California Department of Public Health Center for Healthcare Quality Licensing and Certification Program California Hospice and Palliative Care Association Presentation October 2017 Hospice Defined A Hospice is a public agency or private organization that is primarily engaged in providing care to terminally ill individuals. A certified Hospice must meet federal conditions of participation and have a valid Medicare Provider Agreement. Hospice care is a comprehensive set of services described in 1861(dd)(1) of the {Social Security} Act, identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, and spiritual needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. State Licensure Statutory Authority and Guidelines California Health and Safety (H&S) Code Sections 1747 through 1759. California Hospice & Palliative Care Association Standards of Quality Hospice Care 2003 (Effective January 1, 2005) 1
Regulation & Policy Updates Regulation Development In the process of updating the California Code of Regulations, Title 22, to address both hospice program and facilities. Seeking input and comments for consideration as staff develop the regulations Policy Unit In the process of completing the Policy & Procedures on hospice licensure process for provider and facility. Will include the new Hospice Facility Survey Tool. Completion date around November 2017. Training will be implemented following the approval process. Federal Regulations Federal Regulations are found in 42 CFR, Section 418. Statutory authority for applying federal Conditions of Participation (COPs) is found in Section 1861(dd) of the Social Security Act. Appendix M of the State Operations Manual, sections 418.3 through 418.100 contain the Interpretive Guidelines. Appendix Q of the State Operations Manual, contains Guidelines for Determining Immediate Jeopardy. Do I need a hospice license if I own a home health agency? Yes, The operation of a hospice program in California requires a license from CDPH under Health & Safety Code, section 1747. In order to qualify for exemption from hospice licensure under Health & Safety Code, section 1747.1, the hospice program must be certified to participate in the federal Medicare/Medicaid programs. 2
Hospice Licensing and Certification Process Order 1. Hospice licensure 2. Hospice operations 3. Federal hospice certification 4. Addition of hospice as a service on a home health agency license in lieu of hospice licensure Initial Certification Requirements AFL 08-05 Medicare Certification Survey (issued March 25, 2008) CMS S&C 08-03 issued on Nov.5, 2007 Prior to conducting any certification surveys, providers must first provide justification demonstrating significant access to care issues for Medicare beneficiaries, to the appropriate DOs. Providers are encouraged to seek certification through accreditation organization (AOs) for deemed status to avoid delays. Impact Act 2014 The Act is effective six months after the enactment (which was April 6, 2015). Mandates that Medicare certified hospices be surveyed no less than every 36 months. SA must plan and be prepared to conduct surveys of approximately 1/3 of the non-deemed hospices in the state. By April of 2018, all hospices will have been surveyed within the preceding 36 months. 3
Hospice Facility Licensure Category AFL 13-05 (issued May 1, 2013) Effective January 1, 203, Senate Bill 135 established a new hospice facility licensure category and permits a licensed and certified hospice services provider to provide inpatient hospice care through the operation of a hospice facility Under the new law, hospice providers that intend to provide inpatient hospice care in their own facility must apply for a hospice facility license. Applicant must be a licensed and certified hospice facility HOFAs: Total of 38 Open & Active HOFA facilities 2013: 2 2014:8 2015: 8 2016: 9 2017: 11 HOFA facilities for 1 violation, in SFY 2013-14 0033/ Registered Nurse/ Article 1- definitions Top 10 Cited Deficiencies Hospice Deficiencies Count Top 10 Rankings By SFY (1- Most Common) SFY 2016-17 2016-17 2015-16 2014-15 25 1 3 1 0543 / F / PLAN OF CARE / 418.56(b) 0118 / S / Administrative Policies / ART6-6.2(A)(2)(j) Policies - 17 2 4 15 0124 / S / Contractual Services / ART6-6.2(B)(2)(c) Policies - 16 3 1 10 0536 / F / IDG, CARE PLANNING, COORDINATION OF SERVICES / 418.56 14 4 24 48 0555 / F / COORDINATION OF SERVICES / 418.56(e)(2) 14 5 19 2 0115 / S / Administrative Policies / ART6-6.2(A)(2)(g) Policies - 13 6 10 40 0520 / F / INITIAL & COMPREHENSIVE ASSESSMENT OF PATIENT / 418.54 13 7 17 47 0123 / S / Contractual Services / ART6-6.2(B)(2)(b) Policies - 12 8 13 57 0545 / F / CONTENT OF PLAN OF CARE / 418.56(c) 12 9 18 3 0050 / S / Home Health Aide / ART2-2.4(A) 11 10 20 156 TOTAL DEFICIENCIES 147 147 96 106 Referrals to Accredited Organizations Issue: CMS requirement to refer low to medium level non long-term complaints and entity reported incidents to CMS approved Accredited Organizations (AO) Background: In May 2014, CMS informed State Survey Agencies that they must refer all non-ij High complaints and entity reported incidents (ERIs) received against a deemed provider (GACH, HHA, ASC, hospice) to the AO for investigation. AFL 17-11 : Starting August 1, 2017, all non LTC ERI non immediate jeopardy low to medium priority level will be referred by the District Offices to the AOs for investigation. Will reevaluate in 6 months to include NLTC complaints. 4
