Certification Bureau Update Life Safety Code Update amp Emergency Preparedness Break New LTC Survey Process IDR amp Enforcement Questions amp Evaluations Certification Bureau Managers Contact Information ID: 739098
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Slide1
MHCA
Spring 2018Slide2
Agenda
Certification Bureau UpdateLife Safety Code Update & Emergency PreparednessBreakNew LTC Survey Process
IDR & Enforcement
Questions & EvaluationsSlide3
Certification Bureau Managers – Contact Information
Todd Boucher, Bureau Chief
406-444-2038
Tyler Smith, Non-LTC Supervisor
406-444-3459
Tina Frenick, LTC Supervisor
406-444-4463Tony Sanfilippo, LSC/CLIA, Emergency Preparedness406-444-4170Slide4
Certification Bureau Managers – Certification Specialists
Becky Yancy
406-444-5380
Brittney Nelson
406-444-3437
CNAs, New Providers, Change in OwnershipsSlide5
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.govSlide6
Certification Bureau Team Commitments
Public Protection
Communication
Consistency
Accurate Surveys
Continuous EducationSlide7
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 Specialists3 Supervisors - LTC, NLTC, & CLIA/LSCSlide8
CMS Survey & Certification Policy & Memos to States and Regions
S&C POLICY/MEMO
DATE ISSUED
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 CompareSlide9
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.Slide10
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 G- Advanced Copy
Comprehensive update to RHC Regulations
QSOG 18-10-Hospital, CAHs
12/22/17
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 Slide11
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 G670, G700, G848 and G940; Addition of G956 and G984***
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 on-line training course in infection prevention and control for nursing home staff in long-term care settings. Slide12
Website Updates
http://dphhs.mt.gov/qad/Certification.aspxADA Requirements
NEW
Frequently Asked Questions
LTC Process
Compliance Readiness Bulletins
NewslettersSlide13
Questions?Slide14
Life safety code & emergency preparedness
TONY SANFILIPPOSlide15
Life Safety Code Update
Top 10 Life Safety Code Deficiencies
Fire Doors
Legionella
Emergency Preparedness
15Slide16
Top 10 LSC Deficiencies for FFY2017Slide17
Top 10 LSC Deficiencies for FFY 2017 (10/1/16 to 9/30/17)
RANK
TAG
TAG DESCRIPTION
NUMBER OF CITATIONS
PRECENTAGE OF PROVIDERS CITED
PERCENTAGE OF SURVEYS CITED
1
K0353
Sprinkler System - Maintenance and Testing
53
57.7%
70.7%
2
K0920
Electrical Equipment - Power Cords and Extension Cords
37
44.9%
49.3%
3
K0363
Corridor - Doors
29
37.2%
38.7%
4
K0222
Egress Doors
29
35.9%
38.7%
5
K0355
Portable Fire Extinguishers
27
30.8%
36.0%
6
K0321
Hazardous Areas - Enclosure
25
29.5%
33.3%
7
K0211
Means of Egress - General
22
23.1%
29.3%
8
K0293
Exit Signage
20
21.8%
26.7%
9
K0345
Fire Alarm System - Testing and Maintenance
20
21.8%
26.7%
10
K0372
Subdivision of Building Spaces - Smoke Barrier
20
25.6%
26.7%Slide18
Top 10 LSC Deficiencies FFY2017: #1
Sprinkler System Maintenance & Testing K 353Lighting fixtures with in 1 foot of sprinkler headsBody 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
18Slide19
Top 10 LSC Deficiencies FFY2017: #2
Electrical Equipment – Power Cords & Extension Cords K 920Power 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 1019Slide20
Top 10 LSC Deficiencies FFY2017: #3
Corridor Doors K363Storage handle brokenLatching mechanism failed
Any corridor door must latch – resident rooms, closets, office doors, etc.
