Transcript CAPWIZ - National Association for Regulatory Administration

National Association for Regulatory
Administration
Brian Hortert
Concordia Lutheran Ministries
Beth Greenberg, MPA, MA
Regulatory Affairs and Research Manager
Nick Luciano, Esq.
Legislative Council
September 13, 2011
8:30-10:00 AM
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Objectives
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• Provider Experience with Surveys
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• Resources for Quality Improvement
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• Common Goals, Different Perspectives
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• Case Study of Regulatory Change
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Brian Hortert
Executive Director,
Concordia of South Hills
September 13, 2011
Work History
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1986 - Started first Personal Care Home
1992 - Purchased a 2nd home in 1992
1995- Home Health Social Services
1998- Skilled Nursing Social Services and NHA
2001- Present - VP of Personal Care (705
Licensed beds) and CEO of Concordia Lutheran
Ministries of Pittsburgh, a CCRC in Mt.
Lebanon.
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Concordia Lutheran Ministries
Organization
130 year old not for profit, providing:
Adult Day Care
Child Care
Hospice
Home Health
Personal Care
Skilled Nursing and Rehab
Independent Living
Medical Equipment
Pharmacy
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Appointments to Boards of Directors
Medical Equipment
Home Health
Hospice
Pharmacy
CCRC
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Provider Frustrations / Viewpoints
• Perception that Surveyors are unreasonable
• Survey process is punitive
• Difference between regulation and
interpretation
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Surveyor frustrations (as related to
providers)
• Providers view you as the enemy
• Disorganization of providers during the survey
process
• Staff hide during the survey
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Surveyor Frustrations (as related to
outside forces / directors)
• Used for litigation
• Used by politicians during election time
• Chastised for not finding enough deficiencies
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Systemic Frustrations
Providers and Surveyors
• Care delivery in U.S. is in silos (SNF, PC,
Hospital, Home Health)
• Increased demands with decreased resources
• Political environment – Change in
Administration
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Improving Quality
• Director of Education and Compliance
• Mock survey process
• “Call your friendly neighborhood inspector”
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How do we effect change together?
• Help develop a system for worry free selfreporting
• Team approach for effecting change
• Move the silos.
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Common Goals, Different Perspectives
Beth Greenberg
Regulatory Affairs & Research Manager
LeadingAge PA
September 13, 2011
About LeadingAge PA
LeadingAge PA’s mission is to promote the
interests of our members by enhancing their
ability to provide quality services efficiently
and effectively; and by representing our
members through cooperative action.
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…Who Are LeadingAge PA Members?
Many Services
Many Licenses
• Adult Day Services
• Continuing Care
• Home Care
• Home Health
• LIFE Programs
• Nursing Facilities
• Personal Care Homes
• ALL are Nonprofits
• Aging
• Health
• Insurance
• Public Welfare
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Profile of Services – A Sample
Number Who Provide:
Adult Day Services
Home Health
Housing
Government-Subsidized Housing
Nursing Homes
Personal Care Homes
Respite Services
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100
200
300
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The Promise of OBRA ’87…
• OBRA ‘87 legislation, based on a 1986 report
by the Institute of Medicine, strove to:
– create an oversight system that ensured sustained
compliance of nursing homes with regulations.
– foster a high quality of care and high quality of life
for residents.
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Difficult, But Worthwhile
• Challenges occurred
from the outset and
remain in implementing
‘OBRA
• There have been a
series of studies; this
one in 2005 found that
improvement has been
made but more needs
to be done
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LeadingAge Task Force on Survey,
Certification and Enforcement
• In late 2006, LeadingAge (formerly AAHSA)
convened a Task Force to examine the current
oversight system for nursing facilities.
• 20 individuals served on the Task Force
including LeadingAge PA’s Executive Director,
Ron Barth.
• Task Force Report, Broken and Beyond Repair
was issued in June 2008.
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What Went Wrong?
• Why were providers so angry and frustrated?
– A plethora of personal stories about the survey
process, hauntingly similar across geography:
– Negative and adversarial encounters with
surveyors intent on “finding something wrong”
– By the end of the survey providers were angry and
staff were demoralized and ready to quit
– …In spite of the provider’s commitment and
ongoing efforts to provide high-quality care
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What Isn’t Working?
• Focus on punishment rather than quality
improvement (guilty until proven innocent;
surveyors and providers both support a more
consultative role)
• Complexity breeds inconsistency
• Idiosyncratic interpretations of CMS guidelines
• Informal Dispute Resolution (IDR) values
expediency over fairness/cannot change scope
and severity
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What Isn’t Working?
• Inconsistency signals deeper flaws
– The survey system inevitably leads to inconsistent
results and poor feedback regarding real quality issues
because it is characterized by:
“unrealistic expectations about how many
recommended care processes can be measured; poor
definition of measures and methods of measurement;
confusing rules linking measures to deficiency
statements; and a survey culture that depends on expert
judgment.” Dr. Jack Schnelle, Vanderbilt University
– State Operations Manual (SOM) for example
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What Isn’t Working?
