Agenda Region V Long Term Care Provider Association Meeting 13 th Floor Conference Room, 233 North Michigan Avenue December 12 13, 2011

Transcription

1 Agenda Region V Long Term Care Provider Association Meeting 13 th Floor Conference Room, 233 North Michigan Avenue December 12 13, 2011 Monday, December 12 1:00 1:15 PM Introduction and Welcome Walt Kummer 1:15 1:30 PM Data trends Marilyn Hirsch 1:30 2:30 PM Complaint Survey Process Elizabeth Honiotes New Guidance QIS IJ Determination 2:30 3:30 PM Abuse Regulations and LTC Nadine Renbarger Consistency Workgroup 3:30 3:45 PM BREAK 3:45 4:15 PM Elder Justice Act Heather Lang 4:15 4:30 PM National Background Check Charlotte Hodder Project 4:30 4:45 PM Critical Access Nursing Home Tamika Brown Project 4:45 5:15 PM New CMP regulations Heather Lang 5:15-5:45 PM IIDR Jan Suzuki

2 Agenda Region V Long Term Care Provider Association Meeting 13 th Floor Conference Room, 233 North Michigan Avenue December 12-13, 2011 Tuesday, December 13 8:30 10:15 AM Life Safety Code Steve Pelinski Bruce Wexelberg Dan Kristola 10:15 11:00 AM Medicaid and Health Care Verlon Johnson Reform 11:00 11:15 AM BREAK 11:15 11:45 PM Accountable Care Organizations Faye Starcevich 11:45 12:15 PM Health Information Technology Greg Dill 12:15 1:15 PM LUNCH 1:15 1:45 PM Medicare Advantage Plans Ray Swisher 1:45 2:15 PM What Is Your Organization LTC Provider Associations Doing to Improve Quality? 2:15 2:45 PM Potpourri Marilyn Hirsch 2:45 3:00 PM Wrap up Walt Kummer

3 CRITICAL ACCESS NURSING HOME PILOT Tamika J. Brown Principal Program Representative Centers for Medicare & Medicaid Services Region V - Chicago

4 BACKGROUND CANH pilot was designed to address disparities of the quality of care provided in largely minority Medicaid populations Used the infrastructure and resources available through The Advancing Excellence in America s Nursing Homes Campaign

5 ADVANCING EXCELLENCE CAMPAIGN Established in 2006 by a group of 25 different stakeholders Helps homes improve the quality of care and life they provide residents Over 75,000 nursing homes participate in the campaign Work with LANEs (Local Area of Network Excellence)

6 REGION V HOMES IN ADVANCING EXCELLENCE CAMPAIGN Numbers of Homes in Campaign Nation % Illinois % Indiana % Michigan % Minnesota % Ohio % Wisconsin % Percentage of Homes in Campaign

7 LANES Bridge between providers and national Board of Directors, informing and working with nursing homes, consumers and staff to benefit local circumstances and needs Worked together to solve common problems of poor quality care in resourced stressed homes Developed a model using the Advancing Excellence Campaign goals and resources Helped nursing homes develop and/or strengthen internal quality improvement programs to improve quality of care and life to residents (also current role of LANE, however, it was more focus for this project)

8 CANH PILOT Funding by a grant to Leading Age (formally the American Association of Homes and Services for the Aging) from The Commonwealth Fund, an independent philanthropy in New York Worked to eliminate racial disparities Challenged the LANEs to see themselves as a community with shared responsibility for the care being provided to all residents in the community

9 GOALS OF THE CANH PILOT Participating nursing homes Joined Advancing Excellence Campaign Reduced turnover and absenteeism Shifted staffing toward consistent assignment Worked on outcome goals Decreased use of physical restraints Decreased pressure ulcers Improved pain management Worked with peers

10 GOALS OF THE CANH PILOT Participating LANES Achieved a greater cohesion Worked as a positive force for change Took on new challenges Residents and Families See a perceptible change in care received Be asked about satisfaction and suggestions

11 PARTICIPANTS Four States across the country in Metropolitan Statistical Areas with a concentration of low income, minority nursing homes residents Illinois (Chicago) six homes Indiana (Lake County) five homes Ohio (Cleveland) four homes Georgia (Macon) three homes 18 homes at start of project one dropped out before project was over

12 WHAT WAS ACCOMPLISHED? Enrollment in Advancing Excellence Campaign Staff Stability Reduction in absenteeism 80% reduction in call offs Reduction in overtime cost of $40,000 per month All hands on deck approach Consistent Assignment Improved resident and family satisfaction Better staff morale

13 WHAT WAS ACCOMPLISHED? Quality Indicators Improvement in pain management Improvement in facility acquired decubitus ulcers One home went from eleven a month to zero Reduced hospitalization rates Reported reduction from 30% to 11% Fewer complaints and survey tags

14 WHAT WAS ACCOMPLISHED? Three of the four LANEs have expanded related activities encouraged by the increased cohesion and credibility that the pilot helped foster Indiana and Georgia LANEs were able to continue working with the homes & other homes in the area Illinois was able to overcome obstacles and build trust issues and work together All-day conference was held on October with over 200 staff from area nursing homes Presentation by nursing homes Panel of owners Working together with continued support Currently developing other projects

15 ANY QUESTION??????

16 Medicaid Moving Forward Verlon Johnson Associate Regional Administrator Medicaid & Children's Health Operations Centers for Medicare & Medicaid Services 1

17 Achieving a High Performing Medicaid Program Moving from a safety net program To a full partner in the health care system Ensuring better care, better health, lower costs 2

