The request for informal dispute must be made within the same 10 calendar day period the facility has for submitting an acceptable plan of correction

Katrina Magdon Latest Edition July 2014 Obtained from the American Health Care Association www.ahcancal.org or the Alabama Nursing Home Association at 334-271-6214 Five Sections Section 1 - Medicare and Medicaid Requirements for Long Term Care Facilities 42 CFR Part 483, Subpart B Section 2 Survey Protocol Section 3 Survey Procedures for Long Term Care Facilities Section 4 Guidance to Surveyors/Appendix PP Section 5 Exhibits Online version available with search capabilities Chapter 7 SOM Survey and Enforcement April 2014 Revisions to Appendix PP of the SOM: The Centers for Medicare and Medicaid Services (CMS) has revised the Interpretive Guidelines and, where appropriate, Investigative Protocols for the following F Tags to incorporate Survey & Certification (S&C) policy memos issued from October 2003 through May 2014. Specifically, the guidelines have been updated for the following F Tags: F161 - Assurance of Financial Security F202 - Documentation for Transfer and Discharge F208 - Admission Policy F221 - Physical Restraints F278 - Accuracy of Assessment/Coordination/Certification/Penalty for Falsification F281 - Services Provided Meet Professional Standards of Quality F286 - Maintaining 15 Months of Resident Assessments (Use) F332 - Medication Errors/Free of Medication Errors of 5% or Greater F333 - Medication Errors/Residents are Free of Significant Medication Errors F371 Sanitary Conditions F387 - Frequency of Physician Visits/Timeliness of Visits F388 - Personal Visits by the Physician F390 - Physician Delegation of Tasks in SNFs/Performance of Physician Tasks in NFs 1

Revisions to Appendix PP of the SOM: The Centers for Medicare and Medicaid Services (CMS) has revised the Interpretive Guidelines and, where appropriate, Investigative Protocols for the following F Tags to incorporate Survey & Certification (S&C) policy memos issued from October 2003 through May 2014. Specifically, the guidelines have been updated for the following F Tags: F425 - Pharmacy Services F428 - Drug Regimen Review F431 - Service Consultation/Labeling of Drugs and Biologicals/Storage of Drugs and Biologicals F441 - Infection Control F492 - Compliance with Federal, State and local laws and Professional Standards F514 - Clinical Records F516 - Resident Identifiable Information/Safeguard against loss, destruction, or unauthorized use Latest Edition Amended May 25, 2005 Downloaded from www.adph.org Laws and Regulations Healthcare Facility Licensure Rules/Provider Services Nursing Facilities Similar to Federal Requirements Exceptions Definitions Licensing and Administrative Procedures Administrative Management Personnel Pharmacy Services Physical Plant Process Established by the State Must Be in Writing and Available for Review Upon Request Facilities must be offered one informal opportunity, if they request it, to dispute deficiencies with the entity that conducted the survey The notification regarding the availability of informal dispute is in the letter sent with the CMS- 2567 (Statement of Deficiencies) Request for informal dispute must be in writing and contain an explanation of the specific deficiencies that are being disputed 2

The request for informal dispute must be made within the same 10 calendar day period the facility has for submitting an acceptable plan of correction Effective July 1, 2004 IDR outside of DHCF 3 member panel 2 nurses (AUM, Troy State, UAB, etc.) and 1 ALJ Training of Panel - DHCF Decision binding Reminder All facility documents provided during or after a Medicare/Medicaid Survey are under the control of CMS Updated August 11, 2014 Facility has additional 14 days to submit additional information AFTER IDR request submitted ANHA request Survey staff in training permitted to attend IDT meeting as observers If ADPH deletes disputed tags and sends a revised 2567 after request for IDR has been made, then it must be reported to CMS as if the IDR had taken place 3

Escrowing CMPs initially done ONLY for most egregious deficiencies (G and above) IIDRs directly linked with escrowing of CMPs Escrowing occurs on date IIDR is completed OR 90 days after notice of imposition of CMPs IDR (regular process) still available October 1, 2013 all CMPs are subject to escrow Uncertain how frequently the escrow provision has been used Purpose to promote more consistent application of enforcement remedies Effective April 1, 2013 for 6 months (end of September) For S/S F when substandard quality of care is NOT cited and all S/S lower than F consider remedy OTHER than CMP Guidance on: Use of per instance or per day CMP Date to begin CMP CMPs for past non-compliance 2010 $1,211,101(imposed and collected) $910 - $368,550 32 facilities (3 per instance) 2011 $1,019,315(imposed and collected) $260 - $171,535 45 facilities (3 per instance) 2012 $227,363 (imposed and collected) $293 - $52,475 18 facilities (no per instance) 4

