MHCA Spring 2018 Agenda Certification Bureau Update Life
MHCA Spring 2018
Agenda § Certification Bureau Update § Life Safety Code Update & Emergency Preparedness § Break § New LTC Survey Process § IDR & Enforcement § Questions & Evaluations
Certification Bureau Managers – Contact Information § Todd Boucher, Bureau Chief § 406 -444 -2038 § Tyler Smith, Non-LTC Supervisor § 406 -444 -3459 § Tina Frenick, LTC Supervisor § 406 -444 -4463 § Tony Sanfilippo, LSC/CLIA, Emergency Preparedness § 406 -444 -4170
Certification Bureau Managers – Certification Specialists § Becky Yancy § 406 -444 -5380 § Brittney Nelson § 406 -444 -3437 CNAs, New Providers, Change in Ownerships
Contact Information for the Licensure Bureau § Suzi Gravely – Health Care Facility Specialist - General licensure questions 444 - 2676, sgravely@mt. gov § Tara Wooten – Health Care Facility Licensing Program Manager - 444 -1575, tara. wooten@mt. gov § Brian Nelson – Construction Consultant – 444 -6794, brian. nelson@mt. gov § Leigh Ann Holmes – Bureau Chief - 444 -7770, lholmes@mt. gov
Certification Bureau Team Commitments §Public Protection §Communication §Consistency §Accurate Surveys §Continuous Education
Survey and Certification Team § 16 Surveyors – Health & LSC § 8 Open Surveyor Positions § Recent hires January February 2018 - Dianna Bowling, Ellen Burns, & Ryan Tatum § Hiring 4 more surveyors ASAP § CLIA /RHC Surveyor § 2 Certification Specialists § 3 Supervisors - LTC, NLTC, & CLIA/LSC
CMS Survey & Certification Policy & Memos to States and Regions S&C DATE ISSUED POLICY/MEMO TITLE SUMMARY/COMMENTS 18 -01 -NH 10/27/17 Revised Policies regarding the Immediate Imposition of Federal Remedies- FOR ACTION Clarifications to SOM Chapter 7 & IJ issues 18 -02 -NH 10/27/17 Clarification regarding Nurse Aide Training and Competency Evaluation Program (NATCEP/CEP) Waiver and Appeal Requirements Clarification on removal of NATP as far as Waivers and Appeal 18 -03 -HHA 11/17/17 Home Health Agency (HHA) Subunits New HHA conditions of participation for subunits effective 1/13/18 18 -04 -NH 11/24/17 Temporary Enforcement Delays for Certain Phase 2 F-Tags and Changes to Nursing Home Compare
CMS Policy & Memos to States and Regions S&C POLICY/MEMO DATE ISSUED TITLE SUMMARY/COMMENTS 18 -05 -NH 11/24/17 Preparation for Launch of New Long -Term Care Survey Process (LTCSP) Effective 11/28/17 Appendix P is no longer effective. 18 -06 Hospitals 12/08/17 Clarification of Ligature Risk Policy Ligature risks for Psychiatric Patients. 18 -07 -CLIA 12/15/17 Clinical Laboratory Improvement Amendments of 1988 (CLIA) Proficiency Testing (PT) Referral Categories Specific to Proficiency Testing Requirements 18 -08 -NH 12/26/17 An Initiative to Address Facility Initiated Discharges that Violate Federal Regulations Most frequent issue pointed out to Long Term Care Ombudsman.
