Day 2, Morning Plenary 1 CMS and OIG Joint Briefing: Importance and Progress of Improved Background Screenings for Long Term Care Don Howard, CMS Ernie Baumann, CNA Tricia Fields, OIG Michala Walker, OIG
Session Overview We will provide the latest data and trends in maturing populations and the increased demand for long term care. The HHS Office of Inspector General (OIG) will provide a briefing on findings from its study Home Health Agencies Employment of Individuals with Criminal Convictions (OEI-07-14-00130) and the status of its interim evaluation of the NBCP (OEI-07-10-00420). We will present some results of an internal evaluation that identified NBCP best practices. National Background Check Program Annual Training, May 2015 2
Trends: The Maturing U.S. Population By 2050, approximately 88.5 million people will be aged 65 or older, some 20% of the Nation s total population. In 2010, this elderly population was estimated to be about 40 million people, or12% of the Nation s total population. Population 65+ by Age: 1900-2050 Source: U.S. Bureau of the Census Number of Persons 65+ 100,000,000 90,000,000 80,000,000 70,000,000 60,000,000 50,000,000 40,000,000 30,000,000 20,000,000 10,000,000 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Year Age 65-74 Age 75-84 Age 85+ National Background Check Program Annual Training, May 2015 3
Trends: Age and Sex, 2010 vs 2050 Female Male 100 + 0.429 0.172 85-99 11.154 7.286 2050 Age Bracket 65-84 45-64 25-44 55.299 49.974 36.618 32.287 48.516 55.563 2010 18-24 19.497 20.041 0-17 49.785 51.789 80 60 40 20 0 20 40 60 80 Population (Millions) National Background Check Program Annual Training, May 2015 4
Trends: Demand for LTC Services The growth in the elderly population will cause a surge in the number of people in need of long term care services. Some 70% of Americans who reach age 65 will need long term care services and support. Using 2008 Census projections, this means that approximately 33 million elderly people will need long term care services and support in 2015. By 2050, this number will increase to approximately 62 million. The Congressional Budget Office (CBO) estimated that the value of long-term care service provided in 2011 totaled approximately $400 billion. National Background Check Program Annual Training, May 2015 5
Trends: Very Old Americans Those aged 80+ will nearly triple, and aged 90+ will quadruple, between 2010 and 2050. National Background Check Program Annual Training, May 2015 6
Trends: More LTC Recipients Between 2000 and 2040, the number of elderly receiving long term care services will double. Population of recipients of nursing home and paid home care grows faster than does recipients of unpaid care. National Background Check Program Annual Training, May 2015 7
Trends: Greater Need for Caregivers Adults aged 19-64 needed to provide long term care services: National Background Check Program Annual Training, May 2015 8
Conclusion We are in a growth industry. Background check volume for long term care employment will increase substantially for 20-30 years. Continued progress now will help accommodate this growth while maintaining high quality, efficiency, and economy in screenings to reduce abuse of this vulnerable population. National Background Check Program Annual Training, May 2015 9
Speaker Introductions Tricia Fields and Michala Walker HHS OIG OIG studies related to NBCP Ernie Baumann CNA Internal evaluation of NBCP progress National Background Check Program Annual Training, May 2015 10
Office of Inspector General 2015 Work Plan and Current Evaluations Tricia Fields and Michala Walker
OIG Mission and Structure OIG s mission is to protect the integrity of U.S. Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs. 12
OIG Mission and Structure OIG has a responsibility to report to the Secretary and to Congress whenever it finds program and management problems. OIG conducts audits, investigations, and evaluations that result in timely information, cost savings, and policy recommendations for decision makers and the public. 13
OIG Mission and Structure HHS has the largest OIG in the Federal Government. OIG employs nearly 1,600 people across the country to combat fraud, waste, and abuse and to improve the efficiency of HHS programs. 14
OIG Mission and Structure OIG Components: Office of Audit Services Office of Counsel to the Inspector General Office of Investigations Office of Evaluation and Inspections. 15
OIG Mission and Structure Office of Audit Services (OAS): Provides auditing services for HHS Examines the performance of HHS programs and/or its grantees and contractors Helps reduce waste, abuse, and mismanagement of programs Promotes economy and efficiency throughout HHS. 16
OIG Mission and Structure Office of Counsel to the Inspector General (OCIG): Provides general legal services to OIG Represents OIG in all civil and administrative fraud and abuse cases involving HHS programs Negotiates and monitors corporate integrity agreements Issues advisory opinions, fraud alerts, and guidance to health care providers and others on the application of fraud and abuse statutes. 17
OIG Mission and Structure Office of Investigations (OI): Conducts criminal, civil, and administrative investigations of fraud and misconduct Actively coordinates with the Department of Justice and other law enforcement entities Efforts often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. 18
