Bureau of Health Systems Mike Pemble, Director Presentation to

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Michigan Ambulatory Surgery Association
Thursday, March 14, 2013
FSOF State Licensing Surveys – Overview,
Process and Goals
2013 Update
Larry Horvath, Director, Health Facilities Division
Jay Calewarts, Manager, State Licensing Section
MI Department of Licensing & Regulatory Affairs
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
• LARA's Mission
LARA supports business growth and job creation while
safeguarding Michigan's citizens through a simple, fair,
efficient and transparent regulatory structure.
• LARA's Vision
LARA will reinvent government while consistently serving our
customers fairly, honestly and respectfully through an
engaged and creative employee team.
www.michigan.gov
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Bureau of Health Care Services
OCTOBER 18, 2012 – Former Director Hilfinger announced the
creation of the new Bureau of Health Care Services. The new
bureau brought together the bureaus of Health Professions and
Health Systems under one umbrella.
This move simplifies the health care regulatory structure,
breaking down artificial government silos that are inefficient and
impeding improvements in customer service.
By combining these bureaus, the department is able to leverage
natural synergies in the licensing of providers and facilities, and
develop common, effective customer service protocols serving
multiple facets of the health care delivery system.
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Health Facilities Division
• The Health Facilities Division (Formerly the Division of
Licensing and Certification) is within the Bureau of Health
Care Services (formerly Bureau of Health Systems), Michigan
Department of Licensing and Regulatory Affairs.
• The Division is responsible for state licensing and federal
certification of select health facilities, agencies, providers and
suppliers as well as state health facilities engineering plan
review and inspections and radiation safety certifications.
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Health Facilities & Agencies
State Licensed Health Facilities and Agencies:
Ambulance Operations
Clinical Laboratories
County Medical Care Facilities
Freestanding Surgical Outpatient Facilities (FSOF)
Health Maintenance Organizations (HMO)
Home for the Aged
Hospitals (acute and psychiatric)
Nursing Homes
Hospices
Hospice Residences
Substance Abuse Programs
Bold-italics indicates health facilities and agencies state licensed through the Health Facilities Division,
LARA.
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Providers & Suppliers
Federally Certified Providers and Suppliers:
Ambulatory Surgical Centers (ASC)
Clinical Laboratories
Comprehensive Outpatient Rehab Facilities (CORF)
End-Stage Renal Disease (ESRD) Centers
Home Health Agencies
Hospices and Residences
Hospitals (acute and psychiatric)
Nursing Homes (CMCF, HLTCU, etc.)
Portable X-Ray Providers
Outpatient Physical/Speech Therapy Providers
Rural Health Clinics
Bold-italics indicates providers and suppliers federally certified through the Health Facilities Division,
LARA.
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
State/Federal Covered Providers
Licensed/Certified Providers in Michigan 2012:
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429 Nursing Homes
174 Hospitals
59 Psychiatric Hospitals/Units
26 Psychiatric Partial Hospitalization Programs
9 Organ Transplant Facilities
640 Home Health Agencies
105 Hospice Programs and 22 Hospice Residences
176 ESRD Centers (Dialysis)
172 Rural Health Clinics
121 FSOF/ASC
17 CORF
11 Portable X-Ray Providers
203 OPT/Speech Pathology
7,616 Clinical Laboratories
10,038 Radiological Facilities
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Ambulatory Surgical Centers
The total number of ambulatory surgical centers has increase 63.2% from FY
2001 to FY 2011. CMS has put a greater focus on increasing the frequency of
surveys at ASCs. In FY 2010 states and CMS surveyed approximately 33% of all
ASCs, and 25% in FY 2011.
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Regulatory Overview
Sample of Events Requiring State/Federal Approval:
• Initiation of inpatient/outpatient surgical services
• Federal certification request
• Change of ownership
• Relocation of surgical facility
• Replacement of surgical facility
Sample of State Agencies Involved:
• Certificate of Need
• Health Facilities Engineering
• Bureau of Fire Services
• Health Facilities Division
• Health Professions
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
State Licensing Process
• Annual licensure process
• Annual inspections required (MCL 333.20155)
• Pre-licensure survey, Limited license, post-licensure
survey
• $238 licensing fee
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
State Licensing Process
• Excerpts of Code requirements:
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Owner/governing body responsibility
Physicians admitted to practice in facility consistent with capability of facility
Organize, administer, staff and equip to provide regular surgical services
Physicians, nurses and professional staff assure safe performance of surgery
Have written transfer agreement with hospital
Assure proper clinical record management
• Excerpts of Rule requirements:
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Construction
Disaster and emergency procedures
Surgical procedures/medications
Admission and registration
Records
Physician qualifications
Scrub procedures
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
State Licensing Update
• Created the State Licensing Section in
November of 2012.
• I was hired on November 26, 2012
• Two health care surveyors were
transferred from the federal
certification sections on December
10, 2012
• Hired a 3rd health care surveyor who
started on January 7, 2013.
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
State Licensing Update
• Currently 3 health care surveyor dedicated to state
licensing surveys
• Starting with FSOF and Hospice surveys, eventually will
include Hospital (acute and psychiatric) state surveys
• Pam Lindsey, RN, dedicated FSOF surveyor
• Marian Clore, RN, FSOF and Hospice surveyor
• Started conducting FSOF annual surveys January 15
• To date we have completed 22 annual surveys and are
now averaging about 3 to 4 a week
• Public Act 499
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Marian and Pam
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
What to Expect (Cont.)
• Pam and/or Marian will be conducting a
survey w/in a year at all FSOF’s/ASC’s
• Survey based on state code and
administrative rules
• Survey lasts about a half day depending on
the size of the facility and types of surgeries
conducted at facility, etc.
• Deficiencies (if any) noted and usually
corrected onsite with surveyor if possible.
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
What to Expect (Cont.)
• Report emailed out within a couple of days
• No POC. Surveyor will stop back after 60 days to
verify deficiency has been corrected.
• State code and administrative rules for FSOF’s can
be found on our website at
www.michigan.gov/bhcs
Click on health facilities,
then click State Rules
and Federal Regulations
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
State Licensing Goals
• Conduct an annual survey at every FSOF/ASC in the
state
• Develop a process that is not overly burdensome for
the provider while verifying patient safety
• Work with provider to ensure compliance with state
licensing rules and regulations
• Provide prompt feedback
• Follow-up on deficiencies
• Update Administrative Rules
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Working Together
• Contact us if you have any suggestions to improve
the survey process
• Looking at revising the administrative rules,
comments welcome
• Available for questions
• Common goal of providing the best care possible to
the patient
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Helpful Web Sites
Health Facilities Division
http://www.michigan.gov/lara/0,4601,7-154-35299_63294_63302---,00.html
State Code and Rules and Federal Legislation
www.michigan.gov/lara/0,4601,7-154-35299_28142_27655_27662-48069-,00.html
CMS Conditions for Coverage
www.cms.gov/Regulations-andguidance/Legislation/CFCsAndCoPs/index.html?redirect=/CFCsAndCoPs/0
1_Overview.asp
Ambulatory Surgical Center (ASC) – Federal
www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/ASC.html
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
Questions & Answers
Health Facilities Division
Ottawa Building, 1st Floor
611 W Ottawa Street
Lansing, MI 48909
Contact Number: (517) 241-4160
Email: [email protected] , [email protected]
Thank you for your efforts to provide quality health care to
Michigan residents.
C U S T O M E R D R I V E N.
B U S I N E S S M I N D E D.
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