Agency for Health Care Administration

1. Agency for Health Care Administration General Counsel Valda Clark-Christian Inspector General Judy Hefren, Acting Secretary Rhonda Medows, M.D. Division of Administrative Services Christy Gregg Division of Health Quality Assurance Liz Dudek Division of Medicaid Bob Sharpe • Payment of Fines • Payment of Medicaid Overpayments • Medicaid Area Offices • Health Systems Development • Program Analysis • Contract Management • Pharmacy Services • Research • Medicaid Services • Health Facility Regulation • Health Standards & Quality • Field Operations • Managed Health Care • Plans and Construction • Long Term Care Services • Medicaid Program Integrity • Fraud and Abuse • Legal Representation • Imposition of Administrative Sanctions • Receivership

2. Agency for Health Care Administration Long Term Care Unit CaraLee Starnes Facilities Data Analysis Unit Jane Boerger Bureau of Long Term Care Molly McKinstry Assisted Living Unit Alberta Granger Bureau of Plans and Construction Skip Gregory • Plan Review for Health Care Facilities including Nursing Homes Bureau of Managed Care Tom Warring • Regulation of Commercial HMOs • Regulation of Medicaid HMOs – Quality Control, Monitoring and Review Division of Health Quality Assurance Liz Dudek Deputy Rebecca Knapp Bureau of Health Facility Regulation Jeff Gregg Bureau of Field Operations Polly Weaver • Licensure and Certification • Home Care • Acute Care • Labs • Health Care Clinics • Certificate of Need • Financial Analysis • Background Screening • Licensure and Certification Nursing Homes and other LTC Facilities • Teaching Nursing Home Contract Management • Gold Seal Program • Long Term Care Policy Issues • Rule Development • Receivership • Nursing Home Watch List • Guide to Nursing Homes (Joint with FO) • Survey Field Offices • Complaint Administration • Call Center Contract Manager • 5-Day Abuse Reporting Health Standards and Quality Susan Acker • Quality of Care Monitors • Survey Integrity and Support Branch • Informal Dispute Resolution • MDS/OASIS Help Desk • State Survey Training Coordination • Adverse Incidents and Liability Claims • Nursing Home Staffing Reports and Bed Vacancy • Licensure of Assisted Living Programs • Long Term Care Policy Issues

3. Agency for Health Care Administration Medicaid Field Offices 11 FO Managers • Field Offices • Provider Claims Resolution, Technical Assistance, and Policy Training • Medicaid Beneficiary Support, Advocacy, and Assistance Pharmacy Services George Kitchens • Pharmacy Services • Pharmacy Prior Authorization • Restocking Fees Division of Medicaid Bob Sharpe Chief Operating Officer Steve Grigas Chief Financial Officer Ken Thurston Health Systems Development Steve Presnell Program Analysis Robert Butler Research • Reimbursement Policy • Rate Setting • Cost Report Processing & Audits • Medicaid Lease Bonds • Medicaid Budget Estimates • Medicaid Research Projects • Medicaid Up or Out Contract Management • Managed Care Policy Development • MediPass • Disease Management Contract Management Allan Strowd Medicaid Services Bob Maryanski • Medicaid Provider Enrollment • Contract Management for Fiscal Agent • Medicaid Claim Payment • Handbook Development • Waiver Programs • State Plan Program Development • Medicaid Placement Issues • PASSR • Medicaid Nursing Home Bed Reduction Efforts

4. Long Term Care Bed Growth

5. Nursing Home Closures • Nursing Home Closures • 2003 – Three Nursing Homes (459 Beds) • 2002 – Twelve Nursing Homes (1,258 Beds) • 2001 – Six Nursing Homes (605 Beds) • Based Upon Date Residents Were Discharged

6. Nursing Home Occupancy

7. Nursing Home Medicaid Reimbursement Versus Total Cost

8. Nursing Home Reimbursement Versus Patient Care Cost

9. Nursing Home and Assisted Living Facility: Adverse Incidents & Notices of Intent FiledReport to the LegislatureMay 2003 – Status Reportwww.fdhc.state.fl.us - Publications and Forms

10. Adverse Incidents Reported

11. Type Nursing Home Assisted Living Adverse Incidents by Type May 15, 2002 – May 14, 2003 Death 26 17 Brain/Spinal 2 0 Disfigurement 5 2 Fracture/Dislocation 948 332 Functional Limitation 9 No Consent 34 6 Transfer 1568 815 Adult Abuse (A/N/E) 1088 122 Child Abuse 9 Elopement 357 155 Law Enforcement 238 135

12. Adverse Incident InspectionsMay 15, 2002 - May 14, 2003 # of Completed Inspections # With Deficiencies #Serious Deficiencies % With Deficiencies NH ALF NH ALF NH ALF NH ALF GRAND TOTAL 47 35 11 11 3 1 24% 31%

13. Nursing Home Notices of Intent ReceivedUpdated Monthly http://www.fdhc.state.fl.us/MCHQ/Long_Term_Care/FDAU/Reports.shtml

14. Assisted Living Facility Notices of Intent ReceivedUpdated Monthly http://www.fdhc.state.fl.us/MCHQ/Long_Term_Care/FDAU/Reports.shtml

15. Semi-Annual Report onNursing Homes • Liability Claim Information • Notices of Intent to Litigate • Claims File with Clerk of Court • Survey Deficiencies • Federal Quality Measures

16. For-Profit Non-Profit Multi-Facility Owner Total Nursing Home NOIs Reported Licensed Nursing Homes 506 (76%) 163 (24%) 337 (50%) 669 Nursing Homes reporting NOIs 408 (81%) 97 (19%) 275 (55%) 505

17. NOIs Per Nursing HomeBased Upon 505 Nursing Homes Reporting # Nursing Homes # NOIs Reported 129 1 227 2 to 4 115 5 to 9 34 10 or more

18. Notices of Intent By Nursing Home Profit Status

19. Total Federal “F” Tags Cited by Quarter Note: Number is subject to change based on the entry of surveys in the system and other actions that change deficiencies such as IDRs and legal actions.

