Transcript Document 7622582

MAHSA Annual Convention
May 2, 2007
Bureau of Health Systems
Update
Michael Pemble, Director
Division of Operations
Bureau of Health Systems
Question:
Why do the surveyors not stay in the
building until an IJ is removed or
corrected? Subsequently, then how
can an IJ be called days after the
surveyor exited the facility?
Answer:
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Surveyors are not required to stay in the
building until an IJ is removed.
IJs can be called after exit based on
review of information obtained during the
survey, or from other sources after the
survey "exit."
PHC requirement that Division of
Operations Director or Nursing Home
Monitoring Director be involved in making
IJ decision. See MCL 333.20155(20).
Question:
Why is MPRO the sole agency for
Directed POC’s and Directed Inservices? Could there not be another
agency or persons available as a
choice?
Answer:
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MPRO is the service provider of choice for
Directed Inservices and Directed Plans of
Correction based on past practice and feedback
from BHS managers.
Problems with availability of MPRO remediators or
delays in obtaining service should be brought to
the attention of the manager that required DIT or
DPOC. Special circumstances, e.g. a consultant
who is already working with a facility and is a
provider preferred person for remediation can be
discussed with BHS manager.
Question:
If Michigan is awarded the opportunity
to participate in the QIS survey pilot,
how would the state implement this?
Answer:
Michigan will not participate in pilot
project. CMS has announced that
Minnesota will be the only State added
to the pilot, at this time.
See CMS S&C 07-09 for description of
the pilot.
Question:
Why doesn’t the state implement the
dining assistant program when other
states have successfully provided this
added benefit to the residents for
years?
Answer:
The State’s position is it will wait on
legislative action.
Question:
Please explain BHS’s authority to
overturn MPRO’s IDR results.
Answer:
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SOM 7212C(3) NOTE: Informal dispute resolution is a
process in which State Agency officials make
determinations of noncompliance. States should be
aware that CMS holds them accountable for the
legitimacy of the process including the accuracy and
reliability on conclusions that are drawn with respect
to survey findings. This means that while States may
have the option to involve outside persons or entities
they believe to be qualified to participate in this
process, it is the States, not outside individuals or
entities, that are responsible for informal dispute
resolution decisions. CMS will look to the States to
assure the viability of these decision-making
processes, and holds States accountable for them.
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MPRO offers advisory opinion, so BHS
does not technically overturn their
decision. We don't keep statistics how
many times we have rejected MPRO
opinion to delete citation. We reject MPRO
opinion when we feel that it does not
follow regulations or is inconsistent with
facts.
Question:
Why does Michigan report resident to resident
allegations when the other states within CMS
Region V report only those with serious injury,
those requiring medical attention or repeat
offenders who harmed a resident previously, etc?
Could Michigan follow the other states allegation
reporting criteria to reduce the number of intakes
for the state in order to more efficiently deal with
the volume, timelines of investigations, etc?
Answer:
CMS has made it clear, as recently as 2/6/07 that
resident to resident altercations are to be reported
as alleged abuse incidents without any qualification
of seriousness of injury. Michigan will follow the
regulations as we understand them and as CMS
directs.
The Facility Reported Incident Log provides an
alternative method of reporting non-harm abuse,
neglect each time on Forms 362 and 363.
Question:
A facility was already cited for F-324 on an
annual and gave a completion date of 2-1807. The facility then had a complaint survey
obviously prior to the POC date and the
complaint team cited the same tag. Why
wouldn’t the “Summary Report” just reflect
that the facility is already out for F324 and
the POC completion date has not been met
so either report amended with the example
or just stated that facility is working on
POC, etc. Why get a double tag like double
jeopardy?
Answer:
There are no SOM provisions addressing this
situation. Deficiencies may be cited when found.
There is no double jeopardy. Cites are encouraged
when a POC is needed because prior cite is different
example.
In the example, the standard survey covered falls
issue, complaint FRI involved falls and elopement.
Falls issue was cited as M346, state tag only;
elopement cited as F-324 and POC required.
Question:
Why are surveys unannounced?
Answer:
Sec. 20155(1) states “A visit made pursuant to a complaint
shall be unannounced.”
SOM, App. P. “Do not announce SNF/NF surveys to the
facility.”
SOM 2700. “It is CMS policy to have unannounced surveys for
all providers….” “While the unannounced surveys may result
in some minor inconveniences, this policy represents changing
public attitudes and expectations toward compliance surveys.”
