review

◦ Follow-up to see that services arranged have started – follow up within a few days and document

Bottomline with PDPM

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“You gotta know when it’s time to turn the page.”- Tori Amos

Transfer & Discharge – F622, F623, F624, F625

• Have a policy in admission packet on discharge planning, transfers and bed holds.

• When transferring a resident, need to give written notice of transfer to the resident/resident representative as soon as practicable – very important!

• Provide bed-hold policy to resident/resident representative at admission. Need to also send when going to the hospital.

• Notify ombudsman of transfers (can do one time per month)

• If facility is initiating discharge, must notify ombudsman at the time when notifying resident/resident representative

“You don’t have to have it all figured out to move forward.”

- Roy T. Bennett

◦ Start at admission – find out from resident

◦ Document what the resident wants

◦ Reflect resident’s wishes regarding discharge on baseline care plan and later in the comprehensive care plan

◦ Do you want to talk with someone about the possibility of returning to live in the community?

◦ Change care plan when resident/resident representative wishes change or when status of resident changes

◦ Sometimes what the resident wants and family wants may not be the same

◦ When discharge plans differ, may need to involve an outside person, like the ombudsman

Discharge

◦ With COVID restrictions in place, how are you getting this information to the resident and family?

◦ Needs to be done within 48 hours of admission – seeing this not being done or incomplete

◦ Social services

◦ Code status – Make sure you check the baseline care plan that it matches the POLST

◦ Elopement risk – Should match the assessment◦ Discharge – Talk with the resident◦ Psychotropic medications – This should be tracked also◦ PASRR recommendations – Usually, do not have this within

48 hours◦ Meet with resident/family to go over care plan and provide

a summary – Whether by phone or in person ◦ Document how you did the review

“Be the change you want to see

in the world.”

- Gandhi

Baseline Care Plans – F655

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“Our job is improving the quality of life, not just delaying death.”

- Robin Williams

• Policy in admission packet• With COVID restrictions, how have you adapted – How can they file anonymously? Where

are the papers to fill out?• Is the grievance official easily accessible/available?• Action plan – Steps taken to fix grievance – education is not sufficient• Meet with resident and document if satisfied• Have a grievance log• Residents sometimes feel concerns are not heard• Resident Council should be providing their concerns to Social Services• What is a grievance versus what is not• If the concern sounds like abuse/neglect, immediately report to administrator

Grievances – F585

“You are braver than you believe, stronger than you

seem, and smarter than you

think.”- A. A. Milne

Behavioral Health Services – F740-F745

• COVID has played a part in this regulation as it has not been looked at as closely

• Where are we at with complying?

• Are we educating staff?

• What programming are we doing?

• How are you showing the nonpharmacological approaches used, especially before starting or increasing a medication?

• Dementia care, trauma-centered care and meeting resident emotional needs

• Care plan problems

• Approaches that are realistic are key!

“Never say goodbye because goodbye means going away and going away means forgetting.”

- Peter Pan

• Who would have thought after this regulation went into effect November 28, 2019, we would experience so much trauma.

• Trauma is no longer about the past but also the present. It can be about separation from family/friends. It can be about having to not leave your room.

• It can be about losing someone and not being able to be with them when they died.

• There has been so much trauma, loss, and pain in the world – none of us have escaped it.

• We need to assume everyone – staff, residents, families and us, have experienced trauma. It is your job to find out how they experienced it, when and what happened.

• Listen to their stories so that you can better take care of them – ask them, “What can I do to help?”

• People don’t share difficult stories with strangers usually – we have to build the relationship and trust first

• Focus in your meeting with residents and families on what they have been through –what their story is.

Trauma-Centered Care – F742 – F744 (Behavior Health Services)

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“Two things stand out like stone: kindness in another’s troubles, courage in your own.”