CMS Policy & Memos to States and Regions S&C POLICY/MEMO DATE ISSUED TITLE SUMMARY/COMMENTS 18 -09 -RHC 12/27/17 Revised Rural Health Clinic (RHC) Guidance— State Operations Manual (SOM) Appendix GAdvanced Copy Comprehensive update to RHC Regulations QSOG 18 -10 - 12/22/1 Hospital, 7 CAHs Texting of Patient Information among Healthcare Providers in Hospitals and Critical Access Hospitals (CAHs) Revised 01/05/18 ***Revised to clarify providers affected by this policy are Hospitals and CAHs*** Texting of patient information between health care team is done through a secure platform. QSO 18 -11 CLIA 1/5/18 Clinical Laboratory Improvement Amendments (CLIA) Release of Request for Information (RFI) Comments due by March 12, 2018 QSO 18 -12 Deemed Providers & Suppliers 1/12/18 Clarification of the Accrediting Organization’s (AO’s) Role when a Provider or Supplier’s Deemed Status has been Temporarily Removed
CMS Policy & Memos to States and Regions S&C POLICY/MEMO DATE ISSUED TITLE SUMMARY/COMMENTS QSO 18 -13 HHA 1/12/18 Home Health Agency (HHA) Survey Protocol – State Operations Manual (SOM) Appendix B Revised 1/16/18 Revises Appendix B for Home Health Agencies effective 1/13/18 ***Revised Attachments A & B to Reflect Removal of Tags G 670, G 700, G 848 and G 940; Addition of G 956 and G 984*** QSO 18 -14 CLIA 3/16/18 Clarification Regarding Fine Needle Aspiration (FNA) Specimen Adequacy Assessment, Rapid On-Site Evaluation (ROSE) and Workload Limits QSO 18 -15 -NH 3/16/18 Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long Term Care Setting Development of a free online training course in infection prevention and control for nursing home staff in long-term care
Website Updates § http: //dphhs. mt. gov/qad/Certification. aspx § ADA Requirements § NEW § § Frequently Asked Questions LTC Process Compliance Readiness Bulletins Newsletters
QUESTIONS?
LIFE SAFETY CODE & EMERGENCY PREPAREDNESS TONY SANFILIPPO
Life Safety Code Update § Top 10 Life Safety Code Deficiencies § Fire Doors § Legionella § Emergency Preparedness 15
TOP 10 LSC DEFICIENCIES FOR FFY 2017
Top 10 LSC Deficiencies for FFY 2017 (10/1/16 to 9/30/17) PRECENTAGE PERCENTAG OF E OF PROVIDERS SURVEYS CITED RANK TAG DESCRIPTION NUMBER OF CITATIONS 1 K 0353 Sprinkler System - Maintenance and Testing 53 57. 7% 70. 7% 2 K 0920 Electrical Equipment - Power Cords and Extension Cords 37 44. 9% 49. 3% 3 4 5 6 7 8 9 10 K 0363 K 0222 K 0355 K 0321 K 0211 K 0293 K 0345 K 0372 Corridor - Doors Egress Doors Portable Fire Extinguishers Hazardous Areas - Enclosure Means of Egress - General Exit Signage Fire Alarm System - Testing and Maintenance Subdivision of Building Spaces - Smoke Barrier 29 29 27 25 22 20 20 20 37. 2% 35. 9% 30. 8% 29. 5% 23. 1% 21. 8% 25. 6% 38. 7% 36. 0% 33. 3% 29. 3% 26. 7%
Top 10 LSC Deficiencies FFY 2017: #1 Sprinkler System Maintenance & Testing K 353 § Lighting fixtures with in 1 foot of sprinkler heads § Body of light below sprinkler head § Annual test documents § 5 Year obstruction test § Gauge tested or replaced every 5 years NFPA 13, 2010 Edition & NFPA 25, 2011 Edition 18
Top 10 LSC Deficiencies FFY 2017: #2 Electrical Equipment – Power Cords & Extension Cords K 920 § Power strip § Used for refrigerators or microwaves § Tripping hazard § Securely mounted – not hung from cord § Shall Be Rated for Appliance Draw § Shall Not Be Utilized as a Substitute for Fixed Wiring NFPA 99, 2012 Edition Chapter 10 19
Top 10 LSC Deficiencies FFY 2017: #3 Corridor Doors K 363 § Storage handle broken § Latching mechanism failed § Any corridor door must latch – resident rooms, closets, office doors, etc. NFPA 101, 2012 Edition Section 19. 3. 6. 3 20
Top 10 LSC Deficiencies FFY 2017: #4 Egress Doors K 222 § Adding additional latches on inside of doors § Create two processes to open § Shall be only one operation NFPA 101, 2012 Edition Section 7. 2. 1. 5 Locks 21
Top 10 LSC Deficiencies FFY 2017: #5 Hazardous Areas, 1 hour Fire Resistive Rating & Fire Suppression, K 321 § Self or automatic closing doors § Resident room converted to storage room – no self closure provided NFPA 101, 2012 Edition Section 18/19. 3. 2 22
