OHCQ Enforcement Update · • Level 4: Immediate jeopardy, a situation in which immediate corrective action is necessary because the provider’s noncompliance with one or more requirements

OHCQ Enforcement Update March 29, 2017

Office of Health Care Quality Protecting the health and safety of Marylanders

OHCQ’s mission is to protect the health and safety of Marylanders and to ensure there is

public confidence in the health care and community service delivery systems

Office of Health Care Quality

• Issue licenses, authorizing the operation of a business in Maryland

• Recommend certifications to CMS, authorizing participation in the Medicare and Medicaid programs

• Conduct surveys to determine compliance with State and federal regulations, which set minimum standards for the delivery of care

• Educate providers, consumers, and other stakeholders

OHCQ Functions

OHCQ Organizational Chart

Executive Director

Deputy Director of Federal Programs

Long Term Care

Hospitals

Ambulatory Care

Clinical and Forensic

Laboratories

Deputy Director of State Programs

Assisted Living and Adult Medical Day

Care

Developmental Disabilities

Behavioral Health

Director of Administration

Budget and Accounting

Human Resources

Information Technology

Director of Quality Initiatives

Hospital Patient Safety

Chief of Staff

Tricia Nay Executive Director

Margie Heald Deputy Director of Federal Programs

Vanessa Leuthold Program Manager

Ranada Cooper Coordinator

Surveyors Envir. Safety

Frances Curtis Coordinator

Surveyors

Jackie Cooper Coordinator

Surveyors

Patti Melodini Coordinator

Surveyors

Beth Bremner Coordinator

Surveyors

Kathy Schoonover Nurse Administrator

Surveyors

Admin. Support Complaint Unit

MDS Coordinator

OHCQ – Long Term Care Unit

What is OHCQ’s role?

Trust the provider, but verify compliance with the regs

How do I manage all of these regulations?

Consistently do the right thing for the resident

Document what you did

and why you did it

OHCQ Oversees 61 Provider Types

• Birthing Centers • Comprehensive

Outpatient Rehab Facilities

• Cosmetic Surgery Centers

• Freestanding Ambulatory Surgery Centers

• Freestanding Dialysis Centers

• Health Care Staff Agencies

• Home Health Agencies

• Hospices and Hospice Houses

• Major Medical Equipment Providers

• Nurse Referral Service Agencies

• Outpatient Physical Therapy Centers

• Portable X-ray Providers

• Residential Service Agencies

• Surgical Abortion Facilities

• Intermediate Care Facilities

• Forensic Residential Services

• Nursing Homes

• Adult Medical Day Care

• Assisted Living Facilities

• Cholesterol Testing Sites • Cytology Proficiency

Testing • Employer Testing Labs • Federal Waived Labs • Forensic Labs • Health Awareness Test

Sites • Hospital Labs • Independent Reference

labs • Physician Office & Point-

of-Care (State & Federal) • Public Health Testing • Tissue Banks

• DD Respite Services • Group Homes • Habilitation Services • Individual and Family