18 How Will We Get There? Reform Modernization Stewardship Collaboration 3

19 Medicaid Overview Medicaid Title XIX under the Social Security Act Types of services Mandatory service categories/ Optional service categories Eligibility Income and assets/ Mandatory and optional Key Groups Payment States design their own payment methodologies as long as they abide by federal guidelines. 4

20 Medicaid Milestones 1960 s Program Enacted EPSDT Services RECENT CHIP Reauthorization American Recovery and Reinvestment Act Affordable Care Act 1970 s Services Offered in ICFs SSI Program Enacted 2000 s Benefits Improvement Protection Act Health Insurance Flexibility & Accountability Medicare Modernization Act Deficit Reduction Act 1980 s DSH Payments Managed Care & HCBS Waivers Coverage for Pregnant Women Savings for dual eligibles 1990 s Rx Rebate Program 1115 Waivers TANF Block Grants Balanced Budget Act 5

21 Note: Enrollment is in millions of enrollees. Source: Kaiser Commission, Compiled by Health Management Associates from State Medicaid enrollment reports, September Changes in Medicaid Enrollment (December 2004-December 2009)

22 Note: Enrollment percentage changes from June to June of each year. Spending growth percentages in State fiscal year. Source: Kaiser Commission survey of Medicaid officials conducted by Health Management Associates, September Medicaid Enrollment and Spending ( ) 7.6% 8.8% 7.4% 3.8% 5.8% 3.1% 7.5% 8.5% 6.1% Enrollment Growth Spending Growth -0.7% Adopted

23 Note: Total State Medicaid Expenditures includes General Fund and Other State Funds expenditures. Total State Expenditures includes General Fund, Other State Funds, and Bonds. Source: National Association of State Budget Officers, 2008 State Expenditure Report, December State Medicaid Expenditures (2008) State General Fund Medicaid Expenditures as Share of Total State General Fund Expenditures Total State Medicaid Expenditures as Share of Total State Expenditures 83.73% 16.27% Medicaid Expenditures 87.49% 12.51% Total State Medicaid Expenditures Total Expenditures Total State Expenditures

24 Top 5% of Enrollees Accounted for More than Half of Medicaid Spending in FY 2008 Top 5% Top 5% Elderly % Disabled 31.79% 5% Elderly 1.82% Disabled 2.61% Adult.21% Children.36% Bottom 95% of Enrollees Bottom 95% of Enrollees Adults 1.75% Children 3.72% 54% Enrollees Total = 60.6 million Expenditures Total = $292.9 billion Source: FY MSIS 2008, FY MSIS 2007 for AZ, NC, ND, HI, UT, VT, WI

25 Medicare-Medicaid Beneficiaries Account for Disproportionate Shares of Spending Dual Eligibles as a Share of the Medicare Population and Medicare FFS Spending, 2006: Dual Eligibles as a Share of the Medicaid Population and Medicaid Spending, 2007: 21% 36% 15% 39% 79% 64% 85% 61% Total Medicare Population, 2006: 43 Million Total Medicare FFS Spending, 2006: $299 Billion Total Medicaid Population, 2007: 58 Million Total Medicaid Spending, 2007:$311 Billion Kaiser Family Foundation, The Role of Medicare for the People Dually Eligible for Medicare and Medicaid, January

26 March 23, 2010: A New Day For Health Care After a year of striving, after a year of debate, after a historic vote, health care reform is no longer an unmet promise. It is the law of the land. -- President Obama 11

27 The Affordable Care Act: Some Major Themes 1. Expands Coverage 2. Offers New Consumer Protections and Consumer Choice 3. Makes Health Care More Affordable 4. Improves Quality 5. Improves Prevention and Public Health 12

28 13

29 The Triple Aim Population Health Experience Of Care Per Capita Cost

30 A System of Coverage

31 Projected Changes in Coverage by M 16M Exchanges Medicaid & CHIP Employer Nongroup & Other -3M -5M Total new coverage = 32 million Source: Congressional Budget Office, March 2010

32 Sources of Coverage by m 22m 24m 159m 51m Medicaid & CHIP Employer Nongroup & Other Uninsured Exchanges (For All Individuals under 65) Source: Congressional Budget Office, March 2010

33 Who Pays? Estimated Distribution of Costs for Medicaid Coverage Changes: (in billions) Total $464.7 billion Source: Medicaid Coverage and Spending in Health Reform, John Holahan and Irene Headen/Kaiser Commission, May 26, 2010

34 Putting Medicaid Into Reform Medicaid coverage for adults under 133% of the poverty line CHIP and Medicaid coverage for children at higher incomes (State March 23, 2010 levels) Simpler rules Increased federal funding across the board

35 New Paradigm Not a safety net but a full partner in assuring coverage for all Eligible = enrolled Law contemplates a system made up of different components to achieve seamless coverage, quality and cost containment objectives

36 Keeping it Simple 21

37 Putting Reform into Medicaid Creating a high performing Medicaid program Systems upgrades and data/performance standards Delivery and payment reforms Close attention to program integrity

38 Collaboration with States is Essential Systems Support FMAP Rules Benefit Designs Eligibility Rules Basic Option Data Performance Standards Federal Actions Planning Exchange Org Structure Systems New Rules Provider Networks/ Contracts Staffing Training Enrollment State Actions

39 Many Ways to Listen and Learn Public comments on NPRMs and listening sessions State Learning Collaboratives Consumer/advocate input Provider initiatives Other State/Foundation initiatives 24

40 25

41 Electronic Health Records Incentive Program REGION V LTC MEETING DECEMBER 13, 2011

42 Background ARRA $27 Billion Dollars to support EHR over ten years - Doctors & Hospitals - Adopt, implement, and upgrade to certified EHR system - Meaningful Use - Medicare $44,000/ 5 years - Medicaid $63,750/6 years

43 ARRA EHR thus far Creation of Regional Extension Centers Workforce Training Programs Beacon Communities Nationwide Health Information Network Process to certify EHR systems and standards Define meaningful use Support State Medicaid Agencies via 90/10 Paid Incentive Payments..