Top 10 LSC Deficiencies FFY 2017: #6 Gas Equipment – Cylinder & Equipment Storage K 923 § Tanks unsecured § Signage of storage rooms – Medical Gases No Smoking or Open Flame NFPA 99, 2012 Edition Section 11. 6 or Section 5. 1. 3. 1. 9 23
Top 10 LSC Deficiencies FFY 2017: #7 Portable Extinguishers K 355 § Hydrostatic testing intervals § Monthly checks § Labels in place § K extinguishers in kitchens NFPA 10, 2010 Edition Table 8. 3. 1 24
Top 10 LSC Deficiencies FFY 2017: #8 Means of Egress K 211 § Maintained free of obstructions or impediments to full instance use in case of fire or other emergency § Equipment, unused bed & cabinets stored in egress path NFPA 101, 2012 Edition Section 7. 1. 10 25
Top 10 LSC Deficiencies FFY 2017: #9 Alcohol Based Hand Rub Dispensers (ABHR) K 325 § Installed within 1 inch of electrical NFPA 101, 2012 Edition 18/19. 3. 2. 6 26
Top 10 LSC Deficiencies FFY 2017: #10 Doors with Self Closing Devices K 223 § Self closure is removed § Door with self closure is blocked or held open § Doors will not latch when exercised NFPA 101, 2012 27
TOP 10 LSC DEFICIENCIES FOR FFY 2018 (SO FAR)
Top 10 Deficiencies for FFY 2018 (10/1/17 to present) RANK TAG DESCRIPTION PERCENTAGE NUMBER OF OF PROVIDERS OF SURVEYS CITATIONS CITED 1 K 0363 Corridor - Doors 7 9. 3% 53. 8% 2 K 0211 Means of Egress - General 7 8. 0% 53. 8% 3 K 0920 Electrical Equipment - Power Cords and Extension Cords 6 8. 0% 46. 2% 4 K 0321 Hazardous Areas - Enclosure 6 6. 7% 46. 2% 5 K 0923 Gas Equipment - Cylinder and Container Storage 5 6. 7% 38. 5% 6 K 0355 Portable Fire Extinguishers 5 6. 7% 38. 5% 7 K 0353 Sprinkler System - Maintenance and Testing 5 4. 0% 38. 5% 8 K 0511 Utilities - Gas and Electric 5 5. 3% 38. 5% 9 K 0325 Alcohol Based Hand Rub Dispenser (ABHR) 4 4. 0% 30. 8% 10 K 0223 Doors with Self-Closing Devices 4 5. 3% 30. 8%
FIRE DOOR ANNUAL INSPECTIONS
NFPA 80 ANNUAL FIRE & SMOKE DOOR TESTING § CMS S&C 17 -38 Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies § NFPA 80 2010 Requirements – Fire Door Assemblies in health care occupancies – Annual inspection § Does not apply to other non rated door assemblies including corridor doors or smoke barrier doors § Non rated should still be part of facility maintenance program § Cited under K 211 Means of Egress 31
NFPA 80 FIRE DOORS & DAMPERS § Chapter 5 Care & Maintenance § Operability § Doors shutters & windows shall be operable at all times § Must contact testing Laboratory prior to initiating any field modifications § Any assembly replacement shall meet all requirements as original designed & tested 32
NFPA 80 FIRE DOORS & DAMPERS § Inspections & Functional Testing § Fire door assemblies shall be inspected & tested not less than annually § Prior to testing a visual inspection shall be performed to identify damaged or missing parts § Visually inspect assemblies from both sides to assess the overall assembly condition 33
NFPA 80 Fire Doors & Dampers § Minimum items to be documented & verified § No open holes or breaks exist in any surfaces § All light frames or vision panels are securely in place § Frames, Hinges, Hardware & thresholds are securely in place & aligned § No parts are missing or broken § All Door clearances are maintained § Self closing devices are operable 34
NFPA 80 FIRE DOORS & DAMPERS § Minimum items to be documented & verified § Verify door coordinator operation § Verify latching hardware secures door when closed § Verify auxiliary hardware items will not prohibit operation § No field modifications have been performed that may void tested & labeled assembly § Visualize all gasketing & edge seals to verify integrity 35
NFPA 80 FIRE DOORS & DAMPERS § Testing § Upon door installation confirm operation of closing device & full closure of the door § Resetting automatic closing devices shall be in accordance with manufacturers instructions § Written Records shall be maintained & available to the AHJ 36
