CMS Updates

IHCA attended a Region V provider association meeting earlier this month and discussed a number of issues with CMS Region V and Central Office Staff.  The following are notes and updates and notes from that meeting.

1. 5-Star Ratings
Some providers have complained about the accuracy of the staffing rating on the 5-Star website.  Some of the data is not being keyed in correctly, and some issues are occurring because of edits within the CMS system to verify that data.  Specific issues should be addressed with Region staff.
The lack of including therapy staff, in particular Respiratory Therapist staff in vent unit facilities, places those facilities at a disadvantage in the staffing component of the rating system. CMS Central Office indicated it was analyzing whether a therapy component could be added to the rating system.

2. CMP Funds
A new CMP analytical tool (grid) is being developed by Central Office, with input from the Regional Offices, and is expected to be released in early 2013.  According to Region 5 staff, the tool and grid will be rolled out on a pilot basis for use by Regional Offices in their determination/approval of CMPs.  SSAs will not be mandated to use it until some later date.  During the pilot, providers will have an opportunity to comment on the tool for CMS's consideration.

Since last year's S&C Memo (12-13) regarding use of CMP funds was released, only 2 proposals in Region 5 have been submitted for CMS approval.  Details were not released on what those proposals were.  CMS Central Office is working on a report regarding CMP projects across the country with an aim that the report will help other regions see what projects are being approved by CMS.Discussion was had about the National Partnership to Improve Dementia Care and that a potential use of CMP funds would be to fund joint provider-surveyor training.

3. Corporate Compliance
CMS Central Office is in the process of finalizing draft regulations.  It is expected that the draft regulations will be finalized internally at CMS sometime in the next month or so, then released for a 2 month comment period, upon which final regulations will be issued and guidance to states given.
It is hard to imagine a scenario where CMS will have issued final regulations before the March 23, 2013 deadline set out by PPACA for SNFs/NFs to have a compliance program in place.

Region V staff did not have a sense as to whether the regulations being worked on would be materially different than the OIG standards for corporate compliance programs that have already been developed and are available on the OIG website.

4. Dividing SNF/NF into smaller units
A question came up about whether separate, non-connected units, on different campuses could be part of the same Medicare/Medicaid certification.

If the units are more than 250 yards apart, the units may qualify to be a "composite distinct part" as discussed in the regulations.

The main focus for any provider attempting to use the composite distinct part definition is how will the entire facility at all locations meet staffing and certification standards - how will all services be integrated across campuses.

5. Sprinkler Requirement (Federal)
The requirement is effective August 13, 2013 - no exceptions. CMS Central Office is evaluating the sprinkling of outbuildings on a SNF/NF campus.  A determination is expected sometimes after January, 2013 and an S&C memo would be published.  Discussion seems to be focused on what the outbuilding houses and whether it is integral to the operation of the SNF.  For example, if the outbuilding housed a generator, then sprinklers would be required because the generator is integral to the operation, but if it housed lawn mowers, perhaps that is not an integral part of the operation.  More is expected on this.

Antifreeze in Sprinkler Systems - Due to a recent incident regarding use of antifreeze in sprinkler systems, CMS is noting the issuance of an April 2011 NFPA Tentative Interim Amendment to the NFPA Sprinkler Standards that limits the ratio of certain antifreeze agents in sprinkler systems (see http://www.nfpa.org/assets/files/nfpa_safety_alert_on_antifreeze_april_2011.pdf).  The limits are 48% glycerin concentration (good to about 3F) and 36% propylene glycol concentration (good to about 16F) for new systems.

(A side note, CMS is not saying that NFPA TIAs are law, but then again CMS has cited for not following them.)

6.  Life Safety Code
 In addition to the sprinkler discussion, the CMS LSC staff discussed the top 4 tags.

K048 - Evacuation Plans
*    The tag includes 8 requirements, and if one is missing a citation will be issues.  The most often cited deficiency is lack of detail on evacuation of the smoke compartment to a safe area.  The term "safe area" is used in plans, but "safe area" is not defined in the plans and upon inquiry surveyors have found the "safe area" to still be in the same smoke compartment.
*    In addition, many facilities have been cited for not putting additional detail into a general corporately-issued evacuation plan.  Each plan must be specific to the local facility.

K029 - Hazardous Areas
*    Citations were mostly attributed to self-closing doors that don't latch.  Make sure that these doors operate properly.

K069 - Commercial Cooking (NFPA 96)
*    Testing at required frequency not performed
*    No or inadequate documentation on tests performed
*    Kitchen open to corridor
*    Not covering equipment
*    Using mesh filters in the hood (Baffled filters are required)

7. Abuse Guidance/S&C Memo
A final draft of the CMS S&C memo regarding abuse, neglect, etc. is at the CMS Office of General Counsel and should be circulated internally at CMS for final comments this month.  Expected an S&C memo in early 2013.  No insight were or could be given as to the contents of the memo.

Points were made by the provider community about the issues of immediate reporting and through investigation.  One point CMS made is that a facility that has a thorough policy on abuse reporting has taken a good first step, but following the policy is imperative...not doing so is an easy citation.

8. Observation Status
CMS is very aware of the issue that the 3-day inpatient stay requirement is causing for beneficiaries and SNF providers.  Acting Director Tavenner is involved with the issue.  No additional items were discussed by CMS on this issue.

9. Health Information Technology
A brief mention was made that the Office of the National Coordinator for Health Information is beginning work on meaningful use standards for Health IT in the LTC space.  No information was given about whether any funding would be attached to the adoption of such Health IT as it was for the acute care space.

