TOM SCHEIDEL
Chief Operating Officer
Compliance Management Service
• CMS Survey and Enforcement Process
• Life Safety Code Education and Compliance
• cmscompliance@yahoo.com
• 817-456-6238
• 8805 Ridge Run Drive, North Richland Hills,
Texas 76182
The LIFE SAFETY CODE
Survey Process
Making Sure It Is Right
• Development and Redevelopment of the
Regulations/Code
• Oversight of the Survey Process
• Oversight of the State Agency and Surveyors
• Oversight of the Enforcement & Interpretations
• Balancing the System
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
WHO ARE THE PLAYERS?
• CONGRESS AND CMS
– Don’t write the Code!!!
– At the direction of Congress, CMS:
• Incorporates the Regulations “by Reference”
• Updates the Regulations to newer Codes
• Adds additional Regulations where “Necessary”
– Congress responds to:
• Advocates
• Negative Events
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
WHO ARE THE PLAYERS?
• Centers for Medicare and Medicaid Services
– Receives Authority from the Secretary
– Writes Regulations (ex. State Ops Manual)
– Enters into (1864) Agreements with States
– Retains State Budget Allocation Authority
– Details Oversight to 10 Regional Offices
– Statistically oversees Outcomes at States’ Level
– Evaluates Regulations effects / currency
– Maintains Relations with Industry, Code Agencies
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
WHO ARE THE PLAYERS?
• CMS Consortia
– Groups of the 10 Regional Offices
– Efficiency in Sharing
– Collections of Expertise
– Virtual and Vague
– Limited Impact on Providers
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
WHO ARE THE PLAYERS?
• CMS Regions
– 10 Offices geographically follow the Federal Map
• Assigned States within those Regions
– Division of Survey and Certification
• Associate Regional Administrator (Waivers)
• State Representatives
• Certification / Decertification of Providers
• Enforcement Branch (LTC and NLTC)
• Survey Branch (Health, Life Safety Code, CLIA)
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
NATIONAL FIRE PROTECTION
ASSOCIATION (NFPA)
• Write Codes and Standards
– Couple Hundred Titles
– 3 Year Cycle
• Membership Organization
– Industry
– Manufacturers
– Consultants
– Regulators
– Advocates
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
AUTHORITIES
• Authority Having Jurisdiction
– Depends on the Regulations being considered
• Local Fire Authority
– Depends on the local organization
• Waiver Authority
– Depends on the Regulation
– Very limited delegation of authority beyond CMS
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
LIFE SAFETY CODE REQUIREMENTS
• Written by NFPA (Usually)
–
–
–
–
Exceptions are AAMI, ANSI, CGA, ASME, UL, etc.)
Follow a Manual of Style
Written in Conference and Committee
Anyone can recommend a change
• Reviewed & Changed Every 3 Years
– Limited change authority by NFPA
• NFPA 101 (2000 Edition)
– Incorporated by Reference by CMS
– Functions as coordinator
– Mandatory References (Chapter 2)
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
LIFE SAFETY CODE REQUIREMENTS
• NFPA 101 (Life Safety Code)
– Rewritten every 3 years
– Not all incorporated by reference / non-regulatory
• Mandatory References
• Additional Federal Regulations
– Ex. Sprinkler Regulations, Corridor Lighting,
• State Regulations / State Licensure
• In “Complimentary” Codes, Strictest Applies
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-4566238
NFPA 101 (Life Safety Code)
2000 Edition Quick Summary
• Background
• Administration
– Purpose, Applicability, Equivalency
•
•
•
•
•
Mandatory References
Definitions
General Chapters – Applies to All
Occupancy Chapters – 18/19 Health Care
Appendix to the Requirements
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
THE SURVEY
•
•
•
•
•
•
Occurs between the X-month and 15th month
Statewide average of 12 months (SA Managed)
More often for some facilities (SFF)
Complaints are in addition
Health plus Life Safety Code = Survey
Team for Standard Survey
– One Nurse
– Basic Surveyor Trained (Health and Life Safety)
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
STATE OPERATIONS MANUAL
Quick Summary
• Appendix P – Protocol for Long Term Care Survey – with some
investigative protocols
– http://cms.gov/manuals/Downloads/som107ap_p_ltcf.pdf
• Appendix PP – Guidance to Surveyors – “TAGS” – with some
investigative protocols
– http://cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf
• Appendix I – Life Safety Code Survey
– http://cms.hhs.gov/manuals/Downloads/som107ap_i_lsc.pdf
• Appendix Q – Guidelines for Immediate Jeopardy
– http://cms.hhs.gov/manuals/Downloads/som107ap_q_immedjeopardy.
