New Physician Certification for Long Term Care Services (450B) Policies

The Division of Aging has announced two new policies regarding the Physician Certification for Long Term Care Services (450B). Beginning January 1, 2013, the current 450B document will no longer be limited to only the physician's signature. The physician may now delegate, within his or her scope of practice, that responsibility to either a Physician Assistant (PA) or Nurse Practitioner (NP) for whom the physician has supervisory responsibilities. 

This change in policy and practice affects the following:
• Pre-Admission Screening (PAS)
• Pre-Admission Screen Resident Review (PASRR)
• Nursing facility requests for continued stays
• Nursing facility transfers
• New Medicaid pay status
• Clients transition from Medicaid Waiver program to nursing facility admissions
• Nursing facilities must develop a policy regarding their process for assuring compliance with the delegation of the Physicians authority to the PA and/or NP 

As a result of the expansion of 450B signatory responsibility, the State is requesting that completed documents be submitted to the AAA/PAS office within 14 days of the NF admission date for those that require AAA/PAS processing.

Also effective on January 1, the Division of Aging (DA) and the Office of Medicaid Policy and Planning (OMPP) is expanding statewide a piloted electronic 450B (e-450B) process. The new e-450B form utilizes an online "check-off" system that thoroughly describes the resident's condition. It is a summary of the MDS, the "old" 450B, and the eligibility screen used by the AAA/PAS team in determining nursing facility level of care. Required additional documents include the 4B, medication sheets, and the nurse's clinical summary, which includes a narrative of the resident's current condition. No more than 10 pages of documentation including the nurse's clinical summary will be accepted along with the submission of the e-450B. Please also be aware that e-450Bs submitted to the DA without all required documentation will be rejected, denied or returned to the NF for additional information.

With the new web-based process, NF staff completes the e-450B online, saves and prints it, obtains the approved signature (physician, PA, or NP) and then uploads the completed e-450B along with the required documentation. The DA receives the information electronically, reviews and processes it, data-enters Medicaid information as appropriate, and returns the reviewed e-450B electronically to the NF.

The Division will host e-450B trainings at the Indiana Government Center South Auditorium on the following dates and times:

Thursday, January 10, 10:00 am - 12:00 pm
Wednesday, January 16, 1:00 pm - 3:00 pm
Wednesday, January 23, 10:00 am - 12:00 pm
Thursday, January 24, 1:00 pm - 3:00 pm

Please note the above-listed trainings are repeats session. You may attend any training that fits in your schedule. Please bring a copy of the User Guide and the PowerPoint presentation slides to the training (Which may be accessed at https://myweb.in.gov/FSSA/aging/form450b/ as of December 10), as the DA will not have printed copies.

Full implementation will be effective February 1, 2013. After that date, the DA will no longer accept mailed documents.

The Division of Aging has clarified that the request for the completed 450B to be submitted to the PreAdmission Screening agency within 14 days does NOT replace the requirement in IAC 455 1-1-8 requiring that the signed application and Level 1 be submitted to the PAS agency within 5 working days of the date of admission.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions about these new policies.

CMS Survey & Cert Memo – Hand in Hand Training Series for Nursing Homes

CMS released an S&C memo regarding training materials that will be distributed to nursing facilities in December of 2012 regarding nurse aide training on how to care for residents with dementia and on preventing abuse. The training materials consist of an orientation guide and six one-hour video modules, each coming with a DVD and instructor guide.  Annual training is required for nurse aides on dementia care and abuse prevention, but the Hand in Hand Training Series is not mandated to be used and facilities can develop their own training program so long as it conforms to existing requirements. The memo can be accessed in the Members Only section of the IHCA website.

CMS Survey & Cert Memo– Guidance related to Medication Errors and Pharmacy Services

A recent CMS Survey & Cert Memo contains clarification on three specific topics related to medication errors and pharmacy services:  (1) Medication Errors:  Potential medication errors related to medication administration via feeding tube and administration timing for metered dose inhalers and proton pump inhibitors and survey implications; (2) Medication Administration Practices:  The practice of “borrowing” medications and issues related to diversion, control, reconciliation and disposal of medications, including fentanyl patches; (3) Medication Regimen Reviews for Stays under 30 days and/or Changes in Condition:  The need for pharmacist medication regimen reviews when a resident experiences a change in condition and/or for residents admitted for less than 30 days. The memo can be accessed in the Members Only section of the IHCA website.

ISDH Survey Area Changes

The ISDH will be moving to 10 survey areas beginning December 1. The new survey area map is available in the Members Only section of the website, as is a listing of the facilities in Marion County by survey area. Only Marion County is divided up into different areas, hence the listing so that facilities know what area they are in. IHCA will be obtaining a survey area staffing chart in the near future and will distribute it to members.

RUG IV

 In early October, the State proposed that the Nursing Facility reimbursement formula move from RUG III to RUG IV.  Two days after proposing the change, the State retracted the proposal due to questions from the IHCA and other nursing facility associations about the timing of the change (then proposed to be 7/1/13) and the overall impact to facilities (details of which were incomplete by the State’s own data).  Detailed discussions on future implementation of RUG IV into the Nursing Facility reimbursement formula have not yet continued, but quick reference has been made to a potential implementation date of July 1, 2014.  At the request of IHCA, the State has provided the Draft RUG IV 48-Group Calculation Guide for review by the associations and facilities.  IHCA will keep its members update on any additional discussion regarding a transition to RUG IV.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.

VBP Update

The IHCA Board met on November 5 to discuss the State’s proposal to alter the VBP Add-on methodology by removing the Satisfaction Surveys and allocating those points to the Report Card Score (RCS) portion of the add-on.  In agreement with the IHCA Payment Committee’s recommendation, the IHCA Board agreed that the State should implement the VBP Add-on without the Satisfaction Surveys included, resulting in a VBP Add-on where 58% of the add-on is based on the RCS, 10% is based on Nursing Hours Per Resident Day, and 30% is based on retention and turnover of RN/LPNs, CNAs, Administrators, DONs,  and 2% is based upon contracting with an AMDA Certified Medical Director (for more detail on the VBP domains, see http://www.nxtbook.com/nxtbooks/naylor/INHB0112/index.php?startid=6#/6).

However, the Board also directed IHCA staff to continue work on changing the VBP Add-on methodology so that therapy hours are counted in the Nursing Hours Per Resident Day domain, and so that Administrator and DON promotion within a company does not count as turnover.  IHCA has been on record with both of these issues in the past and has communicated again with the State on these points. IHCA Staff is preparing to take additional steps to secure changes in these areas.

