12/21/2016
CMS Regional Meeting: Top Ten Deficiences, New RoPs, Focused Surveys
The Centers for Medicare and Medicaid Services (CMS) held its annual Region V (Ohio, Illinois, Indiana, Michigan, Minnesota and Wisconsin) Long Term Care Provider Association and survey agencies meeting December 13 and 14 in Chicago. LeadingAge Ohio was represented by Janet Feldkamp, Benesch, Stephanie DeWees and Nisha Hammel, LeadingAge Ohio. This is a summary of the key topics shared. LeadingAge Ohio will have additional information and the handouts of the information presented on the LeadingAge Ohio website when CMS sends an electronic copy of the information as there are many handouts that are difficult to read when copied.
Survey and Certification Citations
- As always, CMS provided the top ten (10) survey and certification citations by region and nationally. Similar to FY 2015, F441 (Infection control) made the list in all five regions and nationally for FY2016. In 2 states F441 was cited more than 50 percent. F323 (Accident Hazards) and F309 (Provide Care/Services for Highest Well Being) also made the list in all five states and nationally.
- In Ohio, the top three (3) citations were F441 (25.9%), F371 (25.0%) and F329 (24.8%) on standard surveys.
- Ohio was the lowest in the region on the average number of deficiencies cited per annual (4.2%) and equivalent to the nation on the average number of complaint deficiencies cited (0.6%).
- Ohio ranked third (18 in total) in the region for the number of level 4 tags cited on standard surveys for FY2016. This is a decrease compared to FY 2015 that had 29.
- Exit Conferences: S&C 16-11-ALL
- Social media
Life Safety Code Citations
- Bruce Wexelberg provided the top ten LSC deficiencies. CMS did not provide the helpful tips as they did last year, but are reconsidering it based on requests.
- K62 (Sprinkler System Inspection, Testing, and Maintenance) was the highest LSC cited deficiency in Region V and nationally again in FY 2016. Ensure that the company hired to do the facility’s annual inspection reviews the key components of this citation to confirm compliance.
- K144 (Electrical Systems – Maintenance and Testing) and K50 (Fire Drills) was the other two top cited areas.
- In Ohio, the top three (3) LSC violations were K38 (Discharge from Exits), K62 (Sprinkler System Inspection, Testing and Maintenance) and K144 (Emergency Systems).
Life Safety Code 2012 Highlights
- Bruce Wexelberg shared that the surveyor training on the 2012 LSC is also available to providers under the provider option tab.
- Quick Reference Guide LSC for health care is a good resource
- The K tags have changed and are now based on code section
- The form the surveyors will use is the CMS 2786R
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The person doing the door inspection does not have to have a specific certification. However, the person needs to be “knowledgeable” on the code as demonstrated through training, level of door violations and through interviews.
- Facilities need their HVAC connected to a generator (emergency preparedness regulations)
- To determine compliance with the FSES, the information is plugged into a calculation and given a “pass” or “fail” score.
- However, there are ways in which a facility can demonstrate compliance through the explanation of how they have items that are “equivalent to code” even without the prescriptive requirements in place.
- If a facility feels that they can’t meet the prescriptive requirements of the code the facility can apply for a waiver.
- A waiver determines if the facility can’t meet the pass or fail criteria. It then considers:
- Does it impact the life safety of residents?
- How is it a hardship? (i.e. Financial hardship is an appropriate hardship)
Requirements of Participation
- There were several areas (transfers/discharges, physical plant requirements of a toilet in each resident pertaining to renovations, pre-admission education requirements) that CMS stated that they were unable to provide further guidance prior to the release of Interpretive Guidance anticipated in the summer of 2017.
- In regards to further clarification on willful and deliberate definitions for Abuse, CMS commented that they suggest facilities look at preambles in the federal register.
- CMS responded to the following language: 21c1VIII - §483.21(c)(1)(viii) to require that the facility assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data are available.
Question: What data beyond the 5 star rating are providers expected to be aware of if discharging to another post-acute care provider?
CMS Response: Facilities should provide data on nursing home compare (such as the quality measures). The facility should know what special needs a resident has and then check to see if the other facility provides those services (vent example).
- Surveyors look at “reasonable method for determining compliance”.
- SNF Payroll Based Journal (PBJ)
- Reports will be given to providers first
- 90% of nursing homes have submitted data
- NH Compare will reflect PBJ data at the earliest by the second half of 2017
- Quality Assurance Performance Improvement (QAPI)
- Phase I requirements include the QAA committee – participants, frequency of meeting, and used to correct deficiencies
- QAPI plan is not required at this time
- Behavioral Health
- Phase I includes Non-pharmacological interventions
- Continue to rely on current interpretive guidance
- Pharmacy Services
- Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;
- Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and
- PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident’s medical record and indicate the duration for the PRN order.
- PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
- CMS’ comments: PRN - 14 day (483.45 new)
Phase II
- Psychotropic medications
- 14 day prn can be extended
- Exception – MD document rationale to extend
- Morphine – document clinically indicated
- Antipsychotic medications
- Can NOT be extended
- New order and resident evaluated
- Only class of medications that requires a new order be rewritten every 14 days
- Infection Control
- Phase 1 and 2 Policies and procedures should include the following:
- Identification of infections
- Transmission based isolation
- Least restrictive isolation methods should be used
- Infection control plan should consider all those entering the facility (staff, visitors, contractors, etc)
- Plan is to be updated annually
- CDC – 7 core elements of antibiotic stewardship (Agency for Research and Quality - and nursing stewardship program)
New Survey Process
- The new survey process will be rolled out in 2017 in conjunction with the Phase 2 implementation.
- Refer to: S&C 15-40NH
- CMS will be combing the QIS and Traditional survey process and taking elements from both.
Quality Payment Program
- The Quality Payment Program policy will reform Medicare Part B payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care delivery system.
- Clinicians can choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location, or patient population.
- CMS commented:
- 1 - This meets the initiative of paying for Value or Volume of care.
- 2 - Reduces burden for those seeing patients in different settings
- 3 – Improvement Activities for Clinicians
- Better access to data
- Money follows the clinician (+ or -)
- Group reporting for clinicians
- Improvement activities
Mandatory Model Update
- Under the proposed episode payment models, the hospital in which a patient is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge. The first performance period would run from July 1, 2017 to December 31, 2017.
Impact on SNF’s
- Higher acuity admissions post-surgery
- Adequate cardiac care rehabilitation
- Quality Measures for each of the above is what hospitals are going to be focused on. This includes Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate
Adverse Events Focused Survey
- CMS is not taken any action on these at this time.
Dementia Focused Survey
- CMS provided an update on the S&C letter 16-28NH. This report provides a brief overview of the National Partnership, summarizes activities following the release of Survey & Certification policy memorandum 14-19-NH2 and outlines next steps. Additionally, this report describes the results of the Focused Dementia Care Surveys conducted in FY2015 and the conclusions gathered based upon post-survey data analysis. The report covers the period of Calendar Year (CY) 2014 Quarter 2 through CY2015 Quarter 3.
- S&C 16-28 NH
- Continuing to be conducted, identifying providers with trends/meds/other indicators
- Opportunities for increased staffing, dementia training and non- pharmacological interventions
- Patters also include the lack of changing of diagnoses that do not meet clinical/professional standards (e.g. indicated with schizophrenia but resident does not have it)
MDS Focus Survey
- CMS provided a detailed update on trends from the surveys. A separate guidance will be provided on this.
- Refer to S&C letter with more detail: 17-06 NH
Infection Control Pilot Project
- 3 year pilot
- Improve ability to assess programs for compliance
- Develop new surveyor tools
- Educational in nature, no citations
- Contractors and unannounced
- Hospital CoP changes
- Draft worksheet – surveyor tool includes tracers – go to bedside to observe care
- Developed list of facilities that will be surveyed
- This year 40 hospitals and 40 LTC facilities
- Focus on transitions of care
Infection Control Pilot Project Announcement (December 2015)
Infection Control Pilot Project 2017 Update
Emergency Preparedness
On September 8, 2016 the Federal Register posted the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. The regulation goes into effect on November 16, 2016. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date, on November 16, 2017.
- If a facility has a fire rated door without closures, are those non-required fire rated doors required to be tested?
- CMS Response - Maintain what is installed – don’t take label off.
- Inspect door based on how it is supposed to function. Inspect based on its intended use.
- Risk assessment NFPA 99
- The facility is responsible and surveyor will not do their own independent risk assessment but will check to see if it is accurate.
- Four (4) provisions
- Risk assessment and planning
- Policies and procedures
- Communication plan
- Training and testing
Emergency Preparedness Regulation Guidance
Civil Monetary Penalties (CMPs)
- The total amount in effect of per day CMPs for Ohio in FY 2016 was $4,950,034.
- The average amount in effect was $45,098.
- The average days were 54 and the number of cases were 80.
- S&C memo 16-40
- CMS considers the following factors in establishing amounts:
- Additional for SQC and facility history (3 years) FSQC level or above, repeat deficiencies
- Same grouping cited
- Relationship from 1 deficiency to anther (other J’s cited at same survey)
- Facilities degree of culpability (neglect, indifference).
- Facilities financial situation (submit documents)
DSC LTC Involuntary Discharge Project
CMS provided an update on this project which looks at Involuntary discharge vs. improper/wrongful discharge.
- This is not when a facility is in compliance with the regulation (non-payment)
- S&C 17-07