2010 $13, 942,889(imposed) $12,752,225 (collected) 2011 $15,931,161 (imposed) $ 5,351,205 (collected) 2012 $18,633,836 (imposed) Alabama $227,363 (imposed - 1%) $16,097,683 (collected) CMS Issued Guidance 12/16/11 S&C Letter 12-13-NH Requires CMS to approve use of CMP Funds Restrictions on what they can be used for Atlanta Regional Office Must Approve Alabama Only Few Projects Approved CMP Uses Must have expected outcomes/benefits for residents Must be measured Cannot supplant responsibilities for nursing home to meet existing CMS requirements Consumer and other Stakeholder Involvement Two Categories Opportunity to Correct No Opportunity to Correct State Agency Must Determine Which Category a Facility Falls Into 5

The Regional Office or State Medicaid Agency Should Impose Another Remedy in Addition to Termination for a Facility Not Being Given an Opportunity to Correct No Notice Requirement for State Monitoring Denial of Payment for New Admissions can be imposed 15 calendar days from the date the provider received notice Facilities can appeal enforcement action directly to the Departmental Appeals Board in the Office of the Secretary, HHS Termination Automatic after 6 months if facility not in substantial compliance Denial of Payment for New Admissions Automatic after 3 months if facility is not in substantial compliance NOT GUARANTEED Facilities May Be Given an Opportunity to Correct Before Remedies Are Imposed When They Have No Deficiencies at or Above G Level on the Current Survey or on the Previous Standard or Any Intervening Survey According to CMS, once a facility has been given the opportunity to correct, its status should continue and not be rescinded by subsequent G level findings and subsequent double G status. Once the findings are made and if those findings now place the facility into a mandatory no opportunity to correct status, sanctions in response to these subsequent findings should be imposed immediately. 6

Have Deficiencies at or Above G Level on the Current Survey or on the Previous Standard or Any Intervening Survey Facilities Previously Terminated That Currently Have Deficiencies at G Level or Above on the first survey after Re-entry Into the Program Facilities That Have Immediate Jeopardy Noncompliance against which a per instance CMP was imposed States Have the Discretion to Establish Additional Guidelines Facilities With Serious Compliance Problems on the Current Survey. In Order to Determine This, Consideration at a Minimum Is Given To: Scope and Severity of the Deficiency Willingness and Ability of the Provider to Correct the Deficiency Effectiveness of the Provider s Quality Assurance and Monitoring System to Prevent Recurrence of the Deficiency 7

Abuse The facility must ensure that ALL alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) Thorough investigations Facility fails to take action on verbal and physical abuse Failing to report Failing to take appropriate action resident to resident F309 Quality of Care Failing to provide treatments to a surgical wound as ordered electronic medical records MRSA Failing to assess for pain and provide pain medications to a resident who fell fractured hip without treatment for more than 6 hours F323 Incidents and Accidents Elopement brought back by members of the community Failed to safely transport a resident after a fire on a backboard (not secured) resident fell ANHA approached DHCF to consider granting waivers to rural facilities that would loose their Nurse Aide Training Programs because of Enforcement Remedies DHCF indicates that waivers will be granted in accordance with CMS policy. Facilities must apply and meet criteria for a waiver. 24 8

CMS-2567 Should Be Sent to Facilities 10 Working Days After Last Day of the Survey Revisit Will Occur Between the Date of the Presumed Compliance and the 60th Day Validation Survey Occurs Within 30 days of the State Survey If you receive a letter from CMS regarding the imposition of a CMP, you only have 60 days from receipt of the letter to waive the right to a hearing so that you can receive a 35% reduction in the amount of the fine or to appeal. Those facilities that do not respond to CMS in writing to waive the right to a hearing are being imposed the full amount of the fine, even though they did not request a hearing or appeal. If you receive a letter from CMS regarding the imposition of a CMP, you only have 60 days from receipt of the letter to request a CMS appeal before an Administrative Law Judge. 9