NFPA 80 FIRE DOORS & DAMPERS § Fire Dampers Periodic Inspection & Testing § Each damper shall be inspected & tested 1 year after installation § Inspection Frequency shall be every 4 years, Hospitals shall be every 6 years § All Testing shall be documented indicating type of damper, Fire/ Smoke, the location & date of inspection, the Inspectors name, & any noted deficiencies § Document any corrective actions or repairs § All documentation shall be maintained & made available to the AHJ 37
LEGIONELLA
CMS S&C 17 -30 Legionella Risk § Factors to spread Legionella § Water filters § Showerheads & hoses § Centrally installed misters, atomizers, air washers, & humidifiers § Ice machines § Hot tubs/saunas § Decorative fountains § Medical devices (such as CPAP machines hydrotherapy equipment, bronchoscopes, heater-cooler units) 39
CMS S&C 17 -30 Legionella Risk § Expectations for Healthcare Facilities § Conduct a facility risk assessment to identify where Legionella could grow & spread in the facility water system § Implement a water management system § Utilize ASHRAE industry standard & the CDC toolkit which includes, temperature control, visual inspections & environmental testing for pathogens § Specify testing protocols & document the results of testing & any corrective actions taken § Healthcare facilities are expected to comply & demonstrate measures to minimize Legionella risk, as a condition of participation for CMS 40
EMERGENCY PREPAREDNESS DEFICIENCIES FFY 2018 (SO FAR)
EMERGENCY PREPARDNESS REFERENCES § DPHHS Public Health Emergency Preparedness (PHEP) http: //dphhs. mt. gov/publichealth/phep § CMS State Operations Manual Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance (Rev. , 169, Issued 06 -09 -2017) https: //www. cms. gov/Regulations-and. Guidance/Manuals/downloads/som 107 ap_z_emergprep. pdf § Quality, Safety & Oversight Group - Emergency Preparedness https: //www. cms. gov/Medicare/Provider-Enrollment-and. Certification/Survey. Cert. Emerg. Prep/index. html 42
Emergency Preparedness (EP) for FFY 2018 (11/15/17 to 3/8/18) TAG DESCRIPTION NUMBER OF CITATIONS E 0039 Emergency Preparation Testing Requirements 5 E 0032 Primary/Alternative Means for Communication 5 E 0023 Polices/Procedures for Medical Documentation 4 E 0022 Policies/Procedures for Sheltering in Place 4 E 0015 Subsistence Needs for Staff and Patients 3 E 0026 Roles Under a Waiver Declared By Secretary 3 E 0013 Development of Emergency Preparedness Polices and Procedures 2 E 0018 Procedure for Tracking of Staff and Patients 2 E 0033 Methods for Sharing Information 2 E 0037 Emergency Preparedness Training Program 2
Emergency Preparedness (EP) for FFY 2018 (11/15/17 to 3/8/18) Continued TAG DESCRIPTION NUMBER OF CITATIONS E 0009 Local, State, Tribal Collaboration Process 1 E 0020 Polices for Evacuation and Primary/Alternate Communication 1 E 0024 Policies & Procedures – Volunteers and Staffing 1 E 0025 Arrangement with Other Facilities 1 E 0034 Information on Occupancy/Needs 1 E 0035 LTC and ICF/IID Sharing Plan with Patients 1 E 0036 Emergency Preparedness Training and Testing 1 E 0041 Hospital CAH and LTC Emergency Power 1
EMERGENCY PREPAREDNESS § E 0039 No Documentation of Annual Testing § Annual tabletop § Full scale exercises § Full-scale community based exercise § Update to emergency program based on this analysis. 45
EMERGENCY PREPAREDNESS § E 0032 Communication Plan § Verify plan contains primary & alternate means for communicating § Review the communications equipment or communication systems 46
EMERGENCY PREPAREDNESS § E 0023 Develop and implement emergency preparedness policies and procedures § Medical record documentation system § preserves patient information § protects confidentiality § secures and maintains availability of records 47
EMERGENCY PREPAREDNESS § E 0022 Shelter in Place § Defines means to shelter in place for patients, staff and volunteers who remain in a facility. § Alignment with the facility’s emergency plan and risk assessment. 48
EMERGENCY PREPAREDNESS § E 0015 Subsistence § Food, water, medical and pharmaceutical supplies § Alternate sources of energy to maintain the following: § (A) Temperatures § (B) Emergency lighting. § (C) Fire detection, extinguishing, and alarm systems. § (D) Sewage and waste disposal. 49
