LeadingAge Maryland Update April 24, 2017 Office of Health Care Quality Protecting the health and safety of Marylanders
Today s Presentation Overview of OHCQ Nursing Homes Assisted Living Programs IDR (Informal Dispute Resolution) Process HCQA Grants
Office of Health Care Quality OHCQ s mission is to protect the health and safety of Marylanders and to ensure there is public confidence in the health care and community service delivery systems
OHCQ Functions Issue licenses, authorizing the operation of a business in Maryland Recommend certifications to CMS, authorizing participation in the Medicare and Medicaid programs Conduct surveys to determine compliance with State and federal regulations, which set minimum standards for the delivery of care Educate providers, consumers, and other stakeholders
OHCQ Organizational Chart Executive Director Chief of Staff Deputy Director of Federal Programs Deputy Director of State Programs Director of Administration Director of Quality Initiatives Long Term Care Assisted Living and Adult Medical Day Care Budget and Accounting Hospital Patient Safety Hospitals Developmental Disabilities Human Resources Ambulatory Care Behavioral Health Information Technology Clinical and Forensic Laboratories
What is OHCQ s role? Trust the provider, but verify compliance with the regs
OHCQ Oversees 61 Provider Types Birthing Centers Comprehensive Outpatient Rehab Facilities Cosmetic Surgery Centers Freestanding Ambulatory Surgery Centers Freestanding Dialysis Centers Health Care Staff Agencies Home Health Agencies Hospices and Hospice Houses Major Medical Equipment Providers Nurse Referral Service Agencies Outpatient Physical Therapy Centers Portable X-ray Providers Residential Service Agencies Surgical Abortion Facilities Intermediate Care Facilities Forensic Residential Services Nursing Homes Adult Medical Day Care Assisted Living Facilities Cholesterol Testing Sites Cytology Proficiency Testing Employer Testing Labs Federal Waived Labs Forensic Labs Health Awareness Test Sites Hospital Labs Independent Reference labs Physician Office & Pointof-Care (State & Federal) Public Health Testing Tissue Banks DD Respite Services Group Homes Habilitation Services Individual and Family Support Services Intensive Treatment Programs Adult Group Homes Ambulatory Detoxification Programs Correctional Substance Abuse Programs Education Programs Mental Health Vocational Programs Mobile Treatment Services Opioid Maintenance Therapy Programs Outpatient Mental Health Centers Outpatient Treatment Programs Psychiatric Day Treatment Services Psychiatric Rehabilitation Programs for Adults Psychiatric Rehabilitation Programs for Minors Residential Crisis Services Residential Detoxification Programs Residential Programs Residential Rehabilitation Services Respite Care Services Therapeutic Group Homes Therapeutic Nursery Programs Community Mental Health Centers Correctional Health Care Facilities Federally Qualified Health Centers Freestanding Medical Facilities HMOs Hospitals Patient Safety Programs Residential Treatment Centers
Number of Providers Overseen by OHCQ by Fiscal Year, 2014 2017 14,452 15,043 16,499 18,032 FY 14 FY 15 FY 16 FY 17 Number of Providers
Regulatory Efficiency and Effectiveness Fiscal Year Surveyor Staffing Deficit 2013 107.09 2014 67.90 2015 52.50 2016 52.15 2017 46.05 Fiscal Year Number of Providers 2013 13,000 2014 14,452 2015 15,043 2016 16,499 2017 18,032 Over the past four years, there was a 39% increase in the number of providers with a corresponding 1% increase in OHCQ s total positions and contractual employees
Strategic Planning Process 1. Regulatory Efficiency and Effectiveness: Efficient and effective use of limited resources to fulfill our mandates 2. Core Operations: Focus on core business functions and maintaining accountability 3. Customer Service: Consistent, timely, and transparent interactions with all stakeholders 4. Quality Improvement: Sustain a quality improvement process within OHCQ