OIG Mission and Structure Office of Evaluation and Inspections (OEI): Conducts national evaluations to provide timely, useful, and reliable information Focuses on fraud, waste, and abuse prevention Promotes economy, efficiency, and effectiveness Presents practical recommendations for improving programs. 19
OIG Work Plan OIG Work Plan FY 2015 The HHS OIG Work Plan for FY 2015 summarizes new and ongoing reviews and activities that OIG plans to pursue during the current fiscal year and beyond. 20
OIG Work Plan For each review, the Work Plan describes the primary objectives and the year in which we expect one or more reports to be issued as a result of the review. 21
OIG Work Plan The OIG Work Plan provides brief descriptions of activities that OIG plans to initiate or continue. In choosing activities to include, OIG considers: Mandatory requirements for OIG reviews Requests from Congress and HHS management HHS management and performance challenges Work to be performed in collaboration with CMS and other HHS agencies Emerging issues Unimplemented OIG recommendations. 22
Topics Included in FY 2015 Work Plan Nursing homes Medicare Part A billing Medicare Part B billing during a non-covered Part A stay. Hospice Hospice stays within assisted living facilities Inpatient care claims during a hospice care election. Home health services Prospective payment system. 23
Topics Included in FY 2015 Work Plan, continued Home and community-based services waivers Adult day health care services Unallowable room and board costs. Medicaid HHA worker health screenings Balancing Incentive Program Transfers from group homes or nursing facilities to hospital emergency departments Enhanced provider screening under the Patient Protection and Affordable Care Act. 24
Contact Information OIG Work Plan and all published reports are available at www.oig.hhs.gov Contact information: OIG, Office of Public Affairs (202) 619-1343 paffairs@oig.hhs.gov 25
Mandated Evaluation NBCP Section 6201 of Patient Protection and Affordable Care Act Evaluation must be complete within 180 days of the completion of the nationwide program Five required elements for evaluation. 26
Interim Report NBCP (OEI-07-10-00420) Objective: To provide an interim progress report on the implementation status and early results of the National Background Check Program for long term care employees. 27
Interim Report NBCP, continued Scope: 25 States have received grants as of September 30, 2014 Methodology: Quarterly reports submitted to CMS for the quarter ended September 30, 2014 28
Interim Report NBCP, continued Issues: State program implementation Percentage of applicants disqualified Quality of data submitted. 29
Study HHA Employees (OEI-07-14-00130) Objectives: To determine whether home health agencies (HHAs) conduct background checks on prospective and/or current employees To determine the extent to which HHA employees have criminal convictions To determine whether the criminal convictions of selected employees appear to disqualify them from HHA employment. 30
Study HHA Employees, continued Methodology: Similar to that of Nursing Facilities Employment of Individuals with Criminal Convictions (OEI-07-09-00110; March 2011) Random sample of 105 HHAs Employee roster Survey of background check procedures. Information Transfer Agreement with FBI Matched roster information with criminal history record information. 31
Study HHA Employees, continued Issues: Prevalence of HHAs conducting checks Percentage of HHA employees with criminal convictions Age of convictions Types of convictions In-depth analysis of criminal convictions and State laws regarding employment disqualification for a small group of sampled employees. 32
Questions? 33
Internal Evaluation of Progress, 2014 Approach to the progress evaluation Implementation milestones Best practices (and why they are best ) Outcomes to date Questions. National Background Check Program Annual Training, May 2015 34
Internal Evaluation Developed criteria and milestones from the legislation and grant solicitation requirements Minimized additional information requests Covered all aspects; 21 milestones in 6 categories No scoring, no grades. Assessed impact of various approaches on effectiveness, efficiency, economy, and fairness / due process Assessed progress by using Quarterly Report (QR) narratives and knowledge of State Liaisons (SLs); measured outcomes using the QR data files Identified recommended best practices; next steps for CMS to help States achieve the best practice approaches as closely as possible. National Background Check Program Annual Training, May 2015 35
Internal Evaluation Categories Category I: Meeting grant provisions Category II: Framework for compliance Legislation, list of disqualifiers, direct access workers Category III: Achieving coverage Provider types, employee categories, registry checks Category IV: Fingerprint-based checks (including FBI) Category V: Achieving efficiency Automation, notification process, State rap back Category VI: Meeting due process and workforce needs. National Background Check Program Annual Training, May 2015 36
Internal Evaluation Highlights 1/4 Category I: Meeting grant provisions 3-year grant period is barely adequate 11 of 25 States are submitting program data 22 of 25 States are using a single State agency. Category II: Framework for compliance Legislation, list of disqualifiers, direct access workers Legislation score card: Needed: 18 States (+ 6 minor) Passed fully: 10 States Passed partially: 3 States Grant ended without passing: 1 state. National Background Check Program Annual Training, May 2015 37
