REGULATORY HOT TOPICS
INDEPENDENT OWNERS CONFERENCE
May 2, 2012
La Costa Resort
Carlsbad, CA
STAYING IN THE “NOW”
2012 HOT TOPICS
4
Field Operations Branch Chief
Responsibilities
Branch Chief
District Offices
Specialties
ICF MR
Clinics
Training
Central Applications
State Facilities Unit
Life Safety Code
End Stage Renal Dis.
Transplant Programs
Gen. Acute Care Hospital
Home Health Agencies
Hospices
Adult Day Health Centers
OSHPD
JCAHO
Consultants
Administrative Penalties
Adverse Events
Medical Info. Breeches
ASC
SNFs
Emergency Coordination
Region I
Ley Arquisola
Region II
Region III
Region IV
Region V
Carol Turner Virginia Yamashiro Michael Egstad Ernie Pooleon
Orange, Riverside, San Sacramento,
Diego No./So., Chico, Santa Rosa,
San Bernardino
Fresno
Daly City, East Bay,
San Jose, Ventura,
Bakersfield
New Hired
Region VI
Vacant
Emergency
Prepared.
Dan Kotyk
Los Angeles
County
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
4
3.2 NHPPD STAFFING AUDITS
Current Audit Period: July 1, 2011 through June 30, 2012
 425+ audits completed
 CDPH projects all audits will be completed by August
 80% of audits = facility in full compliance
 10 penalty notices have been issued
3.2 NHPPD Audit Process
 On entrance auditor will provide contact information
for supervisor.
 Auditor will utilize payroll data
 Length of audit: average is 3 days
Audit Staff Hierarchy
Chief
Research
Branch Amy Blandford
Amy Blandford:
916-552-8971
Amy.blandford@cdph.ca.gov
Tina Kruthoff:
916-319-9036
Chief
Forecasting
Tina Kruthoff
Tina.kruthoff@cdph.ca.gov
Leslie Fullerton:
440-7083
Field Audit Chief
Leslie.fullerton@cdph.ca.gov
Pam Power:
916-552-8967
Leslie Fullerton
Pam.power@cdph.ca.gov
Evelyn Schaeffer:
916-445-8567
Evelyn.schaeffer@cdph.ca.gov
Field Audit
Supervisor
Pam Power
Field Audit
Supervisor
Evelyn Schaeffer
3.2 NHPPD Audit Clarifications
 Counting of DON in buildings with 59 or fewer licensed beds- no sign-in of
DON required.
- Corporate payroll- negative deductions, vacation, etc.
- Vacation, sick leave, PTO requests, etc.
- Work hour agreements for salaried staff.
- Leave balance reports indicating paid time off, sick or PTO requests
- Training requests and records.
Nurse Assistants
- HS 280 is key
- NA is employee
- “Counted Hours” are those worked beyond clinical and
NA is “checked off” on related competencies
HS 280 is Key
3.2 NHPPD Audit Clarifications
 Actual Hours Worked – Audit process calculates
nursing staff time by the minute
 Activity Staff- CNAs who are activity staff and
implementing the resident’s plan of care are
“countable”. ( Activity Program Director excluded)
 Dual Role Employees- Must document time providing
nursing services on CDPH 530
3.2 NHPPD Audit Clarifications
 RN Supervisor- Hours are countable as nursing
services
 ADON- ADON hours will be excluded ONLY WHEN
ADON is acting for the DON. ( Does not apply to
facilities of 59 beds or less).
 Re-capping Physician Orders – This is “countable”
time.
3.2 NHPPD Audit Issues
 Staff work in lieu of meal period- must have waiver in
place
 Census- When staff out of building with residentstaff time “countable” for 3.2 NHPPD calculation
 CDPH “FAQ” document remains pending
Check Your Staffing Data!
What do your staffing numbers say?
 OSHPD-submitted staffing data
 CDS 671 – Five Star
 CDPH 3.2 NHPPD audit determination
Independent Informal Dispute
Resolution (IIDR)
 Conducted by staff within the Center For HealthCare
Quality.