44 Why? Increase availability of health information When needed o share with public health agencies Bring current data into one place for clinicians Support better follow-up Automatically check for problems Decision support Reduce costs via improved health care delivery

45 Maximum EHR Incentive Payments

46

47 Active Registrations

48 Medicare EHR Registrations

49 Medicaid EHR Registrations

50 What are the Requirements/Meaningful Use? The Recovery Act specifies the following 3 components of Meaningful Use: 1. Use of certified EHR in a meaningful manner (e.g., e- prescribing) 2. Use of certified EHR technology for electronic exchange of health information to improve quality of health care 3. Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary

51 What are the Requirements/Meaningful Use? Eligible Professionals 15 Core Objectives 1. Computerized physician order entry (CPOE) 2. E-Prescribing (erx) 3. Report ambulatory clinical quality measures to CMS/States 4. Implement one clinical decision support rule 5. Provide patients with an electronic copy of their health information, upon request 6. Provide clinical summaries for patients for each office visit 7. Drug-drug and drug-allergy interaction checks 8. Record demographics

52 What are the Requirements/Meaningful Use? Eligible Professionals 15 Core Objectives (cont.) 9. Maintain an up-to-date problem list of current and active diagnoses 10. Maintain active medication list 11. Maintain active medication allergy list 12. Record and chart changes in vital signs 13. Record smoking status for patients 13 years or older 14. Capability to exchange key clinical information among providers of care and patient-authorized entities electronically 15. Protect electronic health information

53 What are the Requirements/Meaningful Use? Established 3 stages of meaningful use: 2011, 2013 and 2015 Data capture and sharing Advanced clinical processes Improved outcomes

54 Medicare Incentive Payments

55 Medicaid Incentive Payments

56 Future Partnership for Patients Bundled Payment Comprehensive Primary Care Initiatives FQHC Primary Care Practice Demonstration Medicare Shared Savings Program (ACO) Advanced Payment Model Pioneer Model

57 National Top 10 Deficiencies FY11 (All Data from PDQ 12/12/11) Rank K Tag Description # Citations % Providers Cited % Surveys Cited 1 K0147 ELECTRICAL WIRING AND EQUIPMENT 4, % 28.20% 2 K0062 SPRINKLER SYSTEM MAINTENANCE 4, % 27.50% 3 K0018 CORRIDOR DOORS 3, % 26.80% 4 K0029 HAZARDOUS AREAS - SEPARATION 3, % 25.90% 5 K0038 EXIT ACCESS 3, % 20.70% 6 K0025 SMOKE PARTITION CONSTRUCTION 2, % 19.10% 7 K0144 GENERATRS INSPECTED/TESTED 2, % 17.20% 8 K0050 FIRE DRILLS 2, % 16.00% 9 K0012 CONSTRUCTION TYPE 1, % 12.20% 10 K0056 AUTOMATIC SPRINKLER SYSTEM 1, % 11.90% RO V Top 10 Deficiencies FY11 (* Not on National Top 10) Rank K Tag Description # Citations % Providers Cited % Surveys Cited 1 K0029 HAZARDOUS AREAS - SEPARATION % 32.99% 2 K0062 SPRINKLER SYSTEM MAINTENANCE % 29.98% 3 K0144 GENERATRS INSPECTED/TESTED % 28.97% 4 K0018 CORRIDOR DOORS % 28.47% 5 K0050 FIRE DRILLS % 27.50% 6 K0038 EXIT ACCESS % 25.78% 7 K0147 ELECTRICAL WIRING AND EQUIPMENT % 23.10% 8 K0025 SMOKE PARTITION CONSTRUCTION % 21.38% 9 K0052 TESTING OF FIRE ALARM * % 15.21% 10 K0056 AUTOMATIC SPRINKLER SYSTEM % 14.71% IL Top 10 Deficiencies FY11 (* Not on RO V Top 10) Rank K Tag Description # Citations % Providers Cited % Surveys Cited 1 K0050 FIRE DRILLS % 47.20% 2 K0144 GENERATRS INSPECTED/TESTED % 40.10% 3 K0062 SPRINKLER SYSTEM MAINTENANCE % 39.90% 4 K0029 HAZARDOUS AREAS - SEPARATION % 36.90% 5 K0038 EXIT ACCESS % 30.60% 6 K0018 CORRIDOR DOORS % 30.30% 7 K0054 SMOKE DETECTOR MAINTENANCE * % 28.60% 8 K0147 ELECTRICAL WIRING AND EQUIPMENT % 27.20% 9 K0025 SMOKE PARTITION CONSTRUCTION % 26.50% 10 K0069 COOKING EQUIPMENT * % 24.40%