Nursing Homes
OHCQ Long Term Care Unit Tricia Nay Executive Director Margie Heald Deputy Director of Federal Programs Vanessa Leuthold Program Manager Admin. Support Complaint Unit MDS Coordinator Ranada Cooper Coordinator Frances Curtis Coordinator Jackie Cooper Coordinator Patti Melodini Coordinator Beth Bremner Coordinator Kathy Schoonover Nurse Administrator Surveyors Envir. Safety Surveyors Surveyors Surveyors Surveyors Surveyors
Nursing Homes Unit of Measurement FY14 FY15 FY16 Number of licensed nursing homes 232 232 230 Initial surveys of new providers 1 2 0 Full surveys 217 199 199 Follow-up surveys 35 39 41 Civil monetary penalties levied 55 45 54 Denial of payment for new admissions 3 3 5 Complaints and facility self-reported incidents 3,392 2,968 2,486 Complaints and self-reported incidents, no further action 449 287 429 Complaints and self-reported incidents, investigated 2,932 2,460 2,057 Quality of care allegations 2,291 1,949 2,670 Resident abuse allegations 1,128 913 1,254
Scope and Severity Matrix Immediate jeopardy to resident health or safety (4) J K L Substandard quality of care, 221-226, 240-258, 309-333 Substandard quality of care, 221-226, 240-258, 309-333 Substandard quality of care, 221-226, 240-258, 309-333 Actual harm that is not immediate jeopardy (3) G H I No actual harm with potential for more than minimal harm that is not immediate jeopardy (2) No actual harm with potential for minimal harm (1) Substandard quality of care, 221-226, 240-258, 309-333 D E F A B Substandard quality of care, 221-226, 240-258, 309-333 Substandard quality of care, 221-226, 240-258, 309-333 C Substantial compliance Substantial compliance Substantial compliance Isolated (1) Pattern (2) Widespread (3)
CMS Deficiency Categorization Instructions Guidance on Severity Levels Level 1: A deficiency that has the potential for causing no more than a minor negative impact on the residents. Level 2: Results in minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential to compromise the resident s ability to maintain and/or reach the highest practicable level. Level 3: Noncompliance that results in a negative outcome that has compromised the resident s ability to maintain and/or reach the high practicable level. Level 4: Immediate jeopardy, a situation in which immediate corrective action is necessary because the provider s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, serious harm, impairment, or death to a resident.
CMS Deficiency Categorization Instructions Guidance on Scope Levels Isolated: One or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations. Pattern: More than a very limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the facility. Widespread: The problems causing the deficiencies are pervasive in the facility or represent systemic failure that affected or has the potential to affect a large portion of all of the facility s residents.
CMS Deficiency Categorization Instructions Guidance on General Procedures Determine severity and then scope of the practice. When determining scope, evaluate the cause of the deficiency. If the facility lacks a system/policy (or has an inadequate system) to meet the requirements and this failure has the potential to affect a large number of residents in the facility, then the deficient practice is likely to be widespread. If an adequate system/policy is in place but is being inadequately implemented in certain instances, or if there is an inadequate system with the potential to impact only a subset of the facility s population, then the deficient practice is likely to be a pattern. If it affects or has the potential to affect one or a very limited number of residents, then the scope is isolated.