 One year approval of process by CMS
 CAHF goal = independent entity conducts reviews
Facility has G or
above deficiencies
and a CMP will be
Imposed, collected,
and put in escrow
Facility is cited
for deficiencies
In a standard or
complaint survey
Initiated after 1/1/12
facility wishes to
Informally appeal
these deficiencies
Which IDR process
Is appropriate to
Consider?
Facility has
deficiencies
that are D, E,
or F in scope
and severity
IIDR Process Flow
Facility offered IIDR
and formal appeal
rights
(MUST ASK FOR IIDR
within 10 calendar days
of receipt of notice)
Ombudsman
and resident
or family rep
allowed to
comment
Facility offered
IDR and formal
appeal rights
IIDR conducted and
completed within
60 days of request
and a formal written
record is generated
Final changes if
any made and new
2567 issued
Collection of CMP at
time of IIDR
completion or within
90 days of date
of notice of
imposition
Formal appeal
available if
requested timely
Elder Justice Act (EJA)
 Surveyors are now being trained to evaluate facility
compliance:
• Covered individuals are notified of reporting obligations
annually.
• Posted notice is accessible ( in area(s) used by covered
individuals.
• Abuse reporting processes are inclusive of EJA
requirements.
https://member.cahf.org/Operations/Regulatory/tabid/160/
Default.aspx#REPORTING_REQUIREMENTS
September 2011 OIG Report Leads
To Change in Complaint Process
 Effective Immediately: CDPH directed by CMS to use federal
complaint process
 Will impact Five Star Scores
 Onsite complaint visits are now conducted using the federal
abbreviated standard survey process
 P&P and AFL “pending”
 http://oig.hhs.gov/oas/reports/region9/90900114.pdf
COMPLAINTS & ENTITY REPORTED
INCIDENTS
Fiscal
Year
Complaints
Entity
Reported
Incidents
Total
Change from
Complaints +
Baseline
ERIs
Closed
Complaints
Closed Entity
Reported
Incidents
2004/05
9,007
14,778
23,785
Baseline
99.2%
99.6%
2005/06
8,900
19,701
28,601
20.2%
20.2%
98.5%
99.5%
2006/07
9,155
21,705
30,860
29.7%
7.9%
98.0%
99.5%
2007/08
10,544
24,046
34,590
45.4%
12.1%
96.3%
98.9%
2008/09
9,643
26,217
35,860
50.8%
3.7%
90.3%
95.6%
2009/10
9,452
28,533
37,985
59.7%
5.9%
82.9%
91.5%
2010/11
9,586
28,676
38,262
60.9%
0.7%
69.5%
82.6%
2011/12
projection
9,830
*29,633
39,463
65.9%
3.1%
64.6%
79.8%
Annual
Increase
Complaints Completed within 45 and 90 Days
07/01/10-06/30/11
# Complaints to # Complaints
% Complaints
# Complaints
% Complaints
Facility Type
Investigate done in 45 days done in 45 Days done in 90 days done in 90 days
SNFs
5063
2879
56.86%
3415
67.75%
GACHs
2872
764
26.60%
1113
38.75%
IMRs
435
256
58.85%
309
71.1%
HHAs
217
63
29.03%
86
39.63%
ESRDs
132
36
27.27%
75
56.82%
Hospice
79
25
31.65%
46
58.22%
FQHCs
59
29
49.15%
42
71.18%
ASCs
40
6
15.00%
16
40.0%
RHCs
8
2
25.00%
3
37.5%
20
ERIs Completed within 45 and 90 Days
07/01/10-06/30/11
Facility Type
# ERIs to
Investigate
# ERIs done in % ERIs done
45 days
in 45 Days
# ERIs done
in 90 days
% ERIs done
in 90 days
SNFs
7468
3933
52.66%
4730
63.33%
GACHs
6618
1909
28.85%
2546
38.47%
IMRs
2919
1014
34.74%
1587
54.37%
HHAs
85
19
22.35%
26
30.59%
FQHCs
37
10
27.03%
16
43.24%
Hospice
36
9
25.00%
12
36.33%
ESRDs
35
18
51.43%
21
60.00%
ASCs
4
1
25.00%
RHCs
4
2
50.00%
February 2012 OIG Report Criticizes
California Plan of Correction
Oversight
 Deficiency ratings understated for 23 of 178
deficiencies (13 percent);
 Did not ensure that 40 of 52 correction plans (77
percent) contained specific information addressing
the 5 corrective action elements; and
 Did not verify the correction of identified deficiencies
by obtaining evidence of correction.