58 IN Top 10 Deficiencies FY11 (* Not on RO V Top 10) Rank K Tag Description # Citations % Providers Cited % Surveys Cited 1 K0144 GENERATRS INSPECTED/TESTED % 41.40% 2 K0029 HAZARDOUS AREAS - SEPARATION % 22.90% 3 K0050 FIRE DRILLS % 21.30% 4 K0038 EXIT ACCESS % 19.90% 5 K0062 SPRINKLER SYSTEM MAINTENANCE % 18.10% 6 K0046 EMERGENCY LIGHTING * % 16.30% 7 K0056 AUTOMATIC SPRINKLER SYSTEM % 13.30% 8 K0143 OXYGEN TRANSFER REQUIREMENTS * % 13.30% 9 K0025 SMOKE PARTITION CONSTRUCTION % 13.10% 10 K0018 CORRIDOR DOORS % 12.30% MI Top 10 Deficiencies FY11 (* Not on RO V Top 10) Rank K Tag Description # Citations % Providers Cited % Surveys Cited 1 K0029 HAZARDOUS AREAS - SEPARATION % 55.50% 2 K0025 SMOKE PARTITION CONSTRUCTION % 46.90% 3 K0147 ELECTRICAL WIRING AND EQUIPMENT % 45.20% 4 K0062 SPRINKLER SYSTEM MAINTENANCE % 44.70% 5 K0018 CORRIDOR DOORS % 43.60% 6 K0038 EXIT ACCESS % 31.80% 7 K0144 GENERATRS INSPECTED/TESTED % 25.00% 8 K0050 FIRE DRILLS % 24.10% 9 K0052 TESTING OF FIRE ALARM * % 21.30% 10 K0048 EVACUATION PLAN * % 19.70% MN Top 10 Deficiencies FY11 (* Not on RO V Top 10) Rank K Tag Description # Citations % Providers Cited % Surveys Cited 1 K0050 FIRE DRILLS % 15.90% 2 K0029 HAZARDOUS AREAS - SEPARATION % 15.90% 3 K0052 TESTING OF FIRE ALARM % 15.40% 4 K0067 VENTILATING EQUIPMENT * % 14.30% 5 K0144 GENERATRS INSPECTED/TESTED % 12.80% 6 K0056 AUTOMATIC SPRINKLER SYSTEM % 7.60% 7 K0018 CORRIDOR DOORS % 7.30% 8 K0038 EXIT ACCESS % 6.00% 9 K0011 COMMON WALL * % 5.70% 10 K0147 ELECTRICAL WIRING AND EQUIPMENT % 5.50%

59 OH Top 10 Deficiencies FY11 (* Not on RO V Top 10) Rank K Tag Description # Citations % Providers Cited % Surveys Cited 1 K0018 CORRIDOR DOORS % 32.10% 2 K0038 EXIT ACCESS % 28.50% 3 K0062 SPRINKLER SYSTEM MAINTENANCE % 27.60% 4 K0029 HAZARDOUS AREAS - SEPARATION % 27.50% 5 K0144 GENERATRS INSPECTED/TESTED % 25.30% 6 K0050 FIRE DRILLS % 23.60% 7 K0147 ELECTRICAL WIRING AND EQUIPMENT % 22.10% 8 K0056 AUTOMATIC SPRINKLER SYSTEM % 16.40% 9 K0052 TESTING OF FIRE ALARM % 15.80% 10 K0012 CONSTRUCTION TYPE * % 14.90% WI Top 10 Deficiencies FY11 (* Not on RO V Top 10) Rank K Tag Description # Citations % Providers Cited % Surveys Cited 1 K0029 HAZARDOUS AREAS - SEPARATION % 43.00% 2 K0018 CORRIDOR DOORS % 41.60% 3 K0062 SPRINKLER SYSTEM MAINTENANCE % 40.30% 4 K0056 AUTOMATIC SPRINKLER SYSTEM % 33.40% 5 K0038 EXIT ACCESS % 31.00% 6 K0147 ELECTRICAL WIRING AND EQUIPMENT % 27.40% 7 K0025 SMOKE PARTITION CONSTRUCTION % 26.00% 8 K0051 FIRE ALARM SYSTEM * % 21.90% 9 K0050 FIRE DRILLS % 21.40% 10 K0144 GENERATRS INSPECTED/TESTED % 20.50%

60 Top Ten Deficiencies and Helpful Hints to Avoid Them (Deficiency numbers for RO V from FY11) K29 Hazardous Areas - Doors for nonsprinklered hazardous areas must be at least 45min fire resistance rated (there should be unpainted labels on each door) (Existing HC) - Hazardous area enclosures may need to be 1hr fire resistance rated in addition to requiring sprinkler protection (New HC and severe hazard existing HC) - Doors for all hazardous areas need to fully self-close (All hazardous room doors will be tested on a survey) - Soiled utility bins need to be stored in a hazardous room when unattended - Doors can only be held open by a device that releases upon activation of the fire alarm system, local smoke detectors, and/or the sprinkler system - Resident rooms converted into a hazardous storage room, but lack the protection for a hazardous area K62 Sprinkler System Inspection, Testing, and Maintenance - Sprinklers cannot be painted, corroded/oxidized, loaded, or have other impediment. Sprinklers that are painted, corroded, damaged, loaded, or an improper orientation must be replaced - The spare sprinkler cabinet must contain at least six sprinklers, with the stock being at least two of each type and temperature rating of sprinkler installed in the building. Also, there must be a special sprinkler wrench for each type of sprinkler - Quarterly waterflow testing that have all required information documented - Gauges not replaced or calibrated every five years - Holes around sprinkler (integrity of ceiling) that affects the operation of the sprinkler - Antifreeze sprinkler systems with glycerin concentrate greater than 48% (Refer to Updated NFPA Alert Regarding Antifreeze 4/5/11) K144 Emergency Generators - Weekly visual inspections must be conducted and documented (Manufacturer s recommendation list or list of applicable items from NFPA 110 Appendix A) - Monthly load tests must be done for a minimum of 30min under load (cool down without load must be outside of the 30min test) - Monthly load tests for all generators must meet one of the requirements of NFPA 110 Section (There must be sufficient information to show how the load tests meet requirements) - A remote annunciator panel must be installed in a separate location from the generator with an audible trouble signal in a location where it can be heard 24hrs a day (Remote panel trouble indicators should at a minimum mirror the trouble indicators on the generator. If no trouble indicators on generator, remote panel should consist of a general audible and visual trouble alarm) - If generator is located indoors there must be at a battery-powered emergency light in the generator room. If the generator is located outdoors then there either needs to be a battery-powered emergency light at the generator location or it needs to be accessible for a car to provide illumination with its headlights (A flashlight at the generator location does not meet this requirement) - Emergency shutoff for installations dated after the requirement was written into NFPA 110

