Survival Guide for Long-Term Care Providers Update Since SB 1202 Presentation by the Agency for Health Care Administr

1. Survival Guide for Long-Term Care ProvidersUpdate Since SB 1202Presentation by the Agency for Health Care AdministrationSeptember/October 2002

2. Updates & Recent Activities SB 1202 Questions & Answers – Adverse Incidents Liability Claims and Insurance 2002 Legislative Changes Nursing Home Staffing Alzheimer’s Training Gold Seal Program

3. New Slides Blue Background Underlined Text Added to Presentation Not in Handout Post on AHCA Web Site

4. SB 1202 Emphasis on Adverse Incidents Asked Quality of Care Monitors Definition of Adverse Incidents Questions and Answers Published: February 2002 May 2002

5. Adverse Incident Definition Florida Statutes 400.147(5): (a) An event over which facility personnel could exercise control and which is associated in whole or in part with the facility's intervention, rather than the condition for which such intervention occurred, and which results in one of the following:

6. Adverse Incident Definition Florida Statutes 400.147(5)(a) continued… 1. Death; 2. Brain or spinal damage; 3. Permanent disfigurement; 4. Fracture or dislocation of bones or joints; 5. A limitation of neurological, physical, or sensory function; 6. Any condition that required medical attention to which the resident has not given his or her informed consent, including failure to honor advanced directives; or 7. Any condition that required the transfer of the resident, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the resident's condition prior to the adverse incident;

7. Adverse Incident Definition Florida Statutes 400.147(5): (b) Abuse, neglect, or exploitation as defined in s.415.102; (c) Abuse, neglect and harm as defined in s. 39.01 ; (d) Resident elopement; or (e) An event that is reported to law enforcement. (Note: Always defined as adverse incident regardless of facility control. See Chart 5 “Adverse Incident Reporting”.)

8. Adverse Incident Definition Q – What is the Agency’s position on reporting skin tears, bruises or fractures of unknown origin, in terms of adverse incident reporting? Is the same interpretation applied in hospitals? A – If it meets the definition of an adverse incident pursuant to section 400.147 for nursing homes or 400.423 for assisted living facilities it must be reported. There are some differences in the definitions of adverse incidents for hospitals versus nursing homes and assisted living facilities, but each entity is expected to operate in compliance with their respective regulations.

9. Adverse Incident - Elopement Q - How is “elopement” defined for the purposes of adverse incident reporting? A - Elopement is when a resident leaves the facility without following facility policies and procedures for signing out.

10. Adverse Incidents – Baker Act Q – Baker Act referrals and risk management reporting requirements: Does a facility have to report a call for law enforcement transportation as an adverse incident?

11. Adverse Incidents – Baker Act A – Events reported to law enforcement for investigation are considered adverse incidents pursuant to sections 400.147(5)(e), F.S. A call to law enforcement for something other than investigation, e.g.: transportation only, would not alone meet the definition of an adverse incident. However, a Baker Act situation must be reviewed independently to determine if it meets one of the definitions of an adverse incident.

12. Adverse Incident Reporting Q – If, prior to the required report date, facility staff determine that an incident does not meet the definition of an adverse incident as specified in statute, is a report to the Agency still required?

13. Adverse Incident Reporting A – Only those incidents that meet the definition of an Adverse Incident must be reported to the Agency. If the facility is able to determine that the incident does not meet the definition, prior to the required report date, then a report is not required. However, if the facility has not yet determined if the incident meets the adverse incident definition the incident must be reported on the 1-Day report. After the facility investigation is complete and if it is determined that the incident does not meet the definition of an adverse incident, then the facility staff may report on the 15-Day report that the incident was determined not to be an adverse incident.

14. Adverse Incident Report Q – What should a facility provide in the adverse incident report? A - All the questions on the Adverse Incident Report forms should be answered. The description of the incident should include answers to basic questions like Who, What, Where, When, Why, allows AHCA reviewers to determine appropriate action.  

15. Adverse Incident Confidentiality Q – Are a facility’s risk management and quality assurance records protected from public disclosure once they are sent to the Agency, such as with a plan of correction? A – All documents received by the agency are considered public records unless there is a specific public record exemption in law. Only the adverse incident reports themselves are protected from public record. Any documents submitted with a plan of correction are not protected from public disclosure, however, resident unique identifying information remains protected and redacted from documents prior to the release of the records.

16. Adverse Incident Confidentiality Adverse Incident Reports (1-Day and 15-Day) are Exempt from Public Disclosure The 5-Day Report of the Status of an Abuse, Neglect or Exploitation Not Specifically Exempt from Public Disclosure Accept the 15-Day Report by the 5th Day to Meet Federal 5-Day Requirement

17. Adverse Incidents Role of Risk Management Process Identification of Incidents Affect Compliance with Regulations Role of Quality-of-Care Monitor Risk Management Program Adverse Incident Identification Role in the Survey Process Regulatory Compliance Related to Occurrences Current Non-Compliance Except Egregious

18. AHCA Annual Adverse Incident Report 13,772 Adverse Incident reports processed 4,613 determined by facilities to be adverse incidents 3,145 Nursing homes 1,468 Assisted living facilities

19. Adverse Incidents Outcomes Nursing Homes 1,505 Event Required Transfer 1,030 Fracture or Dislocation 879 Abuse (Ch 415) 383 Elopement 318 Event Reported to Law Enforcement 27 Death 21 No Consent 13 Functional Limitation 3 Brain or Spinal Damage 2 Disfigurement

