Transcript What’s Hot What’s Not!

Survey and Certification Analysis
Joan Redden,
VP Regulatory
& Consumer Affairs
2009
( 1,131 surveys)
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Ftag
F371
F323
F279
F309
F441
F431
F514
F425
F329
F241
F253
F281
F278
F246
F465
F221
F315
F328
Description
Sanitary Food
Hazards
Care Plan
Quality Care
Infection Control
Labeling of drugs
Complete Records
Pharmacy procedures
Unnecessary Drugs
Dignity
Housekeeping
Professional standards
Accurate assessment
Accommodate Needs
Other environ. conditions
Restraints
Use of catheter
Special treatments
% of
surveys
58.2%
41.5%
37.8%
37.6%
35.8%
33.6%
32.4%
30.9%
28.7%
27.9%
27.2%
24.8%
22.9%
22.7%
22.6%
20.6%
19.7%
19.3%
2
2010
( 1,134 surveys)
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Ftag
F371
F441
F323
F309
F279
F514
F431
F425
F241
F465
F329
F281
F253
F315
F278
F246
F328
F518
Description
Sanitary Food
Infection Control
Hazards
Quality Care
Care Plan
Complete Records
Labeling of drugs
Pharmacy procedures
Dignity
Other environ. conditions
Unnecessary Drugs
Professional standards
Housekeeping
Use of catheter
Accurate assessment
Accommodate Needs
Special treatments
Emergency procedures training
% of
surveys
59.0%
51.9%
42.0%
38.4%
38.3%
32.6%
31.8%
31.4%
30.9%
28.8%
28.0%
26.8%
24.6%
22.5%
21.7%
21.3%
20.8%
17.5%
3
2011
( 779 surveys*)
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Ftag
F371
F441
F323
F309
F279
F431
F514
F465
F241
F329
F425
F281
F328
F315
F253
F246
F518
F314
Description
Sanitary Food
Infection Control
Hazards
Quality Care
Care Plan
Labeling of drugs
Complete Records
Other environ. conditions
Dignity
Unnecessary Drugs
Pharmacy procedures
Professional standards
Special treatments
Use of catheter
Housekeeping
Accommodate Needs
Emergency procedures training
Pressure Sores
% of
surveys
56.4%
51.3%
44.3%
37.9%
37.1%
32.0%
30.3%
29.7%
27.7%
27.7%
25.0%
24.3%
20.7%
19.6%
18.7%
18.6%
18.0%
16.9%
4
1. Better Health – Reducing use of off-label
antipsychotic reducing re-hospitalizations
2. Better Quality – Robust QAPI programs
3. Reduce Cost – Using CMP’s in education
programs increasing CMP’s for use of off-label
antipsychotic drugs
5
• Primary Objectives:
 Reduce the frequency of avoidable hospital
admissions and readmissions
 Improve resident’s health outcomes
 Improve the process of transitioning
between inpatient hospitals and nursing
facilities
 Reduce overall health care spending
6
Reduce hospital readmissions within 30
days of admission by 15% by
December 31, 2015
Improve customer satisfaction to exceed
90% that would recommend your facility by
December 31, 2015
Increase staff stability and consistent
assignments by 15% by
December 31, 2015
Reduce off-label use of antipsychotics by
15% by December 31, 2012
7
• Studies have estimated that 30% to 67% of
hospitalizations among nursing facilities could
be prevented with well targeted interventions
(Jacobson, et.al.,2010)
• 45% of hospital admissions among MedicareMedicaid enrollees receiving services in SNF
could have been avoided; 314,000 potentially
avoidable hospitalizations $2.6 billion in
Medicare expenditures in 2005
(Walsh et.al, 2010)
8
• In a recent CMS Webinar on April 3rd focused
on support organizations that will partner with
SNF in this initiative. Proposed interventions
included some of the following:
 Education efforts with families/caregivers
 Support for residents and nursing facility staff to
facilitate a successful discharge to the
community as appropriate;
 Health information technology to support sharing
of summaries across transitions in care and
maintenance of accurate, up
to date medication lists
 Enhanced Behavioral
health assessments
treatments and
management
9
Off-Label Antipsychotics
Daniel R. Levinson
Inspector General
May 2011
OEI-07-08-00150
10
• Senator Grassley has expressed concern
about atypical antipsychotic drugs
prescribed for elderly nursing home
residents for off-label conditions
(i.e., conditions other than schizophrenia
and/or bipolar disorder) and/or for residents
with the condition specified in the FDA
boxed warning.