Sec. 20155(9) “The department or a local health department
shall conduct investigations or inspections, other than
inspections of financial records, of a county medical care
facility, home for the aged, nursing home, or hospice
residence without prior notice to the health facility or agency.”
Question:
Once a finding of non-compliance
opens an enforcement cycle, how
does that cycle end?
Answer:
Compliance Date Determination
Compliance can be certified when:
• All deficiencies have been corrected, or
• The facility is in substantial compliance; and
• The facility provides acceptable evidence to establish
correction.
If the facility is in substantial compliance on the date of the
first revisit, the compliance date is automatically the date
accepted in the PoC, unless there is evidence that compliance
was achieved on either an earlier or later date.
If the facility is in substantial compliance on the second
revisit, the compliance date is the date observation, record
review or other evidence substantiates compliance.
Compliance (when correction is verified) is certified as the
date of the 3rd or 4th revisit. CMS does not allow a compliance
date earlier than the revisit date for the third or subsequent
revisits.
When more than one deficiency is involved, the date the
facility is considered to be in compliance is the latest of the
correction dates for the deficiencies.
It should be noted that for OBRA enforcement purposes,
remedies cease when the facility is either in compliance or in
substantial compliance. If deficiencies are not corrected, but
yet reduced to substantial compliance level, the substantial
compliance date(s) for each deficiency and for the facility
overall are evaluated in the same manner as described above.
Enforcement remedies remain in effect until all deficiencies
are corrected or the facility achieves substantial compliance.
Interim Policy
for
Reporting Alleged Abuse,
Mistreatment, Neglect,
Misappropriation and
Injuries of Unknown
Source
CMS Reporting Requirements

42 CFR 483.13(c)(2)
The facility must ensure that all alleged
violations involving mistreatment, neglect,
or abuse, including injuries of unknown
source, and misappropriation of resident
property are reported immediately to the
administrator of the facility and to other
officials in accordance with State law
through established procedures (including
to the State survey and certification
agency).

42 CFR 483.13(c)(4)
The results of all investigations must
be reported to the administrator or his
designated representative and to other
officials in accordance with State law
(including to the State survey and
certification agency) within 5 working
days of the incident, and if the alleged
violation is verified appropriate
corrective action must be taken.
CMS Notice
Centers for Medicare & Medicaid
Services issues S&C-05-09
(12/16/04)
Reiterates the reporting of alleged violations
and the results of the investigation by
nursing homes to the state survey and
certification agency as mandated by 42
CFR 483.13(c)(2) and (4).
Defines the terms “neglect”, “abuse”, “injury
of unknown source” “misappropriation of
resident property”, “immediately” and “in
accordance with State law.”

Complaint vs. FRI Intake History
Complaints
FRIs
*FY 2007 data through March 31, 2007.
1837*
20
07
864*
FY
20
06
FY
20
05
FY
20
04
FY
20
03
FY
20
02
FY
FY
20
01
4500
4462
4000
3500
3000
2500
1780
2000
1342
1208 1081 1082
1500 948
801
1000
565
384
395
210
500
0
Facility Reported Incident Intake
History
4500
4000
3500
3000
595
1837**
801
384
395
20
07
FY
20
06
FY
20
05
FY
20
04
FY
20
03
FY
20
02
210
FY
FY
20
01
2500
2000
1500
1000
500
0
3674*
4462
*Projected based on current totals.
** FRI totals for FY2007, through March 31, 2007.
Facility Reported Incident Intake History
FY 2007 Category 3 – Non-Urgent
300
250
271
245
200
208
150
140
100
118
122
Jan-07
Feb-07
50
0
Oct-06
Nov-06
Dec-06
Mar-07
Facility Participation in Facility
Reported Incident Log
Participating
facilities
Nonparticipating
No Response
Detroit Metro
West
47
22
17
Detroit Metro
East
62
21
11
Southwest
63
15
13
Mid-Michigan
73
4
18
Up-North
48
22
0
293
(67%)
84
(19%)
59
(14%)
Total Nursing
Homes
ABUSE, NEGLECT, MISTREATMENT, MISAPPROPRIATION
AND INJURY OF UNKNOWN SOURCE INVESTIGATION GUIDE
START HERE WITH AN
►ALLEGATION OR SUSPICION OF ABUSE,
NEGLECT, OR MISAPPROPRIATION OF RESIDENT
PROPERTY, OR AN
►INJURY OF SUSPICIOUS ORIGIN (FROM PAGE 2)
1.