61 K18 Corridor Doors - Corridor doors can be held open with a device that releases with a push or pull of the door, if the door is not required to be self-closing or automatically releases upon activation of the fire alarm system if required to be self-closing - Corridor doors in sprinklered buildings must be smoke resisting (gap between the face of door and the stop on the frame cannot exceed.5in). Corridor doors in nonsprinklered buildings must be 20min fire resistance rated or be 1.75in solid-bonded wood core and must be smoke resisting (gap between the face of the door and the stop on the frame cannot exceed.25in - Corridor doors require automatic positive latches - Inactive leaf of double corridor doors must automatically positively latch K50 Fire Drills - Fire drills must be documented (Time, date, transmission of alarm, etc.) - Fire drills must be conducted at a frequency of one per shift per quarter - Fire drills must be conducted under varying conditions (Time during shift, location, type of fire, etc.) K38 Means of Egress - The floor level on each side of the door must be level (In existing buildings there can be a grade change if the change is equal to that of one step) - Delayed-egress devices can only be installed in a building that has either a complete sprinkler system or complete fire detection system. Also, there must be an instruction sign on the door with a delayed-egress device. Delayed-egress devices must release upon activation of the fire alarm or within 15 seconds of an acceptable amount of force being applied to the door for no more than three seconds. Also, there can only be one delayed-egress device in a means of egress - Doors must open with only one releasing operation - Means of egress must be clear and unobstructed at all times and useable in all weather conditions K147 Electrical - Unacceptable use of power strips (Daisy-chained, high-current draw devices, medical equipment) - Missing junction box, light switch, or electrical outlet cover plates - Extension cords being used for more than temporary use

62 K25 Smoke Barriers - Continuity of smoke barriers (Outside wall to outside wall or other smoke barrier and from floor to roof/floor deck above) - Properly firestopped penetrations (Existing penetrations must resist the passage of smoke. New penetrations need an approved through penetration system) - Properly firestopped smoke barrier/floor joint systems (flutes of corrugated metal decks cannot be left open or be filled with only insulation or other loose filled material) - Expandable foam cannot be used (Fire rated expandable foam does not contain a fire resistance rating. It only has a flame spread rating) - Smoke barriers must be continuous to the roof deck of a roof/ceiling assembly K52 Fire Alarm System Testing and Maintenance (K51 Fire Alarm System Installation) - A fire alarm panel must be installed in a supervised location (24hr staffed or have a smoke detector connected to the fire alarm system at the location) - A trouble signal from the fire alarm system must be able to be heard 24hrs a day - Annual fire alarm system test documentation must be complete, accurate, and show test results for all initiating and supervisory devices - Smoke detectors must be located out of the direct airflow of an air supply or return - Wall mounted smoke detectors must be installed between 4in and 12in of the ceiling (Measured to the center of the detector) K56 Sprinkler System Installation - Sprinklers cannot be obstructed by other objects (light fixtures, ducts, cubicle curtains, storage) - Sprinklers must be properly spaced from other sprinklers (Distance between two sprinklers should be between 6ft and 15ft) - Unsupported sprinkler pipe arm-overs cannot exceed 24in for steel pipe (12in for copper pipe) - Sprinkler pipes must be properly supported off the building structure (hangers must be properly spaced for size and type of pipe and all installed hangers must be maintained in their installed locations) - All areas of a building must be sprinkler protected for a building to be considered fully sprinklered (Combustible overhangs greater than 4ft, elevator machine rooms, electrical rooms, walk-in coolers/freezers, and closets are the most commonly omitted areas)

63 LSC Provider Association Meeting Presentation December 12-13, 2011 The 2010 Provider Association Meeting Presentation answered the question, Ways to make the LSC POC, waiver and FSES reviews more efficient. (the answer is noted on this document as an attachment) For the December 12-13, 2011 meeting, two similar topics related to LSC were raised. Topic #1; Recent Changes in granting waivers on plenums, and Topic #2; I have many homes requesting life safety code waivers. They spend many hours and resources preparing the waiver requests that are for the most part, approved by the State but then denied by CMS Region 5. To follow up from last year s Provider association Meeting and provide additional guidance to assist all parties involved in waiver/fses processing. Act Requirements for a LSC waiver: The authority to grant waivers of life safety code provisions is found at Section 1819(d)(2)(B)(i) of the Act and states, The Secretary may waive, for such periods as he deems appropriate, specific provisions of such Code which if rigidly applied would result in unreasonable hardship upon a facility, but only if such waiver would not adversely affect the health and safety of the residents or personnel, The facility must document to the survey agency that there will be no adverse effect on the health and safety of the residents and employees of the facility and that compliance would result in an unreasonable hardship on the facility for each specific code provision recommended for a waiver. Per: SOM 2480 A General SOM Life Safety Code Survey Waiver Guidance How to Meet the Act Requirements(Documentation): SOM Acceptable Plan of Correction Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice Address how the facility will identify other residents having the potential to be affected by the same deficient practice Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Include dates when corrective action will be completed. The corrective action completion dates must be acceptable to the State. If the plan of correction is unacceptable for any reason, the State will notify the facility in writing. If the plan of correction is acceptable, the State will notify the facility by phone, , etc. Facilities should be cautioned that they are ultimately accountable for their own compliance, and that responsibility is not alleviated in cases where notification about the acceptability of their plan of correction is not made timely. The plan of correction will serve as the facility s allegation of compliance.

