HOME HEALTH REGULATORY
UPDATE
Anne Menard
Home Care Unit
Bureau of Long Term Care Services
Currently Licensed
2,315 home health agencies
County with largest #: Miami-Dade 799
371 nurse registries
Palm Beach 86
2,240 homemaker companion services
Miami-Dade 335
Home Health Agencies
70% Certified for Medicare and/or Medicaid
– 707 are not certified, but 160 pending
63% Accredited – 1,457 HHAs
– 850 both state & fed’l (accredited deemed)
– 607 state accredited only
STATE LAW UPDATE
FOR ALL HOME HEALTH AGENCIES
& NURSE REGISTRIES
Criminal Background Screening 2010 Legislation
Legislation that changed the process:
• Replaces all Level 1 background screening with Level 2
screenings
• Requires Level 2 rescreening every 5 years
• All Level 2 screenings must be submitted electronically
• Changes the positions requiring screening
– Employees Who:
• Provide Personal Care or Services Directly to Clients
• Have Access to Client Funds, Personal Property, or Living Area
• Contractors Who Provide Personal Care or Personal Services
Directly to Clients
AHCA Background Screening Process Improvements
to Date


Implemented Electronic Fingerprints Program
Background Screening Data System Rewrite
– Improved Automation and Speed of Results
– Handle Electronic Fingerprints
– Expand Accounts Based on New Florida Law for Provider and Contract
Employers
• Growth in Annual Screening from 63,000 to Over 200,000 Due to
New Florida Law (8/1/2010 to date – 194,332)
• Handle Significant Increase in Workload with Existing Staff/
Resources
• Current Turn Around Time 0 – 5 Days
Issues with Process
• Cannot track screenings until the result is
received at the Agency
• Screenings submitted to incorrect ORI
• Missing or incorrect SSNs
• No provider information retained on screening:
– Unable to notify providers if there is an issue or status
change
– Inability to communicate with providers regarding
rejected prints
Federal Background Screening Grant
• Florida 1 of 12 states awarded a $3 Million
Federal Grant from the Centers for Medicare
and Medicaid Services to expand Background
Screening of Long Term Care Staff
• 2 Year Project: October 2010 – September
2012
Goals for the Federal Background Screening
Grant
• Technology System Improvements (Phase I and II)
– Provide State Criminal History Results to Providers
– Automate Provider Screening Result Notifications
– Eliminate Duplicative Screening
• Connection with Other Data Systems (Phase I)
– Medicare Exclusion Registries/Medicaid Terminations
– Health Practitioner Licensure Information (DOH)
• Rapback (Retained Prints) (Phase II)
– Enable Notification of Arrests for Persons Screened
• Centralize Screening Functions (Phase I and II)
Agency for Health Care Administration
Background Screening Resources
Agency for Health Care Administration Web Site
• http://www.ahca.myflorida.com/backgroundscreening
Questions/Comments/Issues
• bgscreen@ahca.myflorida.com
REPORT UNLICENSED ACTIVITY
Thank you for reporting unlicensed home care.
Reminder: Knowingly providing home health services in an unlicensed
assisted living facility (ALF) or adult family care home (AFCH) -unless HHA or employee reports to the state within 72 hours after
providing services – is grounds to deny, revoke & suspend a license
& impose a fine. 400.474(1)(2)(c), F.S.
If there is no license posted, check at www.FloridaHealthFinder.gov.
Call the AHCA complaint # (888) 419-3456 to report
When providing wound care to ALF residents
• A resident cannot remain in any ALF with stage 3 or 4
pressure sores.
• If a resident is admitted with a stage 2 pressure sore, the
ALF must have:
– Limited Nursing Services (LNS) or Extended Congregate Care
(ECC) license and provide the appropriate nursing care
– The ALF must employ or contract with a nurse to provide the
care
– The resident must contract with a home health agency for
nursing care
If there is no improvement in 30 days, the resident must be
discharged.
ALF residents care limitations
Prohibited Services
• Mechanical lifting equipment – such as Hoyer lifts
• Restraints - only ½ bed rails with physician order every 6 months
• Oral, nasopharyngeal, or tracheotomy suctioning - unless under care of hospice (but ECC can
do tracheotomy suctioning)
•
Peg tubes (feeding tubes) – unless self maintained; except hospice patients where there is licensed staff
to maintain
Restricted Services
• Residents cannot be bed bound – unless Extended Congregate Care license & then only up to
14 days.
• 24 hour nursing services
– Residents may not be admitted to any ALF if they need 24-hour nursing supervision
– Residents who later need 24 hour nursing supervision may stay in an ALF if:
•
•
ALF has an ECC and necessary licensed staff or
ALF has LNS license hospice is providing necessary licensed staff
Please report ALF concerns
• Resident rights – grievances go unanswered or
rights were violated
• Residents neglect
– not receiving their medication
– not getting enough food
– hygiene neglect, wet clothing,
– no staff present
Please report ALF concerns
• Building Safety. Obvious and urgent safety hazards related to
the building such as:
– Unstable construction
– Fire alarms/building systems
– Building safety devices (locking mechanisms)
• Concerns should be made to local building officials
• Obvious and urgent safety hazards unrelated to the building
may be reported to AHCA.