Support Services • Intensive Treatment

Programs

• Adult Group Homes • Ambulatory Detoxification

Programs • Correctional Substance

Abuse Programs • Education Programs • Mental Health Vocational

Programs • Mobile Treatment Services • Opioid Maintenance Therapy

Programs • Outpatient Mental Health

Centers • Outpatient Treatment

Programs • Psychiatric Day Treatment

Services • Psychiatric Rehabilitation

Programs for Adults • Psychiatric Rehabilitation

Programs for Minors • Residential Crisis Services • Residential Detoxification

Programs • Residential Programs • Residential Rehabilitation

Services • Respite Care Services • Therapeutic Group Homes • Therapeutic Nursery

Programs

• Community Mental Health Centers

• Correctional Health Care Facilities

• Federally Qualified Health Centers

• Freestanding Medical Facilities

• HMOs • Hospitals • Patient Safety

Programs • Residential

Treatment Centers

Number of Providers Overseen by OHCQ

by Fiscal Year, 2014 – 2017

14,452 15,043 16,499

18,032

FY 14 FY 15 FY 16 FY 17

Number of Providers

Projected Surveyor Staffing Deficit, FY 13 to FY 17

107.09

67.9

52.5 52.15 46.05

FY13 FY14 FY15 FY16 FY17

Surveyor Staffing Deficit Projected for FY 17

Unit Current # of Surveyors

Needed # of Surveyors

Surveyor Deficit

Long Term Care 37.6 49.82 12.22

Assisted Living 26 32.27 6.27

Developmental Disabilities 33 55.06 22.06

Hospitals 6 6.60 0.60

Laboratories 5 6.01 1.01

Ambulatory Care 13 14.72 1.72

Behavioral Health 6 8.17 2.17

Totals 126.60 172.65 46.05

Coordinator Staffing Deficit Projected for FY 17

Unit Current # of Surveyors

Current # of Coordinators

Needed # of Coordinators

Coordinator Deficit

Long Term Care 37.6 5 7 2 Assisted Living 26 4 5 1 Developmental Disabilities 33 3 6 3 Hospitals 6 1 1 0 Laboratories 5 1 1 0 Ambulatory Care 13 2 3 1 Behavioral Health 6 1 1 0 Totals 126.6 17 24 7

Strategic Planning Process

1. Regulatory Efficiency and Effectiveness: Efficient and effective use of limited resources to fulfill our mandates

2. Core Operations: Focus on core business functions and maintaining accountability

3. Customer Service: Consistent, timely, and transparent interactions with all stakeholders

4. Quality Improvement: Sustain a quality improvement process within OHCQ

Regulatory Efficiency and Effectiveness

Over the past four years, there was a 39% increase in the number of providers with a corresponding

1% increase in OHCQ’s total positions and contractual employees

Fiscal Year

Surveyor Staffing Deficit

2013 107.09

2014 67.90

2015 52.50

2016 52.15

2017 46.05

Fiscal Year

Number of Providers

2013 13,000

2014 14,452

2015 15,043

2016 16,499

2017 18,032

OHCQ Survey Cycle

• Licensure survey or investigation of complaint or self-reported incident

Licensure survey or investigation of

complaint or self-reported incident

After triage, assign to a surveyor or team

Complete unannounced survey

Surveyor documents findings and

coordinator reviews report before issuing

to provider

Receive and review provider's plan of

correction

Coordinator reviews, organizes, and

audits documents, then closes the

survey

Statistics

Nursing Homes

Unit of Measurement FY14 FY15 FY16

Number of licensed nursing homes 232 232 230 Initial surveys of new providers 1 2 0 Full surveys 217 199 199 Follow-up surveys 35 39 41 Civil monetary penalties levied 55 45 54 Denial of payment for new admissions 3 3 5 Complaints and facility self-reported incidents 3,392 2,968 2,486 Complaints and self-reported incidents, no further action 449 287 429 Complaints and self-reported incidents, investigated 2,932 2,460 2,057 Quality of care allegations 2,291 1,949 2,670 Resident abuse allegations 1,128 913 1,254

Scope and Severity Matrix Immediate jeopardy to resident health or safety (4)

J K L

Actual harm that is not immediate jeopardy (3)

G H Substandard quality of care

I Substandard quality of care

No actual harm with potential for more than minimal harm that is not immediate jeopardy (2)

D E F Substandard quality of care, 221-226, 240-258, 309-333

No actual harm with potential for minimal harm (1)

A Substantial compliance

B Substantial compliance

C Substantial compliance

Isolated (1) Pattern (2) Widespread (3)

CMS Deficiency Categorization Instructions

Guidance on Severity Levels • Level 1: A deficiency that has the potential for causing no more than a

minor negative impact on the residents. • Level 2: Results in minimal physical, mental and/or psychosocial

discomfort to the resident and/or has the potential to compromise the resident’s ability to maintain and/or reach the highest practicable level.

• Level 3: Noncompliance that results in a negative outcome that has compromised the resident’s ability to maintain and/or reach the high practicable level.

• Level 4: Immediate jeopardy, a situation in which immediate corrective action is necessary because the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, serious harm, impairment, or death to a resident.