- Princess Diana◦ Use the Trauma Checklist (Life Experiences Checklist) at admission and review when a new behavior occurs or resident shares new information

◦ Document on the social history any trauma information you receive – do upon admission and anytime you receive information on a trauma

◦ Always be on the lookout that any mood/behavior could be due to a trauma in past – ask questions of family/resident

◦ Make sure you have a policy that reflects meeting mental health needs of residents and includes trauma-centered care

◦ Incorporate information regarding the trauma on the care plan

◦ Educate staff both regarding individual residents and traumas as well as how staff should handle residents’ emotional needs overall

◦ 1:1 visits based on resident need (at least PRN) and some residents may benefit from psychosocial groups or outside counseling services – These may need to be modified depending on COVID restrictions in your facilities

◦ Be prepared – watch for signs that approaches are not working and changes to care plan need to be made.

◦ Provide ongoing training to staff as current restrictions can be traumatizing for residents and staff

◦ Be aware that changes in COVID restrictions can be traumatic for the resident

“When you reach the end of your rope, tie a knot and

hang on.” - Abraham

Lincoln

What you need -

◦ Check that you have in place -◦ A policy for dementia◦ Complete staff training – this is ongoing◦ Adapt to cognitive ability of the resident◦ Have programming in place – should be doing some

version ◦ How are you adapting to each resident with

dementia?◦ Have a care plan in place (cognitive status, modified

programming)?

◦ Dementia Surveys were occurring before COVID◦ Alzheimer’s Disease and related Dementia

Services Act (Il Admin. Code 973.100-150) went into effect May 23, 2019

Dementia Regulations – F744

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“Sometimes the smallest things take up the most room in your heart.”

The facility must provide medically-related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident

It has been such a challenge trying to meet residents’ mental health needs with COVID

What does this mean (examples) Advocating and assisting them with their rights Help with grievances, visitations, living arrangements and accommodation of needs Assisting with obtaining clothing, personal items and items to stay occupied Helping with mental health needs, especially during these times Meet needs of residents who are grieving from losses and coping with stressful events

and, keep in mind, they are all grieving. Make sure you are documenting how your meeting these needs.

Medically-Related Social Service Needs – F745

“Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen.”

- Winston Churchill

◦ Residents struggling with depression & anxiety with COVID

◦ Social History – Include what you know about psychiatric health

◦ Psychotropic medication assessment –Nursing typically does this

◦ Consent – Need this with new medication or an increase

◦ Tracking – Track for each class of medicine

◦ Care plan – Target behavior on medication for

◦ GDR – Follow the regulations

◦ Policy – Should have this – check

◦ Non-pharmacological intervention – Very important

◦ Behavior management meetings – Not held lately due to COVID

Psychotropic Medication – F757 – F758

“Umbrellas can’t stop the rain, but can make us stand in the rain.”

Identified Offender Program

• Screening residents

• Fingerprinting

• Make sure identifying risk level on the care plan

• Are you tracking for the offense and care planning?

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“Success is liking yourself, liking what you do, and liking how you do it.”

- Maya Angelou

When are they done?

◦ When to ask for a screening –◦ Significant change in status◦ Reevaluate when there has been psychiatric hospitalization

◦ Do you have a policy?

Being looked at in surveys

PASSR Screenings – F644

As a facility, you decide on the amount and types of training necessary based on a facility assessment.

◦ Effective communication◦ Resident rights/facility responsibilities◦ Dementia management◦ Freedom from abuse/neglect and exploitation◦ Quality Assurance & Performance Improvement◦ Infection control◦ Compliance & Ethics

o Training must include the above, but additional ones may be needed

“Each person must live their life as a model to

others.”

- Rosa Parks

What lies ahead –

- Subpart S

- Medicaid Reimbursement

- Ongoing COVID regulation changes

Can there be more?

Can we take more?

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“Doing the best at this moment puts you in the best place for the next moment.”