NFPA 101, 2012 Edition Section 19.3.6.3
20Slide21
Top 10 LSC Deficiencies FFY2017: #4
Egress Doors K 222Adding additional latches on inside of doorsCreate two processes to open
Shall be only one operation
NFPA 101, 2012 Edition Section 7.2.1.5 Locks
21Slide22
Top 10 LSC Deficiencies FFY2017: #5
Hazardous Areas, 1 hour Fire Resistive Rating & Fire Suppression, K 321Self or automatic closing doors
Resident room converted to storage room – no self closure provided
NFPA 101, 2012 Edition Section 18/19.3.2
22Slide23
Top 10 LSC Deficiencies FFY2017: #6
Gas Equipment – Cylinder & Equipment Storage K923Tanks 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
23Slide24
Top 10 LSC Deficiencies FFY2017: #7
Portable Extinguishers K355Hydrostatic testing intervalsMonthly checks
Labels in place
K extinguishers in kitchens
NFPA 10, 2010 Edition Table 8.3.1
24Slide25
Top 10 LSC Deficiencies FFY2017: #8
Means of Egress K211Maintained 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
25Slide26
Top 10 LSC Deficiencies FFY2017: #9
Alcohol Based Hand Rub Dispensers (ABHR) K325Installed within 1 inch of electrical
NFPA 101, 2012 Edition 18/19.3.2.6
26Slide27
Top 10 LSC Deficiencies FFY2017: #10
Doors with Self Closing Devices K223Self closure is removedDoor with self closure is blocked or held open
Doors will not latch when exercised
NFPA 101, 2012
27Slide28
Top 10 LSC Deficiencies for FFY2018
(so far)Slide29
Top 10 Deficiencies for FFY 2018 (10/1/17 to present)
RANK
TAG
TAG DESCRIPTION
NUMBER OF CITATIONS
PERCENTAGE OF PROVIDERS CITED
PERCENTAGE OF SURVEYS CITED
1
K0363
Corridor - Doors
7
9.3%
53.8%
2
K0211
Means of Egress - General
7
8.0%
53.8%
3
K0920
Electrical Equipment - Power Cords and Extension Cords
6
8.0%
46.2%
4
K0321
Hazardous Areas - Enclosure
6
6.7%
46.2%
5
K0923
Gas Equipment - Cylinder and Container Storage
5
6.7%
38.5%
6
K0355
Portable Fire Extinguishers
5
6.7%
38.5%
7
K0353
Sprinkler System - Maintenance and Testing
5
4.0%
38.5%
8
K0511
Utilities - Gas and Electric
5
5.3%
38.5%
9
K0325
Alcohol Based Hand Rub Dispenser (ABHR)
4
4.0%
30.8%
10
K0223
Doors with Self-Closing Devices
4
5.3%
30.8%Slide30
Fire door annual inspectionsSlide31
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 K211 Means of Egress
31
Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies
Fire and Smoke Door Annual Testing Requirements in Health Care OccupanciesSlide32
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
Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies
Fire and Smoke Door Annual Testing Requirements in Health Care OccupanciesSlide33
NFPA 80 FIRE DOORS & DAMPERS
Inspections & Functional TestingFire 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
33Slide34
NFPA 80 Fire Doors & Dampers
Minimum items to be documented & verifiedNo 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 operable34Slide35
NFPA 80 FIRE DOORS & DAMPERS
Minimum items to be documented & verifiedVerify 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
35Slide36
NFPA 80 FIRE DOORS & DAMPERS
TestingUpon 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
36Slide37
NFPA 80 FIRE DOORS & DAMPERS
Fire Dampers Periodic Inspection & TestingEach 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
37Slide38
legionellaSlide39
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/saunasDecorative fountainsMedical devices (such as CPAP machines hydrotherapy equipment, bronchoscopes, heater-cooler units)
39Slide40
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
40Slide41
Emergency preparedness deficiencies ffy2018
(so Far)Slide42
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/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf
Quality, Safety & Oversight Group - Emergency Preparedness
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html
42Slide43
Emergency Preparedness (EP) for FFY 2018 (11/15/17 to 3/8/18)
TAG
TAG DESCRIPTION
NUMBER OF CITATIONS
E0039
Emergency Preparation Testing Requirements
5
E0032
Primary/Alternative Means for Communication
5
E0023
Polices/Procedures for Medical Documentation
4
E0022
Policies/Procedures for Sheltering in Place
4
E0015
Subsistence Needs for Staff and Patients
3
E0026
Roles Under a Waiver Declared By Secretary
3
E0013
Development of Emergency Preparedness Polices and Procedures
2
E0018
Procedure for Tracking of Staff and Patients
2
E0033
Methods for Sharing Information
2
E0037
Emergency Preparedness Training Program
2Slide44
Emergency Preparedness (EP) for FFY 2018 (11/15/17 to 3/8/18) Continued
TAG
TAG DESCRIPTION
NUMBER OF CITATIONS
E0009
Local, State, Tribal Collaboration Process
1
E0020
Polices for Evacuation and Primary/Alternate Communication
1
E0024
Policies & Procedures – Volunteers and Staffing
1
E0025
Arrangement with Other Facilities
1
E0034
Information on Occupancy/Needs
1
E0035
LTC and ICF/IID Sharing Plan with Patients
1
E0036
Emergency Preparedness Training and Testing
1
E0041
Hospital CAH and LTC Emergency Power
1Slide45
EMERGENCY PREPAREDNESS
E0039 No Documentation of Annual Testing
Annual tabletop
Full scale exercises
Full-scale community based exercise
Update to emergency program based on this analysis.