April 2012 OIG Report Finds Gaps
IN SNF Disaster Preparedness
 Unreliable transportation contracts,
 Lack of collaboration with local emergency
management, and;
 Residents who developed health problems.
 LTC ombudsmen were often unable to support
nursing home residents during disasters;
 SAs reported making some efforts to assist nursing
homes during disasters, mostly related to nursing
home compliance issues and ad hoc needs.
CAHF DISASTER PREPAREDNESS
RESOURCES
 http://www.cahfdisasterprep.com/
 Jocelyn Montgomery, CAHF Director of Clinical Affairs
and Manager of Disaster Preparedness Grant
jmontgomery@cahf.org 916-441-6400 X 214
Antipsychotic Drug Use in
Long-Term Care
California Advocates for Nursing Home Reform
CANHR’s lawyer referral service currently has 125
participating attorney’s all of whom agree to accept at least
two pro bono and two reduced fee cases per year.
Antipsychotic Drug Use in
Long-Term Care
California Advocates for Nursing Home Reform
CANHR receives 15% of attorneys’ fees to support its
advocacy work. In 2009-10, the lawyer referral service
referred 657 clients to panel attorneys in California.
More To Come….
 CANHR is co-sponsoring back-to-back full day
dementia care trainings in San Diego and Los Angeles.
 June 4 – San Diego – only $30 for lunch and materials.
Co-sponsored by San Diego County Long-term Care
Ombudsman and Elder Law & Advocacy.
 June 5 – Los Angeles – only $30 for lunch and
materials. Co-sponsored by Wise and Healthy Aging,
Senior Care Training, and Bet Tzedek.
Antipsychotic Drug Use in
Long-Term Care
“Cause for Alarm:
Antipsychotic Drugs for
Nursing Home Patients”
“Nursing homes should be
penalized for overuse of
antipsychotic medications
for dementia residents,
federal investigator says”
Antipsychotic Drug Use in
Long-Term Care
“Nursing Home Investigation Finds
Errors by Druggists”
“Alzheimer's and Psychoactive Medications -- A Controversial
Decision for Caregivers”
Huffington Post
Antipsychotic Drug Use in
Long-Term Care
Antipsychotic Drug Use in
Long-Term Care
ANTI-PSYCHOTIC MEDICATION WORKSHOP
A Template for CAHF Chapters






Format
Panelists
Suggested Questions
Draft Press Release
Talking Points
CEU information
Located at
www.cahf.org
“Members Only”
Section
Under “Hotlinks”
CDPH Antipsychotic Collaborative
with Department of Health Care
Services
 Collaborative goal:
 Promote appropriate use of antipsychotic medication
by:
 Identifying inappropriate antipsychotic use in SNF residents
with a diagnosis of dementia.
 Provider education.
 Interagency agreement – Started May 2010
 Data provided by MediCal Pharmacy Benefits Division
Antipsychotic Collaborative “Target”
Criteria
Residents currently prescribed either:
 Two antipsychotic medications concurrently
OR
 One ( or more) antipsychotic medication(s) with a
primary diagnosis of Alzheimer’s or dementia with
or without a co-existing diagnosis of SMI
32
CDPH Investigative Process
 Complaint investigation process:
 Survey team limited to Pharmaceutical Consultants on LTC
Task in these District Offices:






Chico
East Bay Fresno
Sacramento
San Diego
San Jose
Santa Rosa/ Redwood Coast
Investigations Findings
May 2010 through January 24, 2011
 Investigations completed: 11
 Regulatory violations cited per investigation: on average five.