Number of Revisits Two are permitted at the State s discretion Third revisit at the discretion of the Regional Office Regional Offices are limited to approving only a total of three revisits Results of Sequestration Regional Office has to approve 2 nd Revisit Providers may experience longer wait times prior to revisit Circumstances when a facility will receive a licensure statement of deficiencies (L Tags) in addition to a federal statement of deficiencies (F tags). Facilities can expect a licensure statement of deficiencies under the following circumstances: 1. For every survey of a licensure-only facility 2. For surveys of certified facilities, a final decision whether to generate a licensure statement of deficiencies will be made by senior management of the Bureau of Health Provider Standards. Situations that will likely lead to a licensure statement of deficiencies include: a. For surveys where there are federal deficiencies rising to the level of actual harm, substandard quality of care, or immediate jeopardy b. For surveys with significant repeat deficiencies c. For surveys that occur within 60 days of a facility s federal termination date d. For surveys of special focus facilities e. For surveys of facilities with a probational license Daily Conferences Clear and timely communication with facility administration and staff Surveyors to conduct mini-conferences to give an update on the progression of the survey and proposed survey determinations as have been completed Thorough Exit Conferences Reasonable efforts will be made to answer facility s questions Ensure that the nature and basis of the deficient practice that will be proposed for citations is well understood by the facility Surveyors must follow SOM (Facility must be provided an opportunity to present additional information DHCF should be notified if procedures not followed DHCF committed to offering a thorough and helpful exit conference and places this responsibility on every surveyor, supervisor and senior management staff 10

Determination of IJ & SCQ One or more team members identify IJ Confer with team If team concurs, supervisor consulted Supervisor must Agree Disagree Ask for more information to be gathered If supervisor agrees, Director of Quality Assurance consulted If disagreement exists, Director of DHCF or Deputy Director of Bureau of Health Provider Standards makes the determination No IJ declared without prior notification and approval of Director of Quality Assurance Director of the Bureau of Health Provider Standards, Staff Assistant to the State Health Officer, and the State Health Officer shall be promptly notified by the Director of QA that an IJ or SQC deficiency has been declared Team notifies facility that IJ or SQC deficiency has been declared Shares evidentiary basis for the determination so that administration can begin correcting problem To facilitate abatement of jeopardy surveyor will remain physically present in the building for a reasonable amount of time Length of time considered reasonable shall depend on the nature of the jeopardy citation and the seed in which the facility is able to abate the jeopardy Quality Assurance and Compliance Review Immediately after exit conference Nursing Home Survey Compliance Officer notified of ALL proposed IJ and SQC deficiency citations All deficiencies resulting in immediate sanctions during a recertification visit are prospectively reviewed by the supervisor, Director of QA, and the Nursing Home Survey Compliance Officer Supervisors, Director of QA, and the Nursing Home Survey Compliance Officer are authorized to alter or delete any proposed findings Change tags Change scope and severity determinations 11

Quality Assurance and Compliance Review Director of QA may restore or delete proposed findings after review by the supervisor Director of DHCF, Deputy Bureau Director or Bureau Director are likewise authorized to delete or restore proposed findings and override decisions made at a lower level Only the State Health Officer or the Assistant to the State Health Officer can override decisions made by the Nursing Home Survey Compliance Officer Quality Assurance and Compliance Review Nursing Home Survey Compliance Officer Reviews all information submitted by the facility Consult with Medical Director whenever an issue of medical judgment arises Medical Director shall be provided with all relevant information Medical Director shall consult with individuals treating physician as he deems appropriate to form a professional judgment about care provided May consult with survey team, facility staff, subject-specific experts as needed Decision regarding a proposed deficiency is promptly communicated with survey team and nursing home Submission of Information by the Facility Information submitted timely (within 72 hours of the close of the business day of the exit conference - if unabated jeopardy, timely submission means within 12 hours after the exit conference) directly to the Nursing Home Survey Compliance Officer Written information must contain and explanation of the significance of the submitted documents Nursing Home Survey Compliance Officer provides written confirmation of receipt of additional information Nursing Home Survey Compliance Officer considers the information along with other information gathered and shares information with survey team, supervisor, Director of QA 12