Internal Evaluation Highlights 2/4 Category III: Achieving coverage Statewide means all provider types and all employee categories, registry checks Professional employees: 13 requiring, 3 attempting Provider types NOT included: Home and community based services (HCBS), 8 States Psychiatric hospitals, 17 States. Assessment of identified registry checks: OIG Exclusions, State NAR: All States either requiring or planning State professional licensing: 16 requiring, + 4 planning Out-of-State registries: 12 requiring, + 4 planning Child abuse (8 requiring, + 4 planning); APS (8 requiring, + 3 planning) Sex offender: Federal (14 requiring, + 8 planning); State (14 requiring, + 4 planning). National Background Check Program Annual Training, May 2015 38
Internal Evaluation Highlights 3/4 Category IV: Fingerprint-based checks All applicants, use for State checks, FBI checks Collect fingerprints for all applicants: 15 States (5 during grant) FBI checks for all applicants: 10 States (5 during grant). Category V: Achieving efficiency Automation, notification process, State rap back All States worked on automation State rap back: 8 States currently implemented, +3 using a related process Notifications problematic without automation, rap back, and a State determination agency. National Background Check Program Annual Training, May 2015 39
Internal Evaluation Highlights 4/4 Category VI: Meeting due process and workforce needs Appeal process and provisional employment policy Provisional employment: All States have a policy Appeals Several types: correction, rehabilitation, court action (e.g., expungement). National Background Check Program Annual Training, May 2015 40
New Mexico Before and After Outcomes Unique pilot State 100% fingerprinting and FBI screenings since before 2004 Background screening unit function at State health department Lots of paper; payments by check No electronic fingerprinting; no electronic criminal history reports. Technical assistance activities performed: Complete web-based provider portal, including automated registry searching, and payment interface Complete screening database integrated with provider information Electronic data exchanges with fingerprint vendor, State Police, and FBI Supported procurement of statewide live scan services. Grant funds used to support State fingerprint and criminal history database upgrades Implemented fully automated system in November 2013. National Background Check Program Annual Training, May 2015 41
NM Impact of Electronic Fingerprinting Implemented Statewide electronic fingerprinting, automated criminal history, and a TA-provided background check system during fall 2013 Results through June 2014: New Mexico CCHSP determinations Before system upgrades (2Q 2013) After system upgrades (1Q 2014) After system upgrades (2Q 2014) Total issued 2,307 8,367 8,811 Eligible 2,255 8,284 8,699 Ineligible 52 83 112 National Background Check Program Annual Training, May 2015 42
NM Speed of Eligible Determinations Cumulative percentage of determination issue times before and after system upgrades, 2Q 2013 vs. 1Q 2014 and 2Q 2014 National Background Check Program Annual Training, May 2015 43
NM Speed of Ineligible Determinations Cumulative percentage of determination issue times before and after system upgrades, 2Q 2013 vs. 1Q 2014 and 2Q 2014 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 10 days & under 20 days & under 30 days & under 50 days & under 2Q 2013 1Q 2014 2Q 2014 National Background Check Program Annual Training, May 2015 44
Reducing State Costs in DC and NM Streamlined screenings based on an existing fingerprint-based check, January June 2014 State Fingerprintbased checks conducted Screenings based on existing checks Costs avoided DC 3,561 1,222 $61,100 NM 17,304 1,789 $59,037 Total 20,865 3,011 $120,137 Notes All existing checks were eligible. Fingerprint processing costs = $50/new applicant All existing checks were eligible. Fingerprint processing costs = $33/new applicant 14.4% of applicants did not require fingerprints to change employers National Background Check Program Annual Training, May 2015 45
Impact of State Rap Back in MI and FL MI State rap back between Jan 2014 Jun 2014: 50,517 new applications filed 5,227 rap back hits 483 individuals (9%) were deemed ineligible FL State rap back, Jan 2013 May 2014: 259,321 applications processed 4,353 rap back hits 1,337 individuals (30%) went from eligible to not eligible Offenses included: Grand Theft Battery and Assault Sex Offenses Exploitation of the Elderly National Background Check Program Annual Training, May 2015 46
Data-Supported Best Practices NBCP internal evaluation shows that the following practices are essential to meet requirements and achieve efficiency, effectiveness, and economy: Maximize electronic exchange of fingerprint status, criminal history information, and rap back Require 100-percent fingerprinting and FBI checks Issue a statewide eligibility determination by the State agency Improve and maintain data reporting and analysis Develop robust State background check system Request authority to query MED files by Social Security number Share registry information electronically Consolidate requirements to integrate with related background checks. National Background Check Program Annual Training, May 2015 47
Thank You! Questions? National Background Check Program Annual Training, May 2015 48