• 14% of elderly nursing home
residents had Medicare
claims for atypical
antipsychotic drugs.
11
• To ensure that payments for atypical
antipsychotic drugs are correct and that
elderly nursing home residents are free
from unnecessary drugs, CMS
recommends:
 Facilitate access to information necessary to
ensure accurate coverage and
reimbursement determinations
 Assess whether survey and certification
processes offer adequate safeguards
against unnecessary antipsychotic drug use
12
• Explore alternative methods beyond survey and
certification processes to promote compliance
with Federal standards regarding unnecessary
drug use in nursing homes
• Take appropriate action regarding the claims
associated with erroneous payments
13
• CMS has identified reducing the off label use of
antipsychotics among patients/residents of
nursing centers as one of its priorities of 2012.
• Since 2006, the number of facilities cited by
CMS for the use of unnecessary medications
(F329) has increased by 75%.
• This intense scrutiny will continue as CMS
continues to increase training, adding
pharmacists to the survey teams, and bolstering
the surveyor interpretive guidance in an effort to
reduce cost, by expecting increased CMP’s!
14








F157 –Notification of Change
F272 – Comprehensive Assessments
F279, F280 – Comprehensive Care Plan
F309 – Provide Care/Services for Highest
Well Being
F425 – Pharmaceutical Services –
Accurate Procedures
F490 - Effective Administration / Resident
Well–Being
F514 - Resident Records – Complete/Accurate
/Accessible
F520 - QAA Committee
15
• The surveyor is cautioned to investigate these
related additional requirements before
determining noncompliance













F157 – Notification of Changes
F154, F155 – Notice of Rights and Services
F272 – Comprehensive Assessments
F279, F280 – Comprehensive Care Plans
F310 – Decline in ADL
F315 – Urinary Incontinence
F319, F320 – Mental and Psychosocial Functioning
F325 – Nutritional Parameters
F327 – Hydration
F385 – Physician Supervision
F386 – Physician Visits
F428 – Medication Regimen Review
F501 – Medical Director
16
17
0.25
0.20
0.15
0.10
0.05
0.00
18
Informed Consent
• Title 22 Section 72527 (a) states:
 (5) To receive all information that is material to
an individual patients decision concerning
whether to accept or refuse any proposed
treatment or procedure. The disclosure of
material information for administration of
psychotropic drugs ....
 The SNF must be able to verify that the patient
or their authorized representative has given
informed consent was obtained by the
prescribing licensed healthcare practitioner
acting within his/her scope of professional
licensure.
19
• New Admissions arriving on Antipsychotics
must verify informed consent
• The person ordering the antipsychotic within
his/her scope of practice shall obtain the
consent (Reasonable person rule applies)
• A Physician may NOT delegate his
responsibility to obtain an informed consent for
an antipsychotic. There is no mandated form or
format to obtaining the consent.
• A SNF may not fill out a form for the MD and
have the responsible party sign
20
• Once the informed consent by responsible
party the have been obtained, they don’t
need to be renewed if there is no change in
circumstances or risk to the resident.
 A reduction in the amount of the
antipsychotic
 Monthly orders with out change
 Transfer back to the SNF without change in
the existing order
21
 Person’s with a diagnosis of dementia
receiving two or more antipsychotics with
or without a significant mental illness
diagnosed
 One antipsychotic without a diagnosis of
significant mental illness
 Chemical restraints 60%
 Inappropriate Antipsychotic use 50%
 Informed consents 20%
22
• The AARP has joined what lawyers call an
unprecedented CLASS-ACTION LAWSUIT
accusing a Ventura nursing home of using
powerful drugs without the informed consent of
residents or family members.
• “The nursing home is literally the one that is
putting the pill in the mouth and they are doing
it without permission.” – said Gregory Johnson,
Oxnard Lawyer who filed the suit.