45Slide46
EMERGENCY PREPAREDNESS
E0032 Communication Plan
Verify plan contains primary & alternate means for communicating
Review the communications equipment or communication systems
46Slide47
EMERGENCY PREPAREDNESS
E0023 Develop and implement emergency preparedness policies and procedures
Medical record documentation system
preserves patient information
protects confidentiality
secures and maintains availability of records
47Slide48
EMERGENCY PREPAREDNESS
E0022 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.
48Slide49
EMERGENCY PREPAREDNESS
E0015 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.
49Slide50
EMERGENCY PREPAREDNESS
E0026 Alternate care sites during emergencies
Providing alternate care under 1135 Waiver
50Slide51
EMERGENCY PREPAREDNESS
E0013 Alignment with identified hazards
All hazards approach evaluation
Annual review of policies
51Slide52
EMERGENCY PREPAREDNESS
E0018 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.
52Slide53
EMERGENCY PREPAREDNESS
E0033 Sharing of Information During and Emergency
Medical documentation and continuity of care
Review policies and procedures on release of patient information
53Slide54
EMERGENCY PREPAREDNESS
E0037 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
54Slide55
CMS EDITS TO E0015 & E0041Slide56
CMS CONSIDERING EDITS TO E0015 & E0041
E0015Changes are related to heating and cooling facility
E0041
Speaks about use of portable generators
Speaks about installation of new generators
56Slide57
BONUS HEADS UP FOR LSCSlide58
GENERATOR FUEL CHECKS
Fuel quality checked annually
NFPA 110
58Slide59
Questions?Slide60
LONG TERM CARE
TINA FRENICKSlide61
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
Computer access difficult for surveyors – Facility staff unavailable to assist
Different survey processes for states
Slide62
Survey Variances – Continued
LTCSP – New Survey Process
Full day of observation – and PRN
Less burden to staff/facility during tour
Resident screening for sample identification - Less documentation
Real-time documentation
MDS integrated into LTCSP, which drives resident focused investigation
LTCSP automatically uploads individual resident information for further investigation – identifies areas of concern
Focus areas for each resident, rather than investigating areas which may not apply to a resident (example - falls)
Nation wide survey process Slide63
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. Slide64
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.Slide65
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.Slide66
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. Slide67
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. Slide68
Recap – LTCSP – Continued
For non interviewable residents, surveyors will look at:
Pressure Ulcers
Dialysis
Infections
ADL Decline
FallsBowel and BladderHospitalizationElopement
Change of Condition Slide69
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
PalatabilityTemperature of meal/items servedService Delivery – Time/Staffing Available
Menu – Followed/Presentation/Dr. Order
Hygiene – Sanitary Practices
Correct Diets Served Slide70
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. Slide71
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 MapInterpretive GuidanceSlide72
Recap – LTCSP – Continued
Closed record review
Dining
Infection Control
SNF Beneficiary Protection Notification Review
Kitchen
Medication AdministrationMedication StorageResident CouncilSufficient and Competent Nurse Staffing QAA/QAPI
The following areas are only investigated if there are identified concerns relating to the sampled residents:
Personal Funds
Environment
Resident Assessment Slide73
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. Slide74
LTCSP Resources
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html
Appendix PP State Operations Manual (Revised 11/22/2017) [PDF, 3MB]
List of Revised FTags [Effective November 28, 2017] [PDF, 152KB]
S&C Memo: Revision to State Operations Manual Appendix PP for Phase 2 (Includes Training Information and Related Issues) [PDF, 121KB]
F-Tag Crosswalk [XLSX, 495KB]
Training for Phase 1 Implementation of New Nursing Home Regulations [PDF, 108KB]
New Long-term Care Survey Process – Slide Deck and Speaker Notes [PPTX, 8MB]
Entrance Conference Form Beneficiary Notice Worksheet (Updated 12/06/2017) [ZIP, 164KB]
LTC Survey Pathways - Updated 12/13/2017 [ZIP, 2MB]