10. NF Value Based Purchasing
CMS Region 5 Staff was unable to give any update on what the status was on CMS's work for a Medicare Value Based Purchasing system.

11. QAPI
CMS is getting ready to release a QAPI guide for facilities to use in implementing the required Quality Assurance and Performance Improvement program. 

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

DEA Proposed Rule – Disposal of Controlled Substances

The Drug Enforcement Agency published a rule in late December to address requirements that govern the secure disposal of controlled substances by DEA registrants and users.  The rules address methods regarding secure disposal including take-back events, mail-back programs, and collection receptacle locations.  It appears that the DEA is not favoring a mail-back program for nursing facilities to utilize due to security concerns, and rather nursing facilities would have to rely upon the voluntary participation of a retail pharmacy with installation of a disposal receptacle.  Several questions arise from this rule and AHCA’s Senior Director of Clinical Services, Sandra Fitzler, wrote the attached synopsis of the DEA’s proposed rule.  A link to the rule is included in Sandy’s memorandum, which is available in the Members Only section of the IHCA website.  Comments on the proposed rule are due February 19th, 2013.

QAPI – CMS S&C Memo and Draft Implementation Guide

Last month CMS released S&C Memo 13-05-NH to State Survey Agencies with a preview of the QAPI At A Glance implementation guide that is set to be formally released in February 2013. (The memo and guide are available in the Members Only section of the IHCA website).  The At A Glance guide is part of CMS’s compliance with the ACA’s requirement to provide technical assistance for each nursing home to implement a QAPI system.  Regulations requiring a QAPI system are forthcoming.  Though the At A Glance guide indicates it is not for distribution, it appears the guide has been well disseminated and IHCA wanted its members to be aware of the guide.

Indiana Value Based Purchasing Update

For the past 20 months, the Indiana Division of Aging and Indiana Office of Medicaid Policy and Planning (together, the “State”) have been writing a proposed rule to alter the methodology behind the currently named Report Card Score Add-on to the Medicaid reimbursement rate.  The State has proposed a multi-domain methodology to determine the amount of add-on a nursing facility could obtain, it is called the Value Based Purchasing Add-on (“VBP Add-on”).  The IHCA has been deeply involved in attempting to improve the State’s VBP Add-on proposal by advocating for fair measurement of the domains, allocation of points, and an overall system where improvement in score correlates to improvement in quality resident care.  To read more about the VBP system, see http://www.nxtbook.com/nxtbooks/naylor/INHB0112/index.php?startid=6#/6.

On December 19, 2012, the State published a proposed rule for VBP, in addition to other changes to the reimbursement system, that would be effective on July 1, 2013.  One difference between the proposed rule and the original design is that for 2013 the resident, family and staff satisfaction surveys will not be part of the VBP score.  While those surveys will be conducted this year, the data would not be available in time to analyze it and make a fair distribution based upon that data by July 1, 2013.  The satisfaction survey data will be collected in 2013 and incorporated into the payment add-on in 2014.  The State is currently negotiating a contract with Press Ganey to conduct the satisfaction surveys.  Once a contract is signed, IHCA will engage the State and Press Ganey to fully educate IHCA members on how the survey process will be conducted.

IHCA is currently writing formal comments to submit to the State at the January 15, 2013 public hearing on the VBP proposed rule.  IHCA continues to be concerned with a number of areas in the VBP proposal, including the lack of recognition of therapy hours when calculating hands on care per resident day (the State is only focusing on hours provided by RNs, LPNs, and CNAs).  In addition, IHCA is concerned with the Administrator and DON turnover measure being too strict and not taking into consideration the internal promotion of Administrators and DONs.  IHCA has also, and will continue, to express concern regarding the heavy reliance on staffing measures within the VBP program given the weak to moderate correlations to improved Report Card Scores.  Without stronger correlations between the measurements and improved quality (as measured by the Report Card Score) it is less likely that incentive payments will make any difference with quality improvement efforts.

To view the proposed rule, see  http://www.in.gov/legislative/iac/irtoc.htm?view=list&lsadocnum=12-279.

Review of 2012 F441 citations

At a recent provider association meeting with CMS Region V the frequency of F441 citations was discussed and frustration was voiced with the myriad of ways F441 can and is cited.  Information was requested from CMS on a breakdown of the different ways F441 is cited so that specific issues could be addressed by providers and perhaps also to aid CMS in categorizing F441 tags in the future for education and quality improvement initiatives.

CMS is taking the discussion under advisement, but in the meantime Kim Rhoades from the Indiana State Department of Health provided the following detail on F441 citations on 2012 surveys (standard and complaint).

F441 was cited on 233 surveys.  F441 was cited:

-84 tags involved Handwashing
-67 tags involved infections control issue during med pass
-41 tags involved using gloves but touching unsanitary surfaces, or not using gloves at all or other issues with gloves (the universal ‘so long as I have gloves on, I can touch anything)
-33 tags involved failure to follow isolation precaution
-32 tags involved glucometers
-32 tags involved mishandling of linens
-27 tags involved issues with TB testing for residents
-23 tags involved various aspects of meal service
-16 tags involved unsanitary equipment other than glucometers
-10 tags involved failing to have tracking of infections, etc. as part of their infection control program
-8 tags involved contamination issues involving would care
-7 tags involved catheter care
-3 tags involved pericare
-3 tags involved 02 tubing
-3 tags involved Scabies
-2 tags involved Trach care
-2 tags involved wound vac
-1 tags involved PICC line care
-1 tags involved no handwashing policy

IHCA encourages its members to study the above list and focus on the most frequent citation pathways for F4441 as it is the  most cited tag.