- Oprah Winfrey

◦ Varies Per Home

◦ Policy On COVID Restrictions (Visitation)

◦ OBRA/Pas Screen (Check It)

◦ Subpart S Screener

◦ POLST Form

◦ HCPOA/Healthcare Surrogate

◦ Resident Rights

◦ Social History

◦ Trauma-centered Care

◦ Discharge Planning

◦ Social Service Evaluation (For Medically-related Social Service Needs)

◦ Care Plan Invites

◦ Care Plans (Includes Baseline)

◦ Advance Directives

◦ Discharge

◦ Mood

◦ Behavior

◦ Reason resident was placed on the psychotropic medication

◦ PAS

◦ COVID restrictions

◦ Trauma

◦ Room moves

◦ NOMNC

◦ ABN form

◦ Written Notification of Transfer

Social Service Documentation

• MDS Sections (Typically C, D, E, Q)

• CAAS

• Supplemental Assessments

(Elopement, Smoking, & Abuse are

examples)

• Clothing inventory

• Behavior Tracking

• Incidental Notes

• Quarterly Notes

• Documentation for Identified

Offenders

• Subpart S

Survey Trendso Care planning resident to resident abuse

o Assessing reasons why a resident may be abusive

o Failure to report abuse

o OBRA screens not done before admission or incomplete

o PASRR recommendations not followed through on care plan

o Baseline care plans not having goals and giving resident a copy not being done

o Residents not knowing how to file a grievance

o Lockbox for grievances and a way to file grievances

o Not having timely follow up to broken/lost glasses

o Not identifying code status at admission and not on baseline care plan

o Physician orders do not match POLST

o Not providing notice of transfer to resident/representative

• Not giving ombudsman notice of resident transfers

• Not providing written notice of transfer

• Not giving the NOMNC form

• Behavior tracking not completed accurately and not individualized to the resident

• Staff not following care plan when dealing with resident behavior.

• If facility initiates discharge, need to notify ombudsman when notifying resident

• Not explaining COVID visitation policy to resident/family

• Not adapting care plan approaches to cognitive status

• Not addressing new behavior on care plan

• No documentation of attempts to change behavior prior to use of psychotropic medications

• Facility-initiated discharges did not have notification in timely manner to resident/representative and

ombudsman

• No documentation of services set up for discharge

• Resident requested transfer/discharge to another facility and staff did not assist with optional placements.

• Not care planning non-compliance with wearing a mask

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• All aspects of infection control, including hand hygiene and PPE have been focused on. Any individual entering facility should be using hand sanitizer upon entering the building.

• Grievances have been a focus and surveyors have looked at resolution of grievances that are brought up at resident council and whether residents are satisfied.

• Surveyors have also looked at the resolution of individual resident grievances and whether individual residents are satisfied with how the grievance has been answered.

• It is expected that resident council will be held each month, whether done on a 1:1 basis or in a group setting.

• Bed-hold information not being given within 24 hours of emergency discharge has been a tag.• Sufficient activity programming; this includes for those residents in isolation. While activity staff may

not be going into individual resident rooms who are in isolation due to COVID, packets can be created for these residents. Staff who are able to go into COVID area can bring the packets to

residents. Activity staff can also use other means for contacting resident, such as touching base with residents if they have access to a phone.

• Not having activities on the weekend• Lack of documentation for leisure activities the resident participates in, meaning the daily

participation records were not maintained and not current

• Need for social services to have care plans in place related to cognition for residents with dementia/cognitive diagnosis

• Surveyors have looked at psychotropic medication assessments regarding the review of the medications and appropriateness.

• Surveyors have been looking at PHQ9 scores to determine if these are rising and corresponding care plans to address steps taken to address mood distress.

• Surveyors are reviewing MDS assessments and looking at individuals with high PHQ9 scores (what is being done to lower scores) – as majority of residents had high scores.

• Surveyors have looked at social service notes for individual residents who may be having an increase in mood distress or behaviors as to what interventions social services is providing to resident.

• Written notice of transfer being given.

• Surveyors have also looked at some general nursing areas including: Infection Control, watching peri care, watching medication passes, and wound care.

• Not sending care plan invites

• F644 – Not getting a new PASARR when resident returns to facility from a psych hospital stay. • Not getting a PAS screen after a resident was diagnosed with schizophrenia.• F645 – Not having a Level II PASARR screen when the OBRA indicated one was needed.• Resident with dementia diagnoses and a mental illness diagnosis – if the MI diagnosis came

after the dementia diagnosis, was it given just to give the antipsychotic medication• Tag relating to residents stating they did not know how to file a grievance and were not given a

copy of the grievance procedure/ contract, etc. at admission.

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QUESTIONS ?

COMMENTS ?

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