Reporting AHCA Complaints
• AHCA Contact (888) 419-3456
• Online report Health Care Facility Complaint
Form at: ahca.myflorida.com/Complaint
• Provide detailed information such as
patient/resident names, dates, times of events
and where the event occurred
Reporting abuse, neglect & exploitation
• Florida law 415.1034, F.S., requires that any person who
“knows, or has reasonable cause to suspect, that a
vulnerable adult has been or is being abused, neglected, or
exploited shall immediately report such knowledge or
suspicion to the central abuse hotline.”
• There is a similar law for children.
• Nurse registries, home health agencies & anyone should
report any suspected or known abuse, neglect or
exploitation of patients to the Department of Children and
Families Abuse Hotline at 1-800-962-2873.
Penalties for providing less than fair
market value services or staffing to ALFs
AHCA may deny, suspend or revoke the license
& shall impose a fine of $5,000 for a HHA or
NR (400.474(6)(b)(c), and 400.506(15)(a), F.S.)
Providing staff free to ALFs, Adult Day Care
Centers & AFCHs (nurses, CNAs, home health
aides, etc.) is a fine of $15,000 for HHAs.
(400.518(4), F.S.)
HHAs Contracting for Therapy
A. Contracting with another business to provide therapy to
patients You refer the patients to the business & they send out
1.
2.
3.
4.
therapists to the patient’s homes. The business you contract with would
need to be:
a home health agency that has therapists, or
a certified rehabilitation agency, or
a comprehensive outpatient rehabilitation facility (CORF), or
[The state law exempts from home health agency licensing certified
rehabilitation agencies and CORFs (400.464(5)(m), FS)]
a therapy practice that provides only one kind of therapy such as
physical therapy.
[An entity that provides a single health care professional discipline is not an
organization for the purposes of home health agency licensing per 400.462
(22), FS]
(from 13.3 of the Frequently Asked Questions, at
www.ahca.myflorida.com/homecare - click on “home health agency”)
HHAs Contracting for Therapy
B. When you have therapists on your staff already & you need a
temporary replacement -- for one that is on vacation, or while you fill
that vacancy or when you have a seasonal shortage -- you can
contract with a health care services pool for temporary staff.
– The state law says that a health care services pool “provides temporary
employment in health care facilities, residential facilities, and agencies …”
(400.980 (1), F.S.).
– “Temporary employment” means “employment whereby a pool hires its own
employees or independent contractors and assigns them to health care facilities
to support or supplement the facilities’ work force in special work situations
such as employee absences, temporary skill shortages, seasonal workloads, and
special assignments and projects” (59A-27.001 (1), Florida Administrative
Code).
(from 13.3 of the Frequently Asked Questions, at www.ahca.myflorida.com/homecare - click on “home
health agency”)
STATE RULE UPDATE
HOME HEALTH AGENCIES
AND
NURSE REGISTRIES
State rule writing
• Cannot write a rule without specific authority
in state law to do so
• Ratification by the Legislature is required if a
rule is likely to increase the regulatory costs
more than $1 million in the aggregate within a
5 year period from the date of
implementation (120.541 (3), F.S. - 2010)
STATE RULE UPDATE
Home Health Agency Rules:
• Starting over with rule development
• Have submitted a draft for rule development to
the Governor’s Office of Fiscal Accountability and
Regulatory Reform
• Once receive approval to begin rule development
- will post draft at web site & Fl Admin Weekly - requesting comments
- will hold rule development workshop
Home health agency rule repeals
AHCA reviewed all programs for rules that could
be repealed
HHA repeal notice published in the 6-24-11 Fla
Admin Weekly & posted at AHCA web site.
Repeal should be effective in August for 2 rules:
1. 59A-8.0086 – Denial, Suspension, Revocation of
License and Imposition of Fines - contents
already in 408, Part II & 400, Part III, F.S.
Home health agency rule repeals
2. 59A-8.0185 – Personnel policies
Joint Administrative Procedures Committee legal review found
that AHCA no longer had legal authority for this rule
What requirements will be removed when this rule is repealed:
• Health statements from employees
• A plan for orientation of all health personnel
• Job descriptions
• A file for each employee - with name, address, next of kin for contact,
evidence of qualifications, the results of background screening, dates of
employment and separation, and evidence of training. Files are kept for 1
year after separation.
Home health agency survey standards
• Will have revised survey standards at the time
the rule repeal takes effect. (August 2011)
• Will remove the standards re 59A-8.0185
Personnel Policies:
H 202 communicable disease (health statement),
H 201 re personnel policies
H 204 personnel records
Nurse Registry Rules
Will be submitting proposed rules -- based on 2010 rule
workshop & comments received -- to the Governor’s
Office of Fiscal Accountability and Regulatory Reform
for approval in July.
Once approval is received, will put at web site & Florida
Administrative Weekly, provide opportunity for
comments & hold a public hearing.
(Note - Health statements are in nurse registry law
400.506(6)(a), F.S. & cannot be removed from rule.)
