PACAH Spring 2016 Department of Health Update Presented by: Susan Williamson, Director Division of Nursing Care Facilities Charlie Schlegel, Director Division of Safety Inspection
Facility and Survey Data 2015 Facilities 702 Facilities 88,233 Beds Surveys Completed 4,277 Total surveys 711 Re-licensure/recertification surveys (Full Health Surveys) 1,316 Revisits (to all types of surveys) 3,327 On-site visits (includes complaint visits)
Facility and Survey Data 2014 Facilities 703 Facilities 88,090 Beds Surveys Completed 3,716 Total surveys 709 Re-licensure/recertification surveys (Full Health Surveys) 1,109 Revisits (to all types of surveys) 2,810 On-site visits (includes complaint visits)
Statewide Deficiency Free Surveys 2013 2014 2015 74 Full Health Surveys were deficiency free 68 Full Health Surveys were deficiency free 53 Full Health Surveys were deficiency free
Surveys with Scope & Severity D & Above 2013 2014 2015 Standard Surveys 651 629 650 Complaint Surveys 390 455 703 Substandard Quality of Care 6 1 3 Immediate Jeopardy Tags 2 11 12
Frequency of DNCF Visits 2015 Number of Visits % of PA facilities 20 + 1.00% 10 to 19 8.83% 6 to 9 21.51% 2 to 5 53.85% 1 14.10%
Frequency of DNCF Visits 2014 Number of Visits % of PA facilities 20 + 0.28% 10 to 19 5.12% 6 to 9 18.63% 2 to 5 56.19% 1 18.92%
Provisional Licenses Issued 2009 29 2010 10 2011-18 2012 2 2013 2 2014 9 2015 19
State Actions Total state actions for 2013 Pl/CMP= 1 Pll/CMP= 0 Plll/CMP= 0 PIV/CMP = 0 Pl only= 1 Pll only= 0 PIII only = 0 PIV only= 0 CMP only= 11 Total = 13 Total state actions for 2014 Pl/CMP= 1 Pll/CMP= 2 Plll/CMP= 0 PIV/CMP = 0 Pl only= 4 Pll only= 2 PIII only = 0 PIV only= 0 CMP only= 8 Total = 17 Total state actions for 2015 Pl/CMP= 6 Pll/CMP= 2 Plll/CMP= 0 PIV/CMP = 0 Pl only= 7 Pll only= 2 PIII only = 1 PIV only= 1 CMP only= 24 Total = 43 Pl=Provisional l license Pll=Provisional ll license Plll=Provisional lll license PIV = Provisional IV license CMP=Civil Monetary Penalty
2015 Complaint Data Complaint Data Total received= 2,591 Total substantiated= 863 (33.31%) Most Frequently Filed Care or Services 66.77% Resident Rights 14.73% Environment 9.32% Onsite investigations conducted= 2,330 (89.93%) Substantiated complaints with citations issued at G or above= 73 (2.82%)
2014 Complaint Data Complaint Data Total received= 1,930 Total substantiated= 483 (25.03%) Most Frequently Filed Care or Services 65.99% Resident Rights 16.98% Environment 8.79% Onsite investigations conducted= 1,725 (89.38%) Substantiated complaints with citations issued at G or above= 29 (1.50%)
Complaint Compilation 2013 Total Complaints Received = 1855 2014 Total Complaints Received = 1930 Total Complaints Substantiated = 446 Total Complaints Substantiated = 488 Total tags cited related to complaints = 353 Highest S/S cited during complaint surveys = L Total tags cited related to complaints = 388 Highest S/S cited during complaint surveys = L
Complaint Comparison 2015 Total Complaints Received = 2591 Total Complaints Substantiated = 861 Total tags cited related to complaints = 642 Highest S/S cited during complaint surveys = L
2015 Incidents Total number of incident reports received: 21,788 Most Frequently reported events Transfer to Hospital 10,432 Abuse 2,941 Other 2,547
2014 Incidents Total number of incident reports received: 19,411 Most Frequently reported events Transfer to Hospital 9,822 Abuse 2,375 Other 2,185
IDR 2012 55 Tags disputed 31% deleted (17) 20% revised (11) 49% upheld (27) 0% withdrawn (0) 2013 69 Tags disputed 19% deleted (13) 7% revised (5) 72% upheld (50) 0% withdrawn (0) 2014 60 Tags disputed 15% deleted (9) 20% revised (12) 63% upheld (38) 2% withdrawn (1) 2015 131 Tags disputed 9% pending (12) 24% deleted (32) 10% revised (13) 56% upheld (73) 1% withdrawn (1)
State IIDR 2012 5 tags disputed 20% deleted (1) 0% revised (0) 80% upheld (4) 0% withdrawn (0) 2013 14 tags disputed 0% deleted (0) 7% revised (1) 86% upheld (12) 7% withdrawn (1) 2014 24 tags disputed 25% deleted (6) 0% revised (0) 75% upheld (18) 0% withdrawn (0) 2015 30 tags disputed 17% pending (5) 20% deleted (6) 10% revised (3) 75% upheld (18) 0% withdrawn (0)
Federal IIDR 2013 10 tags disputed 100% upheld (4) 2014 1 tags disputed 100% upheld (1) 2015 2 tags disputed 100% upheld (2)
Additional Updates Nursing Home Task Force Anonymous Complaints Payroll Based Journal (PBJ) Quality Insights PDA Reporting Wheelchair safety
Frequently Cited Tags Listed below are the top 5 most frequently cited tags in order from most cited. 2013 2014 2015 F309 F441 F323 F514 F371 F309 F441 F514 F323 F371 F309 F441 F514 F323 F371 0309 =PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING 0441 =INFECTION CONTROL, PREVENT SPREAD, LINENS 0514 =RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE 0323 =FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES 0371 =FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY
