2016 Hospital Conference. Objectives. The Bureau of Health Services 5/5/2016

Transcription

1 2016 Hospital Conference Cremear Mims Division of Quality Assurance Bureau of Health Services, Director May 12, 2016 Objectives The audience will understand the role of the Bureau of Health Services. The audience will understand the role of the Wisconsin State Agency in relation to the Center for Medicare and Medicaid Services. The audience will understand the difference between federal and state requirements. 2 The Bureau of Health Services Role of Bureau of Health Services Role of the survey staff Provider oversight Federal workload responsibilities State workload responsibilities 3 1

2 Regulating Non- Long Term Care Providers (NLTC) Budget requirements Federal survey directions Federal Performance Standards Centers for Medicare and Medicaid (CMS) Updates Survey and Certification (S & C) Memos Emergency, Medical, Treatment and Labor Act (EMTALA) 4 Survey Statistics Quarterly citation report Quarterly complaint report tal/statistics.htm#complaints-su 5 Communications with Providers Hospital Forums Public Hospital Meetings Other provider meetings 6 2

3 Summary The role of The Bureau of Health Services. The role of Wisconsin State Agency in relation to the Center for Medicare and Medicaid Services. The difference between federal and state requirements. 7 Questions and Answers 8 Hospital Conference 2016 Supervisor s Role and Responsibility Michelle Doro and Ann Hansen Division of Quality Assurance Section Chiefs May 12,

4 Welcome to the Department of Health Service (DHS) Division of Quality Assurance (DQA) Bureau of Health Services (BHS) Acute Care Compliance Section (ACCS) 10 Connections State Agency Oversight to healthcare and physical environment regulation, rule, code and law. CMS Oversight to healthcare and physical environment Federal regulations Mission & Priority Document issued annually Accreditation organizations Oversight to professional standards of practice 11 Authority Hospitals are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment. 12 4

5 Authority DHS 50 DHS 124 Federal Regulations State Operations Manual 13 Types of Surveys we Conduct o Full Survey o Recertification o Validation Survey o Verification Visit o Complaint Survey o EMTALA o Initial Licensure Survey 14 Breakdown of Survey Activity 15 5

6 Hospital Conference 2016 Complaint Process Nicole Werner Division of Quality Assurance Quality Assurance Program Specialist/ Complaint Intake Coordinator May 12, 2016 Introduction Purpose: Increase the understanding, of the hospitals in Wisconsin, of the role of DQA in complaint investigations. Encourage the fullest use of hospital s own internal grievance processes. 17 Objectives How/why it is initiated, triaged & prioritized Steps from initiation of complaint to completion Process for accredited hospital vs. nonaccredited hospital Regulatory structure (state/federal) Grievance process Prevention of complaints 18 6

7 Who? What? When? Where? Why? Anatomy of a Complaint 19 Who? May be anonymous Do not have to use the hospital s own internal grievance system before contacting DQA 20 What? Complaint and Grievance interchangeable CMS and DHS 124 regulations requiring hospitals to notify patients of DQA s contact information DQA/ BHS 1 West Wilson Street P.O. Box 2969 Madison, WI Phone: (608)

8 When? Incident occurred within the past year Exception possible but rare 22 Where? Off site locations may be federally certified but not part of the hospital for State purposes 23 Why? To identify regulatory noncompliance for the purpose of public protection Some complaints are referred elsewhere Motivations of complainants 24 8

9 Priority categories from the federal data system are: A IJ (Immediate Jeopardy) B - Non-IJ High C - Non-IJ Medium D - Non-IJ Low E - Non-IJ Admin Review/Offsite Investigation F - Referral-Immediately G - Referral-Other H - No Action Necessary 25 Priority A A. IJ (Immediate Jeopardy) is defined as, "A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident." Intakes are assigned this priority if the intake information indicates immediate corrective action is necessary because a provider's or supplier's alleged noncompliance may have caused, or is likely to cause, serious injury, harm, impairment or death to a patient. Such complaints must be investigated within 2 working days of receipt of the CMS-2802 form. IJ also includes all EMTALA allegations. Federally authorized EMTALA investigations and federally mandated reports of death due to restraint/seclusion must be completed within 5 working days after authorization. 26 Priority B B. Non-IJ High is defined as harm that impairs mental, physical and/or psychosocial status of such consequence to the person's well being that a rapid response is indicated. This level of complaint is represented by specific rather than general information, such as, descriptive identifiers, individual names, date/time/location of occurrence, description of harm, etc. This category includes the death investigations mandated under Wis. Stats (2t) and 51.64(1) (deaths in psychiatric treatment areas caused by suicide, restraint, or psychotropic medications). State mandated death reports are assigned a due date within 14 days from the date of receipt of the report of the death. Other Non-IJ High complaints are assigned a due date of 45 calendar days of authorization / prioritization of the complaint. 27 9

10 Priority C C. Non-IJ Medium is defined as noncompliance with one or more requirements caused or may cause harm that is of limited consequence and does not significantly impair the individual s mental, physical and /or psychosocial status or function. 28 Priority D D. Non-IJ Low is defined as situations that may have caused physical, mental and/or psychosocial discomfort that does not constitute injury or damage. 29 Priority E E. Administrative Review/Offsite Investigation is the priority used for complaints/incidents that are triaged as not needing an onsite investigation, however conducts an offsite administrative review ( e.g., written/ verbal communication or documentation) to determine if further action is necessary

11 Priority F & G F. Referral Immediately G. Referral - Other. Referrals are made to Office of Caregiver Quality, Office of Client Rights, Department of Safety and Professional Services, Department of Agriculture, Trade and Consumer Protection, Quality Improvement Orgainization, and other agencies as appropriate 31 Priority H H. No action necessary is the priority used when adequate information about the incident/complaint yields the conclusion that DQA can determine with certainty that no further investigation, analysis, or action is deemed necessary. 32 Role of accreditation in the complaint process CMS review Does complaint represent potential Condition of Participation out of compliance? Consequence of COP out DHS 124 applies in all hospitals EMTALA is totally federally directed 33 11

12 Role of the hospital s own internal complaint/grievance system Condition of participation: Patient's rights. The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital's governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. At a minimum: 34 Role of the hospital s own internal complaint/grievance system The hospital must establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the hospital. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 35 Role of the hospital s own internal complaint/grievance system Surveyor review of hospital s grievance process 36 12

13 Q&A Questions later? Nicole Werner, (414) or Thank you 37 13