Medicare & Medicaid Home
Health Agency Surveys
CMS Revisions
For surveyors from state agencies &
accrediting organizations
CMS has revised the survey process
• For Medicare & Medicaid HHAs recertification
• States & accrediting organizations follow CMS
• Process improvements:
– Uses existing data for pre-survey preparation
– Focuses on standards most directly related to the
delivery of high-quality patient care
2011 – HHA Survey Process
• Emphasizes information from HHA staff
interviews, clinical records & home visits
• Minimizes non-clinical record review paper
compliance
• Provides guidance for surveyors on
expanding the survey & issuing deficiencies
• More specific guidance on citing standard &
condition-level deficiencies
From CMS Basic Home Health Agency
training for surveyors
23
Standard Survey
• Focus on standards most directly related
to delivery of high-quality patient care
• Selected standards to be checked are
called “Level 1 standards”
• Standards are from 9 of 15 Conditions of
Participation -- including Nursing &
Therapy
From CMS Basic Home Health Agency
training for surveyors
31
Conditions & Level 1 Standards
484.10 Patient Rights - G107, G109
484.12 Compliance with Fed/State/Local
Laws - G121
484.14 Organization/Services/Administration
- G123, G133, G143, G144
484.18 Acceptance of Patients, Plan of Care,
Medical Supervision G157, G158, G159, G164, G165, G166
From CMS Basic Home Health Agency
training for surveyors
12
Conditions & Level 1 Standards (cont.)
484.30 Nursing: G170, G172, G173, G174,
G175, G176, G177
484.32 Therapies: G186, G187, G188
484.36 Home Health Aide: G224, G229
484.48 Clinical Records: G236
484.55 Comprehensive Assessment of Patients:
G331, G332, G334, G335, G336, G337,
G338, G340
From CMS Basic Home Health Agency
training for surveyors
13
Standard Survey
• Surveyors stay at standard survey unless deficient
practice is identified in the Level 1 standard
• Per CMS, compliance with Level 1 standards is:
– highly likely to affect care delivery and patient
outcomes and
– the HHA is highly likely to be in compliance with all of
the Conditions of Participation
Standard Survey Ends
HHA Survey ends with standard survey if:
– HHA complies with all Level 1 standards;
– No deficiencies are identified after home visits,
clinical record reviews & interviews with patients
and staff and
– No additional issues/concerns are identified
needing investigation
From CMS Basic Home Health Agency
training for surveyors
14
Survey continues … and becomes partial
extended
• When expected outcomes are not met for one
or more Level 1 standards
• Other issues are recognized by the surveyor
• Survey becomes a partial extended survey
– Level 2 standards are reviewed
– Other standards may be reviewed
From CMS Basic Home Health Agency
training for surveyors
15
484.10 Patient Rights
Standard Survey
Partial Extended Survey
Level 1
Level 2
G107, G109
G101, G108,
G111, G114
Associated
CoPs
484.12,
484.14, 484.18
Consider citing the condition when:
• The HHA is out of compliance with G107 and G109 and
one additional tag within that condition. (G100-G116)
Basic Home Health Agency
43
Extended Survey
• Must be conducted when any
condition level deficiency is found
• All conditions are reviewed
• Must be conducted for accrediting
organization validation surveys that
CMS selects for the states to do
38
Basic Home Health Agency
To find out more
www.cms.gov/manuals
- Select “Internet-only manuals”, then “State
Operations Manual”
- See Appendix B – Home Health Agencies
There is also a link from the AHCA home health
agency page –
www.ahca.myflorida.com/homecare - click on
“home health agency” – see “Federal Regulation
Set used by Surveyors”
Most frequent CoPs not met in 2010
• G 156 – Plan of Care (11 HHAs)
• G 122 – Organization, Services &
Administration – (9 HHAs) not providing services
• G 100 – Patient Rights (8 HHAs)
• G 235 – Clinical Records (8 HHAs)
If you don’t agree with the surveyor
1. Ask the surveyor to show you the survey
standard, law or rule during the survey
2. Discuss with surveyor at Exit Interview
3. Contact the AHCA Field Office Manager
http://ahca.myflorida.com/MCHQ/Areas
4. If still not resolved, contact: Chief of Field
Operations, Polly Weaver (850) 412-4301
AHCA web sites
http://ahca.myflorida.com/homecare -- select “home
health agency” or “nurse registry” – licensing,
state & federal survey standards, emergency
management plan & local plan review contacts, &
answers to frequently asked questions
www.FloridaHealthFinder.com - select “Find
Facilities or Providers” (updated nightly) + also
see Consumer Guides
Contact information – HHA & NR
Anne Menard – Unit Supervisor
Anne.Menard@ahca.myflorida.com
•
Medicare & Medicaid certification HHA
– Cynthia Ibrahim – HHAs I to Z,
& branch approvals, change of
ownership
– Ceather Watkins – HHAs A to
Jan Benesh – HHA & NR
licensing manager
• Ed Barnes - Change of
ownership
• Lenora Lowry – HHA & NR
• Natarsha Humphries – HHA &
NR
• Susan Glass - HHA
H
(850) 412-4403
HQAHOMEHEALTH@ahca.
myflorida.com