 Inappropriate antipsychotic polypharmacy (54%);
 Consultant pharmacist's failure to identify antipsychotic
polypharmacy (54%);
 Care plan related issues (64%)
 Informed consent related issues (27%)
Antipsychotic Use Reduction
Initiatives
 AHCA Quality Initiative- charges members to safely
reduce the off-label use of antipsychotics by 15
percent by December 31, 2012
 CMS Initiative to Improve Behavioral Health and
Reduce the Use of Antipsychotic Medications in
Nursing Homes Residents - aims to reduce the use of
these drugs by 15 percent before the end of 2012
MDS 3.0 and New Public QM
 Psychoactive Medication Use in Absence of Psychotic
or Related Condition
 Check coding at Section I ( Active Diagnosis)
- Schizophrenia and Bipolar disease are exclusions
- Review RAI manual for other related exclusions
Resources
 Improving Antipsychotic Appropriateness in
Dementia Patients (IA-ADAPT) Website
https://www.healthcare.uiowa.edu/igec/IAADAPT
 AHCA
http://www.ahcancal.org/quality_improvement/qualityi
nitiative/Pages/default.aspx
CMS Delivers Antipsychotic
Reduction Message Via You Tube
 Surveyors have a template for evaluating
antipsychotic Rx use in persons with dementia who
do not have psychiatric diagnosis
 Key areas of emphasis:




Consistent assignment
Non-pharmacological interventions
Consultant pharmacist role
Enough staff?
Beyond Verifying Informed
Consent Was Obtained
New surveyor focus:
F 154- Resident/family are fully informed in advance
about care and treatment and of any changes in same
that might affect the resident’s well-being.
- Care planning processes document res/family
agreement with plan of care
- Need to reflect in record how resident/family
informed of plan of care- including medications
CMS Initiative
 If antipsychotic Rx needed in emergent situation
were underlying causes considered?
 Was dose one time with further follow-up?
 If weekend/night- any evidence Rx ordered for staff
convenience?
 Was family notified?
 How is Rx use evaluated via QAA process?
CMS Initiative
 Five Star will display use of antipsychotic Rx for
residents with dementia. (Long Stay)
 State survey agency will be provided with the same
data.
 Video release set for this summer: “Hand in Hand”
CMS You Tube Posting:
http://www.youtube.com/watch?v=U1_rpO0bwbM&list=U
UhHTRPxz8awulGaTMh3SAkA&index=3&feature=plcp
CMS Initiative
Care planning and antipsychotic medication use:
- How will staff monitor to determine if target
symptoms are reduced?
- What side effects will be monitored?
- On interview can nursing staff demonstrate they
know what side effects to watch for?
- Does consultant pharmacist have role in care
planning?
What’s on Your Surveyor’s I Pad?
 This CMS broadcast was designed as an educational
video for state and federal surveyors. It is 2 hours and
30 minutes in length, and provides an introduction to
the 2006 revisions of the Unnecessary Drugs and
Pharmacy Services regulations.
 http://surveyortraining.cms.hhs.gov/pubs/VideoInfor
mation.aspx?cid=1055
What’s on Your Surveyor’s I Pad?
 This presentation was produced by the Centers of
Medicare and Medicaid Services (CMS). This guidance
training includes a slide show presentation, notes for
the instructor, and the general message on each slide.
Some of the goals of this training presentation
include describing the MRR regulation, identifying
compliance with the regulation and issues that lead to
an F428 investigation, and categorizing the severity of
non-compliance issues.
http://www.aging.pitt.edu/professionals/resources/S&
C-06-29-11-F428MedRegReviewInstructorGuide.pdf
CHA Patient Safety Committee
 CAHF Staff now members of this committee
 Focus is safe hand-offs during care transitions from
acute to SNF;
- medication reconciliation
- informed consent
Health Care Acquired Infections
( HAI)
 F441- Surveyors are receiving additional training on
HAI
HAI = symptoms emerge more than 72 hours postadmission.