EMERGENCY PREPAREDNESS § E 0026 Alternate care sites during emergencies § Providing alternate care under 1135 Waiver 50
EMERGENCY PREPAREDNESS § E 0013 Alignment with identified hazards § All hazards approach evaluation § Annual review of policies 51
EMERGENCY PREPAREDNESS § E 0018 Tracking of Patients and Staff § Facilities must develop a means to track patients and on-duty staff in the facility’s care during an emergency event § Describe and demonstrate the tracking system used to document locations of patients and staff. § Tracking system is part of emergency plan. 52
EMERGENCY PREPAREDNESS § E 0033 Sharing of Information During and Emergency § Medical documentation and continuity of care § Review policies and procedures on release of patient information 53
EMERGENCY PREPAREDNESS § E 0037 Training Program § Copies of the facility’s initial emergency preparedness training and annual emergency preparedness training offerings § Determine staff knowledge of plan § Review staff training files for training 54
CMS EDITS TO E 0015 & E 0041
CMS CONSIDERING EDITS TO E 0015 & E 0041 § E 0015 § Changes are related to heating and cooling facility § E 0041 § Speaks about use of portable generators § Speaks about installation of new generators 56
BONUS HEADS UP FOR LSC
GENERATOR FUEL CHECKS § Fuel quality checked annually § NFPA 110 58
QUESTIONS?
LONG TERM CARE TINA FRENICK
Survey Variances – Traditional vs LTCSP Traditional Survey Process Lengthy Tour Over abundance of paperwork Observations at times limited MDS/CAAs not always a focus Unavailable documentation creating delays in the survey process o Computer access difficult for surveyors – Facility staff unavailable to assist o Different survey processes for states o o o
Survey Variances – Continued LTCSP – New Survey Process o Full day of observation – and PRN o Less burden to staff/facility during tour o Resident screening for sample identification - Less documentation o Real-time documentation o MDS integrated into LTCSP, which drives resident focused investigation o LTCSP automatically uploads individual resident information for further investigation – identifies areas of concern o Focus areas for each resident, rather than investigating areas which may not apply to a resident (example - falls) o Nation wide survey process
Resident Focused Survey § The survey should focus on the care and services being provided to the residents within the facility. § The surveyor is looking to see if the care provided meets the residents’ individual needs and preferences, and identified on the individualized care plan. Surveyors will review Care Areas specific to these identified needs.
Resident Focused – Continued The outcome of the process is to see: § What would a “reasonable person” do or how would a reasonable person feel or react to this situation? § The reasonable person is an abstract or hypothetical character who personifies a community ideal of reasonable and responsible behavior.
Recap - LTCSP INTENT: § Screen all residents in assigned area and observe, interview, and complete a limited record review for initial pool residents. § Eight residents for each surveyor (or less), and may include offsite selected, FRIs, complaints, vulnerable, new admits, or others as identified. § There are 8 -10 hours for the screening phase and initial pool.
Recap – LTCSP – Continued § Surveyors will go room to room and meet each resident. § Surveyors are not reliant on staff for resident information, but will interview staff. § During resident visits, surveyors will observe resident rooms, introduce themselves, observe equipment, room cleanliness, resident belongings, and determine if the room is homelike? During this, surveyors will review MDS indicators and the matrix, and then decide if the resident should be included in the initial Pool, based on inconsistencies or concerns identified. § The decision to include a resident in the initial Pool, should be almost immediate, based on the observations on the first day, record review and the identification of inconsistencies from the matrix, or what the resident is reporting during the interview.