Guidance on Scope Levels • Isolated: One or a very limited number of residents are affected and/or

one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations.

• Pattern: More than a very limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the facility.

• Widespread: The problems causing the deficiencies are pervasive in the facility or represent systemic failure that affected or has the potential to affect a large portion of all of the facility’s residents.


Guidance on General Procedures • Determine severity and then scope of the practice. • When determining scope, evaluate the cause of the deficiency. If the

facility lacks a system/policy (or has an inadequate system) to meet the requirements and this failure has the potential to affect a large number of residents in the facility, then the deficient practice is likely to be widespread.

• If an adequate system/policy is in place but is being inadequately implemented in certain instances, or if there is an inadequate system with the potential to impact only a subset of the facility’s population, then the deficient practice is likely to be a pattern.

• If it affects or has the potential to affect one or a very limited number of residents, then the scope is isolated.

Most Frequently Cited Federal Deficiencies

in Nursing Homes in FY 16 Federal Tag Description of Tag Total Citations

F 309 Provide care and services for highest well being 169 F 514 Resident records, complete, accurate, and accessible 145 F 279 Develop comprehensive care plans 118 F 323 Free of accidents, hazards, supervision, devices 103 F 329 Drug regimen is free from unnecessary drugs 93 F 278 Assessment accuracy, coordination, certified 90

F 280 Right to participate in planning care, revise care plan 90

F 431 Drug records, label, store drugs and biologicals 88 F 371 Food procurement, store, prepare, and serve, sanitary 81 F 281 Services provided meet professional standards 78

Number of Actual Harm and Immediate

Jeopardy Deficiencies by Federal Tag in SFY 15 Federal

Tag Description of Tag G H I J K L

F 151 Right to exercise rights, free of reprisal 1 F 155 Right to refuse, formulate advance directives 7 1 1 F 157 Notify of changes (injury, decline, room) 4 F 223 Free from abuse, involuntary seclusion 1 F 224 Prohibit mistreatment, neglect, and misappropriation 1 F 225 Investigate and report allegations 1 1 F 279 Develop comprehensive care plans 1 F 309 Provide care and services for highest well being 5 1 F 314 Treatment and services for pressure sores 1 F 318 Increase or prevent decrease in range of motion 1 F 323 Free of accidents, hazards, supervision, devices 12 2 1 1 F 327 Sufficient fluid to maintain hydration 1 F 329 Drug regimen is free from unnecessary drugs 1 2 F 385 Residents’ care supervised by a physician 2 F 431 Drugs records, label, store drugs and biologicals 1 F 501 Responsibilities of medical director 1 1 F 502 Administration 1 F 511 Radiology findings, promptly notify physician 1

Tags at G or above – 54 38 4 0 5 6 1

Number of Actual Harm and Immediate

Jeopardy Deficiencies by Federal Tag in SFY 16 Federal

Tag Description of Tag G H I J K L

F 155 Right to refuse, formulate advance directives 4 1 F 157 Notify of changes (injury, decline, room) 2 F 223 Free from abuse, involuntary seclusion 2 1 F 224 Prohibit mistreatment, neglect, misappropriation 5 F 272 Comprehensive assessments 1 F 309 Provide care and services for highest well being 6 1 1 1 F 314 Treatment and services for pressure sores 7 1 1 F 315 No catheter, prevent urinary tract infection 1 F 319 Treatment/services for mental and psychosocial 1 F 323 Free of accidents, hazards, supervision, devices 18 3 2 F 325 Maintain nutritional status unless unavoidable 1 F 328 Treatment and care for special needs 1 F 329 Drug regimen is free from unnecessary drugs 2 F 333 Residents are free of significant med errors 1 F 441 Infection control, prevent spread, linens 1 F 501 Responsibilities of medical director 1 F 505 Promptly notify physician of lab results 1 F 520 Quality assurance committee 1

Tags at G or above – 68 44 2 0 14 8 0

Number of Actual Harm and IJ Deficiencies by

Federal Tag in SFY 17 YTD (July – March) Federal Tag Description of Tag G H I J K L