NO LATER than 9:00 a.m. on the third calendar day following the exit. If the third calendar days is a weekend day or a state holiday then the information is due 9:00 a.m. on the next business day after the third calendar day. In the case of unabated immediate jeopardy, the additional information must be submitted within 12 hours after the exit. Check fax machine settings to ensure correct date and time Make sure you keep fax confirmation page Confirmation of information Bernadette Harville 334-206-3079 Substandard Quality of Care - Means one or more deficiencies related to participation requirements under Resident Behavior and Facility Practices (F221-F225); Quality of Life (F240-F258); Quality of Care (F309- F334) AND with a scope and severity of F, H, I, J K or L. Expanded Survey - Means an Increase Beyond the Core Tasks of a Standard Survey. A Standard Survey May Be Expanded at the Surveying Entity s Discretion. When Surveyors Suspect Substandard Quality of Care They Should Expand the Survey to Determine If Substandard Quality of Care Does Exist. 13

Extended Survey - Means a Survey That Evaluates Additional Participation Requirements Subsequent to Finding and Verifies the Existence of Substandard Quality of Care During a Standard Survey. In All Cases of Immediate Jeopardy the Provider Agreement Must Be Terminated No Later Than 23 Calendar Days From the Survey Date If the Immediate Jeopardy Is Not Removed Assess Residents for Risk System in Place to Prevent Accidents/Incidents System Works When Problem Detected If not, System Changed Continuous Training and Education of Staff Regarding System, Recognizing Problems and Any Changes to the System 14

Guidance Issued 2012 Administrator is required to Provide written notification of the impending disclosure A plan for relocation of residents Must be done at least 60 days prior to impending closure Administrator could face sanctions if not done in accordance with guidance CMS Issues S&C 14-01-NH 10/1/13 Reiterates Resident s Rights to Formulate Advance Directives Summary Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times. Facility CPR Policy Some nursing homes have implemented facility-wide no CPR policies. Facilities must not establish and implement facility-wide no CPR policies. Surveyor Implications - Surveyors should ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not reflect instances where CPR was not initiated by staff even though the resident requested CPR or had not formulated advance directives. 15

Beginning in 2015, CMS will implement the following improvements to the Nursing Home Five-Star Quality Rating System: Nationwide Focused Survey Inspections: Effective January 2015, CMS and States will implement focused survey inspections nationwide for a sample of nursing homes to enable better verification of both the staffing and quality measure information that is part of the Five-Star Quality Rating System. Payroll-Based Staffing Reporting: CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information. This new system will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing. Additional Quality Measures: CMS will increase both the number and type of quality measures used in the Five-Star Quality Rating System. Timely and Complete Inspection Data: CMS will also strengthen requirements to ensure that States maintain a user-friendly website and complete inspections of nursing homes in a timely and accurate manner for inclusion in the rating system. Improved Scoring Methodology: In 2015, CMS will revise the scoring methodology by which they calculate each facility s quality measure rating, which is used to calculate the overall Five-Star rating. 16

The Alabama Department of Public Health has published a proposed rule regarding Alabama Notifiable Diseases and Conditions. Listed below is the section that mostly affects facilities: (2) Disease categories. The State Committee of Public Health designates that the notifiable diseases shall be divided into three categories: (a) Immediate, extremely urgent -diseases/conditions notifiable within four hours of presumptive diagnosis; (b) Immediate, urgent diseases/conditions notifiable within 24 hours of presumptive diagnosis; and (c) Standard diseases/conditions notifiable within seven five days of diagnosis, unless otherwise noted. Said notifiable diseases are enumerated in Appendix I. OSHA has launched a new Ebola webpage https://www.osha.gov/sltc/ebola/index.html that provides information about the disease and how to protect workers. It includes sections on the disease itself, hazard recognition, medical information, standards for protecting workers, control and prevention, and additional resources. The page provides protection information for health care workers. It also links to the CDC and NIOSH Web pages on Ebola. The webpage also includes a new OSHA fact sheet (https://www.osha.gov/publications/osha_fs- 3756.pdf) on protecting workers (not in healthcare or laboratories) involved in cleaning and decontamination of surfaces that may be contaminated with Ebola virus. ASPR Ebola Webpage http://www.phe.gov/preparedness/responders/ebola/ Pages/default.aspx CDC Ebola Webpage http://www.cdc.gov/vhf/ebola/ Please note that the Alabama Department of Public Health is working on an Ebola Tool Kit for nursing homes. More information will be forthcoming regarding this as soon as it is available. 17