Faith Laird, Director of the Division of Aging, emailed IHCA a revised model of the impact that the revised VBP Add-on would have to nursing facilities.  The revisions include the 80th and 20th percentile values for measures where applicable.  In addition, the State indicated that it reviewed CNA turnover rates between urban and rural facilities to test the assertion that urban facilities have higher turnover rates than rural facilities, therefore supporting the need for a probationary period during which turnover would not negatively impact performance in the turnover domain.  Based on the State’s data from nursing facility cost reports, CNA turnover in urban areas measured 1.58 Quality Points and rural areas measure 1.57 Quality Points.

IHCA has requested additional information from the State regarding the data behind the Nursing Hours Per Resident Day calculation, modeling on how the revised methodology would impact the Profit Incentive Add-ons, and detail on actual performance of facilities in each of the domains rather than how many Quality Points were earned by each facility.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.

UPL Program

On November 5, the State held a meeting with the executives of the Non-State Government Owned (NGSO) Nursing Facilities regarding the UPL program.  The three nursing home trade associations were also present at the meeting.  Two issues were addressed.

How the UPL is Calculated
The State had previously discussed the possibility of moving the UPL payment to a facility specific payment versus the current average, pooled amount effective October 1, 2012.  Due to some pushback by certain providers, it was thought that the implementation date would be delayed.  However, the State informed everyone that they will implement this change effective October 1, 2012.  Three documents that discuss and describe the UPL calculation change are available in the Member's Only section of the IHCA website.

To accomplish the calculation change, a State Plan Amendment (SPA) will be filed soon.  If the SPA is not approved by CMS by February 15, 2013, the State will pay the October 1, 2012 – December 31, 2012 interim UPL payment based on the current pooled methodology.  The State would then settle up on the Final June 30, 2013 payment.  The State will calculate quarterly facility-specific UPL payment amounts for all Providers in the UPL program, even for interim payments effective with the October 1, 2012 – December 31, 2012 quarter.  One provider is pushing for a delay to  the January 1, 2012 rate effective date, but it is unclear if a delay will be granted.

How the UPL Money is Distributed
The State is concerned that the growth of the UPL program will cause CMS to investigate the Program and potentially eliminate it.  The State also said that it is concerned that the growth of the UPL program has not had quality care in mind.  To be in front of this, the State initially proposed the following to be effective July 1, 2013:

• 50% of the UPL payments will be distributed as they are today to County Hospitals
• 49.5% of the UPL payments will be put into a Quality Pool and be paid to all Medicaid certified nursing facilities (Not just Providers in the UPL program) based performance within the proposed Phase III – Value Based Purchasing Add-on.
     o When asked, the State did not know how much money this would add to the VBP Add-on.
• .5% of the UPL payments will go to the State to pay for the administration of the UPL Program.

The proposal was met with a number of questions from hospital representatives regarding the fairness of the proposal, where non-participating UPL facilities would have access to UPL funds through a quality payment.  IHCA voiced concern about plowing a potentially vast sum of funds into the VBP Add-on as it is currently designed due to concerns already voiced by IHCA regarding the methodology and the fact that many initiatives that could improve quality would be missed if only the VBP add-on was utilized.

Based on the robust discussion, the State said that the proposal would probably not be effective July 1, 2013, that the split of funds above is not set in stone, and that providers should forward comments and questions to the State.  Those that IHCA has talked to since that meeting agree that the proposal was the opening salvo in a longer discussion on a quality metric program paid for by UPL funds.
IHCA staff has already informed the Board of Directors of this proposal and will be taking further direction from the Board on next steps.  IHCA is also coordinating with the Indiana Hospital Association to ensure that both organizations are on the same page.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.

CMS Survey & Certification Memos

CMS released several S&C Memos to State Survey Agencies in the middle and end of September.  Below are a brief descriptions of each. The full memos are accessible in the Members Only section of the IHCA website.  Please note significant additional guidance to surveyors in the last two memos regarding Advance Directives and End of Life care. Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions or to obtain exhibits.

12-43: Impact of Nursing Shortage on Hospice Care (9/14/12)
The period of time has been extended for hospices to qualify for an “extraordinary circumstance” exemption when they believe that the nursing shortage has affected their ability to directly hire sufficient numbers of nurses. The effective date of this policy has been extended from September 30, 2012 to September 30, 2014.

12-44: “Hand in Hand: A Training Series for Nursing Homes,” on Person-Centered Care of Persons with Dementia and Prevention of Abuse (9/14/12, revised 9/27/12)
Section 6121 of the Affordable Care Act requires the Centers for Medicare & Medicaid Services (CMS) to ensure that nurse aides receive regular training on how to care for residents with dementia and on preventing abuse.  CMS created the Hand in Hand training materials to address the requirement for annual nurse aide training on these important topics. The training program consists of an orientation guide and six one-hour video-based modules, each of which has a DVD and an accompanying instructor guide.  Though Hand in Hand is targeted to nurse aides, it may be valuable to all nursing home caregivers, administrative staff and surveyors. The revised memo indicates that the materials will be sent free to all nursing homes, Regional Offices (RO) and State Survey Agencies no later than December 2012. 

12-45: Advance Copy of Interim Guidance - Revisions to State Operations Manual (SOM), Appendix P-Traditional Survey Protocol for Long-Term Care (LTC) Facilities and Chapter 9/Exhibits including Survey Forms 672, 802, 802S and 802P. (9/27/12)
Survey Protocols for LTC Facilities have been revised for the Traditional Survey process Tasks 1-5C in Appendix P to reflect changes for the: Minimum Data Set (MDS) 3.0; New Quality Measures (QM) Reports; Revised CMS forms 672 and 802, 802S and 802P; and Sampling and reviewing residents receiving psychopharmacological medications, specifically antipsychotic medications. Various Exhibits in Chapter 9,  including survey forms, have been revised to accommodate changes for MDS 3.0 and the new QM Reports. New QM Reports are available for use in the Traditional Survey Process.

12-46: F tag 322—Feeding Tubes (9/27/12)
Revisions have been made to Guidance to Surveyors at F tag 322 in Appendix PP of SOM concerning Feeding Tubes.  F tag 321 is deleted and the regulatory language and guidance moved to F tag 322.   Click here to access ower Point training material with speaker notes for Centers for Medicare & Medicaid Services (CMS) Regional Offices (ROs) and State Survey Agencies (SAs) to be used to train surveyors on this revision to F tag 322 in the SOM. The revisions should be implemented no later than November 30, 2012.

12-47: F tag 155-- Advance Directives (9/27/12)
Revisions have been made to Surveyor Guidance at F tag 155 in Appendix PP of the SOM, to include resident’s rights to: Establish Advance Directives and Accept or decline treatments. An advance copy of the surveyor guidance revision is included in the memorandum.  Click here to access Power Point Training material with speaker notes for Centers for Medicare & Medicaid Services (CMS) Regional Offices (ROs) and State Survey Agencies (SAs) to be used to train surveyors on this revision to F tag 155 in the SOM. The revisions should be implemented no later than November 30, 2012.