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IMMEDIATELY
Secure resident’s safety
Assess the resident, provide medical and/or psychosocial treatment as necessary
Examine the resident’s injury and/or psychosocial changes and document the description in the medical
record
Remove alleged perpetrator (staff, family, or visitor) from contact with all residents and staff pending
outcome of investigation
Take measures to prevent recurrence if alleged perpetrator is a resident
Document date and time injury was discovered in the resident’s medical record
Notify physician if the injury (physical and/or psychosocial) has the potential to require physician
intervention
Notify the resident’s legal representative if there is a significant change in health status
Immediately (no later than 24 hours) notify the administrator
Administrator or designee notifies BHS, local law enforcement, and/or other state agencies as required
Immediately (no later than 24 hours) notify BHS of all allegations by one of the following methods:
1) complete the BHS-OPS-362 online submission form found on the BHS website, 2) fax the BHS-OPS-362
form, or 3) call BHS to report followed by a fax of the completed BHS-OPS-362
Facility Incident Report - 24 Hours (BHS-OPS-362)
2.
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INVESTIGATE
Document date and time of all notifications per facility policy
Interview and/or obtain statement from person reporting allegation or suspicion
Interview and/or obtain statement from victim/resident
Interview and/or obtain statement from alleged perpetrator
Interview and/or obtain statements from potential witnesses as determined by the scope of the
investigation
Review the resident’s medical record for relevant information (diagnosis, history, similar injuries, etc.)
Review materials and complete investigation (refer to abuse investigation protocol and facility policy)
3.
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WITHIN FIVE WORKING DAYS OF INDCIDENT
Report the results of investigation to the administrator
Report the results of investigation to BHS on the BHS-OPS-363 form and submit by fax with
supporting documentation
Initiate corrective measures (if applicable) to prevent recurrence
Facility Investigation Report - 5 Working Days
(BHS-OPS-363)
NOTE TO PROVIDERS USING THE FACILITY LOG:
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Incidents and findings that involve harm are reported on the BHS-OPS-362 and
BHS-OPS-363 forms and recorded on the facility log.
Incidents and findings that do not involve harm are recorded on the facility log
only.
INJURY OF UNKNOWN SOURCE (IUS)
DETERMINATION
RESIDENT
INJURY
(source to be
investigated)
1.
Was the injury
observed by
any person or
explained by
the resident?
YES
The source of injury is
known AND abuse or
neglect is alleged or
suspected; return to #1
on Page 1 of the
Investigation Guide and
proceed with immediate
action, investigation
and report of alleged
abuse/ neglect finding.
NO
The director of nursing (or designated licensed staff) should determine the scope of
investigation based on the nature of the injury and professional judgment with the
following, "Is the injury suspicious:
 A. Because of the extent or location of the injury (e.g., the injury is located in an area
not generally vulnerable to trauma), or
 B. Due to the number of injuries observed at one particular point in time or the
incidence of injuries over time?"
2.
Is there a
suspicion that
abuse/neglect
may have
occurred?
(Box A or B
checked)
YES
Return to # 1 on
Page 1 of the
Investigation Guide
and proceed with
immediate action,
investigation and
report of alleged
abuse/neglect
finding.
NO
 Document summary of conclusion of investigation.
 Review the resident’s plan of care and revise as necessary to prevent recurrence of
injury.
 Complete determination within 24 hours of incident; no report to BHS is necessary if
answers to questions 1 and 2 are “NO.”
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
BUREAU OF HEALTH SYSTEMS
ABUSE ELEMENTS GUIDELINE
ELEMENTS OF ABUSE INCLUDE:
1.
2.
3.
A RESIDENT TO RESIDENT, STAFF TO RESIDENT OR VISITOR TO RESIDENT ABUSIVE ACT THAT
IS WILLFUL; OR
NEGLECT;
(AND) PHYSICAL HARM, PAIN OR MENTAL ANGUISH
A.