Most Frequently Cited Federal Deficiencies in Nursing Homes in FY 16 Federal Tag Description of Tag Total Citations F 309 Provide care and services for highest well being 169 F 514 Resident records, complete, accurate, and accessible 145 F 279 Develop comprehensive care plans 118 F 323 Free of accidents, hazards, supervision, devices 103 F 329 Drug regimen is free from unnecessary drugs 93 F 278 Assessment accuracy, coordination, certified 90 F 280 Right to participate in planning care, revise care plan 90 F 431 Drug records, label, store drugs and biologicals 88 F 371 Food procurement, store, prepare, and serve, sanitary 81 F 281 Services provided meet professional standards 78
Number of Actual Harm and Immediate Jeopardy Deficiencies by Federal Tag in SFY 15 Federal Description of Tag G H I J K L Tag F 151 Right to exercise rights, free of reprisal 1 F 155 Right to refuse, formulate advance directives 7 1 1 F 157 Notify of changes (injury, decline, room) 4 F 223 Free from abuse, involuntary seclusion 1 F 224 Prohibit mistreatment, neglect, and misappropriation 1 F 225 Investigate and report allegations 1 1 F 279 Develop comprehensive care plans 1 F 309 Provide care and services for highest well being 5 1 F 314 Treatment and services for pressure sores 1 F 318 Increase or prevent decrease in range of motion 1 F 323 Free of accidents, hazards, supervision, devices 12 2 1 1 F 327 Sufficient fluid to maintain hydration 1 F 329 Drug regimen is free from unnecessary drugs 1 2 F 385 Residents care supervised by a physician 2 F 431 Drugs records, label, store drugs and biologicals 1 F 501 Responsibilities of medical director 1 1 F 502 Administration 1 F 511 Radiology findings, promptly notify physician 1 Tags at G or above 54 38 4 0 5 6 1
Number of Actual Harm and Immediate Jeopardy Deficiencies by Federal Tag in SFY 16 Federal Description of Tag G H I J K L Tag F 155 Right to refuse, formulate advance directives 4 1 F 157 Notify of changes (injury, decline, room) 2 F 223 Free from abuse, involuntary seclusion 2 1 F 224 Prohibit mistreatment, neglect, misappropriation 5 F 272 Comprehensive assessments 1 F 309 Provide care and services for highest well being 6 1 1 1 F 314 Treatment and services for pressure sores 7 1 1 F 315 No catheter, prevent urinary tract infection 1 F 319 Treatment/services for mental and psychosocial 1 F 323 Free of accidents, hazards, supervision, devices 18 3 2 F 325 Maintain nutritional status unless unavoidable 1 F 328 Treatment and care for special needs 1 F 329 Drug regimen is free from unnecessary drugs 2 F 333 Residents are free of significant med errors 1 F 441 Infection control, prevent spread, linens 1 F 501 Responsibilities of medical director 1 F 505 Promptly notify physician of lab results 1 F 520 Quality assurance committee 1 Tags at G or above 68 44 2 0 14 8 0
Number of Actual Harm and IJ Deficiencies by Federal Tag in SFY 17 YTD (July March) Federal Tag Description of Tag G H I J K L F 152 Legal surrogate 1 2 F 155 Right to refuse, formulate advance directives 1 5 F 156 Notice of rights and services, advance directives 1 1 F 157 Notify of changes (injury, decline, room) 1 2 1 F 201 Transfer and discharge requirements 1 1 F 203 Notice before transfer 1 F 204 Orientation for transfer or discharge 1 1 F 223 Free from abuse, involuntary seclusion 3 1 1 F 225 No employment of individuals guilty of abuse or neglect 1 1 F 280 Right to participate in planning care, revise care plan 1 F 284 Post-discharge plan of care 1 1 F 309 Provide care and services for highest well being 4 2 1 1 F 314 Treatment and services for pressure sores 3 F 323 Free of accidents, hazards, supervision, devices 12 9 1 F 329 Drug regimen is free from unnecessary drugs 1 1 F 333 Residents are free of significant med errors 1 F 353 Sufficient nursing staff 1 F 371 Food procurement, store, prepare, and serve, sanitary 1 F 385 Residents care supervised by a physician 1 F 441 Infection control, prevent spread, linens 1 1 F 490 Administration 2 F 501 Responsibilities of medical director 1 F 520 Quality assurance committee 1 Tags at G or above 75 25 0 0 28 11 11
Number of Actual Harm and IJ Deficiencies by SFY Year Number of Tags G H I J K L 2015 54 tags at G or above 38 4 0 5 6 1 2016 68 tags at G or above 44 2 0 14 8 0 2017 75 tags at G or above (July March) 25 0 0 28 11 11
Federal Remedies July 22, 2016 CMS memo: Mandatory Immediate Imposition of Federal Remedies and Assessment Factors Used to Determine the Seriousness of Deficiencies for Nursing Homes
Federal Remedies CMS must now immediately impose a CMP any time an IJ is cited Irrespective of a state recommendation to impose or not impose a remedy, the CMS RO must immediately impose, without permitting a facility an opportunity to correct deficiencies, one or more federal remedies based on the seriousness of the deficiencies or when actual harm or Substandard Quality of Care (SQC) is identified.
