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
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
Organization
Branches
•
Business Office
–
–
–
•
Health Care Surveillance
–
–
–
–
–
•
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
Schedules and conducts unannounced, on-site, objective, and outcomebased 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
PROVIDER TYPE
# IN WYOMING
LICENSED ONLY
Adult Day Care Center
8
8
Assisted Living Facility
26
26
Ambulatory Surgical Center
20
Boarding Home
9
Critical Access Hospital
CERTIFIED ONLY
LICENSED & CERTIFIED
DEEMED
20
4
16
1
9
16
Community Mental Health
Center
3
Comprehensive Outpatient
Rehabilitation Facility
1
1
End Stage Renal Dialysis
Center
9
9
Federally Qualified Health
Center
13
Freestanding Diagnostic
Treatment Center
3
13
1
1
Home Health Agency
43
14
Hospital
11
Hospice Facility
19
Intermediate Care Facility for
Mentally Retarded
Nursing Care Facility
1
11
10
1
1
38
38
1
1
Psychiatric Residential
Treatment Facility
3
3
Psychiatric Hospital
2
Rehabilitation Facility
2
Rehabilitation Hospital
1
2
2
18
Total Providers
1
18
Outpatient Physical Therapy/
Speech Pathology
Rural Health Clinic
29
245
1
1
146
13
18
61
38
Surveyors
Surveyor
Certification (SMQT)
Experience (Yrs)
Credentials
Linda Brown
Health
11
RN, BS, CPHQ
Janelle Conlin
Health
12
OTR/L
Russ Forney
Health, CLIA
7
PhD, MT
Larry Goodmay
Health, Life Safety
9
MS
Catherine Hoff
Health
<1
RN, BS
Tony Madden
Health
6
RN
Kathryn May
Health
2
RN
Pat Prince
Health
19
RN, BSN
Lori Reuss
Health
8
RD, LD
Julia Van Dyke
Health
<1
RN
Average
7.5 yrs
Note: Currently recruiting to fill 2 vacant surveyor positions
Wyoming Performance Standards
FFY 2013
(As of 05/02/13)
NURSING HOMES
38 providers
TIER
REQUIREMENT
CURRENT STATUS
COMPLETED
Tier 1
•15.9 Mo Max Interval
•12.9 Mo Avg
•13.4 Mo Max Interval
•11.7 Mo Avg
•0 > 15.9 Mo
Tier 2
•NH Oversight & Improvement Program
•2:4 staggered surveys done
•1 SFF
Tier 3
NA
NA
Tier 4
NA
NA
Comparison of Frequently Cited
LTC Health Tags
FY2013 (to date)
(Data Source: S&C PDQ/Run Date: 05/07/2013)
WYOMING
Top 5
REGION 8
Top 5
NATIONAL
Top 5
Tag #
Description
%
Surveys
Cited
(15
surveys)
Tag
#
Description
%
Surveys
Cited
(279
surveys)
Tag
#
Description
%
Surveys
Cited
(6,639
surveys)
F441
Facility Establishes
Infection Control Prog
73.3%
F441
Facility Establishes
Infection Control
Program
49.5%
F441
Facility Establishes
Infection Control
Program
37.8%
F309
Provide Necess Care
for Highest Prac Well
Being
53.3%
F323
Facility Is Free of
Accident Hazards
45.9%
F371
Store/Prepare/Distrib
Food Under Sanitary
Conditions
34.5%
F371
Store/Prepare/Distrib