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EXAMPLES OF ABUSIVE ACTS ARE:
HITTING,
SLAPPING,
KICKING,
UNREASONABLE CONFINEMENT, INVOLUNTARY SECLUSION,
INTIMIDATION,
DELIBERATE INFLICTION OF PAIN INTENDED AS CORRECTION OR PUNISHMENT,
PHYSICAL THREATS,
USE OF ORAL, WRITTEN, OR GESTURED LANGUAGE THAT WILLFULLY INCLUDES
DISPARAGING OR DEROGATORY TERMS TO RESIDENTS OR THEIR FAMILIES,
HUMILIATION, HARASSMENT, THREATS OF PUNISHMENT OR DEPRIVATION,
SEXUAL ABUSE, SEXUAL HARASSMENT, SEXUAL COERCION, OR SEXUAL ASSAULT,
UNWELCOME TOUCHING OF A SEXUAL NATURE, REQUEST FOR SEXUAL FAVOR,
INTENTIONALLY WITHHOLDING FOOD, CARE, MEDICATIONS, ASSISTANCE,
FAILURE TO PROVIDE GOODS AND SERVICES NECESSARY TO AVOID HARM,
MENTAL ANGUISH, MENTAL ILLNESS,
SEPARATION OF A RESIDENT FROM OTHER RESIDENTS OR OTHER CONFINEMENT
AGAINST THE RESIDENT’S WILL.
B.
EXAMPLES OF PHYSICAL HARM, PAIN OR MENTAL ANGUISH ARE:
-- CUTS, SKIN TEARS, BRUISING, PUFFINESS, TENDERNESS OF THE
SKIN/MUSCLE,
-- SPRAINS,
-- FRACTURES,
-- BROKEN BONES,
-- ALL BURNS,
-- ANY INJURY THAT IMPAIRS FUNCTION OF ARM, LEG, HAND,
-- VISIBLE EMOTIONAL DISTRESS; WITHDRAWAL OR FEAR
C.
“WILLFUL” MEANS DELIBERATE OR INTENTIONAL, NOT ACCIDENTAL.
D.
INSTANCES OF ABUSE OF ALL RESIDENTS, EVEN THOSE IN A COMA, CAUSE
PHYSICAL HARM, PAIN OR MENTAL ANGUISH.
E.
USE OF DISPARAGING AND DEROGATORY TERMS CAN BE ABUSE REGARDLESS
OF AGE, ABILITY TO COMPREHEND, OR DISABILITY OF RESIDENT.
RULES
1.
INCIDENTS ARE REPORTABLE ON BHS-OPS-362 IF THEY INCLUDE ELEMENTS FROM “A” AND
“B”, I.E., AN ABUSIVE ACT AND HARM. THESE INCIDENTS ARE ALSO REPORTED ON THE
FACILITY LOG.
2.
INCIDENTS THAT INCLUDE ELEMENT “A” BUT NOT “B” ARE RECORDED ONLY ON THE FACILITY
LOG, I.E., THERE IS NO “HARM” TO RESIDENT.
3.
INVESTIGATION RESULTS ON BHS-OP-363 ARE REQUIRED IF A BHS-OPS-362 REPORT IS
FILED. THE INVESTIGATION RESULTS ARE ALSO SUMMARIZED ON THE FACILITY LOG.
4.
INVESTIGATION RESULTS FOR NON-HARM ALLEGATIONS ARE REPORTED ONLY ON THE
FACILITY LOG.
NOTE: TO PROVIDERS NOT PARTICIPATING IN “THE INTERIM SYSTEM OF REPORTING ABUSE,
NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF PROPERTY,” ALL INCIDENTS AND
FINDINGS CONTINUE TO BE REPORTED ON THE BHS-OPS-362 AND BHS-OPS -363.
PAST NON-COMPLIANCE
To cite past non-compliance, all three (3) of
the following criteria must apply:
1) The facility must have been out of
compliance with a regulatory requirement
at the time the incident occurred.
2) The non-compliance must have occurred
after the exit date of the last standard
survey and before the current survey.
PAST NON-COMPLIANCE
(CONTINUED)
3) There must be specific evidence that the
facility corrected the non-compliance, at
the time of the incident, and is in
substantial compliance at the current
survey.
Past compliance evidence must show that
the facility identified the (alleged)
deficiency, developed and implemented
corrective action following the incident.
BHS Website Links
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Sample Facility Reported Incident log
http://www.michigan.gov/document/mdch/bhs_FRI_log_3-22-07_191638_7.doc

Abuse and Neglect Investigation Guide
http://www.michigan.gov/documents/mdch/bhs_Abuse_and_Neglect_Investigation_Guide_191625_7.doc
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Abuse Elements Guideline
http://www.michigan.gov/documents/mdch/bhs_ABUSE_ELEMENTS_CHECKLIST_191628_7.doc