 Antimicrobial StewardshipCMS is now holding facilities accountable for physician
prescribing.
 CAUTI, CLABSI
Title 22 Top 10 Tags 2011
Rank
Regulation
Description
1
T22 DIV5 CH3 ART5-72521(d)
Administrative Policies and Procedures
427
2
T22 DIV5 CH3 ART3-72311(a)(1)(A)
Nursing Service--General
225
3
T22 DIV5 CH3 ART3-72311(a)(1)(B)
Nursing Service--General
207
4
T22 DIV5 CH3 ART3-72311(a)(2)
Nursing Service--General
187
5
T22 DIV5 CH3 ART5-72543(e)(3)
178
6
T22 DIV5 CH3 ART3-72313(a)(2)
Patients' Health Records
Nursing Service--Administration of
Medication
7
T22 DIV5 CH3 ART5-72527(a)(10)
Patients' Rights
156
8
T22 DIV5 CH3 ART3-72315(b)
Nursing Service--Patient Care
145
9
T22 DIV5 CH3 ART3-72311(a)(1)(C)
Nursing Service--General
141
10
T22 DIV5 CH3 ART5-72533(c)(5)
Employee Personnel Records
47
Frequency
177
126
F TAGS 2012
F Tag
Percentage of Facilities Cited
F 371 – Food- Sanitary Conditions
56%
F 441 - Infection Control
52%
F 323 - Accidents/Supervision
42%
F 309- Necessary Care/Services
39%
F 279 - Care Plan Comprehensive
36%
F 514- Clinical Record maintained
32%
F 431 - Labeling/Storage/Control of
Drugs
31%
F 465 - Physical Environment
29%
F 329 - Unnecessary Drugs
27%
F 241 - Dignity
26%
CMS Scrutinizing Room Size
Waivers
 Triage residents placed in smaller spaces
 Probe and Document routinely- are residents:
- Able to move about room;
- Is path of travel clear;
- Is adaptive/personal equipment accommodated ?
 Evaluate resident/family satisfaction
Top K Tags 2012
K TAG
CA
US
K147- Electrical
55.1%
28%
K018- Corridor Doors
53.9%
26%
K062- Automatic Fire Sprinkler
Maintenance
44.5%
27%
K144- Emergency Generator Testing
and Inspection
35.9%
16%
K012- Building Construction Type
32.9%
12%
ENFORCEMENT IN 2012
 Deficiency Free Surveys
CA
1.5%
US
9.3%
 Immediate Jeopardy
1.9%
1.4%
 Substandard Quality of Care
2.2%
 G Level or Above
1.3%
2.6%
Five Star In California
FIVE STARS
18 %
FOUR STARS
26.5%
THREE STARS
21.5%
TWO
STARS
20%
ONE
STAR
13.4%
Looking Ahead
What’s Happening Next?
AHCA Quality Initiative
 Safely Reduce Hospital Readmissions: By March 2015, reduce
the number of hospital readmissions within 30 days during a
SNF stay by 15 percent.
 Increase Staff Stability: By March 2015, reduce turnover
among nursing staff (RN, LPN/LVN, CNA) by 15 percent.
 Increase Customer Satisfaction: By March 2015, increase the
number of customers who would recommend the facility to
others up to 90 percent.
 Safely Reduce the Off-Label Use of Antipsychotics: By
December 2012, reduce the off-label use of antipsychotic
drugs by 15 percent.