pdf
• Chapter 7 – Enforcement Guidelines for LTC
– http://www.cms.hhs.gov/manuals/downloads/som107c07.pdf
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
LIFE SAFETY CODE
PRINCIPLES OF COMPLIANCE
• Facilities Must Prove Compliance
– (F-454) 42 CFR 483.70(a) – Shall comply with the
Life Safety Code
• As Part of the Standard Survey, States MUST
determine compliance with the Health and
LSC Requirements
– K-Tag (LSC) Survey is performed by surveyor
having completed the LSC Basic training
– F-Tag (Health) Survey is performed (lead) by
surveyor having completed LTC Basic training
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
STATE OPERATIONS MANUAL
Example of LSC/Health Crossover
• F323 - §483.25(h) – …as free as possible from
accidents / supervision to prevent accidents
– Smoking Regulations
– Electric Cords / Tripping
– Doors Blocked Open
– Heating Unit Surfaces
• F456 - §483.70(c)(2) Maintain all essential
mechanical, electrical, and patient care
equipment in safe operating condition.
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
Example of LSC/Health Crossover
• F454 - §483.70 Physical Environment
– §483.70(a) Life Safety From Fire
– NFPA 101 (Life Safety Code) 2000 Edition
– The facility must be designed, constructed, equipped, and
maintained to protect the health and safety of residents,
personnel and the public.
• F459 - §483.70(d)(1)(iii) Have direct access to an exit
corridor;
– There is no authority under current regulations to approve
a variation to this requirement.
– Additional guidance is available in NFPA 101), 12-2.5.1,
which is Tag K41 of the Life Safety Code Survey
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
Example of LSC/Health Crossover
• F455 - §483.70(b) Emergency Power
– §483.70(b) (1) An emergency electrical power system
must supply power adequate at least for lighting all
entrances and exits; equipment to maintain the fire
detection, alarm, and extinguishing systems; and life
support systems in the event the normal electrical
supply is interrupted.
– §483.70(b)(2) When life support systems are used, the
facility must provide emergency electrical power with
an emergency generator ( as defined in NFPA 99,
Health Care Facilities) that is located on the premises
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
DEMONSTRATE “LSC” COMPLIANCE
• Demonstrate compliance with the
PRESCRIPTIVE Life Safety Code
• Demonstrate EQUIVALENCY to PRESCRIPTIVE
requirements of the Life Safety Code
• WAIVER of the PRESCRIPTIVE requirements
• Plan of Correction with WAIVER of the
PRESCRIPTIVE requirements
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
BOTTOM LINE WITH LSC COMPLIANCE
• MULTIPLE AGENCIES
– CMS / Feds
– State
– Local Fire
• MULTIPLE MANUALS
– NFPA
– SOM
– LICENSURE
• MANY REQUIREMENTS – Too Many To Count
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
ACTIONABLE ITEMS
• Staff can be taught
– Maintenance Staff
•
•
•
•
How to establish controls of the environment
How to monitor compliance for “hot button” issues
How to work with contractors (Signatures)
What to report to Admin/Assistant
– Clinical Staff
• What systems are in place
• How to comply / When to compromise systems
• What to report to Admin/Assistant
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
CMS OVERSIGHT OF STATE AGENCY
• Prospectively through
– State Plan Amendments
– Budget process (Staff and Resources)
• On Line through
– Periodic meetings and Conference Calls
– Complaints against the State Agency
• Retrospectively through
– Reporting
– State Agency Evaluation Program
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
State Agency Evaluation Program
• Q-1 through Q-9
• Can directly affect Federal Financial
Participation (FFP)
• Evolving Standard – sometimes late!
