healthcare licensing & surveys ron pearson, m.h.a., c.f.a.a.m.a. state survey agency director...
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Healthcare Licensing & Surveys
Ron Pearson, M.H.A., C.F.A.A.M.A.
State Survey Agency Director
Laura Hudspeth, MSc, RD, LD
Chief, Healthcare Surveillance Branch
Julia Van Dyke, RN
Lead Health Surveyor
May 2013
HLS Mission
– Federal (85%): • Serve as the agency for certification of healthcare facilities operating in
Wyoming (Title XVIII, Social Security Act, Section 1864)• HLS acts on behalf of the Secretary (HHS) as Federal Contractor applying
and enforcing Federal standards• CMS Survey and Certification program assures basic levels of quality and
safety for Medicare and Medicaid beneficiaries– State (15%):
• Serve as the regulatory agency for licensure to operate within Wyoming (WY Statutes 35-2-901 thru 35-2-910)
• Protect health, safety and welfare of patients (residents) of licensed healthcare facilities
• Jurisdictional authority over fire safety and building codes for construction involving healthcare facilities
Organization
Branches
• Business Office– Manages daily operations of office including records, reports, equipment,
supplies, vehicles, IT, budget, and HIPAA/FOIA requests– Performs licensing and administrative functions– Maintains HLS website and training records
• Health Care Surveillance– Schedules and conducts unannounced, on-site, objective, and outcome-
based surveys– Investigates complaints from all sources including EMTALA violations– Reviews/validates incidents reported by providers – Oversees CNA/LTC Abuse Registry and CNA Training Program – Directs training program
• Life Safety & Construction– Reviews and approves healthcare construction plans and projects– Conducts Life Safety code surveys for licensure and certification
PROVIDER TYPE # IN WYOMING LICENSED ONLY CERTIFIED ONLY LICENSED & CERTIFIED DEEMED
Adult Day Care Center 8 8
Assisted Living Facility 26 26
Ambulatory Surgical Center 20 20 4
Boarding Home 9 9
Critical Access Hospital 16 16 1
Community Mental HealthCenter
3 3
Comprehensive OutpatientRehabilitation Facility
1 1
End Stage Renal DialysisCenter
9 9
Federally Qualified HealthCenter
13 13
Freestanding DiagnosticTreatment Center
1 1
Home Health Agency 43 14 29 1
Hospital 11 11 10
Hospice Facility 19 1 18
Intermediate Care Facility forMentally Retarded
1 1
Nursing Care Facility 38 38
Outpatient Physical Therapy/Speech Pathology
1 1
Psychiatric Residential Treatment Facility
3 3
Psychiatric Hospital 2 2
Rehabilitation Facility 2 2
Rehabilitation Hospital 1 1 1
Rural Health Clinic 18 18
Total Providers 245 61 38 146 13
Surveyors
Surveyor Certification (SMQT) Experience (Yrs) CredentialsLinda Brown Health 11 RN, BS, CPHQ
Janelle Conlin Health 12 OTR/L
Russ Forney Health, CLIA 7 PhD, MT
Larry Goodmay Health, Life Safety 9 MS
Catherine Hoff Health < 1 RN, BS
Tony Madden Health 6 RN
Kathryn May Health 2 RN
Pat Prince Health 19 RN, BSN
Lori Reuss Health 8 RD, LD
Julia Van Dyke Health <1 RN
Average 7.5 yrs
Note: Currently recruiting to fill 2 vacant surveyor positions
Wyoming Performance StandardsFFY 2013
(As of 05/02/13)
NURSING HOMES38 providers
TIER REQUIREMENT CURRENT STATUS COMPLETED
Tier 1 •15.9 Mo Max Interval•12.9 Mo Avg
•13.4 Mo Max Interval•11.7 Mo Avg•0 > 15.9 Mo
Tier 2 •NH Oversight & Improvement Program •2:4 staggered surveys done•1 SFF
Tier 3 NA NA
Tier 4 NA NA
Comparison of Frequently Cited LTC Health Tags
FY2013 (to date)