12-48: F tag 309—Quality of Care – End of Life (9/27/12)
Revisions have been made to Guidance to Surveyors at F tag 309 in Appendix PP of SOM regarding End of Life Care. Click here for Power Point training material with speaker notes for Centers for Medicare & Medicaid Services (CMS) Regional Offices (ROs) and State Survey Agencies (SAs) to be used to train surveyors on this revision.  The revisions should be implemented no later than November 30, 2012.

CMS Asks for Comments Regarding Dementia Care Guidance

AHCA has been asked by CMS to engage members to collect comments on three documents concerning CMS guidance on dementia care.  The documents include a draft S&C memo and updates to Appendix P and Appendix PP and can be accessed in the Members Only section of the IHCA website. Please submit any comments you may have to Zach Cattell at zcattell@ihca.org or 317-616-9001 by October 2 or directly to Lyn Bently at lbentley@AHCA.org by October 3.

Focus on Improving Dementia Care and Reducing Antipsychotic Use

CMS has requested that all SSA surveyors inquire into a facilities plans and actions to improve dementia care and reduce antipsychotic medication use.  ISDH has indicated that its surveyors will make such an inquiry on every survey, and record the responses.  The responses are not used in the survey process, but CMS is wanting discussions surrounding dementia care and antipsychotic medication use to be prevalent as the issues are targeted for improvement.

Indiana Medicaid Recovery Audit Contractor (RAC) to Begin Work

Indiana Medicaid released a Banner Page on Tuesday of this past week formally announcing the approval of Health Management Systems (HMS) as the RAC vendor for Indiana long term care facilities. They will perform a comprehensive review of Medicaid claims spanning a four year period (with the most recent 12 months from the date of the start of the review excluded).  Audits will focus on, but not be limited to, payments made for dates of service after discharge, duplicate payments, appropriateness of reporting of Medicare and third-party payments, and errors related to patient liability application or collection.

It is imperative that facility personnel recognize notices from HMS and elevate to the appropriate person in the company.  Tight timelines apply to complying with records request from the HMS.  The presentation from HMS that was provided to IHCA in June of this year and the Banner Page are available for access in the Members Only section of the IHCA website.

Partnership to Improve Dementia Care and reduce Unnecessary Antipsychotic Drug Use in Nursing Homes

CMS released a Survey & Certification Memorandum to State Survey Agencies regarding this new initiative. In 2012, Centers for Medicare & Medicaid Services (CMS) launched the Partnership to Improve Dementia Care in Nursing Homes to promote comprehensive dementia care and therapeutic interventions for nursing home residents with dementia-related behaviors.  Stakeholders, such as AMDA and AHCA are sending letters to support the Partnership to Improve Dementia Care in Nursing Homes.  The S&C Memo is available in the Member's Only section of the IHCA website, as is a list of Q&As related to the initiative that have been fielded by Region V staff.

In support of the initiative, IHCA will be sending data to its member facilities regarding their antipsychotic use rate.  The data can also be sorted for an entire corporate entity, should you so desire that information.  If you would like that aggregate data for all facilities in your company, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Value Based Purchasing – Phase III

The new RFP for a contractor to administer the resident, family and staff satisfaction survey portion of the Value Based Purchasing (VBP) program is due to be released on September 9th, responses will be due on October 6th and the plan is to award a contract on December 6th.  The Surveys would begin in January, be completed by March, and data would flow to M&S by April 1st.  The goals is to being the VBP reimbursement add-on, that replaces the Report Card Score add-on, on July 1, 2013.

The VBP program is a 12-domain weighed methodology that that facilities across the State will measured against for purposes of qualifying for a performance and quality-based Medicaid add-on payment.  IHCA has been very active with the State in development of the program and urging the State to correct certain deficiencies in the original methodology.  That original methodology was first developed in 2012 by a group called the Clinical Expert Panel, comprised of resident advocates, industry representatives, and other clinical stakeholders.

For more information about VBP, please see the Spring Edition of the IHCA Magazine at http://www.nxtbook.com/nxtbooks/naylor/INHB0112/index.php?startid=6#/6, or please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.

IGT/UPL Calculation Changes

Last Wednesday, August 29th, the IHCA, along with Payment Committee co-chair Rick Mittman of BKD, Jim Leich (Leading Age) and Bob Decker (HOPE) met with representatives of Indiana Medicaid, the Division of Aging, and Myers & Stauffer (collectively, the “State”) on a number of outstanding reimbursement matters.  Just before the meeting took place, the State added to the agenda an item about the IGT/UPL calculation for NSGO nursing facilities.  IHCA learned that morning that that State would be filing notice that same day to amend the State Plan Amendment to provide for a new UPL calculation methodology for NSGO nursing facilities.

The State’s new methodology for UPL calculation will compare the difference of a facility’s Medicaid per diem rate and the reasonable estimate of the Medicare rate.  The State will no longer use the proportional share pool distribution based on the percentage of a facility’s Medicaid days in relation to the total number of Medicaid days in the pool.  There is no fiscal impact to the State, but as to individual facilities there is likely to be a difference in the UPL payments since it will now be based on the facility’s rate.  This change is set to be effective 10/1/12.  The notice may be found at http://www.in.gov/legislative/iac/20120829-IR-405120507ONA.xml.html.

IHCA has informed the IHCA Board of Directors and the IHCA Payment and Reimbursement Committee about the issue and will engage the State at the direction of our members.  In addition, the State confirmed at last week’s meeting that they are having preliminary discussions about establishing quality metrics as conditions to participate in the IGT/UPL nursing facility program.  Neither OMPP or Div. of Aging had any detail to share at that meeting.  IHCA impressed upon them our interest in engaging the State on the concept so that any change is not a surprise and is a reasonable approach to incentivizing quality.

Please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org with any questions.

Field Audit Penalty

In late May 2012, the Office of Medicaid Policy and Planning (OMPP) released an Emergency Rule to implement changes to the State Plan Amendment resulting from the increase in the Quality Assessment Fee (QAF).   Most of the changes found in the Emergency Rule were expected as the IHCA has been constantly engaged with the State to ensure that the benefits promised to the long term care profession and its residents were carried through.  One provision that came as a surprise, however, was language instituting a 10% penalty on a providers per diem Medicaid rate if the provider failed to comply with certain documentation requests during a field audit of the provider’s books and records.  IHCA engaged OMPP on this issue recently.

Although the State was not willing to reduce or eliminate the 10% penalty they put in place in the Emergency Rule, the IHCA  was successful on a number of items within the details and implementation of the new rule.  The State explained that only a very small number of providers would be subject to the penalty because of the State’s internal documentation request procedures.  Those procedures provide for at least 135 days, and 165 days when a 30 day extension is requested, to respond prior to a 10% penalty being imposed.  IHCA requested that these procedures be published and the State appeared willing to publish these procedures either on Myers & Stauffer’s website or as a Provider Bulletin.