F 152 Legal surrogate 1 2 F 155 Right to refuse, formulate advance directives 1 5 F 156 Notice of rights and services, advance directives 1 1 F 157 Notify of changes (injury, decline, room) 1 2 1 F 201 Transfer and discharge requirements 1 1 F 203 Notice before transfer 1 F 204 Orientation for transfer or discharge 1 1 F 223 Free from abuse, involuntary seclusion 3 1 1 F 225 No employment of individuals guilty of abuse or neglect 1 1 F 280 Right to participate in planning care, revise care plan 1 F 284 Post-discharge plan of care 1 1 F 309 Provide care and services for highest well being 4 2 1 1 F 314 Treatment and services for pressure sores 3 F 323 Free of accidents, hazards, supervision, devices 12 9 1 F 329 Drug regimen is free from unnecessary drugs 1 1 F 333 Residents are free of significant med errors 1 F 353 Sufficient nursing staff 1 F 371 Food procurement, store, prepare, and serve, sanitary 1 F 385 Residents’ care supervised by a physician 1 F 441 Infection control, prevent spread, linens 1 1 F 490 Administration 2 F 501 Responsibilities of medical director 1 F 520 Quality assurance committee 1

Tags at G or above – 75 25 0 0 28 11 11

Number of Actual Harm and IJ Deficiencies by SFY

Year

Number of Tags G H I J K L

2015

54 tags at G or above 38 4 0 5 6 1

2016

68 tags at G or above 44 2 0 14 8 0

2017

75 tags at G or above (July – March) 25 0 0 28 11 11

Plan of Correction

Regulatory Violations

If OHCQ identifies a regulatory violation, then a notice is issued:

a) Citing the violation or deficiency (Statement of Deficiency aka 2567), b) Requiring the facility to submit an acceptable PoC within 10 calendar days of receipt of the notice of violation, c) Notifying the facility of sanctions or possible sanctions or that failure to correct the violation may result in sanctions, and d) Offering the program the opportunity for an Informal Dispute Resolution (IDR)

Plan of Correction

• A plan developed by the facility and approved by the survey agency that describes the actions the facility will take to correct deficiencies and specifies the date by which those deficiencies will be corrected

Plan of Correction

• Documents the specific deficiencies cited • Documents promises made by the facility to correct

the concern(s) • Becomes the public document disclosing the facility’s

deficiencies and what is being done to remedy them

Failure to return an acceptable PoC within the allotted time frame may result in a sanction

Timing

• OHCQ evaluates whether the corrective action will result in compliance within an acceptable timeframe

• General guideline: about 60 days

Acceptability

• An acceptable PoC demonstrates to a reasonable degree of certainty that the provider is able to furnish adequate care (that meets minimum standards) and which does not jeopardize the health and safety of residents

• An acceptable plan of correction demonstrates a path to both achieve and maintain compliance leading to improved quality of care

Five Elements of a PoC

1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice

2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice

3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur – This requires analysis of cause

Five Elements of a PoC

4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. – This requires analysis of cause

5. Include dates when corrective action will be completed

Accountability

• Facilities should be cautioned that they are ultimately accountable for their own compliance, and that responsibility is not alleviated in cases where notification about the acceptability of their plan of correction is not made timely

Considerations for Each Element

• Can the provider implement the plan? – PoC must be specific and realistic, stating exactly how the

deficiency was or will be corrected – Facility must be able to implement the plan and the plan

must be verifiable

• Can the proposed action correct the practice? – If implemented, this could fix the concern

PoC is a Public Document

Do not include identifiable data Do not under or over-promise Accountability (by title) Dates Signature

Past Noncompliance

Citations of Past Noncompliance

• Past noncompliance may be identified during any survey of a nursing home

• Cited more frequently during complaint investigations and reviews of self-reported incidents

• Can be cited during health and life safety code surveys

• Civil money penalty may be imposed by CMS for the number of days of past noncompliance

Criteria for Citing Past Non-compliance

1. Facility was not in compliance with the specific regulatory requirement at the time the situation occurred;

2. Noncompliance occurred after the exit date of the last standard (annual recertification) survey and before the current survey; and

3. Sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey.

Facility Actions when Violation is Identified

• Facility should develop and implement a plan of correction as soon as possible

• Plan needs to include all the components of an acceptable plan of correction

• Provide this information as part of the investigation if related to a self-reported incident

• Provide this information to the surveyor if an on-site investigation occurs


• Past noncompliance is documented on the SoD at the actual deficiency tag where past noncompliance is identified

• Scope and severity rating is assigned • Surveyors document on the SoD the nursing home’s

actions to correct the deficiency


• SoD states “Past noncompliance: no plan of correction required” in provider’s plan of correction column of SoD

Informal Dispute Resolutions

Informal Dispute Resolution

• It is the process by which a provider disputes part or all of a deficiency

• It is requested by a provider after written deficiencies are issued

Requesting an IDR

• The cover letter for a statement of deficiency includes information regarding the provider’s right to request an IDR – Request is submitted to the Deputy Director within 10

business days from the provider’s receipt of the SoD – Request should include the reason for the dispute, i.e.,

additional facts – Supporting documents should be attached

• An incomplete IDR process will not delay the effective date of any enforcement action

Outcomes of Nursing Home IDR and IIDR by

Federal Tag, 9/1/15 – 3/23/17

No change 22%

Tag changed 2%

Tag removed 40%

Scope/severity changed 6%

Example removed 20%

S/S changed, example removed 1%

139 federal tags

Reasons for Nursing Home Informal Dispute

Resolution Decisions, 9/1/15 – 3/23/17

No change 34%

Additional info provided

28%

Facility non-culpable 5%

Insufficient evidence 10%

Inaccurate facts 5%

Wording change 6%

Other 13% 139 federal tags

IDRs are Informal

• Presentations are not by attorneys • Proceedings are not under the formal rules of

evidence • There is no formal stenographer • There is no testimony under oath

Potential Benefits of an IDR

• Remove or lessen the deficiency • Modify the deficiency to accurately reflect the facts • Put the deficiency under a different tag • Remove or lessen a civil money penalty • Gain credibility with your competence • Improve the quality of the survey process • Make an ethical point

Potential Downsides of an IDR

• The time needed for preparation • The effort needed for preparation • The cost associated with preparation • The emotional drain on everyone involved • Loss of credibility

Provider’s Rationale

• Additional facts • Misinterpretation of information • First-hand account that clarifies the issue • Full explanation of the issue • Additional documentation • Studies that support your actions

Quality of Evidence

• Administrator’s written statement that maintenance checked the hot water temp. on the morning of the incident

• DON’s written statement that 7 employees attended a CPR course, but the certificates were all lost

• Blog from a European doctor about his opinion on managing diabetes

• The maintenance employee comes to the IDR and explains what he did on the morning of the incident

• Seven employees, in their own words, document in writing that they attended a CPR course on a given day

• New England Journal of Medicine peer-reviewed article on managing diabetes

Provider’s Preparation

• Read the deficiency • Determine what you will dispute • Reread the deficiency • IDR focuses on if the practice is deficient or not • Other topics are not discussed during the IDR, but

will be addressed in other ways – Complaints about a specific surveyor are handled through

the State’s HR system

What Providers Bring to the IDR

• Key personnel • Written deficiency • Plan of correction • Relevant portions of the chart • Any additional written documents • Any additional reference information

Straight from the Horse’s Mouth

• Don’t underestimate the value of the truth from the primary source

• In one complex case, the GNA involved in the incident was more credible than the Director of Nursing who was not in the building

Who from OHCQ attends an IDR?

• Surveyor or surveyors that wrote the disputed deficiency

• Survey Coordinator • Program Manager • Deputy Director of Federal Programs • Chief Nurse • Medical Director • Executive Director may attend

What does the OHCQ coordinator bring to the IDR?