• Regulations that don’t encourage culture
change or person-centered innovations; do
POCs bring about compliance or just increase
paperwork?
• Poor communication – strained during survey;
nonexistent between surveys
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Series of Recommendations
• 31 recommendations
• S. 3407 in last Congress (not enacted):
Institute of Medicine to study nursing home
survey
• Many of the state-level recommendations are
reflected in LeadingAge PA’s 2011-12 Public
Policy Objectives
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Summary of Task Force
Recommendations
• Improve the quality of survey teams;
• Foster effective communication among
regulators, surveyors and providers;
• Improve consistent application of regulations;
• Encourage providers to strive for excellence;
• Facilitate accurate reporting to consumers;
• Improve fairness of enforcement and dispute
resolution.
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Policy Objectives 2011-12
• Promote meaningful changes to the nursing
facility survey process to create a residentfocused, outcome-related system.
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This system must:
– Promote and encourage consumer-focused care;
– Take swift and appropriate actions where poor care is
found;
– Apply a standard of reasonableness and proportionality
to punitive actions;
– Introduce an effective appeals process;
– Provide for an impartial dispute resolution process;
– Encourage and complement exemplary care;
– Mandate joint provider-surveyor training; and
– Require government surveyors to understand the entity
they are reviewing and the consumers being served.
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So what are we doing about this?
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QI initiatives
Data initiatives
Regulation and Survey Initiatives
Legislation
– HB 1052 and SB 1095 (Reform of Nursing Home
IDR Process)
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Some Examples - Good Survey
Experiences
• Inappropriate behavior/treatment of staff –
reported and corrected.
• Surveyors addressed issues during survey that
encouraged us on our journey toward person
centered care
• Surveyors actually commented that we made
good progress at minimizing incidence of
pressure areas.
• Field Office uses this location to orient new team
leaders/surveyors.
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Examples – Bad Survey Experiences
• Continuing difficulty with surveyors through
many years regarding physiological need
regarding positioning devices or wheelchair
positioning.
• Non-nurse surveyors conducting chart reviews
have difficulty interpreting charts.
• At Exit Interview, always state: “We are not
here to find the good things you are doing…”
Why not?
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Member Feedback on Surveys
• Sense that existence of poor quality nursing
homes lead surveyors to believe all homes are
poor quality.
• Would like more advice on how to comply when
the surveyors find a home out of compliance.
• Joint training is essential – we could learn so
much from each other.
• Indicator survey, done in PCHs with good history
of compliance…appreciated and a good way to
direct more resources where needed.
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Quality Improvement Initiatives
• Regulation and Survey
• CMS Quality Assurance/Quality Improvement
and Patient Safety Initiatives
• Quality Improvement Organizations (QIOs)
• Advancing Excellence
• Focused initiatives such as PA Restraint Reduction
Initiative (PARRI)
• PA Patient Safety Authority
• Accreditation
• Consumer Education/Involvement
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http://www.healthcare.gov/center/programs/partnership/index.html
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http://www.nhqualitycampaign.org/
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Goal: Quality of Life for Each Nursing
Facility Resident
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We have different roles but same goal.
The work is difficult but worthwhile.
We are making progress…
But we are not there yet.
We must continue to work together and
achieve this goal, for the benefit of the
residents.
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September 13, 2011
A Case Study of Regulatory Change
Nick Luciano, Esq.
Legislative Counsel
LeadingAge PA
September 13, 2011
Landscape of Licensed Community
DPW licenses Personal Care Homes for the
Commonwealth of Pennsylvania.
As of August 31, 2011 there are:
• 1336 Licensed Personal Care Homes
• 67,344 Licensed Personal Care Beds
• 47,355 Residents in PCH’s (70.3%
Occupancy)
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Landscape of Licensed Community
Snapshot of Residents by Age, Need, and Income Resident
Description of Resident
Residents 60 Years of Age or Older
Residents with a Mobility Need
Residents with Mental Illness
Residents with Dementia
Residents with a Physical Disability
Number
42,016
8,806
6,890
4,398
3,751
% of Pop.
87.06%
18.25%
14.27%
9.11%
7.77%
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Landscape of Licensed Community
Total Capacity and Number of Licensed Personal Care Homes
Month/Year
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December 2010
December 2009
December 2008
December 2007
December 2006
December 2005
Homes Capacity Homes % Capacity
Change % Change
1,362 68,012 - 4.36% - 1.77%
1,424 69,237 - 0.14% +0.12%
1,426 69,151 - 4.42% - 2.46%
1,492 70,154 - 7.96% - 5.60%
1,621 74,316 +1.44% +2.53%
1,598 72,479 - 5.44% - 3.00%
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Case Study: Personal Care Home
Occupancy Code Statement of Policy
 DPW issued a draft Statement of Policy on February 2,
2010 mandating that all PCH’s serving immobile
residents must be I-2 construction.
 What this meant for providers is that no NEW immobile
residents could be admitted until facilities are retro-fitted
to I-2 specifications. No current residents will be
displaced.