Aside from the penalty amount itself, if a penalty is put in place OMPP will limit the duration of that penalty to no longer than 12 months.  Before IHCA’s engagement on this issue, a penalty could last indefinitely.  In addition, OMPP will consider shortening the duration of the penalty to less than 1 month if the provider responds with adequate documentation within that period.  Furthermore, OMPP will automatically grant a 30 day extension for time, will subject all documentation requests during a field audit to a materiality standard, and will require OMPP review of Myers & Stauffer’s documentation requests.  Each of the above issues will be addressed by the IHCA in written comments once the permanent rule, which replaces the Emergency Rule, is published for comment.

Please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org with any questions.

Nursing Facility Reimbursement Appeals Reduction Plan

In 2011, the Indiana General Assembly passed legislation requiring the Office of Medicaid Policy and Planning (OMPP) to utilize portions of the increased Quality Assessment Fee (QAF) collected from nursing facilities to discharge provider liability for certain pending administrative appeal(s). 
Last week, IHCA met with OMPP officials to review draft documents concerning the process for executing this requirement.  OMPP has called the project the Appeals Reduction Plan.

The OMPP Office of General Counsel (OGC) presented draft documents concerning the process for withdrawal of audit and rate appeals filed for Rate Effective Dates on or before 7/1/11.  In exchange for the withdrawal of the filed appeals, the provider’s potential liability from the audit adjustment will be discharged as the State will utilize the $20M in QAF to satisfy that potential liability.  Obviously a provider’s decision to withdraw the appeal will be an individual choice based upon many factors.  IHCA’s Payment and Reimbursement Committee has been very active in discussing this issue and is providing guidance to IHCA members.

The Appeals Reduction Plan is likely to begin with a small number of providers in about 4 to 6 weeks, once the draft documents are finalized.  IHCA will have another opportunity to review the documents prior to the program’s start.  OMPP is likely to meet with the first small group of providers and their counsel (at the provider’s choice) to walk through the process and iron out any issues before rolling the program out statewide.  OMPP anticipates, in coordination with Myers & Stauffer, that the batch process will work backwards in time with the newest appeals being dealt with first, followed by older appeals.

IHCA staff will continue to work with the State and update IHCA members on the issue as new information becomes available.  Please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org with any questions.

IHCA and Success Development, inc. Partner to Offer RCA/HFA, SSD and Preceptor Courses

The Indiana Health Care Association is proud to announce its partnership with Success Development, inc. to offer Residential Care Administrator/Health Facility Administrator, Social Service Designee and Preceptor courses. IHCA strives to provide opportunities for the state’s long term care workforce to further their careers, and these courses directly address that goal. Success Development, inc., a development firm with 20-plus years of experience in the areas of coaching, consulting, speaking and training services, shares this mission.

“By offering RCA/HFA, SSD, and Preceptor courses in-house at IHCA, we will once again be providing critical training opportunities for the future workforce needs for our members and non-members,” said Scott Tittle, President of IHCA.  “Success Development is the perfect partner as it provides the highest quality training opportunities.”

The Residential Care Administrator/ Health Facility Administrator course is a state approved six-week program (three-week for RCA) that provides the informational foundation needed to have a successful AIT/internship experience and to pass the RCA/HFA licensing exams, after completing the five or six month internship requirement in a residential care or health care facility.

The Social Service Designee course offers the basic knowledge to fulfill the role of a Social Service Designee.  Upon successful completion of the 48 hour course, attendees will receive a certificate to fulfill requirements defined in the state regulations for nursing facilities/long term care facilities.

The Preceptor course fulfills one of the eligibility requirements to be approved as a Preceptor to gives you the chance to become certified or recertified as a state approved mentor for  an Administrator-in-Training. This state approved eight-hour program will provide the informational foundation to be a skilled Preceptor.

“I’m excited to be partnering with IHCA,” said Vivian Wright-Defrees, CEO of Success Development,inc. “When like minded organizations come together, synergy can occur.”

For more information on these courses or to register for the upcoming RCA/HFA training (HFA - September 17-October 26, RCA – September 17 – October 5), visit www.ihca.org or contact Vivian Wright-Defrees at 317-596-0707 or vwrightdefrees@successdevelopment.biz.

Out of Hospital DNR

Over the past year, the IHCA has fielded questions from members about the change in Indiana law that requires the use of the State-issued Out of Hospital DNR form in order for a resident of a nursing facility  to have a valid DNR order in a nursing facility.  The law was passed in the 2011 Session of the Indiana General Assembly and became effective on July 1, 2011.  In order to further assist IHCA members with compliance and ensuring the resident is treated according to his or her wishes, a memorandum that further explains the requirement to use the Out of Hospital DNR form for DNR orders in a nursing facility (or any other location outside of a hospital) and the Out of Hospital DNR form are available in the Members Only section of the IHCA website.

If you have any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Nursing Home Compare Technical Users' Guide

In conjunction with the Nursing Home Compare that were recently launched, CMS has also released an updated Technical Users' Guide to the Nursing Home Compare Five-Star rating system, which includes information about the cut-points for the staffing and quality measure ratings.  You can access the manual at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf.

IIDR Update

The contract with Maximus Federal to perform the new Federally required IIDR process (an optional process for facilities) has finally been signed by the State.  Facilities should expect that CMS will now begin to issue notice of Civil Money Penalty and the option to participate in IIDR.  Tight timelines apply to electing and participating in IIDR.  For more information, visit the ISDH Informal Dispute Resolution Information Center at http://www.in.gov/isdh/25304.htm.

Sprinkler and Smoke Detector Surveys

July 1, 2012 was the deadline for Indiana Nursing Facilities to have installed sprinkler systems and smoke alarms.  The ISDH issued notice in the June ISDH Long Term Care Newsletter that they would begin surveying for the requirement and will take licensure action to revoke the license of any facility not in compliance.  To assist with facility compliance, a copy of the ISDH Surveyor worksheet that is being used in the surveys is available in the Members Only section of the IHCA website.

The ISDH indicated that they are aware of one facility in Indiana that has not installed any sprinkler system and licensure action is commencing against that facility.  In addition, the ISDH is finding that several facilities have not met the requirement to have a smoke detector in each resident care room.

Attorney General Investigations Due to ISDH Incident Reports Sent to AG in Error

On July 20, IHCA alerted members that the Indiana Attorney General has recently opened around 100, or more, investigations of licensed practitioners in nursing facilities (mainly RNs and LPNs) in the past couple of weeks.  These investigations have apparently been generated by the ISDH’s sending of incident reports to the AG along with a signed letter from the ISDH referring the incident report as a consumer complaint for AG investigation.  It is IHCA’s understanding that ISDH’s sending of these uninvestigated or investigated but unsubstantiated incidents/complaints has been occurring for a long time, however only in the last several weeks have those incident referrals been accompanied by a signed letter from ISDH referring the matter to the AG.  It is this signed letter with referral that had triggered the AG investigations.