Food Under Sanitary
Conditions
46.7%
F371
Store/Prepare/Distrib
Food Under Sanitary
Conditions
43.0%
F323
Facility is Free of
Accident Hazards
29.9%
F323
Facility is Free of
Accident Hazards
40.0%
F309
Provide Necess Care
for Highest Prac Well
Being
35.5%
F309
Provide Necess Care
for Highest Prac Well
Being
24.9%
F279
Develop
Comprehensive Care
Plans
33.3%
F329
Drug Regimen is Free
From Unnecessary
Drugs
31.9%
F329
Drug Regimen is Free
From Unnecessary
Drugs
22.5%
Comparison of Frequently Cited
LTC Health COMPLAINT Tags
FY2013 (to date)
(Data Source: S&C PDQ/Run Date: 05/07/2013)
WYOMING
Top 5
REGION 8
Top 5
NATIONAL
Top 5
Tag #
Description
% Surveys
Cited
(25 surveys)
Tag
#
Description
% Surveys
Cited
(248
surveys)
Tag
#
Description
% Surveys
Cited
(21,532
surveys)
F323
Facility is Free of
Accident
Hazards
28.0%
F323
Facility is Free of
Accident Hazards
12.1%
F323
Facility is Free of
Accident Hazards
5.7%
F241
Dignity and
Respect of
Individuality
12.0%
F309
Provide Necess
Care for Highest
Prac Well Being
8.1%
F309
Provide Necess Care
for Highest Prac Well
Being
4.2%
F441
Facility
Establishes
Infection Control
Prog
12.0%
F441
Facility Establishes
Infection Control
Prog
6.9%
F157
Inform of
Accidents/Sig
Changes/Transfer/Etc
2.6%
F225
Not Employ
Persons Guilty
of Abuse
12.0%
F281
Services Provided
Meet Professional
Standards
4.8%
F225
Not Employ Persons
Guilty of Abuse
2.5%
F425
Pharmaceutical
Svc – Accurate
Procedures, RPH
12.0%
F241
Dignity and
Respect of
Individuality
4.0%
F514
Clinical Records Meet
Professional
Standards
2.1%
Comparison of Frequently Cited
LTC Life Safety Code Tags
FY2013 (to date)
(Data Source: S&C PDQ/Run Date: 05/07/2013)
WYOMING
Top 5
REGION 8
Top 5
NATIONAL
Top 5
Tag #
Description
% Surveys
Cited
(15 surveys)
Tag
#
Description
% Surveys
Cited
(279
surveys)
Tag
#
Description
% Surveys
Cited
(6,628
surveys)
K147
Electrical Wiring
and Equipment
73.3%
K062
Sprinkler System
Maintenance
48.4%
K147
Electrical Wiring
and Equipment
31.1%
K062
Sprinkler System
Maintenance
53.3%
K147
Electrical Wiring
and Equipment
45.2%
K062
Sprinkler System
Maintenance
30.4%
K025
Smoke Partition
Construction
40.0%
K038
Exit Access
37.6%
K029
Hazardous Areas –
Separation
25.7%
K050
Fire Drills
33.3%
K018
Corridor Doors
36.6%
K018
Corridor Doors
25.6%
K052
Testing of Fire
Alarm
33.3%
K029
Hazardous Areas
– Separation
34.4%
K038
Exit Access
20.4%
Survey Citation Patterns
Based on Last Current Uploaded
Standard Health Surveys
(Data Source: Casper 0311S / Run Date: 05/07/2013)
# of Providers
# of Providers Cited
for SQC
# of Providers
Zero Health Deficiencies
WY
38
1
1
Region
630
15
42
U.S.