(Data Source: S&C PDQ/Run Date: 05/07/2013)
WYOMINGTop 5
REGION 8Top 5
NATIONALTop 5
Tag # Description % Surveys
Cited(15
surveys)
Tag #
Description % Surveys
Cited (279
surveys)
Tag #
Description % Surveys
Cited (6,639
surveys)
F441 Facility Establishes Infection Control Prog
73.3% F441 Facility Establishes Infection Control
Program
49.5% F441 Facility Establishes Infection Control
Program
37.8%
F309 Provide Necess Care for Highest Prac Well
Being
53.3% F323 Facility Is Free of Accident Hazards
45.9% F371 Store/Prepare/Distrib Food Under Sanitary
Conditions
34.5%
F371 Store/Prepare/Distrib Food Under Sanitary
Conditions
46.7% F371 Store/Prepare/Distrib Food Under Sanitary
Conditions
43.0% F323 Facility is Free of Accident Hazards
29.9%
F323 Facility is Free of Accident Hazards
40.0% F309 Provide Necess Care for Highest Prac Well
Being
35.5% F309 Provide Necess Care for Highest Prac Well
Being
24.9%
F279 Develop Comprehensive Care
Plans
33.3% F329 Drug Regimen is Free From Unnecessary
Drugs
31.9% F329 Drug Regimen is Free From Unnecessary
Drugs
22.5%
Comparison of Frequently Cited LTC Health COMPLAINT Tags
FY2013 (to date)
(Data Source: S&C PDQ/Run Date: 05/07/2013)
WYOMINGTop 5
REGION 8Top 5
NATIONALTop 5
Tag # Description % Surveys Cited
(25 surveys)
Tag #
Description % Surveys Cited (248
surveys)
Tag #
Description % Surveys
Cited (21,532
surveys)
F323 Facility is Free of Accident Hazards
28.0% F323 Facility is Free of Accident Hazards
12.1% F323 Facility is Free of Accident Hazards
5.7%
F241 Dignity and Respect of
Individuality
12.0% F309 Provide Necess Care for Highest Prac Well Being
8.1% F309 Provide Necess Care for Highest Prac Well
Being
4.2%
F441 Facility Establishes
Infection Control Prog
12.0% F441 Facility Establishes Infection Control
Prog
6.9% F157 Inform of Accidents/Sig
Changes/Transfer/Etc
2.6%
F225 Not Employ Persons Guilty
of Abuse
12.0% F281 Services Provided Meet Professional
Standards
4.8% F225 Not Employ Persons Guilty of Abuse
2.5%
F425 Pharmaceutical Svc – Accurate
Procedures, RPH
12.0% F241 Dignity and Respect of
Individuality
4.0% F514 Clinical Records Meet Professional Standards
2.1%
Comparison of Frequently CitedLTC Life Safety Code Tags
FY2013 (to date)
(Data Source: S&C PDQ/Run Date: 05/07/2013)
WYOMINGTop 5
REGION 8Top 5
NATIONALTop 5
Tag # Description % Surveys Cited
(15 surveys)
Tag #
Description % Surveys Cited (279
surveys)
Tag #
Description % Surveys Cited (6,628
surveys)
K147 Electrical Wiring and Equipment
73.3% K062 Sprinkler System Maintenance
48.4% K147 Electrical Wiring and Equipment
31.1%
K062 Sprinkler System Maintenance
53.3% K147 Electrical Wiring and Equipment
45.2% K062 Sprinkler System Maintenance
30.4%
K025 Smoke Partition Construction
40.0% K038 Exit Access 37.6% K029 Hazardous Areas – Separation
25.7%
K050 Fire Drills 33.3% K018 Corridor Doors 36.6% K018 Corridor Doors 25.6%
K052 Testing of Fire Alarm
33.3% K029 Hazardous Areas – Separation
34.4% K038 Exit Access 20.4%
Survey Citation PatternsBased on Last Current Uploaded
Standard Health Surveys
(Data Source: Casper 0311S / Run Date: 05/07/2013)
# of Providers # of Providers Cited for SQC
# of ProvidersZero Health Deficiencies
WY 38 1 1
Region 630 15 42
U.S. 15,686 431 1,505
11.1
7.1 6.9
8.9
7.56.8
9.6
7.4
6.4
11
8
6.1
11.7
7.34
5.95
8.47.44
5.75
Wyoming Region 8 Nation
FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013
Average Number of Deficiencies(Data Source: S&C PDQ / Run Date: 05/07/2013)
60
94
6758
920 18 13
