California Department Of Public Health Licensing and Certification Division

Carol Littler,

A n n u a l R A P S e s s i o n A p r i l 2 6 , 2 0 1 2

CENTER FOR HEALTH CARE QUALITY O

VERVIEW

• • • • Patient safety protection through: Licensing & Certification (L&C): Evaluate facilities, agencies, and professionals for compliance with state and federal laws and regulations in order to license/certify them to operate in California.

Laboratory Field Services: Enforce quality standards in clinical and public health laboratories, and blood and tissue banks both within and outside California serving Californians.

Healthcare Associated Infection Program: Conduct surveillance, prevention and public reporting of infection rates.

LICENSING & CERTIFICATION PROGRAM

VISION AND MISSION

• Vision: • L&C strives to operate a responsive, uniform enforcement program in accordance with state licensing and federal certification requirements, to encourage provider-initiated compliance and quality of care improvement activities, and to assure quality of care.

• Mission: • Promote the highest quality of care in community settings and health facilities, improve access to care and assure quality of care.

MAJOR ACTIVITIES

 Ensure quality health care delivery by nearly 8,000 facilities in 30 different facility and agency types.

 Certify facility and agency compliance with federal requirements.  Conduct approximately 27,000 complaint investigations and 7,000 licensing surveys annually.

 Certify over 160,000 nurse assistants, home health aides and hemodialysis technicians.

 License over 3,000 Nursing Home Administrators.

 Train, inspect, drill, and educate facilities in efforts.

LICENSING AND CERTIFICATION MAJOR ACTIVITIES, CONT.

• Field Operations Branch: • Employs approximately 600 dedicated, highly skilled and qualified Registered Nurses, Medical, Pharmaceutical and Nutritional Consultants.

• Conducts approximate 1,350 on-site inspections of nursing homes, annually.

LICENSING & CERTIFICATION STAFFING AND BUDGET

Staffing

 1,111.45 positions in 14 district offices, statewide: • Survey Staff – 556.00

• Professional Certification Branch – 87 • Administrative Staff – 468.45

 Los Angeles County Department of Public Health  200 staff under contract  Conducts licensing and certification activities within LA County.

COMPLAINTS & ENTITY REPORTED INCIDENTS

Fiscal Year

2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Complaints Entity Reported Incidents Total Complaints + ERIs Change from Baseline Annual Increase Closed Closed Entity Reported Incidents

9,007 8,900 9,155 10,544 9,643 9,452 9,586 14,778 19,701 21,705 24,046 26,217 28,533 28,676 23,785 28,601 30,860 34,590 35,860 37,985 38,262 Baseline 20.2% 29.7% 45.4% 50.8% 59.7% 60.9% 20.2% 7.9% 12.1% 3.7% 5.9% 0.7% 99.2% 98.5% 98.0% 96.3% 90.3% 82.9% 69.5% 99.6% 99.5% 99.5% 98.9% 95.6% 91.5% 82.6% 2011/12 projection 9,830 *29,633 39,463 65.9% 3.1% 64.6% 79.8%

COMPLAINTS COMPLETED WITHIN 45 AND 90 DAYS 07/01/10-06/30/11

Facility Type # Complaints to Investigate # Complaints done in 45 days % Complaints done in 45 Days # Complaints done in 90 days % Complaints done in 90 days SNFs GACHs IMRs HHAs ESRDs Hospice FQHCs ASCs RHCs 5063 2872 435 217 132 79 59 40 8 2879 764 256 63 36 25 29 6 2 56.86% 26.60% 58.85% 29.03% 27.27% 31.65% 49.15% 15.00% 25.00% 3415 1113 309 86 75 46 42 16 3 67.75% 38.75% 71.1% 39.63% 56.82% 58.22% 71.18% 40.0% 37.5%