64 SOM Life Safety Code Survey Waiver Guidance SOM Temporary Waiver SOM Continuing Waivers o SOM 2480B Meeting Intent of LSC Waiver would not adversely affect patient health and safety (Does the waiver only address what is minimally required by the LSC or does it address Meeting the Intent of LSC, SOM 2480B) Fire Load All materials which might contribute to the fuel aspect of a fire within the building and requirements pertaining to construction, interior finish, draperies, furnishings, and building equipment; Fire Containment Those elements which tend to restrict the spread of flame, smoke, or fire gases throughout the building, such as corridor wall construction, subdivision of floor areas, and protection for vertical openings; Fire Extinguishment Elements which help to put out the fire as quickly as possible. They include alarm systems, portable extinguishers, sprinkler systems and special requirements for protection of hazardous areas; Evacuation Those elements which facilitate the removal of occupants from the scene of the fire. They include details of the emergency plan and exiting capability from the building; Other Features The administrative and operational features such as housekeeping techniques, smoking regulations, and the fire emergency plan which, if not properly implemented, could result in hazardous fire situations; *Note: Intent of LSC is similar to FSES/Containment Safety, Extinguishment Safety, People Movement Safety and General Safety The following additional considerations should also be evaluated by the fire authority since they may have an important bearing on the safety of patients in facilities which request a waiver: 1. Staffing considerations such as staff-patient ratios, staffing patterns, and scope of staff training to handle fire emergencies; 2. Availability and adequacy of compartment and horizontal exits, such as areas to hold patients during a fire emergency; 3. Location and number of ambulatory and non-ambulatory patients; 4. Availability, extent, and type of automatic fire detection and fire extinguishment systems provided in the facility; 5. Means for notifying the fire department in case of fire; and 6. Effectiveness of fire department (e.g. types of equipment available, number of personnel normally responding to a fire call, distance to the nearest fire station, and normal response time of the fire department). The total fire safety of a building is dependent upon the combined effect of the factors mentioned above. Each building is a unique problem from a fire safety point of view and should be evaluated by the fire authority on its own merits. Not all requirements are of equal importance in all situations.

65 If it can be established that a particular deficiency does not materially affect the overall level of safety, it is reasonable to hold that the fire safety characteristics of the facility have not been compromised and that the intent of the LSC has been met. o SOM 2480C Elements Considered in Determination of Unreasonable Hardship Estimated cost of the installation Extent and duration of the disruption of normal use of patient areas resulting from construction work Estimated period over which cost would be recovered through insurance premiums and increased payment related to cost Availability of financing Remaining useful life of the building 2011 Sprinkler Status Update Rank in RO V States for Sprinkler Status per facilities not Sprinkler Protected o Illinois 250 facilities not sprinkler protected as of March 4, 2011 (1) o Indiana 18 facilities not sprinkler protected as of March 4, 2011 (6) o Michigan 149 facilities not sprinkler protected as of March 4, 2011 (2) o Minnesota 24 facilities not sprinkler protected as of March 4, 2011 (4) o Ohio* 20 facilities not sprinkler protected as of March 4, 2011 (5) o Wisconsin 79 facilities not sprinkler protected as of March 4, 2011 (3) *State Requirement so this number is believed to be based on deficiencies at the time of data Change in RO V States for Sprinkler Status (13 Month Change), Rank in Percentage o Illinois 292 facilities not sprinkler protected as of 02/09/ facilities not sprinkler protected as of 03/04/2011 5% difference, 32% Not Fully Sprinkler Protected (2) o Indiana 29 facilities not sprinkler protected as of 02/09/ facilities not sprinkler protected as of 03/04/2011 2% difference, 4% Not Fully Sprinkler Protected (5) o Michigan 178 facilities not sprinkler protected as of 02/09/ facilities not sprinkler protected as of 03/04/2011 7% difference, 35% Not Fully Sprinkler Protected (1) o Minnesota 34 facilities not sprinkler protected as of 02/09/ facilities not sprinkler protected as of 03/04/2011 3% difference, 6% Not Fully Sprinkler Protected (4) o Ohio 26 facilities not sprinkler protected as of 02/09/ facilities not sprinkler protected as of 03/04/2011 1% difference, 2% Not Fully Sprinkler Protected (6) o Wisconsin 85 facilities not sprinkler protected as of 02/09/ facilities not sprinkler protected as of 03/04/2011 2% difference, 20% Not Fully Sprinkler Protected (3)