• Written deficiency • Plan of correction • Surveyor notes • Pertinent regulations • Any additional reference information

Expectations of the OHCQ Surveyor

• OHCQ surveyor should be prepared to: – Succinctly describe the deficient practice – Explain the source of the information -- from the medical

record or an interview – Explain the rationale for the scope and severity of the

deficiency

Discussion at the IDR

• After introductions and an explanation of the process, the provider is asked to explain their disagreement with each deficiency that is disputed

• The provider leads the presentation of their information

• During the discussion, clarifications and additional facts from both sides will be elicited

Length of an IDR

• Typically an IDR lasts an hour, but it may be shorter or longer depending on the number of tags disputed and the amount of information to discuss

Is there a winner in an IDR?

• The common goal of both sides should be to arrive at the truth via a fair process

• At the end of the process, both sides may have to agree to disagree on the final decision

Number of IDRs per Fiscal Year

Fiscal Year Number of IDRs 2009 40 2010 47 2011 37 2012 40 2013 31 2014 45 2015 46 2016 32

2017 (July – March) 27

Appreciate these Differences

• Seeking the truth vs. arguing a point • Top priority is patient care vs. removing the

deficiency • Presenting all the facts vs. presenting partial facts to

support an alternate explanation • Getting written statements from the staff to give

additional information vs. statements to dispute your own written record

Ineffective Strategies

• “Screaming” does not mean “screaming” • “Pain” does not mean “pain” • Arguing “clinical judgment” without any clinical

rationale to support the decision • Arguing that the survey process itself is unfair • “I will lose my job” • “I won’t get my bonus”

• Don’t sacrifice your credibility

After the IDR

• After your presentation, the provider leaves and OHCQ personnel remain to discuss it or arrange a time to discuss it

• OHCQ reviews the written deficiency, the regulations, and any additional information that was provided

• We may ask for additional information from the provider after the IDR

• Generally we contact the provider within one week with our decision

Why are deficiencies changed?

• Evidence does not support the deficiency • Regulations were too narrowly interpreted • It was based on a surveyor’s opinion versus a

regulation or standard of care • Too close of a call

Case Discussion “My head fits through the side rails”

Warning: Do Not Attempt

Nursing Home Side Rails

• Prior to this nursing home’s annual survey, there was a side rail associated death in Montgomery County

• Surveyors closely looked at this facility’s side rails

Side Rail Safety

• Referred to FDA Guidelines • The zones were as much as 1 ½ inches beyond the

recommendations on multiple beds • No cone available, so surveyor used a tape measure

to obtain the distance in various zones • Cone is used in the Guidelines

IDR: Reconsideration

• Representative from national manufacturer of side rails came to demonstrate equipment

• OHCQ’s burden was to demonstrate that the side rail was likely to cause serious harm to the patient in the bed at the time of our survey

Considerations

• Size of the patient’s head and other body parts that may become entrapped

• Ability of the patient to move independently • Cognitive impairment • Previous entrapments or near-entrapments

Immediate Jeopardy

• A situation in which the provider’s noncompliance with one or more require-ments of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

Result of the IDR

• This case was cited as an Immediate Jeopardy, but after the IDR it was changed to a D for failure to document the risks and benefits of a side rail for this individual

Final Thoughts for Providers

• Focus on disputing the written deficiency • Share your big picture perspective • Speak openly and honestly • State the facts and bring the evidence • Make sure that the key staff attend • Stay focused on the deficiency, not the surveyors • Don’t sacrifice your credibility

Final Thoughts for OHCQ

• Focus on the written deficiency • Share your big picture perspective • Speak openly and honestly • State the facts and bring the evidence • Stay focused on the deficiency • Don’t sacrifice your credibility • Be prepared

Enforcement Actions

79

OHCQ Authority

• Agent of Centers for Medicare and Medicaid Services • Agent of the Secretary of Department of Health and

Mental Hygiene • Agent of Developmental Disabilities Administration • Agent of Behavioral Health Administration

CMS Prioritization of Tier Activities

• Tier I: Surveys required by statute • Tier II: Complaint investigations and targeted surveys • Tier III: Providers seeking Medicare participation who

do not have the option of being deemed (Lower priority for states that haven’t completed Tier I and II activities)

• Tier IV: Providers seeking Medicare participation who have the option of being deemed (Lowest priority for states that haven’t completed Tier I and II activities)

Federal Remedies

• July 22, 2016 CMS memo: Mandatory Immediate Imposition of Federal Remedies and Assessment Factors Used to Determine the Seriousness of Deficiencies for Nursing Homes

Federal Remedies

• CMS must now immediately impose a CMP any time an IJ is cited

• Irrespective of a state recommendation to impose or not impose a remedy, the CMS RO must immediately impose, without permitting a facility an opportunity to correct deficiencies, one or more federal remedies based on the seriousness of the deficiencies or when actual harm or Substandard Quality of Care (SQC) is identified.