Recap – LTCSP – Continued § Record review should be limited and completed after interviews and observations. The surveyor should continue to complete the observations while working on resident record reviews, by completing the record reviews on the floor, not in the conference room. § Hardcopy documents obtained and returned to the Bureau should be supporting evidence relating to the deficient practice identified.
Recap – LTCSP – Continued § For non interviewable residents, surveyors will look at: § § § § § Pressure Ulcers Dialysis Infections ADL Decline Falls Bowel and Bladder Hospitalization Elopement Change of Condition
Recap – LTCSP – Continued § All surveyors observe first FULL meal, and the dining task will also be completed during the survey. Investigations will include all dining locations in the facility. § Surveyors may observe and interview for: § § § § § Assistance Provided Adaptive Equipment Positioning Palatability Temperature of meal/items served Service Delivery – Time/Staffing Available Menu – Followed/Presentation/Dr. Order Hygiene – Sanitary Practices Correct Diets Served
Recap – LTCSP – Continued § In-depth investigation for care areas marked by surveyors, which may require further investigation during the screening period § Only includes ACTIVE residents § The LTCSP system generates the listing for the Final Sample, based on surveyors data put into the system and then auto generated from the MDS data. The surveyor then reviews for changes as needed.
Recap – LTCSP – Continued All concerns identified for sampled residents, and include two ways: § Investigation by Resident § Investigation by Care Areas § Surveyors will use the Critical Element Pathways § Weight calculator § Body Map § Interpretive Guidance
Recap – LTCSP – Continued § Closed record review § Resident Council § Dining § Sufficient and Competent Nurse Staffing § Infection Control § QAA/QAPI § SNF Beneficiary Protection Notification The following areas are Review only investigated if there § Kitchen are identified concerns relating to the sampled § Medication Administration residents: § Medication Storage § Personal Funds § Environment § Resident Assessment
Surveyor Comments - LTCSP § The facility staff may feel more pressure, as time and observations with the residents and staff have increased. Staff are willing to share care related concerns, staffing issues, and equipment needs, with surveyors. § The survey process and time spent with the resident is more tailored to resident care needs, and therefore, more care concerns identified. § The facilities appear to understand the change for the LTCSP, and are adjusting. Facility’s have not appeared to show any opposition to the new process.
LTCSP Resources https: //www. cms. gov/Medicare/Provider-Enrollment-and. Certification/Guidancefor. Laws. And. Regulations/Nursing-Homes. html * Appendix PP State Operations Manual (Revised 11/22/2017) [PDF, 3 MB] * List of Revised FTags [Effective November 28, 2017] [PDF, 152 KB] * S&C Memo: Revision to State Operations Manual Appendix PP for Phase 2 (Includes Training Information and Related Issues) [PDF, 121 KB] * F-Tag Crosswalk [XLSX, 495 KB] * Training for Phase 1 Implementation of New Nursing Home Regulations [PDF, 108 KB] * New Long-term Care Survey Process – Slide Deck and Speaker Notes [PPTX, 8 MB] * Entrance Conference Form Beneficiary Notice Worksheet (Updated 12/06/2017) [ZIP, 164 KB] * LTC Survey Pathways - Updated 12/13/2017 [ZIP, 2 MB] * LTCSP Procedure Guide [PDF, 1 MB] * LTCSP Initial Pool Care Areas - Updated 11/17/2017 [ZIP, 1 MB] * Survey Resources - Updated 12/13/2017 [ZIP, 10 MB] * Matrix with Instructions - Content Unchanged [PDF, 299 KB] * LTCSP Mapping Document [PDF, 740 KB]
LTCSP SURVEY OUTCOMES By Deficiency
Deficiency Trending
Office Of Inspector General – Top Ten Deficiencies Top 10 Federal Health Deficiencies Cited for Nursing Homes During FFY 2016 (10/01/2016 - 09/30/2017). chfs. ky. gov/. . . /0/Top 10 Citations. LTC. pdf
Montana – Deficiency Trending December 1, 2016 – January 25, 2017 K – 2 Deficiencies: Abuse 226 Infection Control 441 G – 2 Deficiencies: Highest Well-Being 309, Pressure Ulcers 314 F – 3 Deficiencies: SS Qualifications 251, Food Storage/Sanitation 371 Infection Control 441 December 1, 2017 – January 25, 2018 G – 2 Deficiencies: Bowel and Bladder 690 Pain 697 F – 1 Deficiency: Dietary Staffing 801
Deficiency Variances – Continued December 1, 2016 – January 25, 2017 E – 24 Deficiencies – and 3 Deficiencies were cited for more than one facility, which included: December 1, 2017 – January 25, 2018 E – 16 Deficiencies cited with 3 of them cited at three facilities, which included: 656 - Comprehensive Care 281 – Professional Standards Plan 371 – Dietary Services 761 - Medications Store/Label 441 – Infection Control 880 – Infection Control