Based on recent discussions with the ISDH, the referrals that were sent in error are being retracted by the AG in cooperation with the ISDH staff.  The ISDH indicated that the AG will send closure letters to the affected professionals that had been referred to the AG by the ISDH in error.

Division of Aging Exploring Changes to Pre-Admissions Screening Process

IHCA attended a meeting on Friday, July 27th with representatives of the Division of Aging, other nursing home associations, the Indiana Association for Area Agencies on Aging and the AARP to listen to the Division’s discussion regarding the Indiana Pre-Admissions Screening process.  The Division is thinking about pursuing a change to the Indiana PAS process that would extend the period of time in which a nursing facility has to complete the application and Level 1 process from 5 days to 21 days, and thereafter the AAA would see the resident between day 21 and day 60 in order to perform options counseling as required by Indiana law.  The Division explained that the change is being considered because they do not believe the current PAS process is meaningful to the client/resident, and requires options counseling too early into a client/resident stay before knowing enough about the long term conditions to provide adequate options to the client/resident.

The Division has not placed the proposal in writing and the proposal, captured above, represents a discussion of ideas presented by the Division.  IHCA and other associations are being engaged to help think through a potential change.  If you someone on your staff is interested in assisting the IHCA discuss the PAS process with the Division, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

CMS Taking Comments to Potentially Address Use of Observation Stays Barring 3-day Qualifying Inpatient Stay

On July 6, CMS released the Hospital Outpatient Prospective Payment System update proposed rule.  The American Health Care Association (AHCA) has long been interacting with CMS regarding the increasing use by hospitals of Observation Stays that many times bar a patient from meeting the 3-day Qualifying Inpatient Stay necessary for admission into a SNF.  Hospitals increasing use of Observation Stays is mainly due to hospitals' fears that inpatient stays may be later denied as medically unnecessary.

This proposed rule has been posted at http://www.ofr.gov/OFRUpload/OFRData/2012-16813_PI.pdf . It is over 600 pages long and still available only in the display copy.   However, an excerpt of the observation stay issue is available in the Member's Only section of IHCA's website.

AHCA will submit comprehensive comments on the current system, the inclusion of observation days in the calculation of the 3-day stay, and other issues and potential improvements.  Comments are due to CMS by September 4, 2012.  If you would like to submit comments for AHCA's use, please send them to Zach Cattell at zcattell@ihca.org, and Zach will collate IHCA comments and get them to AHCA.  AHCA is requesting that all member comments be sent to them by August 10 to insure timely inclusion of all comments.

CMS Approves Indiana’s Nursing Facility State Plan Amendment

On May 23rd, 2012, CMS provided notice to Indiana Medicaid that CMS had approved the State Plan Amendment (SPA) submitted by the State in October of 2011.  The SPA was submitted as a result of the 2011 State Budget bill that called for maximization of Indiana’s Nursing Facility Quality Assessment Fee (QAF).  IHCA supported the effort to maximize the QAF in order to increase reimbursement to nursing facilities and to fund Phase III of the nursing facility quality add-on that will move away from sole dependence on the Report Card Score to a Value Based Purchasing methodology comprised of 12 quality metrics.

IHCA is working to obtain details on the implementation plan for the SPA, specifically to ensure that re-processing of the entire fiscal year’s claims is done correctly and to avoid creation of cash flow issues to nursing facilities.  Due to the State having submitted the SPA after October 1, 2011, many of the benefits from the SPA impact claims made as of October 1, 2011 and forward.  This means that while the QAF will be increased retroactive to July 1, 2011, benefits will not be seen in claims from that first quarter of the fiscal year.

The benefits that will be realized in State Fiscal Year 2012 from the approved SPA include an increase to the Quality Assessment Add-on (by virtue of the increase in the QAF), an increased maximum Report Card Score Add-on, a 75-cent add-on to the Administrative Component to recognize a portion of previously disallowed costs related to direct patient care and patient care supports, and a separate increases to the Administrative Component to 110% in 2012 and 108% in 2013.

In addition, starting July 1, 2012 (State Fiscal Year 2013), the approved SPA will permit reimbursement for the following previously disallowed costs:
• Educational seminars for administrative, direct and indirect care staff
• Support license fees for general and administrative software and hardware
• Support and license fees for software used in hands-on resident care
• Rental costs for low air loss mattresses and pressure support devices and oxygen concentrators up to $1.50 PPD
• Denture replacement costs that exceed current Medicaid expenditure limitations
• Legend and non-legend sterile water for any purpose
• Cable or satellite TV
• Pets, pet supplies, maintenance and vet expenses
• Costs related to non-ambulance travel and transportation of residents

The approved SPA will also increase the capitalization threshold from $500 to $1,000.
As details become available regarding implementation of the SPA and retroactive adjustment of claims from State Fiscal Year 2012, IHCA will update member facilities.

If you have questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Changes to Nursing Home Compare & 5-Star Expected This Year

AHCA recently notified State Affiliates of a meeting between CMS and stakeholder groups regarding upcoming changes to Nursing Home Compare and the 5-Star Rating.  AHCA reported the following:

Upcoming changes to the Nursing Home Compare website, expected to be implemented this summer, in addition to updating the look, feel and some functionalities of the website,  include:

•    Posting of survey deficiency reports (2567 forms), beginning for surveys conducted in calendar year 2011.  Until CMS has access to Plans of Correction electronically, anticipated in 2014, this information will not be reflected on the website.
•    Reporting on the new MDS 3.0-based quality measures, including 2 new measures of off-label use of antipsychotic drugs (long-stay prevalence and short-stay incidence)
•    Inclusion of ownership information.
•    Reporting on physical therapist staffing levels.

Longer-term considerations for future enhancements currently in the early phases of exploration include reporting on special capabilities and services offered by facilities to better support consumer identification of facilities that can meet specialized needs and reporting of consumer satisfaction information.  No information was provided as to the expected timeline for potential incorporation of these data.


The Five-Star Rating system will also be modified this summer to incorporate the new quality measures and adjust expected staffing calculations based on MDS 3.0 data.  The approach to revising these measures and calculations has been designed to transition with minimal change to the overall distribution of ratings. CMS also reported that overall trends in Five-Star ratings since the debut of the system in 2008 have shown improvement, with an increasing proportion of facilities receiving 4- and 5-star ratings and fewer receiving 1-star ratings.

IHCA will continue to provide updates as CMS shares additional information and firms up their timeline for rolling out these changes.  Provider preview reports are currently available via the CASPER system.