Focused MDS Survey 5 states (PA, MD, VA, IL, and MN) In addition to regular survey Survey for accuracy and documentation supporting coding decisions Surveyor training done via webinar, no training for provider Announced October 31, 2014 will be expanded to ALL states in early 2015 Scope of focused surveys will be expanded to include an assessment of staffing levels. The assessment will aim to verify the data self-reported by the nursing home and identify changes in staffing levels throughout the year. States will be expected to allocate two surveyors for each survey requiring 2 days on average Survey protocol and tools are being developed Record review, resident observation, and staff and/or resident interview will be used to validate MDS3.0 coding and staffing levels. Focused Dementia Care Survey 5 states (NY, CA, IL, MN, and LA) In addition to regular survey No training for provider Dementia experts to accompany surveyors as additional set of eyes May 2014 (S&C: 14-34-NH) F 314 - Use of Pasteurized/Unpasteurized Eggs Unpasteurized eggs must be fully cooked (internal temperature of 160 F) both yolk and white Pasteurized eggs can be served soft scrambled, soft cooked or sunny side up Use of signed agreements between facility and resident regarding liability is NOT permitted 18

S&C: 14-42-NH Effective August 22, 2014 Training tools are free Six on-line modules lasting about 10 minutes each Video testimonials Quizzes Each address the needs and rights of older LGBT adults http://lgbtagingcenter.org/training/buildingrespect.cfm Issued September 8, 2014 Effective October 9, 2014 Implements the Secure and Responsible Drug Disposal Act of 2010 Expands options available to collect controlled substances from ultimate users for the purpose of disposal, including Take-back events Mail-back programs Collection receptacle locations Expands authority of authorized hospitals/clinics and retail pharmacies to voluntarily maintain collection receptacles at long-term care centers http://www.justice.gov/elderjustice/ Launched in September Serves as a resource for elder abuse prosecutors, researchers, practitioners and for victims of elder abuse and their families Provides forum for law enforcement and elder justice policy communities to share information and enhance public awareness about potential abuse 19

Who Must Report? Covered Individuals Employees Contractors/Vendors Physicians Nurse Practitioners Ancillary Service Providers (dialysis, hospice, ambulance services providers, etc.) When Must These Events Be Reported? Events that cause reasonable suspicion that could/do result in serious bodily injury must be reported within 2 hours of forming such suspicion Events that cause reasonable suspicion that could/do not result in serious bodily injury must be reported within twenty-four hours of forming such suspicion Where are these Reports to be Made? The law requires that we inform local law enforcement of events that give us reasonable suspicion to believe that a crime has been committed against an Elder Usually local police department Streamline approach Develop a policy Develop a Elder Justice Act Facility Reporting Form Contact local law enforcement verbally Document who you spoke to, what you said, and when you made the report Keep with incident reports and not with the medical record Lifts for safety requires 2 person Check Manufacturer guidelines!!! epoc Now required Must enroll www.qtso.com Contact Pam Carpenter or Mia Sadler 334-206-5111 20

Exclusion list False claims - Check Updated LEIE Database! Contractors, nurses, nurse aides, etc. The US Department of Health and Human Services (HHS), Office of Inspector General (OIG) releases updates to its List of Excluded Individuals and Entities (LEIE) database file, which reflects all OIG exclusions and reinstatement actions up to on a quarterly basis. The updated files are posted on OIG s website at https://oig.hhs.gov/exclusions/exclusions_list.asp, and healthcare providers have an "affirmative duty" to check to ensure that excluded individuals are not working in their facilities or face significant fines. Instructional videos explaining how to use the online database and the downloadable files are also available on the OIG website at http://oig.hhs.gov/exclusions/download.asp. Given the penalties and recent government warnings, long term care providers should check the LEIE on a regular basis. Single-Use Device Reprocessing S&C: 14-25- NH Issued May 9, 2014 Nursing homes may purchase reprocessed singleuse devices when these devices are reprocessed by an entity or third party reprocessor that is registered with the FDA Single-use devices (SUD) must be discarded after use and are never used for more than one resident. New Medicaid Alert issued August 20, 2014 Replaced previous Alert issued November 21, 2013 New Administrator of Estate Designation Form Designated administrator may utilize these funds for the payment of burial expenses or for some other use Remaining funds left to the estate may be subject to Medicaid estate recovery 21