• Some Steady-State Issues
– Surveyor Performance
• Skills in Survey
• Documentation
– Enforcement Actions (DPNA / CMP / Revisit)
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
GAO Reporting
• State Agencies Under-report Scope and
Severity & Understate Serious Care Issues
• State Agencies Under-utilize Temporary
Managers
• State Agencies not overseeing SFF’s
• CMS is not overseeing LSC Training Program
• CMS CO is not Overseeing State Agency Data
• CMS Correctly Implemented “2013 Sprinklers”
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
Inspector General Reports
•
•
•
•
CMP not being collected
DPNA not being implemented
Fraud not being reported
State Fraud Task Force
– (50% Accepted / 30% from SA)
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
Actionable Items
• State Agency Evaluation impact will become
more noticeable and changes evident (+ / - )
• GAO Revisits CMS Issues approximately every
5-6 years
– Think LSC
– Think MDS
– Think Data Accuracy
• OIG Publishes their work list annually
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
Balancing the System
• State Survey Agencies serve many masters
– State Legislature
•
•
•
•
Program Direction
Funding
Staffing
Leadership and Oversight
– Industry
– CMS
– Public
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
Balancing The System
• CMS serves many masters
– Administration
– Congress
– Inspector General
– GAO
– Advocacy
– Industry
– Professional Associations
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
Survey Process Actionable Items
• Complaint Surveys can get out of hand
– A place in the “Annual” survey
– A role for advocates
– Investigative Guides can help
• New Health Survey (QIS)
– can be assisted but not managed
– Data Intense (TIME!!!)
• LSC Survey – No process change
– More invasive as surveyors get smarter
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
Enforcement Process
Actionable Items
• Enforcement process begins at the first finding
• Asking questions will help with POC and Dates
of Correction
• Informal Dispute Resolution
– Based on schedule in “Letter”
– When something “Should Not Have Been Cited”
– Interpretation Request is a form of IDR
• Equivalency to the Code is Compliance
• Waivers are a LEAST FAVORITE option
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
LSC Actionable Items
• Administrator / Assistant Administrator
– Principles of the Life Safety Code (Classes)
– Systems to Monitor Life Safety Systems
– Contracting to promote LSC Compliance
– Principles of Non-Compliance (Forensics)
– Monitoring Methods for Preventative Maintenance
• AR/BOM
– Records Requirements for LSC Compliance (Copies)
• If you have a records expert, introduce LSC
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
SUMMARY – WHAT CAN BE DONE
• Most Surveyors follow a format
– Records should match that format
– Tour should be done with pen & paper & keys!
• Records should be scanned for back-up
– In the same format
– Available in case others “disappear”
– Second person with access
• Responsive but not maniacal!
• Ask lots of questions at exit – real questions
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
SUMMARY - WHAT CAN BE TAUGHT
(That will impact Compliance / Enforcement)
•
•
•
•
•
•
•
Principles of the LSC
Top 10 Deficiencies
Immediate Jeopardy Items / Responding
Last 2 Years Deficiencies
How to respond to Paperwork / Signatures
Care and Feeding of the LSC Surveyor
When/Who to raise an interpretation question
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238
The LIFE SAFETY CODE
Survey Process
• What is going to happen to the LSC is known 2-3 years in
advance.
• The Survey Process changes due to Demand for Change
from others
• Oversight of the State Agency and Surveyors is done by
the State itself, CMS, HHS, and GAO (CMS)
• Oversight of the Enforcement & Interpretations is
performed by Regional Office and Central Office
• Balancing the System – Documentation and
Communications are the best policy for minimizing or
eliminating enforcement actions
Tom Scheidel, COO, Compliance Management Services, CMSCOMPLIANCE@YAHOO.COM, 817-456-6238