Resources DNCF 717-787-1816 DSI 717-787-1911 Message Board www.health.state.pa.us CMS Website www.cms.hhs.gov State Operations Manual http://cms.hhs.gov/manuals/downloads/som107ap_pp_ guidelines_ltcf.pdf
Overview CMS Proposed Rules Update Emergency Preparedness 2012 LSC 2012 LSC Waivers DSI Plan of Corrections
CMS Proposed Rules CMS proposed rule on emergency preparedness requirements published in the Federal Register on 12/27/2013 CMS proposed rule on adoption of the 2012 LSC and NFPA 99 published in the Federal Register on 4/16/2014
CMS Proposed Rules Typically, comment period open for 60 days CMS must then respond to the comments Then the rule can become final with likely phase-in period Over 2 years since the proposed rule on emergency preparedness and nearly 2 years since the proposed rule on adoption of the 2012 LSC and NFPA 99
CMS Proposed Rules
2012 LSC Waivers CMS issued S&C Letters permitting the use of specific 2012 LSC requirements through the categorical waiver process Many facilities are taking advantage of the waivers
2012 LSC Waivers What are categorical waivers? These waivers do not require the facility to formally request and receive prior approval from CMS These waivers are not cited during the survey process These waivers do require notification of the intent to use the waiver The waivers are documented in the initial comments of all surveys
2012 LSC Waivers How is notification accomplished? A template letter has been created for facilities Complete the template letter and forward to DSI The facility will receive a response letter for their survey file to produce at future Life Safety Code surveys
S&C-12-21-LSC 2012 LSC and culture change The Pioneer Network, Rothschild Foundation and other groups worked with NFPA to make changes to support the culture change movement in long term care
S&C-12-21-LSC LSC section 18/19.2.3 Capacity of Means of Egress and more specifically the requirements at 18/19.2.3.4 which allow, under certain circumstances, projections into the means of egress corridor width for wheeled equipment, fixed furniture and non-continuous projections
S&C-12-21-LSC LSC section 18/19.3.2.5 Cooking Facilities, more specifically the requirements at 18/19.3.2.5.2, 18/19.3.2.5.3, 18/19.3.2.5.4 and 18/19.3.2.5.5 which allow certain types of alternative kitchen cooking arrangements
S&C-12-21-LSC LSC section 18/19.5.2 Heating, Ventilating, and Air Conditioning, more specifically the requirements at 18/19.5.2.3(2), (3) and (4) which allow the installation of direct vent gas fireplaces in smoke compartments containing patient sleeping rooms
S&C-12-21-LSC LSC section 18/19.7.5 Furnishings, Mattresses, and Decorations, including section 18/19.7.5.6 which allows the installation of combustible materials on walls, doors and ceilings
S&C 13-58-LSC Additional provisions added as waiver items: Medical Gas Alarm Panels Openings in Exit Enclosures Emergency Generators Door Locking Arrangements Suites Testing of Waterflow Devices and Pumps Recycling Containers
S&C 13-58-LSC Openings in exit enclosures Existing unoccupied mechanical spaces with firerated doors may open into an exit enclosure in accordance with Section 7.1.3.2(9)(c) of 2012 NFPA 101 Space must only contain non-fuel-fired mechanical equipment No combustible storage Fully sprinklered building
S&C 13-58-LSC Emergency generators Annual load bank testing for diesel-powered generators reduced from 2 continuous hours to 1 hour and 30 minutes per Section 8.4.2.3 of 2010 NFPA 110 All other testing and inspection requirements must be met
S&C 13-58-LSC Door locking arrangements Expansion of special locking arrangements to areas where the patients pose a security risk or where patients require specialized protective measures for their safety per Sections 18/19.2.2.2.2 18/19.2.2.2.6 Emergency departments with secure holding rooms Pediatric/nursery units
S&C 13-58-LSC Waterflow and pump testing Quarterly testing of vane-type and pressure switch type waterflow devices extended to semiannual testing per Sections 2-3.3 and 5-3.2 of 2011 NFPA 25 Weekly testing of electric motor-driven pump assemblies extended to monthly per Sections 5.3 and 8.3 of 2011 NFPA 25
S&C 13-58-LSC Recycling containers Increase in size of containers used solely for recycling of clean waste or patient records awaiting destruction from 32 gallons to 96 gallons when outside of a hazardous storage area per Section 18/19.7.5.7.2 of 2012 NFPA 101 Note that the containers must be compliant with FM 6921
2012 LSC Waivers There have been common errors in waiver election letters, specifically with door locking devices
Door Locking Arrangements The 2012 LSC details two different scenarios: Areas where the clinical needs of patients require specialized security measures or where patients pose a security threat Areas where patients require specialized protective measures for their safety
Door Locking Arrangements Specialized security measures or where patients pose a security threat Examples given are dementia units, psychiatric units and forensic/detention units These doors may be locked with the provision that staff can readily unlock doors at all times This language is essentially the same as the 2000 LSC
