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MHCA  Spring 2018 Agenda MHCA  Spring 2018 Agenda

MHCA Spring 2018 Agenda - PowerPoint Presentation

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MHCA Spring 2018 Agenda - PPT Presentation

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

care amp enforcement emergency amp care emergency enforcement resident deficiencies survey preparedness fire facility testing ltcsp doors nfpa health

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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.