Federal Remedies Category 2 remedies: CMS added termination and temporary management as possible remedies
Past Noncompliance
Citations of Past Noncompliance Past noncompliance may be identified during any survey of a nursing home Cited more frequently during complaint investigations and reviews of self-reported incidents Can be cited during health and life safety code surveys Civil money penalty may be imposed by CMS for the number of days of past noncompliance
Criteria for Citing Past Non-compliance 1. Facility was not in compliance with the specific regulatory requirement at the time the situation occurred; 2. Noncompliance occurred after the exit date of the last standard (annual recertification) survey and before the current survey; and 3. Sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey.
Facility Actions when Violation is Identified Facility should develop and implement a plan of correction as soon as possible Plan needs to include all the components of an acceptable plan of correction Provide this information as part of the investigation if related to a self-reported incident Provide this information to the surveyor if an on-site investigation occurs
Nursing Home Plan of Correction
Five Elements of a Nursing Home PoC 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur This requires analysis of cause
Five Elements of a Nursing Home PoC 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. This requires analysis of cause 5. Include dates when corrective action will be completed
How do I manage all of these regulations? Consistently do the right thing for the resident Document what you did and why you did it
Assisted Living Programs
Assisted Living Unit Org Chart Deputy Director, State Programs Carol Fenderson Program Manager Shawn Settles 1 Adm. Specialist 2 Office Service Clerks 1 Sanitarian Coordinator, Waiver Unit Vacant Coordinator, Licensure Unit Shaliek Maxwell-West Coordinator, Unlicensed AL and AMDC Lisa Turnage Coordinator, Complaint Unit Laura Norman 7 Nurse Surveyors 7 Nurse Surveyors 2 AMDC Nurse Surveyors 2 AL Unlicensed Nurse Surveyors 2 Nurse Surveyors 7 Nurse Surveyors 1 Office Secretary
Assisted Living Programs Units of Measurement FY14 FY15 FY16 Number of licensed assisted living programs 1,482 1,497 1,531 Renewal surveys 679 1,038 992 Initial surveys 109 162 196 Other surveys 62 156 204 Complaints received 903 1,307 1,534 Complaints investigated 683 1,217 923
Types of Assisted Living Surveys Initial or pre-licensing survey Renewal or annual survey Level of care survey Licensure standard waiver survey Bed increase survey Follow-up surveys Investigation of unlicensed facilities
Most Frequently Cited Deficiencies in State Tag Assisted Living Programs in FY 16 Description of Tag Number of Citations 3680 Medication Management and Administration 304 2780 Delegating Nurse 281 3330 Service Plan 275 4630 General Physical Plant Requirements 274 2600 Other Staff - Qualifications 245 2530 Alternate Assisted Living Manager 194 2550 Other Staff - Qualifications 165 2560 Other Staff - Qualifications 159 2220 Assisted Living Manager 153 4900 Emergency Preparedness 153
Assisted Living Plan of Correction (PoC) An acceptable PoC demonstrates to a reasonable degree of certainty that the provider is able to furnish adequate care that meets minimum standards and which does not jeopardize the health and safety of residents
Assisted Living PoC 1. How are you going to correct the deficiency? 2. What is the date when you will have each deficient practice corrected? 3. How are you going to prevent the deficient practice from recurring 4. Who will be responsible for ensuring that the deficiency does not recur?