Door Locking Arrangements Areas where patients require specialized protective measures for their safety Examples given are emergency departments, pediatric units and maternity units These arrangements were not specifically addressed in the 2000 LSC and are the only areas requiring a waiver
Categorical Waivers What happens to all the categorical waivers that facilities have elected to use when CMS adopts the 2012 LSC? The waivers are based on the 2012 LSC, therefore the facility will be compliant with the 2012 without the continued use of the waiver
Other 2012 Changes Annual fire door inspection requirement in accordance with NFPA 80 A written record that is signed and dated by the knowledgeable individual performing the inspection must be maintained and made available to the AHJ Training available?
2012 NFPA 99 Changes System Verification Testing shall be conducted by a party technically competent Must meet the requirements of ASSE 6030, Professional Qualifications Standard for Medical Gas Systems Verifiers
2012 NFPA 99 Changes System Maintenance Persons maintaining the medical gas systems shall be qualified through one of the following: Training and certification through the health care facility on the specific equipment installed in the facility ASSE 6040, Professional Qualifications Standard for Medical Gas Maintenance Personnel ASSE 6030, Professional Qualifications Standard for Medical Gas Systems Verifiers
2012 NFPA 99 Changes System Maintenance Continued Training and certification through the health care facility on the specific equipment installed in the facility Training program/policy/procedure and certification documentation would be required to demonstrate compliance
CMS Proposed Changes Significant items to note: NFPA s 4 or more residents, but CMS is 1 or more NFPA permits 6 inch corridor projections, but ADA only permits 4 inch projections No roller latches, positive latching only for corridor doors
CMS Proposed Changes Significant items to note (continued): NFPA increases fire watch/evacuation requirements to when the sprinkler system is out of service for 10 or more hours in a 24 hour period CMS proposes to keep the current requirement of 4 or more hours in a 24 hour period
CMS Proposed Changes Significant items to note (continued): CMS proposes to not adopt the emergency preparedness requirements in 2012 NFPA 99, due to working on their own requirements
Plan of Correction The most common rejection is due to not including the 4 required items: The fix Date fixed Plan to keep from having to fix again Monitoring the fix to make sure it stays fixed
Plan of Correction Another common rejection is in reference to correcting penetrations of fire-rated assemblies For example The penetration will be sealed The penetration will be filled with fire caulk The penetration will be sealed using UL approved specific product and manufacturer
Plan of Correction Why would that get rejected? As we stated before, a POC is a plan that includes 4 parts In addition, a penetration must be sealed with a through-stop penetration system We will not approve or promote the thought that one part of the system is an appropriate plan of correction
Plan of Correction This: Not this:
Plan of Correction If your POC gets rejected, you will receive an email from the individual reviewing the POC with a reason for rejection Do not resubmit the exact same thing that just got rejected Read the reason for rejection, and if you have any questions, please contact the POC reviewer
Plan of Correction Federally certified nursing homes: Must correct deficiencies within 90 days of the exit of the survey or CMS will deny payments for new admissions Must correct deficiencies within 180 days or CMS will terminate the facility from the program
POC and Time-Limited Waivers If correction of a LSC deficiency is going to take more than 90 days, a Time-Limited Waiver (TLW) must be requested The TLW is to be requested at the Plan of Correction (POC) of the initial LSC survey. If requested later, there is no guarantee that it will be approved by CMS within the survey track timeframe for the survey
POC and Time-Limited Waivers Field offices are a great resource for what information is required within the TLW request letter and for sample letters All TLW requests are reviewed by the field office and forwarded to central office Upon review by central office, TLW s can then be recommended to CMS
POC and Time-Limited Waivers There is no specific timeframe that CMS responds to TLW requests. Depending on their schedule, it can be two weeks or possibly two months
Questions?
Contact Information Charlie Schlegel Director Department of Health Division of Safety Inspection 2150 Herr St., 1st Floor, Ste A. Harrisburg, PA 17103 Phone: 717.787.1911 Fax: 717.787.1491 www.health.state.pa.us cschlegel@pa.gov