15,686
431
1,505
Average Number of Deficiencies
(Data Source: S&C PDQ / Run Date: 05/07/2013)
FY 2008
FY 2009
FY 2010
FY 2011
FY 2012
FY 2013
11.7
11.1
11
9.6
8.9
8.4
7.5 7.4
7.1
Wyoming
8
Region 8
7.34 7.44
6.9 6.8
6.4 6.1
5.95 5.75
Nation
Complaints
180
160
140
120
100
80
60
40
20
0
169
161
123
112
94
67
60
9
2010
58
20
18
13
2011
2012
2013
NH's ONLY
ALF's ONLY
ALL
Complaints
Nursing Homes
# Pending
# Substantiated
# Unsubstantiated
No Action
41
37
31
26 26
26
26
27
23
22
18
11
11
16
18
9
7
2
2008
54 Rec'd
2009
65 Rec'd
0
2010
61 Rec'd
2011
77 Rec'd
2012
67 Rec'd
3
2
2013
58 Rec'd
Complaints
Assisted Living Facilities
# Pending
# Substantiated
# Unsubstantiated
No Action
13
10
8
5
6
3
0
2
1
0
2010
9 Rec'd
5
4
1
0
2011
20 Rec'd
2
0
2012
18 Rec'd
2013
13 Rec'd
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
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)
State Performance Standards Review
(FY 2012)
FREQUENCY
Met / Not Met
Off Hours Surveys for Nursing Homes
Met
Frequency of Nursing Home Surveys
Met
Frequency of Non-Nursing Home Surveys – Tier 1
Met
Frequency of Non-Nursing Home Surveys – Tier 2
Met
Frequency of Non-Nursing Home Surveys – Tier 3
Met
Frequency of Data Entry of Standard Surveys (Non-Deemed
Hosp/NH)
NH – Met
NDH - Not Met
(3 CAHs – avg 71 days)
State Performance Standards Review
(FY 2012)
QUALITY
Met / Not Met
Documentation of Deficiencies on Form CMS-2567
Met
Conduct of NH Surveys IAW Federal Standards (FOSS)
Met
Documentation of Non-Compliance IAW Federal Standards (FOSS)
Met
Accuracy of Documentation During NH Comparative Surveys
Met
Prioritizing Complaints and Incidents
Met
Timeliness of Complaint and Incident Investigations
Met
Quality of EMTALA Investigations
Met
Quality of Complaint/Incident Investigations for Nursing Homes
Met
State Performance Standards Review
(FY 2012)
ENFORCEMENT
Met / Not Met
Timeliness of Mandatory DPNA Notification for Nursing Homes
Met
Processing of Termination Cases for Non-NH Providers/Suppliers
Met
Special Focus Facilities for Nursing Homes
Met
Federal Oversight Surveys (FOSS)
(2011 - 2012)
SURVEY TEAM
CONCERN
IDENTIFICATION
SAMPLE
SELECTION
GENERAL
INVESTIGATION
KIT/FOOD SVC
INVESTIGATION
MEDICATIONS
INVESTIGATION
DEFICIENCY
DETERMINATION
NH Survey
(Amie Holt)
Betty, Pat
5
5
5
5
5
5
NH Survey
(Sage View)
Linda, Kathy,
Karla
5
5
5
4
5
4
Complaint Inv.
(Cheyenne HC)
Tony
5
5
5
N/R
N/R
5
NH Survey
(Thermopolis)
Linda, Lori,
Larry, Kathy
5
5
5
5
3
5
NH Survey
(Pioneer)
Pat, Betty,
Kathy, Larry
5
5
5
5
5
5
NH Survey
(Life Care Chey)
Pat, Lori,
Linda
5
5
5
5
5
5
5 = Extremely Effective
4 = Very Effective
3 = Satisfactory
2 = Less Than Satisfactory
1 = Much Less Than Satisfactory
Federal Oversight Surveys (FOSS)
(2013)
SURVEY TEAM
CONCERN
IDENTIFICATION
SAMPLE
SELECTION
GENERAL
INVESTIGATION
KIT/FOOD SVC
INVESTIGATION
MEDICATIONS
INVESTIGATION
DEFICIENCY
DETERMINATION
NH Survey
(Westview)
Pat, Linda,
Russ, Larry,
Rae Anne
5
5
5
5
5
5
NH Survey
(Life Care Chey)
Linda, Pat,
Lori
5
5
5
5
5
5
5 = Extremely Effective
4 = Very Effective
3 = Satisfactory
2 = Less Than Satisfactory
1 = Much Less Than Satisfactory
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
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
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
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
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
Questions ?