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 ?