Smoking Ban Guidance

House Enrolled Act 1149, Indiana’s Statewide Smoking Ban, becomes effective on July 1, 2012. The ban applies to most places of employment and public places, including nursing homes and assisted living facilities.  IHCA has developed a guidance document for members’ reference when implementing changes to their smoking policies in light of the new law. Click on the link to the Members Only section of the IHCA website to view this document.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 for additional information or with questions.

CMS Issues Inpatient Hospital and LTCH Proposed Rules

The Centers for Medicare & Medicaid Services has issued a proposed rule that would update Medicare payment policies and rates for inpatient stays to general acute care hospitals paid under the Inpatient Prospective Payment System (IPPS), and long-term care hospitals (LTCHs) paid under the LTCH Prospective Payment System. 

In the proposed rule,  CMS projects that general acute care hospital payment rates will increase by 2.3 percent in FY 2013.  The 2.3 percent is a net update after inflation, improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes.   Payments for IPPS hospitals are expected to increase by approximately 0.9 percent or $904 million in FY 2013.  CMS also projects that LTCH payments will increase by approximately $100 million or 1.9 percent.

The proposed rule makes a number of changes to payment policies and rates, including:

• Adding the Medicare spending per beneficiary measure to the Hospital VBP Program, which would affect all Part A and Part B payments beginning in FY 2015;

• Establishing a new methodology and the payment adjustment factors for excess readmissions for heart attack, heart failure and pneumonia, and

• Several changes to the LTCH payment system that would:
oExtend the existing moratorium on the “25 percent threshold” policy for one year;

o Apply a 1.3 percent reduction to the first year of a proposed three-year phase-in of a budget neutrality adjustment, so that the proposed adjustment will not apply to discharges occurring on or before Dec. 28, 2012; and,

o Include the IPPS comparable amount payment option for discharges occurring on or after Dec. 29, 2012 in Medicare payments for very short stays in LTCHs.  

To read the press release and fact sheets, go to:  http://www.cms.gov/Newsroom/Newsroom-Center.html.

The proposed rule can be downloaded from the Federal Register at: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1.

CMS will not require independent LTC pharmacists

by Ruta Kadonoff, Vice President, Quality & Regulatory Affairs, American Health Care Association

In a welcome response to comments submitted by AHCA and other stakeholder groups, The Centers for Medicare and Medicaid Services (CMS) reported on April 2 that they will not move forward in the immediate term with a proposal to require LTC facilities to hire independent consultant pharmacists, while reserving the possibility of doing so in the future if reductions in “inappropriate prescribing,” including the off-label use of antipsychotic drugs, are not observed. This decision was reflected in a final rule with comment period for the Medicare Advantage and prescription drug benefits programs for Calendar Year 2013.

In an October, 2011 Federal Register Notice, CMS discussed a potential new requirement for LTC consultant pharmacists to be independent of any affiliations with the facility's pharmacies, pharmaceutical manufacturers and distributors, or any affiliates of these entities. CMS reasoned that such a requirement was necessary to ensure that consultant pharmacist decisions were objective, unbiased, and in the best interest of nursing home residents. CMS now indicates that, “From comments received on this issue, we now believe a more targeted and less disruptive approach is warranted.”

In December 2011, AHCA submitted comments to CMS on this proposal, which the AHCA Pharmacy Workgroup was instrumental in shaping. In those comments, AHCA agreed that it is important to minimize the potential for a conflict of interest on the part of the consultant pharmacist and argued that current regulations and Guidance to Surveyors provides adequate support for CMS to deal with potential conflicts. AHCA also provided 6 alternative suggestions to minimize potential conflict of interest, provided data from the one state that requires an independent pharmacist that suggests “independence” does not necessarily result in reduction of use of antipsychotics and listed (with supporting information) advantages to having the consultant pharmacist associated with the dispensing pharmacy.

CMS is now soliciting additional comments to help determine a more comprehensive approach to eliminate overprescribing and reduce the use of antipsychotic drugs in LTC. CMS also strongly encourages the LTC industry to voluntarily adopt the following changes to increase transparency:

• Separate LTC consultant contracting for dispensing and other pharmacy services;

• Pay fair market rates for consultant pharmacist services; and

• Disclose to LTC facilities any affiliations of consultant pharmacists that pose potential conflicts of interest (this may include the execution of consultant pharmacist integrity agreements.)

CMS adds that if the expected improvements in prescribing behavior and antipsychotic drug use do not occur through voluntary practice changes, they will use a future notice and comment rulemaking to propose requirements to comprehensively address these concerns.

The AHCA/NCAL Quality Initiative

Long term and post-acute care leadership from the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) have announced a multi-year initiative to meet new quality goals, including reducing hospital readmission rates and improving staff retention.

The Quality Initiative focuses on four goals designed to improve quality of care in America's skilled nursing centers and assisted living communities.

1. Reduce Hospital Readmissions: By March 2015, reduce the number of hospital readmissions within 30 days during a SNF stay by 15 percent.
2. Increase Staff Stability: By March 2015, reduce turnover among nursing staff (RN, LVN, CNA) by 15 percent.
3. Reduce the Off-Label Use of Antipsychotics: By December 2012, reduce the off-label use of antipsychotics by 15 percent.
4. Increase Customer Satisfaction: By March 2015, increase the number of customers who would recommend the facility to others up to 90 percent.
(Please note: NCAL is currently developing its specific measures and targets.)

The Quality Initiative goals have been defined for the next three years to foster sustainable change and set specific benchmarks for the long term and post-acute care profession to build upon. AHCA/NCAL is challenging its membership to hold itself accountable in ensuring a higher quality, lower cost health care system.

"The quality initiatives goals set forth by the AHCA compliment our efforts in Indiana as we move towards the most robust value-based purchasing program in the country," said Scott Tittle, President of the Indiana Health Care Association. "The combined focus of these measures and those in the VBP program relating to reducing employee turnover, improving staff retention, and achieving high marks in employee, resident, and family satisfaction should result in improving the experiences of residents and staff in our member facilities.  Indiana members want to thank the AHCA for taking this very important step and being the leader nationally in improving resident care."

Reaching the targets set in each goal in the Quality Initiative will improve the health of thousands of seniors and people with disabilities, while at the same time driving down health care costs. When AHCA members achieve the goal of reducing hospital readmissions by 15 percent, 26,000 fewer people will go back to the hospital each year. Improving staff satisfaction will result in more consistent staffing in long term and post-acute care settings, keeping more than 615,000 in their jobs.  Less off-label use of antipsychotic medications will help patients avoid the health complications that come with the drugs. More satisfied residents and families means that AHCA member facilities are fulfilling the mission of providing quality care.

AHCA/NCAL has created a volunteer-led Quality Cabinet to coordinate and monitor the progress of the Quality Initiative. More information about the Initiative is available online at qualityinitiative.ahcancal.org.