ERIS COMPLETED WITHIN 45 AND 90 DAYS 07/01/10-06/30/11

Facility Type SNFs GACHs IMRs HHAs FQHCs Hospice ESRDs ASCs RHCs # ERIs to Investigate 7468 6618 2919 85 37 36 35 4 4 # ERIs done in % ERIs done 45 days in 45 Days # ERIs done in 90 days % ERIs done in 90 days 3933 1909 52.66% 28.85% 4730 2546 63.33% 38.47% 1014 19 10 34.74% 22.35% 27.03% 1587 26 16 54.37% 30.59% 43.24% 9 18 1 2 25.00% 51.43% 25.00% 50.00% 12 21 36.33% 60.00% 11

COMPLAINT/ERI & POC CHALLENGES

Implementation of LTC Federal complaint process

• Phased in approach • • Development of Complaint P&P and retraining of staff Impact on Federal Grant Allocation

Timely initiation of backlog and closure of initiated investigations OIG Plan of Correction Audit Findings

• Reinforce CMS requirements that each POC include the 5 elements for an acceptable POC (OIG audit report) • Reinforce the need to on-site visits to determine if facility is implementing its POC •

Solutions

Implementation of SOM Chapter 5, Section 5070 • (Closure of LTC ERIs if received and not initiated before recertification survey.) Would like this for non-LTC as well • Preparing All Facility Letter and District Office Memo

QUALITY AND ACCOUNTABILITY PROGRAM

For SKILLED NURSING FACILITIES

QUALITY AND ACCOUNTABILITY PROGRAM

• • • Collaborative effort between Departments of Public Health and Health Care Services.

Implement Skilled Nursing Facility Quality and Accountability Program.

Provide incentive payments to facilities for achieving minimum scores on Quality Measures.

QUALITY AND ACCOUNTABILITY PROGRAM

• • • • • • Quality Measures Staffing Physical Restraints • • Facility-acquired Pressure Ulcers Immunizations Influenza Pneumococcal Patient/Family Satisfaction Survey • Other measures added in subsequent years

QUALITY AND ACCOUNTABILITY PROGRAM

• • • All Facility Letter 11-19 for compliance audits: In-depth accounting of facility compliance with 3.2 nurse-staffing requirements.

Helps determine whether program yields staffing rates that are instrumental to changes in health care outcomes.

• Audit all SNFs every year • • • Administrative Penalties $15,000 non-compliant 5-49% of audited days $30,000 non-compliant >49% of audited days

EMERGENCY PREPAREDNESS/ DISASTER RESPONSE BRANCH

EMERGENCY PREPAREDNESS/ DISASTER RESPONSE

• • • • • • Core Responsibilities/Activities • Life Safety Code • Emergency Preparedness/Disaster Response • State Facilities Unit Background: Created in 1998 following Northridge Earthquake.

Assists licensed facilities to prepare for, respond to, and recover from disasters/emergencies. Ensure patient health and safety during extreme events.

Educate and train response partners including: facilities, counties, provider associations, and state/federal agencies and departments.

OPEN ISSUES

• • • • • • 3.2 NHPPD Audit Process High Profile Facility Closures LA County Contract Renewal CMS Grant Compliance Medical Breaches Health Facility Consumer Information System

ADMINISTRATIVE SERVICES BRANCH

ADMINISTRATIVE SERVICES BRANCH

• • Personnel and Business Services Section • Ensures timely processing of hiring and benefit documents and related personnel requests.

• Provides effective, efficient business services and operational support to internal & external customers. • Liaisons with CDPH Human Resources, Program Support and Contracts Management, as well as Department of Personnel Administration. Fiscal Operations& Grant Administration Section • Program fiscal liaison with CDPH Budget and Accounting, Centers for Medicaid and Medicare Services, Department of Finance, Health and Human Services Agency, Legislature, Legislative Analyst's Office and public.

ADMINISTRATIVE SERVICES BRANCH H

EALTH

C

ARE

F

ACILITY

F

EES

• Annual Fees • H&S Code 1266(d) requires by Feb. 1: • Budget Year Health Facility License Fees; • • Based on L&C Program activity costs; Staffing and system analysis data includes, but not limited to: • Surveyors and other personnel devoted to licensing & certification activities.