Effective September 15, 2014 Nursing home facilities shall maintain documentation regarding the disbursement of any deceased resident funds. This documentation should include the resident s name, Social Security number, the person or entity to which payment was made, and the amount of funds submitted should be forwarded to the attention of the Estate Recovery Unit of the Third Party Division. To satisfy this requirement, nursing homes may choose to fax the completed Administrator of Estate Designation Form to the Alabama Medicaid Agency at 334-353-4820 at the time the funds are disbursed. A streamlined process for making MDS-Q referrals, with reduced The Local Contact Agency is no longer Alabama Department of Rehabilitation Services Gateway to Community Living office at the Alabama Medicaid Agency. Providers are now able to enter referrals into the online system. A dedicated staff person, Ann Duncan (Clairann.Duncan@medicaid.alabama.gov), will be available Monday through Friday at 334-353-3273 to respond to all referrals and provide assistance. For more information, go to http://www.medicaid.alabama.gov/content/4.0_pro grams/4.3.0_ltc/4.3.5_gateway_to_living.aspx Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility Regulations distinguish funds under $50 and those over $50. Funds in excess of $50 constitute pooled Resident Trust Fund Account. Funds in excess of $50. The facility must deposit any residents personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility s operating accounts, and that credits all interest earned on residents funds to that account. (In pooled accounts, there must be a separate accounting for each resident s share.) Funds less than $50. The facility must maintain a resident s personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund. 22

There is federal oversight and regulations providing detailed resident fund protection requirements; There is absolute protection because of the requirement for a surety bond; Resident trust accounts are held to certain very strict standards and defined criteria by the state and federal regulations. This includes an interest bearing bank account and a requirement to provide the resident or family/agent with a quarterly accounting; Nursing facilities must offer residents at the time of admission access to a bonded trust account; The resident must sign a written authorization to be part of the resident trust fund, whether it is direct deposit or by personally depositing funds. This authorization provides the directions for how funds will be managed. For example, the resident can give instructions to pay the monthly share of cost/patient liability (for a Medicaid eligible resident) and/or for personal purchases. A monthly billing statement is system generated to detail the monthly charges and payments; Resident trust fund accounts are audited by surveyors; Typically the nursing facilities reconcile and self-audit the accounts monthly; A representative payee is an individual or organization appointed by SSA to receive Social Security and/or SSI benefits for someone who cannot manage or direct someone else to manage his or her money. The main responsibilities as a representative payee are to use the benefits to pay for the current and foreseeable needs of the beneficiary and properly save any benefits not needed to meet current needs. A representative payee must provide to SSA an accounting of the payee s use of benefits and savings when SSA requests a report from the payee; therefore, keep records of expenses. S&C Memos likely within next 6 months Abuse Alarms Protection of resident funds New Tag F525 likely within next 6 months Addressing contracts between nursing facilities and hospices Expect some global chances to Appendix P and PP within the next year Clarification on who can be on a survey team Common policies between QIS and Standard Surveys Payroll based staffing Voluntary late 2015 Mandatory 2016 23

Quality Assurance and Performance Improvement (QAPI) Focus on Re-hospitalizations Health Care Reform and the Elder Justice Act Medication Safety Reducing Adverse Drug Events Preventing Healthcare Associated Infections Oral Care survey protocol Protection Under QA Documents F441 infection control F371 sanitary conditions (food) F323 accidents/supervision F309 highest well-being F329 unnecessary drugs US F371 sanitary conditions (food) F441 infection control F315 catheterization F253 safe/clean home-like environment F282 services must be provided by qualified personnel AL F431 labeling of drugs F279 comprehensive plan of care F241 - dignity F514 clinical records F282 services must be provided by qualified persons US F323 accidents/supervision F241 dignity F314 pressure ulcers F312 resident receives services to maintain good nutrition/grooming/hygiene F328 proper treatment and care for specialized services AL 24