 DPW points finger at Department of Labor and Industry.
 Labor and Industry points finger at DPW.
 We didn’t really care about the who…just the why. Our
world had changed, without anything having changed.
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Case Study: The Backstory
How in the world did we get here? Away we go…
 1980: DPW begins licensing Personal Care Homes under Act 105
 1984: Fire & Panic Law regs. adopted—PCH’s grouped in C-2 class
along with hotels & motels. NF’s and hospitals grouped in C-1 class.
 1988: Act 185 amends Welfare Code to allow immobiles to reside in
PCH’s.
 Immobiles defined as “unable to move from one location to another or has difficulty in
understanding and carrying out instructions without the continued full assistance of
others.
 Act also requires L&I to evaluate the fire and safety laws for PCH’s and recommend to
General Assembly new classifications for PCH’s.
 1990: L&I reports to General Assembly that PCH’s should be C-1.
 1996: L&I Task Force developed amendments to Fire & Panic
regulations…but abandoned the effort as efforts ramped up to pass the
Pennsylvania Construction Code Act.
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Case Study: The Backstory
How in the world did we get here…continued…
 1999: Act 45 passed—Pennsylvania Construction Code Act.
 Sect. 104—Applies to “construction, alteration, repair and occupancy of all buildings.”
 Sect. 104(d)—“Nothing in this act shall limit the ability of the Department…to
promulgate or enforce regulations which exceed the requirements of this act.”
 Sect. 1102—Repeals all portions of the Fire & Panic Act but regulatory authority.
 Incorporates by reference the International Building Code.
 2004: UCC regs. allow for alternative construction materials and
methods if approved by an accredited organization.
 2005: 2600 PCH regulations finalized. Fire safety issues addressed,
but no mention of Occupancy Permit changes…hmmm.
 2006: IBC updated. Assisted Living and Residential Care facilities
specifically identified as I-1. Occupants of AL’s described as “capable
of responding to an emergency…without physical assistance.”
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Case Study: The Backstory
Yes…there’s more…
 2009: IBC updated. Group I-1 is unchanged, but I-2 includes new
definition for Nursing Homes as “serving 5 persons and any of the
persons are incapable of self-preservation.”
 It is this last phrase that led DPW to publish its draft statement in
February 2010. DPW equated its definition of “resident with mobility
needs” with the IBC definition of “incapable of self-preservation.”
 DPW claimed that the IBC update in 2009, an effective regulatory
change, made an I-1 facility an inappropriate placement for an
immobile resident.
 After much discussion and negotiation, DPW decided to publish as
final on September 18, 2010 with an effective date of November 1,
2010. The fallout was significant.
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Case Study: The Response
 Major statewide provider associations assessed how to
reverse, or at least postpone implementation of the policy.
 Fight could be on the issue of an unpromulgated regulation, forcing the
Department to proceed through the regulatory process.
 Fight could be in the Legislature, where legislators would make a
definitive statement on what is an appropriate occupancy permit for
facilities serving PA’s seniors in a home-like setting.
 Might be able to persuade the Department to delay implementation, and
allow for equivalencies of safety through staffing, programming, and
other fire suppressive measures such as sprinklers.
 The result was an amalgam of all three.
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Case Study: The Response
 DPW—under pressure from the legislature—convened a
working group of stakeholders to look at the problem.
 Consumer advocates liked the Statement of Policy and wanted it
implemented.
 Providers did not like it and wanted to build in alternatives or
equivalencies to avoid cost-prohibitive retro-fitting.
 After a series of meetings, there eventually was consensus
that the statement of policy was not beneficial as drafted.
 The issue came down to access…with some legal questions
thrown in for good measure.
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Case Study: The Response
Why was access an issue?
 As noted earlier, there are 1336 licensed PCH’s with over
47,000 residents—and 18% of those residents have some
“mobility need”.
 According to DPW’s numbers, only 43 PCH’s had the
appropriate occupancy designation. That’s a BIG gap.
The question also had been raised as to whether I2 was the safest designation for this population.
 I-2 actually is less safe than I-1 when looking at interior walls
between individual units, while exterior walls withstand more
under I-1.
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Case Study: The Response
What was the result?
 January of 2011 the Department decided to
suspend implementation of the Statement of
Policy.
 The workgroup was to continue to meet in order
to arrive at language that could be accepted by
all parties.
 Currently in the midst of this process.
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Case Study: The Lesson
How could this have been avoided?
 DPW should have convened a meaningful
workgroup at the outset.
 Get all of the appropriate parties in the
appropriate meetings.
 Assume that all “parties” are “partners” working
toward the same end goal.
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Contact Information
Brian Hortert
Executive Director,
Concordia of South Hills
• 412-278-1300
• [email protected]
Nick Luciano
Legislative Counsel,
LeadingAge PA
• (717) 790-3947
• [email protected]
Beth Greenberg
Regulatory Affairs &
Research Manager,
LeadingAge PA
• (717) 790-3948
• [email protected]
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