20. Practitioner Review Medical Quality Assurance Investigates Practitioners for Violations of Practice Acts Review All Adverse Incident Reports Practitioners Being Investigated Receive a Copy of the Adverse Incident Report Other Staff Names are Removed

21. Staff Disciplinary Actions Referred for Investigation: 567 Total Referred Out of 13,772 Reports 410 Certified Nursing Assistants 149 Licensed Nurses 3 Nursing Home Administrators 3 Pharmacists 2 Physical Therapist Average 5% of Referred Result in Prosecution 361 Investigations Completed: 50 Found Probable Cause 95 Dismissed Ten Emergency Actions Against Practitioners

22. Liability Claims Reported to AHCA 1,123 Liability Claims Reported: - 1,050 Nursing Homes - 73 Assisted Living Facilities 33 Claims are for incident dates or residency dates since May 2001 1090 (97%) of liability claims reported for incidents or residency dates prior to May 2001, and extend as far back as 1990

23. Nursing Home Liability Claims Received by Month

24. Top Reasons for Claims Reported Nursing Homes: 260 Other 159 Death 133 Fracture 89 Abuse 75 Transfer Involved Assisted Living: 13 Other 13 Fracture 12 Death 10 Transfer Involved 4 Abuse

25. Liability Insurance Requirement Insurance required for Nursing Homes and ALFs Recent changes for nursing homes – now require General and Professional Liability Insurance No Minimum coverage Amounts are Required No Licenses have been Denied or Revoked to Date for Failure to have Insurance since January 1, 2002 The Risk Retention Group is working on a product to be available in September – primarily ALFs $6 million advance to the Risk Retention Group for capitalization of the fund

26. Nursing Home Bed Occupancy

27. 2002 Legislative Changes AHCA Semi-annual Report First report due December 30, 2002 Data reported on a monthly basis Number of Notices of Intent to Litigate received Number of complaints filed with the Clerk of the Court Incident dates (or residency dates) Regulatory history including: Deficiencies cited & Nursing Home Guide information Nursing Home Watch List Federal CMS Quality Information Project

28. 2002 Legislative Changes Continuing Care Retirement Community (CCRC) residents are not considered new admissions for the purposes of the moratorium on new admissions required for insufficient staffing - SB 1246 amends 651.118 (13) (CCRC must meet staffing ratios) Medicaid Lease Bonds for Leased Nursing Homes - Exempts certain municipal bond leases from the lease bond requirement - Allows payment to a Medicaid overpayment fund in lieu of posting the Lease Bond Increase in Medicaid reimbursement to assist with cost of liability insurance

29. Staffing Information Since January 1, 2002: 138 facilities cited for one of the following staffing citations: 109 citations for failure to meet the minimum staffing standards in the statute (N063) – 11 Class IV, balance Class III – Look at multiple periods 49 citations for failure to have sufficient staff to meet resident needs (F353) 14 citations for failure to self-impose a moratorium if staffing ratio is not met for 2 consecutive days (N069) mandatory Class II deficiency Note: Averages reported generally meet the required levels

30. Report Staffing InformationNursing Homes AHCA collects semi-annual reporting of staff ratios, turnover and stability Next report: - Will be sent to all facilities in September, 2002 - Due October 20, 2002 - Anticipate on-line submission of staffing reports and monthly bed vacancy by October, 2002 Centers for Medicare and Medicaid Services (CMS) also posts staffing data on Nursing Home Compare - From the CMS 671 form (provider completes during annual survey)

31. Nursing Home Information Know What Others See About Your Facility Reconcile Information – IDR Online – Federal and State Public File Public Information Office (850) 414-6044

32. Alzheimer’s Disease Training Department of Elder Affairs Rule is finalized, mailed to nursing homes in May - 58A-4.001(2), F.A.C. http://elderaffairs.state.fl.us/doea/mark.html (see Nursing Home Alzheimer’s Training) Nursing Home Training Provider Certification and Curriculum Approval maintained by the Florida Policy Exchange Center on Aging at USF at www.fpeca.usf.edu Recent Questions and Answers from the Department of Elder Affairs – Attached Teaching Nursing Home – CD-ROM Alzheimer’s Training for LPNs – Contact LTC Unit – Richard Kelly

33. Legal Activity

34. Other Legislative Updates

35. Gold Seal Award Recipients River Garden Hebrew Home for the Aged, Jacksonville The Pavilion for Health Care, Penney Farms John Knox Village Medical Center, Tampa Florida Presbyterian Homes, Lakeland Memorial Manor, Pembroke Pines Menorah Manor, St. Petersburg Presentation made by Lt. Governor Brogan on July 24, 2002

36. Gold Seal Criteria

37. Gold Seal Financial Criteria

38. Gold Seal Financial Criteria

39. Gold Seal Criteria

40. Gold Seal Process

41. Current Gold Seal Reviews

42. Gold Seal Benefits

43. Resources AHCA Web Site: www.fdhc.state.fl.us AHCA Annual Report on Adverse Incidents Gold Seal Applications Licensure Applications and Forms Nursing Home Guide Nursing Home Watch Lists Florida Health Stats – Locate Facilities/Providers Long-Term Care Unit (850) 488-5861