20. Total Federal “K” TagsCited by Quarter

21. Most Serious Nursing Home Deficiencies

22. Calendar Quarter Number of Facilities Number of Nursing Homes on the Watch List by Quarter April 1, 2001 – June 30, 2001 83 July 1, 2001 – September 30, 2001 90 October 1, 2001 – December 31, 2001 91 January 1, 2002 – March 31, 2002 84 April 1, 2002 – June 30, 2002 92 July 1, 2002 – September 30, 2002 72 October 1, 2002 – December 31, 2002 55 January 1, 2003 - March 31, 2003 63

23. Recent Legislative Changes Nursing Homes • Staffing • Allows one day at 97% of staffing requirements without citation if facility does not have a Conditional license • Adds greater flexibility to sharing of staff in a retirement community – rules may be developed • CNA increase to 2.9 delayed until May 1, 2004 • Gold Seal – AHCA will modify financial criteria • Accept reviewed financial statement • CCRCs may use DOI financial criteria if accredited

24. Recent Legislative Changes • Quality of Long Term Care Facility Improvement Trust Fund • Allows state portion of federal nursing home fines to be deposited into fund • Modifies projects that may be funded • Payment of fines • All entities regulated by AHCA must pay or make arrangements to pay monies due to AHCA prior to a change of ownership • Medicaid expansion of the long-term care diversion • Expand LTC Diversion Program to serve more recipients • Plan for reduction in the number of Medicaid nursing home beds

25. Assistance with Eating Federal Regulation • Federal Register Vol. 68, No. 187, Friday September 26, 2003 http://www.access.gpo.gov/nara/index.html • Modifies Code of Federal Regulations effective October 27, 2003 • Authorizes use of “paid feeding assistants” if: • The individual has successfully completed a State-approved training course and • Use of such assistants is consistent with state law Florida Law • Section 400.23(3)(b), Florida Statutes authorizes the agency to develop rules to allow properly trained staff to assist residents with eating; rule must specify: • Minimum training requirements • Resident physiological conditions or disorders that require nursing personnel assistance • Rule must be in place before implementation in Florida

26. Federal Requirements • Supervision • Must work under the supervision of an RN or LPN • Must call a supervisory nurse for help on the resident call system in an emergency • Resident Criteria • Residents without complicated feeding problems, including difficulty swallowing, recurrent lung aspirations and tube or parenteral/IV feedings • Base selection upon charge nurse’s assessment and resident’s latest assessment and plan or care • Training Requirements • Minimum 8 hours

27. Quality Improvement Activities Update • Nursing Home Project • QIO is lead • MDS data utilized and publicly reported • Contact Florida Medical Quality Assurance Linda Wilkes 1-813-354-9111 • Operation Spot Check • Attorney General’s Office has lead • MDS Data Verification Project (DAVE) • 28 On-site visits to date • Designed to audit MDS data • Facilities identified based on off-site record reviews and random selections

28. Nursing Home Staffing Citations 2002 - 260 Citations (206 Facilities) 166 for N063 (Staffing Ratios) 16 for N069 (Self-Imposed Moratorium) 78 for F353 (Insufficient to Meet Needs) 21 for N063 with F353 57 for F353 without N063 2003 to date - 129 Citations (116 Facilities) 74 for N063 (Staffing Ratios) 3 for N069 (Self-Imposed Moratorium) 52 for F353 (Insufficient to Meet Needs) 6 for N063 with F353 46 for F353 without N063

29. 7/1/02-6/30/03 1/ 2 3 4 5/ 6 7 8 9 / 10 11 Nursing Home Immediate Jeopardy by Region Current IJ Surveys 5 3 4 3 4 6 5 2 Past IJ (F698) 1 1 1 Total 5 3 4 4 4 7 6 2

30. Top 10 Deficiencies Nursing Homes • F371 Food must be stored, prepared and distributed under sanitary conditions • F281 Services provided by the facility must meet professional standards • F279 Facility must develop comprehensive care plans for each resident • F514 Facility must maintain clinical records professionally and accurately • F241 Facility must treat residents with dignity and respect

31. Top 10 DeficienciesNursing Homes Continued • F432 Drugs must be stored in locked compartments at proper temperature • F253 Facility must provide adequate housekeeping and maintenance services • F309 Facility must provide necessary care for highest practicable well being • F280 Comprehensive care plan must be timely, accurate and periodically reviewed • F323 Facility must be kept free of accident hazards

32. Top 10 Complaint AllegationsNursing Homes Allegation Total Confirmed • Resident Care 890 108 • Resident Rights 469 58 • Medicine Prob/Errors/Formulary 326 63 • Staffing 324 33 • Resident/Patient Abuse/Neglect 287 43

33. Top 10 Complaint AllegationsNursing Homes Continued Allegation Total Confirmed • Falls/Injury 222 26 • Dietary 218 26 • Pressure Sores 177 18 • Physical Plant 168 28 • Infection Control 167 19

34. AHCA Web Site: www.fdhc.state.fl.us Long-Term Care Unit (850) 488-5861 Facilities Data Analysis Unit (850) 922-6089 Field Operations (850) 414-9796 Health Standards and Quality (850) 922-9138 Resources