66 LSC Issues (Problems) NFPA 101 Life Safety Code, 2000 Edition o Fully sprinkler protected means fully sprinkler protected o CMS-2786R is to NFPA 101, 2000 Edition, Chapter 2 Mandatory Reference to NFPA 13, 1999 Edition for sprinkler protection o SOM, Appendix I Survey Procedures and Interpretive Guidelines for Life Safety Code Surveys is to NFPA 101, 2000 Edition. o May 8, 2003, S&C Memo 03-21, Adoption of NFPA 101, 2000 Edition o NFPA clarification supports elevator machine rooms have always been required to be sprinkler protected o 1994 Edition of NFPA 13 provided system design guidance, but did not change the requirements for sprinkler protection of elevator machine rooms Attachment from LSC Provider Association Meeting Presentation Question: Ways to make the LSC POC, waiver and FSES reviews more efficient Answer: SOM Acceptable Plan of Correction o Document of CMS website under Web Based Manuals Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice Address how the facility will identify other residents having the potential to be affected by the same deficient practice Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Include dates when corrective action will be completed. The corrective action completion dates must be acceptable to the State. If the plan of correction is unacceptable for any reason, the State will notify the facility in writing. If the plan of correction is acceptable, the State will notify the facility by phone, , etc. Facilities should be cautioned that they are ultimately accountable for their own compliance, and that responsibility is not alleviated in cases where notification about the acceptability of their plan of correction is not made timely. The plan of correction will serve as the facility s allegation of compliance. SOM Life Safety Code Survey Waiver Guidance o The authority to grant waivers of life safety code provisions is found at Section 1819(d)(2)(B)(i) of the Act and states, The Secretary may waive, for such periods as he deems appropriate, specific provisions of such Code which if rigidly applied would result in unreasonable hardship upon a facility, but only if such waiver would not adversely affect the health and safety of the residents or personnel, The facility must document to the survey agency that there will be no adverse effect on the health and safety of the residents and employees of the

67 facility and that compliance would result in an unreasonable hardship on the facility for each specific code provision recommended for a waiver. SOM Temporary Waiver A temporary waiver for a defined time period may be considered for a finding for which corrective action will take more than 90 days to complete. o Based on DoPNA LTC only o Documentation should match a well documented POC Extensions and modification of this timetable are not envisioned except under extreme circumstances. Failure of the facility to follow the timetable and the milestones established in the approved temporary waiver would subject the facility to the remedies prescribed in the enforcement regulations. o Enforcement Timetables, SOM Day 1 The date of the follow up survey. No sooner than the provider s projected correction date. 3 rd Month - DoPNA 6 th Month Termination When the temporary waiver of life safety code requirements is in effect, the facility should have increased fire safety awareness. This increased fire safety awareness may include the establishment of interim safety measures such as a fire watch during construction, an increased number of fire drills and training of staff at the facility, or other measures that would provide an increased measure of fire protection. SOM Continuing Waivers When noncompliance cannot be corrected without unreasonable financial hardship on the facility and it does not pose a threat to residents health and safety. The State cites the deficiency on each annual survey although they do not expect it to be corrected by the facility due to the existence of the waiver. Examples are provided in the SOM. CMS grants waivers after an evaluation of the specific life safety code deficiency cited and its impact on the life safety of the facility. 1 year to 3 years. The POC would cite the existence of a waiver. Sprinkler Language in all Letters Required Sprinkler Status by August 13, 2013 On August 13, 2008, CMS published a final rule that requires all long-term care facilities to be equipped with a complete supervised automatic sprinkler system by no later than August 13, Facilities with no or partial sprinkler systems installed and/or that use waivers or the Fire Safety Evaluation System (FSES) to comply with the current sprinkler requirements have until August 13, 2013 to install or upgrade the sprinkler system. Please review your facility s sprinkler system to ensure it fully complies with the National Fire Protection Association s (NFPA) Standard for the Installation of Sprinkler Systems (1999 Edition, NFPA 13). The Federal survey process requires review of the sprinkler system to determine if the system is providing complete coverage or only partial coverage. Complete coverage means that the entire facility, including all closets, storage areas and walk-in coolers and freezers are sprinkler protected. There are specific requirements for overhangs attached to the outside of the building (1999 Edition, NFPA

68 13, Section ), electrical equipment rooms (1999 Edition, NFPA 13, Section ) and Elevator Hoistways and Machine Rooms (1999 Edition, NFPA 13, Section ) that are the responsibility of the facility to understand and comply with, that may result in costly upgrades that will require time to complete. Since there is no waiver and/or FSES provision after August 13, 2013, it is imperative that you ensure that your facility is fully sprinkled in accordance with the regulation on August 13, Failure to do so is likely to result in enforcement remedies, including but not limited to termination. If you have any questions regarding the sprinkler status requirements, please contact Daniel Kristola, LSC Principal Program Representative in the Chicago regional office at Waiver vs. FSES o FSES is an equivalency, not a waiver o A waiver should have the same components of a FSES (areas covered in the POC that reflect safety that is above what is minimally required by the LSC) to permit the waiver.

69 Timing of Complaint Surveys Potential Changes to SOM Surveyor Guidance Clarifications IJ Determination Process QIS

70

71 IJ initiate onsite survey within 2 work days of receipt; Non-IJ High initiate onsite survey within 10 working days of prioritization; Non-IJ Medium no timeframe specified, onsite should be scheduled; Non-IJ Low Investigate during the next onsite survey. Reference State Operations Manual, Chapter 5.

72 ESRD in Nursing Homes Hospice Services in Nursing Homes Tube Feeding

73 F282 Be provided by qualified persons in accordance with each resident s written plan of care. Citation for care not provided by qualified staff, or; Citation for care not provided in accordance with the resident s plan of care.

74 F332 Medication Errors Biologicals are counted as an opportunity for error during the medication pass observation. (includes influenza and pneumonia vaccines, PPD test); Heparin flush for a gastrostomy tube is also counted as an opportunity.

75

76 Investigation process must proceed until it confirms or rules out IJ; After determining IJ exists, consider the following re; facility compliance: The entity either created a situation or allowed a situation to continue which resulted in serious harm or a potential for serious harm The facility had an opportunity to implement corrective or preventive measures.