Deficiency Variances – Continued December 1, 2016 – January 25, 2017 December 1, 2017 – January 25, 2018 D – 24 Deficiencies – 7 cited at 2 or more facilities, which included: D – 27 Deficiencies – 7 cited at 2 or more facilities, which included: 225 – Abuse/Reporting/Investigation 550 – Resident Rights 241 – Dignity and Respect 610 - Abuse/Reporting/Prevention 278 - Assessment Accuracy 657 – Comprehensive Care Plan 279 – Comprehensive Care Plan 686 – Pressure Ulcer Treatment/Prevention 281 – Professional Standards 323 – Accidents and Hazards 425 – Pharmacy Services 758 – Unnecessary Antipsychotics/PRN Use 849 – Hospice
Is Montana Similar?
QUESTIONS?
DISPUTE RESOLUTION & ENFORCEMENT TYLER SMITH
DISPUTE RESOLUTION
Dispute Resolution • No changes to the process as of now • Reminders: • Ensure your request is timely • Ensure your request is detailed • Ensure your request contains the necessary information • Call the Bureau with minor changes
Dispute Resolution • Reminders: • State’s Letter vs. CMS letter • IIDR • Montana has had one requested • Montana has also written a recommendation for one
ENFORCEMENT
Enforcement S&C 18 -04 -NH • Issued November 24, 2017 • Temporary Moratorium on Imposing Certain Enforcement Remedies – Phase 2 • Freeze Health Inspection Star Ratings • Methodological Changes & Changes in Nursing Home Compare • Availability of Survey Findings
Enforcement Temporary Moratorium on Imposing Certain Enforcement Remedies – Phase 2 • 18 -Month Moratorium for: • CMPs • DDPNA • Discretionary Termination • Does not apply to F 608 (reporting reasonable suspicion of crime) • Phase 1 or 2 are still subject to Mandatory DPNA and Termination • Remaining remedies can still be imposed
Enforcement Penalty for failure of covered individuals to report to the Secretary and 1 or more law enforcement officials any reasonable suspicion of a crime against a resident, or individual receiving care, from a long-term care facility. Maximum - $221, 048 Penalty for failure of covered individuals to report to the Secretary and 1 or more law enforcement officials any reasonable suspicion of a crime against a resident, or individual receiving care, from a long-term care facility if such failure exacerbates the harm to the victim of the crime or results in the harm to another individual. Maximum - $331, 572 Penalty for a long term care facility that retaliates against any employee because of lawful acts done by the employee, or files a complaint or report with the State professional disciplinary agency against an employee or nurse for lawful acts done by the employee or
Enforcement Tags affected: • F 655 – Baseline Care Plan • F 740 – Behavioral Health Services • F 741 – Sufficient/Competent Direct Care/Access Staff-Behavioral Health • F 758 – Psychotropic Medications related to PRN Limitations • F 838 – Facility Assessment • F 881 – Antibiotic Stewardship Program • F 865 – QAPI Program and Plan related to the development of QAPI Plan • F 926 – Smoking Policies
Enforcement Temporary Freeze of Five-Star Ratings | Methodologic Changes • Designed to allow all facilities to go through new survey process • Includes surveys with dates after 11/28/17 • Rating will not use information from 3 rd oldest survey • Will be based on two most recent cycles • 60% most recent • 40% prior
Enforcement Availability of Survey Findings • Post entire 2567 • Summaries of most recent survey • Total # of Deficiencies • Highest Severity and Scope • Deficiency free surveys • Information on Quality Measures, staffing, and eventually new staffing data from the Payroll-Based Journal program
Enforcement S&C 18 -08 -NH Facility Initiated Discharges “Facilities are required to determine their capacity and capability to care for the residents they admit, so in the absence of atypical changes in residents’ conditions, it should be rare that facilities who properly assess their capacity and capability of care for a resident then discharge that resident based on the inability to meet their needs. ”
Enforcement Facility Initiated Discharges Concerns: • Unsafe and/or traumatic • Residents uprooted from familiar settings • Termination of relationships with staff and other residents • Relocated long distances away • • Results in fewer visits from family and friends (depression) Homeless Most Commonly Reported Reason • Discharged due to behavioral, mental, and/or emotional expressions or indications of resident distress.