GAO Issues Study on Implementation of the Quality Indicator Survey

by Lyn Bentley, AHCA Senior Director of Regulatory Services

This week the GAO issued a study:  Nursing Home Quality: CMS Should Improve Efforts to Monitor Implementation of the Quality Indicator Survey.  The study states that CMS has not done an adequate job of monitoring the implementation of the Quality Indicator Survey (QIS).   While CMS has taken some steps to monitor implementation progress of the QIS, the monitoring has not been systematic nor is it consistent with federal internal control standards.

Of particular interest is the GAO position that “In the case of the QIS-based routine survey process, information collected through performance goals and measures could help CMS routinely monitor the extent to which the objectives of the QIS are being achieved.  This information could also inform future efforts by CMS to modify and improve the QIS process as needed.”  CMS agreed with the need for certain performance measures – particularly with regard to examining the effect of the QIS on surveyor consistency.

GAO Recommendations to CMS
• Develop a means – such as performance goals and measures – to routinely monitor the extent to which CMS is making progress in meeting the objectives established for the QIS;

• Develop and implement a systematic methodology to track state survey agencies’ progress with implementation activities; and

• Develop and implement a systematic method for obtaining, compiling, and sharing information from state survey agencies about their implementation experiences.

CMS Responses to the GAO Recommendations
CMS concurred with these recommendations and intends to:

• Establish new or modify existing measures or processes to more effectively monitor CMS’s progress towards meeting QIS goals and objectives.  CMS is already reviewing available data related to the QIS (for example, data on survey workload, survey deficiencies, and the number of surveys performed) to more effectively monitor the QIS and guide improvement efforts.

• Formalize the data collection method used to track states’ progress with QIS implementation activities.  CMS will institute an automated process to obtain updated information on states’ progress with training surveyors which, when combined with existing data, could provide a more accurate assessment of implementation activities in any state.

• Enhance existing and add new methods of sharing information on the QIS with states.  CMS plans to expand existing information sharing opportunities (for example, quarterly calls and presentations at annual meetings) to be available to all states, not just those in the process of implementing the QIS.  CMS is also considering using a web-based capability to facilitate sharing information on QIS implementation.

OIG issues memorandum report on Nationawide Program for Background Checks

In January, the Department of Health and Human Services Office of the Inspector General (OIG) issued a report entitled Nationwide Program for National and State Background Checks for Long-Term-Care Employees – Results of Long—Term-Care Provider Administrator Survey. As you may recall, this nationwide program is a voluntary program identified in and funded by the Affordable Care Act provides grants to states to implement programs to conduct federal background checks on prospective long-term-care employees. According to the OIG, the purpose of the survey was to collect baseline data on current practices regarding conducting background checks on potential employees and the effects on the long-term-care workforce.

This report focused on the impact national background checks have on the availability and quality of long-term-care employees. To determine the impact, a sample of long-term-care administrators in states participating in this program were surveyed. According to the OIG, the survey results indicate that 81 percent of the administrators had a sufficient pool of applicants for job vacancies. Those administrators who had an insufficient pool of applicants “cited prospective employees’ preferences for working in health care settings other than long-term care, low pay, and lack of desire to work in a rural area.”

Based on the timeline for development of this report, it is important to note that administrators from 10 of the 17 states that are currently participating in this program were surveyed. It is possible that results will differ when more states are included in the survey.

IHCA Chooses Silverchair Learning Systems as Its Online Training Partner

IHCA has chosen Silverchair Learning Systems as its partner to provide effective online training solutions that will help improve operations and reduce costs to members.

“We are very excited about the vast resources and experience that Silverchair will bring to our members through high-quality and cutting-edge online training,” said Scott Tittle, President of IHCA.

This partnership gives IHCA members access to a highly effective and affordable turn-key learning program that delivers, tracks, and reports on educational programs for their entire organization. Silverchair’s training program provides a complete curriculum of in-service and regulatory courses required by CMS and OSHA, as well as important resident care topics that specifically address the needs of senior care providers and their employees. The program can also be customized to include material specific to an organization.

“As a native Hoosier, I’m especially glad to have the opportunity to partner back home again in Indiana,” said Mike Mutka, President and COO of Silverchair Learning Systems. “We are excited to see how Silverchair will enhance the training of members at the more than 200 facilities that are partnered with IHCA.”

IHCA joins eight other American Health Care Association state chapters who have chosen Silverchair as their online learning partner. IHCA has negotiated exclusive pricing with Silverchair, making the learning management and online training system available to its members at a substantial discount.

Please visit the IHCA website for details on free courses and other benefits of this new partnership!

ISDH Establishes a New Independent Informal Dispute Resolution Process for Long Term Care Facilities

by Zach Cattell, JD, IHCA General Counsel

On December 30, 2011 the ISDH issued a new ISDH Division of Long Term Care Policy and Procedure implementing the Federal requirement to establish an Independent Informal Dispute Resolution (IIDR) process for long term care facilities. The new IIDR process has been established to provide long term care facilities an opportunity, without cost to facilities, for an entity independent of the State Survey Agency to review certain aspects of survey deficiencies.

The ISDH IIDR Policy and Procedure includes two attachments, one with contact information for the ISDH IIDR lead and one with a timeline of the IIDR process (click here for the documents: IIDR Policy and Procedure; Attachment A – Contact Information; Attachment B – Timeline). The ISDH has also established a Informal Dispute Resolution Information Center at http://www.in.gov/isdh/25304.htm.

Applicability of the New IIDR Process

The new IIDR process is an option for facilities to elect if the facility is the subject of a Civil Money Penalty (CMP) that may be collected and placed in an escrow account. Until further notice from Federal and State regulators only those deficiencies that cite actual harm or immediate jeopardy (G or above) will be subject to the CMP collection and escrow and only those deficiencies will trigger the opportunity for IIDR. Any CMPs imposed for D, E and F deficiencies will be collected under the current informal dispute resolution process run by the ISDH and are not subject to the new IIDR process.

In the December 30, 2011 ISDH Newsletter, the ISDH provided the following key components to the ISDH-developed IIDR process:

1. The new ISDH Informal Dispute Resolution Policy and Procedure is effective January 1, 2012.

2. The ISDH will continue to offer traditional informal dispute resolution for all licensing and certification surveys conducted at comprehensive care facilities. The "informal dispute resolution" process refers to the review process conducted by ISDH Long Term Care Supervisors. The informal dispute resolution process may be either a paper review or a face-to-face review as requested by the facility. There is no fee to the facility for the informal dispute resolution process.

3. Effective January 1, 2012, an independent informal dispute resolution process is available to skilled nursing facilities (SNF) and nursing facilities (NF) that meet certain requirements related to a civil money penalty (CMP) imposed by the Centers for Medicare and Medicaid Services (CMS). The process is conducted by a CMS-approved "independent entity" that has contracted with the ISDH to provide this service. There is no fee to the facility for the independent informal dispute resolution process.