112
169161
123
020406080
100120140160180
2010 2011 2012 2013
NH's ONLY ALF's ONLY ALL
Complaints
ComplaintsNursing Homes
200854 Rec'd 2009
65 Rec'd 201061 Rec'd 2011
77 Rec'd 201267 Rec'd 2013
58 Rec'd
11
0
16
26
2326
18
37
22
26
31
26
41
27
18
2
11
97
32
# Pending # Substantiated # Unsubstantiated No Action
ComplaintsAssisted Living Facilities
20109 Rec'd 2011
20 Rec'd 201218 Rec'd 2013
13 Rec'd
00
0
2
3
8
13
5
5
10
4
6
1 2
1
0
# Pending # Substantiated # Unsubstantiated No Action
Informal Dispute Resolution (IDR)
• Informal opportunity to challenge facts and evidence surrounding disputed deficiencies
• Informal administrative process—not formal evidentiary hearing• May dispute assigned scope and severity of citation if it has
resulted in substandard quality of care or immediate jeopardy • IDR frequency
• 6 (FFY 2011)• 8 tags requested = 4 upheld, 2 modified 2 reversal
• 3 (FFY 2012)• 3 tags requested = 1 upheld, 1 modified, 1 reversal
• 3 (FFY 2013 to date)• 5 tags requested = 2 upheld, 2 modified, 1 reversal
How HLS Is Evaluated
– Standard Surveys • Comprehensive survey of all major requirements for quality
– Complaint Investigations• Investigation of complaint and provider’s compliance with CMS requirements
– Comparative Surveys• CMS conducts independent survey within 60 days of State survey to compare results
– Observational Surveys (Federal Oversight Surveys)• CMS team accompanies State survey team
– State Performance Standards Review• CMS assessment of State Survey Agency’s performance in targeted review areas
– Frequency (6 standards)– Quality (8 standards)– Enforcement (3 standards)
State Performance Standards Review (FY 2012)
FREQUENCY Met / Not Met
Off Hours Surveys for Nursing Homes Met
Frequency of Nursing Home Surveys Met
Frequency of Non-Nursing Home Surveys – Tier 1 Met
Frequency of Non-Nursing Home Surveys – Tier 2 Met
Frequency of Non-Nursing Home Surveys – Tier 3 Met
Frequency of Data Entry of Standard Surveys (Non-Deemed Hosp/NH)
NH – MetNDH - Not Met
(3 CAHs – avg 71 days)
State Performance Standards Review (FY 2012)
QUALITY Met / Not Met
Documentation of Deficiencies on Form CMS-2567 Met
Conduct of NH Surveys IAW Federal Standards (FOSS) Met
Documentation of Non-Compliance IAW Federal Standards (FOSS) Met
Accuracy of Documentation During NH Comparative Surveys Met
Prioritizing Complaints and Incidents Met
Timeliness of Complaint and Incident Investigations Met
Quality of EMTALA Investigations Met
Quality of Complaint/Incident Investigations for Nursing Homes Met
State Performance Standards Review (FY 2012)
ENFORCEMENT Met / Not Met
Timeliness of Mandatory DPNA Notification for Nursing Homes Met
Processing of Termination Cases for Non-NH Providers/Suppliers Met
Special Focus Facilities for Nursing Homes Met
Federal Oversight Surveys (FOSS)(2011 - 2012)
SURVEY TEAM CONCERN
IDENTIFICATIONSAMPLE
SELECTIONGENERAL
INVESTIGATIONKIT/FOOD SVC
INVESTIGATIONMEDICATIONS
INVESTIGATIONDEFICIENCY
DETERMINATION
NH Survey(Amie Holt) Betty, Pat 5 5 5 5 5 5
NH Survey(Sage View)
Linda, Kathy, Karla 5 5 5 4 5 4
Complaint Inv.(Cheyenne HC)
Tony 5 5 5 N/R N/R 5
NH Survey(Thermopolis)
Linda, Lori, Larry, Kathy 5 5 5 5 3 5
NH Survey(Pioneer)
Pat, Betty, Kathy, Larry 5 5 5 5 5 5
NH Survey(Life Care Chey)
Pat, Lori, Linda 5 5 5 5 5 5
5 = Extremely Effective 4 = Very Effective 3 = Satisfactory 2 = Less Than Satisfactory 1 = Much Less Than Satisfactory
Federal Oversight Surveys (FOSS)(2013)
SURVEY TEAM CONCERN
IDENTIFICATIONSAMPLE