State # of Residents RN Hours LPN/LVN Hours CNA Hours Total # of Licensed Nurse Per Day Per Day Per Day Staff Per Resident Day AL 100.4 39 minutes 1 hour 3 min 2 hours 38 minutes 1 hours 43 minutes FL 106.2 43 minutes 57 minutes 2 hours 48 minutes 1 hour 41 minutes GA 95.3 31 minutes 1 hour 4 min 2 hours 11 minutes 1 hour 35 minutes KY 80.5 53 minutes 58 minutes 2 hours 31 minutes 1 hour 50 minutes MS 78.9 49 minutes 1 hour 2 hours 26 minutes 1 hour 49 minutes NC 88.5 46 minutes 52 minutes 2 hours 25 minutes 1 hour 38 minutes SC 89.2 51 minutes 58 minutes 2 hours 29 minutes 1 hour 50 minutes TN 91.5 41 minutes 1 hour 2 min 2 hours 15 minutes 1 hour 43 minutes US 87.5 49 minutes 50 minutes 2 hours 28 minutes 1 hour 39 minutes Information has been obtained from the CMS Nursing Home Compare website regarding nurse staff hours. The information was last updated on October 2014. The chart numbers reports the average nursing staff hours worked each day divided by the number of residents. These nurse staff numbers come from reports obtained by the state survey agency and include the hours reported for a two-week period prior to the time of state inspection. CMS receives this data and converts it into the number of staff hours per resident per day. This information is collected the same way in every state using uniform documents distributed by the state survey agency. 73 6.00% 5.60% 5.00% 4.00% 3.20% 3.00% 2.40% 2.50% 2.30% 2.00% 2.00% 1.00% 0.40% 0.30% 0.60% 0.00% AL FL GA KY MS NC SC TN Nation 74 6.00% 5.00% 4.90% 4.30% 4.00% 3.70% 3.00% 2.50% 2.60% 3.00% 2.00% 1.00% 0.90% 0.60% 0.30% 0.00% AL FL GA KY MS NC SC TN Nation 75 25

35.00% 33.30% 30.00% 25.00% 20.00% 20.70% 17.00% 15.00% 10.00% 9.70% 10.10% 10.60% 11.30% 6.80% 5.90% 5.00% 0.00% AL FL GA KY MS NC SC TN Nation 76 35.00% 31.90% 30.00% 25.00% 20.00% 19.30% 15.00% 15.40% 10.00% 8.40% 10.10% 10.20% 10.50% 6.40% 5.90% 5.00% 0.00% AL FL GA KY MS NC SC TN Nation 77 6 5.4 5.7 5 4.7 5 4.3 4 4 3.9 3 3.1 2.6 2 1 0 AL FL GA KY MS NC SC TN Nation 78 26

4.00% 3.50% 3.50% 3.00% 2.50% 2.20% 2.00% 1.70% 1.80% 1.50% 1.30% 1.00% 0.90% 0.90% 0.50% 0.4 0.40% 0.00% 2006 2007 2008 2009 2010 2011 2012 2013 2014 79 5.00% 4.50% 4.00% 4.30% 3.50% 3.00% 2.50% 2.00% 2.20% 2.20% 1.80% 1.50% 1.00% 1.30% 1.30% 0.90% 0.50% 0.00% 0.00% 0.40% 2006 2007 2008 2009 2010 2011 2012 2013 2014 80 25.00% 20.00% 19.70% 15.00% 13.90% 13.60% 13.60% 11.60% 10.00% 9.20% 9.70% 5.00% 4.30% 4.80% 0.00% 2006 2007 2008 2009 2010 2011 2012 2013 2014 81 27

20.00% 18.00% 18.90% 16.00% 14.00% 13.60% 12.00% 10.00% 9.50% 11.30% 12.70% 10.50% 8.00% 6.00% 4.00% 2.00% 2.20% 2.60% 0.00% 2006 2007 2008 2009 2010 2011 2012 2013 82 8 7 7.3 6.6 6 5 5.2 4 4.2 4 3 3.5 3.4 3.7 3.7 2 1 0 2006 2007 2008 2009 2010 2011 2012 2013 83 1800 1600 1400 1673 1517 1200 1195 1000 967 837 900 800 791 785 836 600 400 200 0 2006 2007 2008 2009 2010 2011 2012 2013 84 28

CMS Nursing Home Compare http://www.medicare.gov/nhcompare/home.asp CMS Survey and Certification Letters http://www.cms.hhs.gov/surveycertificationgeninfo/p MSR/list.asp#TopOfPage CMS Transmittals http://www.cms.hhs.gov/transmittals/2006trans/list.a sp#topofpage Alabama Department of Public Health www.adph.org Alabama Nursing Home Association www.anha.org American Health Care Association www.ahcancal.org 29