Healthcare Licensing & Surveys

1. May 2013 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

2. 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

3. Organization

4. 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

6. Surveyors Note: Currently recruiting to fill 2 vacant surveyor positions

7. Wyoming Performance StandardsFFY 2013(As of 05/02/13)

8. Comparison of Frequently Cited LTC Health TagsFY2013 (to date)

9. Comparison of Frequently Cited LTC Health COMPLAINT TagsFY2013 (to date)

10. Comparison of Frequently CitedLTC Life Safety Code TagsFY2013 (to date)

11. Survey Citation PatternsBased on Last Current UploadedStandard Health Surveys

12. Average Number of Deficiencies (Data Source: S&C PDQ / Run Date: 05/07/2013)

13. Complaints

14. Complaints Nursing Homes

15. Complaints Assisted Living Facilities

16. 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

17. 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)

18. State Performance Standards Review (FY 2012)

19. State Performance Standards Review (FY 2012)

20. State Performance Standards Review (FY 2012)

21. Federal Oversight Surveys (FOSS)(2011 - 2012) 5 = Extremely Effective 4 = Very Effective 3 = Satisfactory 2 = Less Than Satisfactory 1 = Much Less Than Satisfactory

22. Federal Oversight Surveys (FOSS)(2013) 5 = Extremely Effective 4 = Very Effective 3 = Satisfactory 2 = Less Than Satisfactory 1 = Much Less Than Satisfactory

23. 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

24. 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

25. 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

26. 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

27. 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

28. Questions ?