SELECTIONGENERAL
INVESTIGATIONKIT/FOOD SVC
INVESTIGATIONMEDICATIONS
INVESTIGATIONDEFICIENCY
DETERMINATION
NH Survey(Westview)
Pat, Linda, Russ, Larry, Rae Anne 5 5 5 5 5 5
NH Survey(Life Care Chey)
Linda, Pat,Lori 5 5 5 5 5 5
5 = Extremely Effective 4 = Very Effective 3 = Satisfactory 2 = Less Than Satisfactory 1 = Much Less Than Satisfactory
Civil Monetary Penalties
• Background• CMS sets health, safety and quality requirements that facilities must meet in
order to participate in Medicare and Medicaid programs• CMS routinely inspects nursing homes to ensure compliance with
requirements for participation• Congress has authorized CMS to impose enforcement remedies to achieve
facility compliance with requirements• Remedies are designed to minimize time between identification of violations
and final imposition of remedies– May range from directing specific actions and timeframes needed to
correct a deficiency under a directed plan of correction to those that provide facilities with financial incentives to return to and maintain compliance
– Considerations: » Scope & Severity of deficiency (ies)» Relationship of one deficiency to other deficiencies » Facility’s prior history of noncompliance» Likelihood that remedy(ies) will achieve correction and continued compliance
Civil Monetary Penalties(Cont’d)
• Selecting Enforcement Remedies– Severity of remedy should increase with severity of deficiency
– Immediate Jeopardy, J, K, and L: Facilities are terminated within 23 days or temporary management is imposed. CMPs from $3,050 to $10,000 per day or $1,000 to $10,000 per instance of noncompliance may also be imposed
– Noncompliance that is actual harm (G, H, and I) require one or a combination of remedies:
» Temporary management» Denial of Payment for New Admissions (DPNA)» Per day CMP of $50 to $3,000; or» Per instance CMP of $1,000 to $10,000 per instance of noncompliance
– Additional remedies may be imposed for noncompliance that is actual harm» Depends on severity of deficiency and facility’s compliance history» Combination of state monitoring, DPNA, and a CMP may be imposed
Other Issues
• Electronic incident reporting
• Involuntary discharges from LTC facilities• Non-payment• Safety issue (perceived danger to staff or residents)• Resident may appeal decision to State
• Office of Administrative Hearings• WDH Director makes final decision• Currently working with AG, DUPRE & CMS to clarify policy guidance
Reporting Alleged Abuse
• Put processes in place to ensure either the providers, complainants, or HLS staff are notifying DFS or law enforcement of allegations of abuse/neglect/financial exploitation– DFS presentation at HLS In-Service Training– Met with DFS (APS) Representative – Health Surveys
• Review policies, ask for abuse log/file, staff interviews• Adherence to written policies (screen, in-service, how allegations
investigated)• All allegations must be investigated and resident protected• Reported to law enforcement or DFS and additional agencies
(HLS, BON, Ombudsman)– Incident Reporting
• Same requirements
Rules for Assisted Living Facilities
• Jan 2013: ALF Working Group formed• Reps from ALFs, associations, Medicaid, HLS• 23 issues/topics introduced for evaluation
• Feb 2013: Subgroups formed to work issues• Management (Laura Hudspeth)• Care (Sharon Skiver)• Life Safety (Todd Wyatt)• Staffing (Julia Van Dyke)
• Jun 2013: Subgroups recommend Rules changes
• Jul – Sep 2013: Promulgate changes to Rules
Questions ?