Reducing Hospital Readmissions
 “Bounce Backs”
- 24-28 hours -----relates to hospital quality of care
Calculation:
# of SNF patients admitted to a hospital (excluding ER-only visits and
observations stays) from the SNF within 30 days of hospital discharge
÷
All SNF admissions to this facility within 3 days of hospital discharge
OSHA National Emphasis Program
Focus on SNFs
TARGET: Facilities with a DART of over 10%
In effect April 5, 2012 through April 2015
1. Ergonomic stressors associated with lifting
2. Slips, trips, and falls
3. Bloodborne pathogens
4. Exposure to TB and;
5. Workplace violence
For further information:
https://member.cahf.org/Operations/Regulatory/WhatsNew/ta
bid/516/Default.aspx
Medication-Related Harm- LTC
Facilities
One out of ten SNF residents suffers a medication
related injury ( out of 100 beds) every month.
• 42% are preventable
• Serious injuries- 61% are preventable
Incidence of adverse drug events in two large academic long-term care
facilities- JAMA, March 2005
Medication Safety Event Tracking
( MedSET)
 New CDPH initiative to evaluate medication-related
events that are cited. Includes LTC, Acute , ESRD, etc.
 12 categories with 85 sub-categories
 Looks at medication-related events and trends
 Includes only deficiencies written by CDPH
pharmacists.
uc
t
el,
Pa
ck
rC
om
m
2
3
1
no
log
y
1
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e
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on
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mp
ete
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y
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bin
g
20
18
16
14
12
10
8
6
4
2
0
Pr
od
Rx
O
Pr
es
cr i
Number of AP Occurrences
Med SET
Error Categories
Medication
System- 20XX
Event Tracker
15
6
2
1
Error Category
59
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Un
ilu
au
re
th
to
or
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ize
de
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r
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fo
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rd
er
ed
s
Un
Co
ne
ns
ce
en
ss
t
ar
yM
ed
Or
de
rS
et
s
No. of Occurrences
Med SET
Medication System Event Tracker
Prescribing
10
9
8
7
6
5
4
3
2
1
0
8
7
3
2
1
1
3
3
4
2
1
Error Subcategories
4
2
1
1
MDS 3.0 QM Report
STATE AVERAGE
NATIONAL AVERAGE
Moderate/Severe Pain (S)
22.3%
23.2%
Moderate/Severe Pain (L)
10.7%
12.2%
Hi-Risk Residents w/Pressure Ulcers (L)
7.9%
7.6%
New/Worsened Pressure Ulcers (S)
1.5%
1.9%
Physical restraints (L)
3.9%
2.3%
30.9%
44.5%
Falls w/ Major Injury (L)
1.8%
3.5%
Behavior Sx Affecting Others (L)
19.6%
23.8%
Depressive Symptoms
3.1%
7.9%
Urinary Tract Infection (L)
8.0%
8.2%
Catheter Inserted/Left in Bladder (L)
5.3%
5.1%
Low-Risk residents Who Lose Bladder
Control
43.4%
41.7%
6.5%
6.8%
13.8%
17.2%
Psychoactive Rx Use in Absence of
Psychotic or Related Condition (L)
Falls (L)
Excessive Weight Loss (L)
Need For Help w/ADLs Increased (L)
MDS 3.0 SECTION Q
 Expect CDPH to increase focus on facility compliance
with MDS 3.0 Section Q
 Does facility have documented evidence of follow-up
with the designated county “Lead Agency” when a
resident expresses the desire to learn about options
for living in the community?
http://www.dhcs.ca.gov/services/ltc/Pages/MDS3,Sectio
nQ.aspx
Quality Assurance and
Performance Improvement (QAPI)
Overview
 Mandated as part of Affordable Care Act, enacted March, 2010
 National implementation in 2013
 Legislation requires CMS to establish QAPI program standards
and provide technical assistance
 A demonstration project will develop and test QAPI in nursing
homes
QAPI Demonstration
QAPI RESOURCES
AHCA QAPI RESOURCES:
http://www.ahcancal.org/facility_operations/survey_cer
tification/Documents/QAPI_resources.pdf
Five Elements of QAPI
 Design and Scope
• Governance and Leadership
• Feedback, Data Systems and Monitoring
• Performance Improvement Projects (PIPs)
• Systematic Analysis and Systemic Action
The Quality Indicator Survey
QIS
67
The Quality Indicator Survey
 CMS’ new computerized Federal survey process.