Enforcement Facility Initiated Discharges So, why the discussion? • Transfer of Enforcement Cases • Questionable/Unsafe Setting • Resident remains hospitalized • Facility Pattern • Others?
Enforcement S&C 18 -01 -NH (10/27/17) • Update to Chapter 7 – Survey and Enforcement Process SNF/NF • Released as draft, comments were due by December 1, 2017 • Replaces 16 -31 -NH (7/29/16) • Updates to: • 7304 – Mandatory Immediate Imposition of Federal Remedies • 7306 – Timing of Civil Money Penalties • 7308 – Enforcement Actions When Immediate Jeopardy Exist • 7309 – Key Dates When Immediate Jeopardy Exists • 7313 – Procedures for Recommending Enforcement Remedies • 7400 – Enforcement Remedies for SNF, NF and SNF/NF
Enforcement S&C 18 -01 -NH • 7304 • Removed No Opportunity to correct for SQC (F) tag • Update to “Double G” language • • Separated by Certification of Compliance, different noncompliance cycles SFF modification • Excludes F level deficiencies for F 812, F 813, and F 814 • Add Definition of “Standard” survey • Choosing Remedies • CMS RO considers the extent of noncompliance (one-time mistake), larger systemic concerns, or an intentional action of disregard for resident health and safety.
Enforcement 7304 continued… IJ which resulted in serious injury, harm, impairment or death VS. IJ with no resultant serious injury, harm, impairment or death
Enforcement 7304 continued… Updated discussion on Types of Remedies • CMP • Directed In-Service Training • Directed Plan of Correction • Temporary Management • Denial of Payment of all New Medicare and Medicaid Admissions • Denial of all payment for all Medicare and Medicaid Residents • State Monitoring • Termination
Enforcement 7306, 7308 & 7309 • Updates to language on dates and timing for remedies during IJs. 7313 • Updates to language for recommending enforcement when IJ does not exist 7400 • Language updates
Enforcement Common Questions: • Discretionary (Optional) Denial Of Payment • Immediate Jeopardy – 2 days • Non-Immediate Jeopardy – 15 days • Mandatory Denial of Payment • 90 days • Substandard care (3) surveys
Enforcement - Common Questions Release from Denial of Payment • Process: Revisit survey is completed and compliance is verified SSA completes internal paperwork, finalizes recommendation for certification in system Forward finalized paperwork to RO issues letter rescinding DPNA as of date of complian Compliance letter is forwarded to Noridian Administrative Services
Enforcement - Common Questions Loss of NATCEP|NACEP Program Causes: • Within two years operated under: 1819(b)(4)(C)(ii)(II) or 1919(b)(4)(C)(ii) [Licensed Nurse] waiver • Has been subjected to an extended or partial extended survey (SQC) • Assessed a CMP of $10, 483 or greater • DPNA has gone into effect *Example • Appointment of temporary manager • Termination
Enforcement - Common Questions
Newsletter Distributed Quarterly on/around the 15 th of the month • February, May, August, and November We encourage everyone to sign up • mtssad@mt. gov Do you have a topic you would like discussed?
QUESTIONS?
CERTIFICATION BUREAU CONTACT INFORMATION: Phone 406 -444 -2099 Fax 406 -444 -3456 Email MTSSAD@MT. GOV
2018 – The 18 th year of the 3 rd millennium, the 18 th year of the 21 st century, and the 9 th year of the 2010 s decade.
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