77 Survey Team must (in part) Identify the three components of IJ Harm, Immediacy, Culpability Determine the specific federal regulation Consult with the State Survey Agency, as necessary.

78 Culpability Did the facility know about the situation? When? Should the facility have known? When? Did the facility implement appropriate corrective measures? Did the facility re-evaluate the measures to ensure the situation was corrected?

79 Region V Implementation Ohio fully implemented Minnesota fully implemented Indiana implementation began in January Wisconsin Band 4* Illinois Band 5* Michigan Band 6* *subject to change, no dates set.

80 A few bumps in the road CMS Stretching out the Implementation Timetable Does not affect timeline for current QIS states; Allows resource focus to current QIS states & regions. Prior to expansion to add l states: Shorten survey time; Resolve technological issues; Reduce training time; Make other improvements. CMS to re-examine the band schedule.

81

82

83 National Background Check Program Mrs. Charlotte A. Hodder, RN, BSN, CRRN

84 National Background Check Program H.R The Patient Protection and Affordable Care Act January 5, 2010 (pages ) Sec 6201

85 National Background Check Program Secretary of HHS shall establish a program to identify efficient, effective, and economical procedures for long term care facilities or providers to conduct background checks on prospective direct patient access employees on a nationwide basis. (page 603)

86 National Background Check Program Similar terms from pilot under section 307 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law ; 117 Stat. 2257)

87 National Background Check Program CMS has contracted with CNA to work with the Grantee states and CMS. This includes researching out the individual state laws and setting up data base systems for computer utilization.

88 National Background Check Program Current non state participants include CNA CMS-CO (which consist of the Core Team & Project Officers) CMS-Office of Acquisition & Grant Management (OAGM) CMS RO FBI HHS OIG

89 National Background Check Program Present 17 Grantee States AK IL NM CA KY NV CT ME OK DC MO RI DE NC UT FL WV

90 National Background Check Program Fifth Solicitation announced November 11, 2011 with a deadline of February 12, nfo/04_backgroundcheck.asp

91 National Background Check Program National Conferences 1. Nashville, TN March St. Louis, MO-9/12-16/2011 {American Health Care Association (AHCA) and Association of Health Facilities Survey Agencies (AHFSA) attended} 3. A third one is being planned tentatively for May 8-10, 2012 in Salt Lake City, UT.

92 National Background Check Program COMMUNICATION Monthly calls with CNA, CMS, FBI, HHS OIG & states to keep up to date of what is happening Grantee States have monthly calls with their Project Officer and the CMS Regional Office contact person CMS Core team has phone calls with all the involved parties at different times

93 National Background Check Program IMPORTANT ISSUES Working on rap back system between the states by way of the state police and the FBI in order to have connecting databases for criminal offenses (page 604)

94 National Background Check Program IMPORTANT ISSUES (cont.) Federal match of 1 (state) to 3(federal) to get the system up and running (page 606)

95 National Background Check Program IMPORTANT ISSUES (cont.) CMS Long Term Care Criminal Conviction Work Group working on a list of convictions for conviction for a relevant crime (page 607).

96 National Background Check Program Long Term Care Providers (pages ) 10 Provider Types Skilled Nursing Facilities Nursing Facilities Home Health Agency Hospice Care Providers Long Term Care Hospitals

97 National Background Check Program Long Term Care Providers (pages ) 10 Provider Types (cont.) Providers of Personal Services Adult Day Care Resident Care Providers (may be more by state) Intermediate Care Facility for the Mentally Retarded Any other facility of provider type of long-term care services under such titles as the participating State determines appropriate

98 National Background Check Program WEBSITES nfo/04_backgroundcheck.asp

99 CHICAGO REGION V TELEPHONE DIRECTORY Midwest Division of Survey & Certification Kummer, Walt (ARA) Jerry, Sandlin (DARA) Renbarger, Nadine Non LTC Certification & Enforcement Sanyal, Sahana (Manager) Blake, Leontyne (Secretary) Lewis, Jacqueline (Emtala/Psy Hosp) Le-Yuen, Mai (IL/MN/WI) Para, Pamela Potjeau, Michael Publ, Sylvia Samuels, Marilyn (IN/MI/OH) Ysrael, Stephanie Survey Branch 2 Honiotes, Elizabeth (Manager) Bailey, David Bundalian, Roselisa Lowe, Tiffany (Secretary) Simpson, Sharon Swistowicz, Tamra (OH) Vause, Christine Wexelberg, Bruce White, Sharon (WI) Survey Branch 1 Survey & Certification Coordination Hirsch, Marilyn (Manager) Brooks, RaShelle (Secretary) Castillo, Raymond (IN/OH Labs) Castrejon, Lisa Clay, Liz (IL/WI Labs) Culp, Annette Dykstra, Mark (MI/MN/WI Budgets) Myler, Susan ( MI/MN Labs) Pak, Justin (IL/IN/OH Budgets) Reeves, Nancy Rice, Lorraine LTC Certification & Enforcement Lang, Heather (Manager) Brown, Tamika (IL/MN) Delich, Steve (MI/WI) Hodder, Charlotte Kristola, Daniel Miller, Sharon (Secretary) Murray, Mennie Porter, Valerie Suzuki, Jan (IN/OH) Vergel De Dios, Maria Area Code: 312 Prefix: 3= 353 6= 886 Thomas, Pam (Manager) Ali-Moron, Khayriyyah (MN) Barrett, Kevin Brandush, Gregg Frye, Joseph Munir, Aminah Parr, Jean Pelinski, Steve Wassel, Mary (IL) Zaleski, Diane (MI)

100

101

102

103

104

105

106

107