 Same regulations and guidance. Appendix PP and F
tags.
 Intended to improve consistency across the nation.
 CA facilities can expect fewer deficiencies than
traditional survey process. Tendency of QIS to bunch
findings into fewer regulations.
68
Training process for surveyors
 Surveyors who have met Surveyor Minimum
Qualifications Test will require:
 5 days classroom training
 4 day mock survey
 2 full recertification surveys of record with trainer
69
QIS
 Stage 1
 Initially review large samples, up to 70 current and
former residents randomly selected by software.
Conduct family, resident and staff interviews, resident
observations and clinical record reviews.
 Results of preliminary investigations calculated by
software to determine Quality of Care and Quality of
Life Indicators (QCLIs).
70
QIS
 Stage 2
 Investigation of triggered resident specific care areas
 Completion of Mandatory Facility Tasks and NonMandatory Facility Tasks.
 Final analysis and exit

?
Meeting with Maintenance
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QIS and California




Fully implemented in AZ and HI for Re-certifications.
CA in Band 5, initially scheduled for July 2012.
Will be delayed until 2013.
Completing process in CA will take a while, up to
three years.
 There may be an increase in time between surveys
during implementation period; the 12.9 month
average or 15.9 maximum may lengthen during grace
period.
72
What to expect as a facility
 Majority of surveys will have 4 surveyors
 Surveys should take 5 days
 Sample size and number of surveyors is the same with
exception of very small, <40, or very large facilities.
 Surveyors will have
a few lengthy
team meetings
in conference room.
Do not be alarmed.
73
What to expect with QIS
 To date, well received by providers.
 Process tends to seek less
input from DON’s. More
information from residents
and other facility staff.
74
Specific changes Staff will notice
 For DON/Administrator: entrance conference information
needed ASAP.
 Facility will know survey sample.
 Less involvement until Stage 2.
 For Direct Care Staff: no facility tour, however required
staff interviews for all residents. Consumes less staff time.
 Same information will be requested on every survey. Will
help facility and surveyors to have it readily accessible.
 *The following timeline
is for illustration and
can vary based on
survey.
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National Background Check Program
 Sec 6201(a) National rollout continues through 2012.
 18 States and Territories have already started.
 Next round of State solicitations ends 02/28/2012.
Details in S&C 12-11, released 12/09/2011.
 Background clearance for prospective long term care
employees with direct access to residents
 Including adult day care and residential care facilities
 Registries development
 Fingerprinting
76
CMS MEMO ON ABUSE
REPORTING
 Currently in draft
 CAHF working with AHCA on comments
 Imposes “strict liability” standard
 Uses “reasonable person” standard for reporting
determinations
Policies and Procedures
 Effective?
 Comprehensive v Cumbersome?
 Current?
Effective
 Does QA review include assessment of effectiveness?
 Communicated to those who must implement?
 Is there a feedback mechanism for users?
Too Little or Too Much?
 Inventory current policies
 Check that Required P&P are in place (state and
federal)
 Carefully evaluate existing P&P and edit when:
-too lengthy
- unclear
- not required/needed
Policy and Procedure Resources
 Heaton Resources/Med-Pass
 $279.00
 Comes with manual and cd – cd has documents in
word format so you can make changes
 It is updated twice a year – the first year is
included. After the first year the updates are about
half that cost.
Customer service @ 800-438-8884
Policy and Procedure Resources
Anderson Health :
 Administrative Manual
 Health Information/Record Manual
Each manual is sold in hard copy format, and a CD is
included as well for no additional cost.
Each manual is sold for $149, plus a $10.70 postage fee
for a total of $159.70. There is also an annual fee of $35
per manual to receive updates.
Email: office@ahis.net