• • • • Facilities receiving full surveys.

Timeliness of complaint investigations.

Citation review conferences and arbitration hearings.

Data on deficiencies and citations issued.

SYSTEMS, TECHNOLOGY AND RESEARCH BRANCH

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SYSTEMS, TECHNOLOGY, AND RESEARCH BRANCH

• Research Section Conduct research on quality of health care provided by California's health professionals, health facilities, and laboratories. • • • Staffing Audits Section Monitor, enforce, and report on nursing staff levels in long-term care facilities.

Program Applications Support Section • Support and oversee information technology needs for staff and health services providers.

POLICY & ENFORCEMENT BRANCH

POLICY & ENFORCEMENT

• Policy Section: • promotes program-wide consistency and standardization; communicate Department position on legislation impacting Program; assess need for new/revised field policies and procedures.

• Provider Certification Section: • Process certification requests and monitor enforcement actions against Title 19 certified providers.

POLICY & ENFORCEMENT

• Registered Nurse Section: • Assists in legislative analysis, writing regulations, providing technical assistance to headquarters and L&C Field staff on survey issues, monitoring regulatory compliance of providers enrolled in waiver programs, and assisting in handling appeals of L&C investigations.

REGULATIONS IN PROCESS

• ICF DD-N Regulations— • Health and Safety Code 1275.3 mandates that the Department of Public Health and the Department of Developmental Services jointly develop and implement licensing and Medi-Cal regulations appropriate for ICF DD-N regulations. • Tuberculosis Testing Regulation • Allows for use of a broader choice of TB screening test. • Medical Information Breach Regulation • Clarify and specify statutory language related breach violations in all affected facility types.

REGULATIONS IN PROCESS

• General Acute Care Infection Control Revision • Revises Title 22 Section 70739 Infection Control Program to reflect changes in current infection control statutes. • General Acute Care & Special Hospitals Regulations • Reviews and revises Title 22 Division 5 Chapter 1 General Acute Care Hospital regulations in order to modernize an increasingly obsolete regulation set.

PROFESSIONAL CERTIFICATION BRANCH

PROFESSIONAL CERTIFICATION BRANCH

• Aide and Technician Certification Section • Certifies Nurse Assistants (CNA), Home Health Aides (HHA), and Hemodialysis Technicians (CHT); maintains State Registry; and has oversight of Training Programs.

• • Criminal Background Section Grants/denies criminal record clearances for CNAs, HHAs; deny applications, revoke/suspend certificate; represents Department at administrative appeal hearings.

PROFESSIONAL CERTIFICATION BRANCH

• • Investigation Section • Investigates allegations/complaints against CNAs, HHAs, and CHTs; initiates administrative actions (denying an application, revoking/suspending a certificate/placing the certificate holder on a diversion program); and represents Department at administrative appeal hearings.

Nursing Home Administrator Program • Licenses Nursing Home Administrators; administers Nursing Home Administrator State Examination; investigates allegations/ complaints; oversees Administrator-in-Training Program and Preceptors; and approves/denies continuing education providers and courses for Nursing Home Administrators.

PROFESSIONAL CERTIFICATION BRANCH ADP TRANSITION

• Department of Alcohol and Drug Programs transferring into Center for Health Care Quality effective July 1, 2012: • • • Driving Under the Influence Program Narcotic Treatment Program Counselor Certification

CDPH/DHCS ANTIPSYCHOTIC COLLABORATIVE

• • Goal: Identify facilities where inappropriate antipsychotic medication is being used; and once identified corrective action is implemented— ultimately improving patient care and reducing health care costs.

Resident Selection • • • Polypharmacy: those who are older than 55 y/o (with diagnosis of SMI or dementia); Monopharmacy: with dementia, no SMI, and greater than 65 y/o Serious Mental Issues (SMI) includes for example major depression, scizophrenia, bi-polar disorder, etc.

DHCS – Department of Health Care Services

ISSUES

• Independent Information Dispute Resolution • Standard Admission Agreement • Retail Food Requirements • Other issues