• The case brings up debate over the use of
chemical restraints to control the behavior of
people in nursing homes with Alzheimer’s
disease and other dementia.
23
• The University of Iowa website containing the
antipsychotic drug resources is finally live.
• Facilities can log into the site at
https://www.healthcare.uiowa.edu/igec/IAADAPT.
• Please note that individuals wishing to use the site will
be required to log-in.
• It is quick, simple and free.
24
25
26
• In Oct 2011, CMS was considering a stricter
rules to oversee patients’ drug regimes.
• The agency said it was “strongly
encouraging” providers to voluntarily adopt
the following changes:
 Separate contracting for long-term care
consultant dispensing and other pharmacy
services
 Pay fair market rates for consultant
pharmacist services
27
• In Oct 2011, CMS was considering stricter rules
to oversee patients’ drug regimes.
• The agency has decided against the policy
because it “would be highly disruptive to the
industry without reducing utilization.”
Bloomberg News 4/3
• “The agency has decided to “further study the
issues after stakeholders raised concerns that
patterns rather than consultant pharmacists
were driving overuse.” The Hill 4/3
28
• AHCA Pharmacy Workgroups urged regulators
to take another tack, pointing out that current
survey guidance dealt adequately with potential
conflicts of interest and that the benefits of
having affiliated pharmacists would be lost
under an independent model
• AHCA offered a series of alternatives, including
a requirement for consultant pharmacist to sign
an integrity/ethical agreement and a
requirement for separate written contracts
between the pharmacy, consultant pharmacist
and long-term care facility
29
• The agency said it was “strongly encouraging”
providers to voluntarily adopt the following
changes:
 Separate contracting for long-term care
consultant dispensing and other pharmacy
services
 Pay fair market rates for consultant pharmacist
services
 Disclose to long-term care facilities any
affiliations of pharmacist that pose potential
conflicts of interest – Disclosure “may include the
execution of consultant pharmacist integrity
agreements”
30
• AB 641 (Feuer) eliminated the citation review
conference and increased the maximum of a
“B” citation to $2,000.
 Since 2004 a total of 15 cases were dismissed
out of 955 citation actions for a rate of 1.6 %
dismissal, or taking into consideration that 11
citations were related to one single case that
would decrease the rate to .0.52%
 In 2009 and 2010 only 7/8% and 6.22% of all
LTC facilities requested a CRC.
31
• CRC appeals requested prior to January 1,
2012 will continue to be conducted pursuant to
HSC Section 1428.
• Although the legislation eliminated the CRC
appeal process for contesting citations, a
licensee can continue to contest a class “AA” or
“A” in superior court
• The remaining law still allows a licensee to
contest a class “B” citation through either an
administrative hearing or binding arbitration
32
• Finally this bill gives statutory authority to DHS
to recommend that CMS impose a CMP when
DPH determined that a SNF is not in
compliance with both state and federal
requirements, or dual tract enforcement.
33
34
• Beginning after January 1, 2012 the federal
requirement for IIDR process will apply to all
standard and complaint surveys in which a
CMP is imposed and are subject to being
collected and escrowed. (S&C 12-08)
• States may not charge the SNF for IIDR
process
• The IIDR is an informal administrative
procedure to provide the facilities, under certain
circumstances the opportunity to dispute cited
deficiencies through a process independent
form the State survey agency
35
• CMS retains ultimate authority for the survey
findings and imposition of CMP.
• IIDR are provided within 30 calendar days of
the notice of imposition of CMP that is subject
to being collected and placed in escrow.
• IIDR will be completed with in 60 calendar days
of the facilities request.
• A written report written prior to the collection to
include the resident, Ombudsman and center
with an ability for opportunity for written
comment.
• CMP will be escrowed 90 days after the notice
of CMP or completion of the IIDR process.
36
• CMS will initially only collect and escrow this
penalties that are imposed for the most serious
deficiencies cited at actual harm.
• CMP collected “may not be used for survey and
certification process but must be used entirely
for activities that protect and improve the quality
of care for residents.
• 50% reduction in a CMP in certain cases for
prompt correction and self-reported noncompliance.
37
• Upon receipt of the IIDR written record the
State will review the recommendations and:
 They may agree and send the notice to the
provider with in 10 calendar days.