Federal Remedies

• Category 2 remedies: CMS added termination and temporary management as possible remedies

Federal CMPs in SFY 16

• 38 federal CMPs in SFY 16, totaling $2,839,489 • Average amount is $74,723 • Range from $1,235 to 474,337

Our common ground is the individuals that we serve

��OHCQ Enforcement Update�March 29, 2017��Office of Health Care Quality�Protecting the health and safety of MarylandersOHCQ’s mission is to protect the health and safety of Marylanders and to ensure there is public confidence in the health care and community service delivery systems OHCQ FunctionsOHCQ Organizational ChartOHCQ – Long Term Care UnitWhat is OHCQ’s role?How do I manage all of these regulations?OHCQ Oversees 61 Provider Types Number of Providers Overseen by OHCQ� by Fiscal Year, 2014 – 2017Projected Surveyor Staffing Deficit, FY 13 to FY 17Surveyor Staffing Deficit Projected for FY 17Coordinator Staffing Deficit Projected for FY 17Strategic Planning ProcessRegulatory Efficiency and EffectivenessOHCQ Survey CycleStatisticsNursing HomesScope and Severity MatrixCMS Deficiency Categorization Instructions� Guidance on Severity LevelsCMS Deficiency Categorization Instructions� Guidance on Scope LevelsCMS Deficiency Categorization Instructions� Guidance on General ProceduresMost Frequently Cited Federal Deficiencies� in Nursing Homes in FY 16Number of Actual Harm and Immediate� Jeopardy Deficiencies by Federal Tag in SFY 15Number of Actual Harm and Immediate� Jeopardy Deficiencies by Federal Tag in SFY 16Number of Actual Harm and IJ Deficiencies by� Federal Tag in SFY 17 YTD (July – March)�Number of Actual Harm and IJ Deficiencies by SFY�Plan of CorrectionRegulatory ViolationsPlan of CorrectionPlan of CorrectionTimingAcceptabilityFive Elements of a PoCFive Elements of a PoCAccountabilityConsiderations for Each ElementPoC is a Public DocumentPast NoncomplianceCitations of Past NoncomplianceCriteria for Citing Past Non-complianceFacility Actions when Violation is IdentifiedCitations of Past NoncomplianceCitations of Past NoncomplianceInformal Dispute ResolutionsInformal Dispute ResolutionRequesting an IDROutcomes of Nursing Home IDR and IIDR by� Federal Tag, 9/1/15 – 3/23/17�Reasons for Nursing Home Informal Dispute� Resolution Decisions, 9/1/15 – 3/23/17IDRs are InformalPotential Benefits of an IDRPotential Downsides of an IDRProvider’s RationaleQuality of EvidenceProvider’s PreparationWhat Providers Bring to the IDRStraight from the Horse’s MouthWho from OHCQ attends an IDR?What does the OHCQ coordinator bring to the IDR?Expectations of the OHCQ SurveyorDiscussion at the IDRLength of an IDRIs there a winner in an IDR?Number of IDRs per Fiscal YearAppreciate these DifferencesIneffective StrategiesAfter the IDRWhy are deficiencies changed?Case Discussion�“My head fits through the side rails”Warning: Do Not AttemptNursing Home Side RailsSide Rail SafetyIDR: ReconsiderationConsiderationsImmediate JeopardyResult of the IDRFinal Thoughts for ProvidersFinal Thoughts for OHCQSlide Number 78Enforcement ActionsOHCQ AuthorityCMS Prioritization of Tier ActivitiesFederal RemediesFederal RemediesFederal RemediesFederal CMPs in SFY 16Our common ground is the individuals that we serve