4. The Independent Informal Dispute Resolution process will only apply to standard (annual) and/or complaint surveys begun on or after January 1, 2012, that initiate an enforcement action for which a civil money penalty is imposed and subject to being placed in escrow. Any revisit survey conducted on or after January 1, 2012, that is associated with standard or complaint surveys begun prior to January 1, 2012, will not be subject to the Independent Informal Dispute Resolution Process.

5. Only civil money penalties which are imposed based on a deficiency or deficiencies cited for actual harm or immediate jeopardy to resident health or safety (i.e., at a scope and severity level of G or above) will be subject to civil money penalty collection and escrow provisions. Those deficiencies which result in the imposition of such civil money penalties will trigger a facility's opportunity to participate in the independent informal dispute resolution process. CMS will provide notice of the opportunity to participate in the independent informal dispute resolution process. The facility will request an independent informal dispute resolution through the ISDH.

6. The ISDH will be contracting with an independent entity for the independent informal dispute resolution process. The ISDH will provide contact and process information for that entity when a facility requests the independent process.

Independent Informal Dispute Resolution Entity

As noted by the ISDH in item #6 above and in the December 30, 2011 ISDH Newsletter, the State has not yet awarded a contract as proposals to the State were due on January 5, 2012. The ISDH believes that the independent entity will be in place in time for use by facilities.

Additional Considerations

The new IIDR process, with its requirements and timing limitations, is untested in Indiana or anywhere else in the country and there will undoubtedly be questions that arise. Due to the timing limitations (the process must be completed within 60 days from a facility’s request for IIDR), the new IIDR process for Indiana facilities will be entirely paper-based and no in-person meetings will occur. For the traditional ISDH-led informal dispute resolution process, a facility can choose either paper-based review or in-person review.

Because the ISDH will continue to administer the ISDH-led informal dispute resolution process and because facilities will not be able to go through both the ISDH-led process and the new IIDR process for the same deficiencies, the ISDH will not schedule an ISDH-led informal dispute resolution process, if requested, until a determination of whether CMP will be imposed that can trigger a facility’s right to the new IIDR. It will be key that a facility submit all supporting documentation to the ISDH through the ISDH Survey Report System when electing the ISDH-led process as requests for that process will not be considered until all documentation is submitted. Once it is known whether CMP is to be imposed for a deficiency, then a facility can choose either the ISDH-led process or the new IIDR process.

In addition, facilities and their counsel should consider how the IIDR process will impact any decision to request or waive a formal hearing on cited deficiencies. CMS and ISDH have been clear that the new IIDR process is not and will not be used to delay timing of the formal hearing process. Request for a formal hearing will likely have to occur near the same time that an IIDR is requested due to timing requirements.

IHCA will continue to monitor the development of Indiana’s IIDR process. For additional information please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Congress Agrees on Two-Month Extension to Payroll Tax Cut and Extended Unemployment Compensation: "Doc Fix" and Outpatient Therapy Caps Exceptions Process Receive Similar Reprieve

The U.S. Congress passed a two-month payroll tax cut extension just eight days before its scheduled January 1, 2012 expiration after House Republicans dropped their objections under growing political pressure. President Obama signed the extension, guaranteeing that 160 million workers will continue to receive a two percent cut in their social security payroll taxes. Also included in the package was a freeze in physician Medicare payments, which avoided a massive 27.4% cut set for January 1, 2012; an extension of expanded unemployment compensation benefits; and an extension of the Medicare Part B outpatient therapy cap exceptions process under which SNFs and other providers can avoid therapy caps for certain patient diagnoses.

Congress will use the two-month reprieve to try to come to a full year agreement on the “extenders” package. The Senate and the President had supported a one-year extension, but the House had originally balked at the idea, accusing them of “kicking the can down the road” and failing to enact any long range deficit reduction legislation. A one or two-year extension will hinge on the ability of Congress to come to an agreement about how to pay for the various program extensions. Congress has appointed a conference committee to resolve the controversy. The committee has until March 1 to decide what to fix, for how long, and how to pay for it. None of the conferees named to date are from Indiana.

The original House version of the “extenders” package had called for a cut in federal reimbursement for public and private Medicare “bad debts” to 55 percent. Such a cut would have had a huge impact in states, like Indiana, whose Medicaid programs do not reimburse SNFs for Medicare Part A co-payments. We understand in this two month review, our industry is once again in Congress’ sights as potential “pay for” solution. Our national affiliate, the American Health Care Association, is following the issue closely and advocating for alternative funding sources such as savings from reduced re-hospitalizations.

We will bring you more information on the issue as it becomes available. Meanwhile, members with questions may call (317-616-9031) or email IHCA President Scott Tittle at stittle@ihca.org for additional information.

CMS Region V Updates

by Zach Cattell, IHCA General Counsel

IHCA recently had the opportunity, along with several other states’ long term care associations, to meet with the survey and certification staff of CMS Region V. The following information was discussed:

• Citation patterns by state and by region. See attached charts that summarize the top ten citations for Region V as well as a total deficiencies cited by severity level. F441, F371, F323 and F279 were in the top ten for all states in Region V.

• QIS will continue to be implemented in the states where training has started, but no new states will begin QIS training until further funding is identified. In addition, QIS will continue to only apply to annual surveys and there is no word at the current time as to if or when QIS will apply to complaint surveys.

• Elder Justice Act – Crimes Reporting

     1. Unfortunately, no new guidance or insights were discussed by CMS as to the rollout of the      reporting requirement. CMS stands by its last issued guidance

     2. The Region V staff was unsure as to when CMS Central Office would be issuing any additional guidance or promulgating regulation to implement the CMP and excluded individual provisions of the law

     3. Facilities should continue to follow the guidance issued by CMS and the ISDH to implement the crimes reporting requirement

• Independent Informal Dispute Resolution (IIDR)

     1. A new CMS S&C Memorandum was published on December 2, 2011 that superseded the October 14, 2011 memorandum on the implementation of IIDR. The new Memorandum is attached and includes the Interim Advance Guidelines that will be placed in the State Operations Manual regarding the IIDR process.

     2. The ISDH is working on its own guidance regarding IIDR since it is required by CMS to implement the IIDR program for Indiana. The ISDH is expected to release guidance when the new IIDR process goes into effect on January 1, 2012.

     3. The new IIDR process will only apply to all standard or complaint surveys begun on or after January 1, 2012 and include enforcement action on a G-level deficiency or higher for which Civil Money Penalty may be assessed and escrowed.

     4. IHCA is analyzing the CMS and ISDH guidance.

• Life Safety Code citation history for 2011. See attached charts regarding Life Safety Code citations for Region V states, comparisons of the top ten citations from 2010 to 2011, as well as CMS’s tips on how to avoid the top ten deficiencies. Indiana’s #1 Life Safety Code deficiency was K144 – Emergency Generators for the second year in a row.
 
Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.