 If the State disagrees, will send their comments
to CMS RO for review and final decision.
 Once final agreement is made the State will
provide the written notification to the facility
within 10 days with adjustments for any
deficiency including scope and severity.
 CMS sends out a notice to escrow the money.
38
39
Memorandum
• The CMS in collaboration with the CDC seeks to
identify current State Health Department and
State Survey Agency HAI prevention programs
for nursing homes.
• We will begin the initial pilot scan of seven
randomly selected States (Nebraska,
Washington, Texas, Illinois, North Carolina,
Colorado and Massachusetts) in late March
2012.
• Our goal is to determine how the current nursing
home HAI prevention programs operate and
learn from the States’ experiences.
• This will help the development of a national
infection prevention program for nursing homes.
40
Part of Pilot Program
• ALFs, ICFs/ID and NFs must have a policy that
protects residents from vaccine-preventable
diseases.
• ALFs, ICFs/ID and NFs do NOT have to provide
the vaccines to employees and contractors,
however, such facilities may choose to do so.
• The policy must specify the vaccines that an
employee or contractor must received based on
the risk that the employee or contractor presents
to residents.
• The facility must also have procedures to verify
that the employee or contactor either complied
or is exempt from the required vaccines.
41
• CMS is focusing on hospitals enhancing SNF
inspections
• LTC- HAI affect 3.2 million residents annually
• Acute Care-1.7 HAI annually (Data supplied by
CAHF)
• Hospital are now testing IC tools (Checklist for
Surveyors) and soon they will be modified for
SNF
 The focus of Infection Control is associated with
central line infections, UTI, Blood stream
infections with MRSA, VRE, and Clostridium
difficile. (CDI)
42
• On March 23, 2010, Affordable Care Act
passed
• Section 6102© contains provisions for
establishing and implementing QAPI program
for nursing homes
• Program included establishing standards
(regulations) and providing technical assistance
with development of best practices to meet
standards
• Think of it as “QAPI”
43
1
• Design and Scope
2
• Governance and Leadership-Critical
and Foundational
3
• Feedback, Data Systems and
Monitoring
4
• Performance Improvement Projects
(PIPS)
5
• Systematic Analysis and Systematic
Action
44
Final rule issued in late 2012 or early
2013
Nursing facilities must have a QAPI
program in place with written plan a year
after final rule
Surveyor training starting in 2012
45
Draft - Ref: S&C: 12-XX-
Facility Responsibility
• Under F223 & F224, a nursing home is responsible for
the actions of its employees, contractors, and
volunteers.
• Even if a facility provides evidence that “it did
everything to prevent abuse or neglect,” this regulatory
language means that a facility is responsible for those
under facility management.
46
Draft - Ref: S&C: 12-XX-
Abuse – F223
• If the resident is the primary source of
information, the team should conduct further
information gathering and analysis (i.e.,
interviews with family & staff or record reviews)
• If additional sources are not available – the
citation of a deficiency may be based on
resident information alone.
• The reasonable person concept should be
applied in cases where the resident’s reaction
to a situation of abuse is markedly incongruent
with the level of reaction the reasonable
person would have to that situation
47
Draft - Ref: S&C: 12-XX-
Resident-to-Resident Abuse
•The facility is responsible for identifying
residents who have a history of disruptive or
intrusive interactions, or who exhibit other
behaviors that make them more likely to be
involved in an altercation.
Visitor-to-Resident Abuse
•The facility should have policies that address
the prevention of abuse, mistreatment or
misappropriation of resident property, including
how to ensure the health and safety of each
resident with regard to family members or legal
guardians, friends, or other individuals.
48
Draft - Ref: S&C: 12-XX-
Visitor-to-Resident Abuse
The resident has the right and the facility must
provide immediate access to any resident by the
following
• Subject to the resident’s right to deny or withdraw
consent at any time, immediate family or other
relatives of the resident; and
• Subject to reasonable restrictions and the
resident’s right to deny or withdraw consent at any
time, others who are visiting with the consent of the
resident
• Policies should address - denying access or
providing limited and supervised access to a visitor
if that individual has been found to abusing,
exploiting, or coercing a resident
49
Draft - Ref: S&C: 12-XX-
Neglect
• The facility’s policies and procedures that
prohibit neglect should include HOW the facility
will provide supervision, monitoring, sufficient
and knowledgeable staff, and appropriate
oversight and support from the administration.