Referrals to Accredited Organizations Communication: All AOs contacted and notified of CA s intent to refer. AOs indicate they are ready. L&C contacted the provider associations to alert them of this pending change. L&C issued an All Facility Letter (AFL 17-11) to affected providers on the referral process change. Implementation Process: Intake and triage into ACTs. L&C to transfer intake information to newly developed referral form for transmission to AO. Note referral in ACTs and letter to complainant or facility. Training: L&C has developed and provided training material for staff on how to implement this process at the District Offices. Implementation date: August 1, 2017 Los Angeles District Office CDPH contracts with Los Angeles County Department of Public Health, Health Facilities Inspection Division, to perform the licensing and certification function, inspection, consultation, investigation of complaints, and verify compliance with the licensing program for health facilities, clinics, agencies and centers located in Los Angeles County for which licensure is required by the California Health and Safety Code and Welfare and Institution Code. The Los Angeles District Office Region is divided into four District Offices (North, West, East and San Gabriel). Los Angeles District Office - changes Changes to the LA County contract (July 2015- June 2018), include separation of licensing and certification functions. All licensing functions (initials and relicensing) are now responsibility of the CDPH, L&C program during the contracted years. Centralized Application Unit (CAU) will process the all licensing applications. The Los Angeles County has responsibility for federal enforcement/certification as specified in the contract. CDPH L&C is also designated to perform a portion of federal enforcement/certification workload, such as as complaint validation, full validation or sample validations previously delegated to LA County, for facilities and providers within LA county. 5
Centralized Application Unit (CAU) Mission The Centralized Application Unit s (CAU) mission is to ensure standardization and consistency of the state licensing and federal certification application process. To better accomplish this mission and fully centralize the process, the CAU has absorbed all facility applications previously processed by the Center s district offices. The CAU has increased staffing and is actively implementing efficiencies to improve the timeliness of processing applications. Centralized Application Unit Activities Process Initial and Change of Ownership (CHOW) applications for approximately 30 long-term and nonterm care facilities and management companies. Process all report of changes (14 types) which include but are not limited to: location, name, service, beds, stock transfers, address, administrator, director of nursing, governing board, geographical areas, indirect ownership, etc. Issue all initial and renewal licenses. Respond to Public Records Act requests and media inquiries. Respond to CAU main telephone line and mailbox inquiries. Centralized Application Unit Process Provider submits application to CAU. Applications should not be sent directly to the district offices. CAU reviews the application to ensure it is complete and all required documents have been submitted. Once CAU deems the application complete, it is forwarded to the district office who will schedule an onsite survey, if applicable. Once the survey has been completed, the district office will provide approval to CAU so the license can be generated. CAU will issue the license and send directly to the provider. For Los Angeles County, licensing surveys are conducted by other district offices and the process differs slightly. 6
Centralized Application Unit Staffing Current Staffing: 1 Manager II (Nora Salazar) 2 Manager I s (Andrea Sanders & Stephanie Devlin) 2 Program Technician (Intake Unit) 13 Analysts (Processes Applications) 2 Retired Annuitants (Policies/Procedures/Checklists) 1 Student Assistant CAU has been approved to increase its staffing with five (5) analyst and two (2) manager positions with an additional seven (7) positions to be added in the future. Recruitment is currently underway to fill the seven positons. Centralized Application Unit Workload Volume (2015 Current) All License Types Initial and Change of Ownership (CHOW) applications: o 1,422 received o 765 processed o 657 pending Report of Change Requests: o 5,580 received o 1,538 processed o 4,042 pending License Renewals (not including provisional licenses): o 8,745 processed annually Data as of September 22, 2017 Centralized Application Unit Hospice Volume (2015 Current) Initial and Change of Ownership (CHOW) applications: o 189 received o 84 processed o 105 pending Report of Change Requests: o 1,055 received o 311 processed o 744 pending License Renewals (not including provisional licenses): o 1,285 processed biennial Data as of September 22, 2017 7
Centralized Application Unit Contact Information Nora Salazar, Section Chief (916) 552-8762 nora.salazar@cdph.ca.gov Andrea Sanders, Unit Manager (916) 552-8754 andrea.sanders@cdph.ca.gov Stephanie Devlin, Unit Manager (916) 319-9611 stephanie.devlin@cdph.ca.gov CAU Main #:(916) 552-8632 cau@cdph.ca.gov All completed applications packages and report of changes requests must be submitted to CAU at the address below: California Department of Public Health Licensing and Certification Program Centralized Applications Unit P.O. Box 997377, MS 3207 Sacramento, CA 95899-7377 Licensing & Certification Contact Information Virginia Yamashiro, Chief of Field Operations Non-Long Term Care (916) 440-7360 Virginia.Yamashiro@cdph.ca.gov Jackie Lincer, Branch Chief, Region VI (interim) (714) 567-2906 Jackie.Lincer@cdph.ca.gov Tina Paschke, Branch Chief, CAU (916) 324-0326 Tina.Paschke@cdph.ca.gov End of Presentation Questions or comments? 8