LTCSP Procedure Guide [PDF, 1MB]
LTCSP Initial Pool Care Areas - Updated 11/17/2017 [ZIP, 1MB]
Survey Resources - Updated 12/13/2017 [ZIP, 10MB]
Matrix with Instructions - Content Unchanged [PDF, 299KB]
LTCSP Mapping Document [PDF, 740KB] Slide75
LTCSP Survey Outcomes
By Deficiency Slide76
Deficiency Trending Slide77
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/
Top10
Citations
LTC
.pdfSlide78
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 Slide79
Deficiency Variances – Continued
December 1, 2016 – January 25, 2017
E – 24 Deficiencies – and 3 Deficiencies were cited for more than one facility, which included:
281 – Professional Standards
371 – Dietary Services
441 – Infection Control
December 1, 2017 – January 25, 2018
E – 16 Deficiencies cited with 3 of them cited at three facilities, which included:
656 - Comprehensive Care Plan
761 - Medications - Store/Label
880 – Infection Control Slide80
Deficiency Variances – Continued
December 1, 2016 – January 25, 2017
D – 24 Deficiencies – 7 cited at 2 or more facilities, which included:
225 – Abuse/Reporting/Investigation
241 – Dignity and Respect
278 - Assessment Accuracy
279 – Comprehensive Care Plan
281 – Professional Standards
323 – Accidents and Hazards
425 – Pharmacy Services
December 1, 2017 – January 25, 2018
D – 27 Deficiencies – 7 cited at 2 or more facilities, which included:
550 – Resident Rights
610 - Abuse/Reporting/Prevention
657 – Comprehensive Care Plan
686 – Pressure Ulcer Treatment/Prevention
755 – Pharmacy Services
758 – Unnecessary Antipsychotics/PRN Use
849 – Hospice Slide81
Is Montana Similar? Slide82
Questions?Slide83
Dispute Resolution & ENFORCEMENT
TYLER SMITH Slide84
Dispute ResolutionSlide85
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 changesSlide86
Dispute Resolution
Reminders:
State’s Letter vs. CMS letter
IIDR
Montana has had one requested
Montana has also written a recommendation for oneSlide87
EnforcementSlide88
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 FindingsSlide89
Enforcement
Temporary Moratorium on Imposing Certain Enforcement Remedies – Phase 2
18-Month Moratorium for:
CMPs
DDPNA
Discretionary Termination
Does not apply to F608 (reporting reasonable suspicion of crime)
Phase 1 or 2 are still subject to Mandatory DPNA and Termination
Remaining remedies can still be imposedSlide90
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 nurse. Maximum - $221,048Slide91
Enforcement
Tags affected:
F655 – Baseline Care Plan
F740 – Behavioral Health Services
F741 – Sufficient/Competent Direct Care/Access Staff-Behavioral Health
F758 – Psychotropic Medications related to PRN Limitations
F838 – Facility Assessment
F881 – Antibiotic Stewardship Program
F865 – QAPI Program and Plan related to the development of QAPI Plan
F926 – Smoking PoliciesSlide92
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 Slide93
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 programSlide94
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.”Slide95
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. Slide96
Enforcement
Facility Initiated Discharges
So, why the discussion?
Transfer of Enforcement Cases
Questionable/Unsafe Setting
Resident remains hospitalized
Facility Pattern
Others?Slide97
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/NFSlide98
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 F812, F813, and F814
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.Slide99
Enforcement
7304 continued…
IJ which resulted in serious injury, harm, impairment or death
VS.
IJ with
no
resultant serious injury serious injury, harm, impairment or death
Slide100
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 Slide101
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 updatesSlide102
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) surveysSlide103
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 RO issues letter rescinding DPNA as of date of compliance
Compliance letter is forwarded to Noridian Administrative ServicesSlide104
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
TerminationSlide105
Enforcement - Common Questions Slide106
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?Slide107
Questions?Slide108
Certification Bureau Contact information:
Phone 406-444-2099 Fax 406-444-3456 Email MTSSAD@MT.GOVSlide109
2018 – The 18th year of the 3rd millennium, the 18th year of the 21st century, and the 9th year of the 2010s decade.