• In addition, these policies and procedures must
be implemented
• Neglect at F224 should not be cited in addition
to the quality of life Tag unless the incident(s)
of neglect includes a failure either for an
individual resident over time or across multiple
issues, or for a group of residents for a specific
issue(s)
50
Draft - Ref: S&C: 12-XX-
Hiring
• While it may be good practice, the Federal
regulations do not require the facility to check
any State or Federal registries or agencies for
employees who are not nurse aides, but the
facility must conduct required screening
• CMS has acknowledged that nursing homes
are not required by regulation to perform
criminal background checks on ALL staff,
however, CMS has specified that the facility
should check all references, and make
“reasonable efforts” to uncover criminal
backgrounds
51
Draft - Ref: S&C: 12-XX-
Immediate Reporting
• Previously, CMS identified that “Immediately”
means as soon as possible, but should not
exceed 24 hours after discovery of the incident,
in the absence of a shorter State timeframe
requirement
• It has been reported that some providers take
24 hours to investigate all alleged violations
and only report the incident if it is
substantiated. This interpretation does NOT
meet the intent of the requirement
• The intent of F225 is that as soon as the facility
is aware of a situation that meets the reporting
requirements – they immediately due the
notification
52
• Nursing home sprinkler
regulations - 5 year phase in
(Aug 2013)
• Mandates full sprinkler maintenance
requirements
• Waivers can’t be used to satisfy this
requirement
• As of 2011, 89% of the facilities were in
compliance with sprinklers
53
• 2102 LSC changes have been approved by
NFPA
• S&C 12-21- LSC issued 3/9/12 updated CMS
 Previously restricted items in the exit corridors
 Recognition that a kitchen is not a hazardous
area and can be open to an exit corridor under
certain circumstances
 Changes allowing and installation of direct–vent
gas fireplaces and solid fuel burning fireplaces
 Changes in the requirements allowing the
installation of combustible decorations
54
• Due to the complex nature of some of the
requirements, each waiver request will have to
be evaluated separately in the interest of fire
safety and to ensure that the facility has
followed all LSC requirements and the
equipment has been installed properly by the
facility.
• All waiver requests will be processes in the
regular fashion with input from the Sate Survey
Agency and final approval by CMS regional
office.
55
• The Occupational Safety and Health
Administration (OSHA) announced a National
Emphasis Program (NEP) to encourage
compliance with safety and health standards at
nursing centers through programmed
inspections.
• Effective 4/5/12 for 3 years
56
• Background:
 According to OSHA, surveys indicate that nursing and
residential care facilities “continue to have one of the
highest rates of injury and illness.”
 In light of the safety and health challenges facing
nursing and residential care facilities, OSHA issued its
NEP to drive compliance with the relevant standards
Residential Care Facilities with a DART (Days Away,
Restricted Work Activity, Job Transfer) rate of over
10.0 may be targeted under the NEP. safety and
health challenges facing nursing and residential care
facilities, OSHA issued its NEP to drive compliance
with the relevant standards
 The enforcement program will not focus on residential
mental health and substance abuse facilities or
assisted living facilities without on-site nursing care
operations.
57
• In general, the NEP directs OSHA to focus their
inspections on:
 Ergonomic stressors associated with lifting
patients
 Slips, trips, and falls
 Bloodborne pathogens
 Exposure to tuberculosis
 Workplace violence
58
• Ref S&C: 12-02-NH IIDR
• S&C 11-30 NH for reporting Reasonable Suspicion of a
Crime in LTC; 42 CFR 483.13 © F225 for abuse and
reporting
• Office of Inspector General http://oig.hhs.gov
• Caring people for Dementia and Problem
Behavior https://www.healthcare.uiowa.edu/igea/IAADPT
• QAPI tips for implementation
https://www.cms.gov/surveycertificationGenifo
/05QAPI.asp
• California Department of Public Health ALF 12-08
Increased B citation www.cdph.ca.gov
• AARP Joins Lawsuit
http://www.vcstar.com/news/2012/may/01/aarp-joinsantipsychotic-drug-lawsuit-against/?p...
59
60