PoC Acceptability An acceptable plan of correction demonstrates a path to both achieve and maintain compliance leading to improved quality of care With all four elements, the plan has to be both: Reasonable (can be implemented) Credible (will fix the concern)
Informal Dispute Resolutions
Informal Dispute Resolution Process by which a provider disputes part or all of a deficiency Requested by a provider after SOD is issued Cover letter for an SOD includes information regarding the provider s right to request an IDR Request should include the reason for the dispute Supporting documents should be attached An incomplete IDR process will not delay the effective date of any enforcement action
IDRs are Informal Presentations are not by attorneys Proceedings are not under the formal rules of evidence There is no formal stenographer There is no testimony under oath
Potential Benefits of an IDR Remove or lessen the deficiency Modify the deficiency to accurately reflect the facts Put the deficiency under a different tag Remove or lessen a civil money penalty Gain credibility with your competence Improve the quality of the survey process Make an ethical point
Potential Downsides of an IDR The time needed for preparation The effort needed for preparation The cost associated with preparation The emotional drain on everyone involved Loss of credibility
Provider s Rationale Additional facts Misinterpretation of information First-hand account that clarifies the issue Full explanation of the issue Additional documentation Studies that support your actions
Provider s Preparation Read the deficiency Determine what you will dispute Reread the deficiency IDR focuses on if the practice is deficient or not Other topics are not discussed during the IDR, but will be addressed in other ways Complaints about a specific surveyor are handled through the State s HR system
Quality of Evidence Administrator s written statement that maintenance checked the hot water temp. on the morning of the incident DON s written statement that 7 employees attended a CPR course, but the certificates were all lost Blog from a European doctor about his opinion on managing diabetes The maintenance employee comes to the IDR and explains what he did on the morning of the incident Seven employees, in their own words, document in writing that they attended a CPR course on a given day New England Journal of Medicine peer-reviewed article on managing diabetes
Discussion at the IDR After introductions and an explanation of the process, the provider is asked to explain their disagreement with each deficiency that is disputed The provider leads the presentation of their information During the discussion, clarifications and additional facts from both sides will be elicited
Ineffective Strategies Screaming does not mean screaming Pain does not mean pain Arguing clinical judgment without any clinical rationale to support the decision Arguing that the survey process itself is unfair I will lose my job I won t get my bonus Don t sacrifice your credibility
After the IDR After your presentation, the provider leaves and OHCQ personnel remain to discuss it or arrange a time to discuss it OHCQ reviews the written deficiency, the regulations, and any additional information that was provided We may ask for additional information from the provider after the IDR Generally we contact the provider within one week with our decision
Is there a winner in an IDR? The common goal of both sides should be to arrive at the truth via a fair process At the end of the process, both sides may have to agree to disagree on the final decision
Outcomes of Nursing Home IDR and IIDR by Federal Tag, 9/1/15 3/23/17 Example removed 20% S/S changed, example removed 1% No change 22% Tag changed 2% Scope/severity changed 6% Tag removed 40% 139 federal tags
Reasons for Nursing Home Informal Dispute Resolution Decisions, 9/1/15 3/23/17 Inaccurate facts 5% Wording change 6% Other 13% 139 federal tags No change 34% Insufficient evidence 10% Facility non-culpable 5% Additional info provided 28%
Health Care Quality Account Grants
Health Care Quality Account Grants Funds collected from civil money penalties imposed by CMS or OHCQ to nursing homes and by OHCQ to assisted living programs Support activities that improve the quality of life of individuals who reside in NHs and ALPs. Three non-lapsing special funds: Federal nursing home account State nursing home account State assisted living account
Grant Applications Applications are accepted throughout the year Grants are awarded on a rolling basis, contingent on funding Committee reviews the applications: OIG, OAG, and from OHCQ Executive Director, Chief Fiscal Officer, Deputy Director of Federal Programs, Deputy Director of State Programs, and Chief Nurse CMS must approve the use of federal funds
Grant Awards in State FY 2016 In State FY 2016, OHCQ awarded seven grants totaling $518,091.50 Beacon Institute, $225,000 Eastern Shore Area Health Education Center, $27,715 Charles E. Smith Life Communities (Hebrew Home of Greater Washington), $43,590 Beacon Institute, $8,750 Eastern Shore Area Health Education Center, $8,337.50 Mid-Atlantic Public Health Training Center, The Johns Hopkins Bloomberg School of Public Health, $119,709 Beacon Institute, $84,990
Available Funds for HCQA Grants Funds available for grants as of November 4, 2016: Account Balance Federal nursing home 1,945,996 State nursing home 244,546 State assisted living 12,588 Total $2,203,130
Contact Information Margie Heald 410-402-8101 margie.heald@maryland.gov Carol Fenderson 410-402-8047 carolm.fenderson@maryland.gov Tricia Tomsko Nay 410-402-8055 tricia.nay@maryland.gov
Our common ground is the individuals that we serve