Surveyor Training Programs Available

CMS’s Survey and Certification Group announced a series of three web-based surveyor training programs regarding care of persons with dementia and unnecessary antipsychotic medication use.  The training programs are available for non-surveyors and can be accessed at the CMS website.  Below is a summary of the training contents and instructions on how to access the materials.

Content includes:
1. How to identify whether a systematic, individualized approach was implemented for a resident with dementia
2. How to identify that a systematic process is in place and has been followed for persons with dementia in the facility
3. How to evaluate the role of the resident, consultant pharmacist, physician/NP/PA, medical director, direct care staff, family and other members of the interdisciplinary care team
4. How to identify other associated tags related to care of persons with dementia and unnecessary medication use.

The third installment of the training will address how to cite severity and other aspects of deficiency citations in more detail, based on new guidance at F309, Care of Residents with Dementia, and revised guidance at F329 that is in development.

The first video program is 40 minutes in length.  The second self-study may take anywhere from 45 minutes to 1 hour or somewhat longer, depending on the knowledge and experience of the individual surveyor student.

How to Access these Videos for Non-Surveyors:  If you are a provider or do not wish to receive credit for viewing the program follow the instructions below.
1. Go to http://surveyortraining.cms.hhs.gov
2. Click on the “I am a Provider” tab
3. Click on the “Reduction in Unnecessary Medications in Nursing Homes” at the menu at the top of the screen
4. Click on the program that you wish to view.

For webinar technical questions contact Duva Clyburn at Duva.clyburn@cms.hhs.gov or Etolia Biggs at Etolia.biggs@cms.hhs.gov.

CMS Advance Guidance on F441 – Infection Control

CMS is clarifying and revising guidance to surveyors in Appendix PP of the State Operations Manual (SOM) regarding citations under F441 related to 42 CFR §483.65(c).  The memo addresses laundry detergents with and without antimicrobial claims, use of chlorine bleach rinses, water temperatures during the process of washing laundry, maintenance of laundry equipment and laundry items, and ozone laundry cleaning systems.  The memo can be accessed in the Members Only section of the IHCA website.

Nursing Facility Compliance and Ethics Program – The Deadline is Near

AHCA’s VP of Legal Affairs, Dianne De La Mare, issues a memo on January 31 regarding the upcoming March 23rd deadline for nursing facilities to have in place an effective compliance and ethics program as required by the Affordable Care Act (ACA).  In short, while the ACA requires CMS to promulgate rules upon which nursing facilities would rely in development of the compliance programs that have not yet been published, it is recommended that nursing facilities strive to meet the March 23rd deadline for implementing a compliance program.  It is expected that the compliance program regulations will be based off of the HHS Office of Inspector General guidance from 2000 and 2008, and facilities should look to those OIG materials when developing their programs.  Please see Dianne’s memo below:

According to the statutory language in section 6102 of the Affordable Care Act (ACA), which added Section 1128I of the Social Security Act, all skilled nursing facilities (SNFs) and nursing facilities (NFs) must have in operation an effective compliance and ethics program by March 23, 2013.  As reported previously, under the ACA, the HHS Secretary working with the Office of Inspector General (OIG) is required to promulgate regulations for designing and implementing a compliance and ethics program by March 23, 2012; but this deadline has passed with no regulations. In 2012, AHCA contacted OIG about the regulation and was told that CMS was drafting the compliance and ethics rule.  Subsequently, AHCA staff contacted CMS and we were told that the agency is in the process of drafting the rule and could not share information or timelines.  As a result, many nursing facility providers are confused about how they should proceed in the design and implementation of a compliance and ethics program, and when they must meet the deadline for implementing a program.
 
The ACA statutory language discussing the compliance and ethics program says that “on or after the date that is 36 months after the date of the enactment of this section,” a facility must “have in operation a compliance and ethics program…consistent with the regulations developed…”  As a matter of statutory construction this language is unclear, and the federal government could choose to interpret the compliance date using the March 23, 2013, deadline.   In some ACA provisions, there is specific language stating that the policy is effective notwithstanding failure to issue regulations.  In other ACA provisions, there is specific language stating that a policy change requires the issuance of a regulation before it can be effective.  The ACA compliance and ethics requirement language, however, provides no explanation of whether or not the statutory deadline is dependent on the release of a final rule or if it can stand independently.

Therefore, AHCA strongly encourages SNF/NF providers to strive to meet the statutory deadline (March 23, 2013) for designing and implementing a compliance program whether or not CMS has released a final rule.  We recommend, as we have for many years, that providers (if they haven’t already) begin the process of designing and implementing a compliance and ethics program by reviewing the information on AHCA’s website at http://www.ahcancal.org/facility_operations/integrity/Pages/Compliance-Programs.aspx; the OIG guidance for SNFs/NFs released in 2000 at https://oig.hhs.gov/authorities/docs/cpgnf.pdf; and the OIG supplemental guidance released in 2008 at https://oig.hhs.gov/compliance/compliance-guidance/docs/complianceguidance/nhg_fr.pdf. 

The ACA also specifically mentions the 8 components that must be incorporated into a compliance and ethics program, which are all discussed in the aforementioned links:
• The organization must have established compliance standards and procedures that reduce criminal, civil and administrative violations;
• Specific high-level personnel within the organization much have overall responsibility;
• The organization must use due diligence to ensure that employees have not been excluded from working in the Medicare or Medicaid program;
• The organization must effectively communicate and train employees on the standards and procedures outlined in the compliance and ethics program;
• The organization must have effective auditing and monitoring systems in place to detect criminal, civil or administrative violations;
• The standards and procedures must be consistently enforced;
• After a violation is detected, the organization must take reasonable steps to respond to any violations; and the organization must periodically evaluate the compliance and ethics program

ISDH Leadership Conference – Abuse and Neglect

The ISDH recently announced its spring leadership conference date and topic.  The program will focus on Abuse and Neglect and will be held on April 9, 2013 in Indianapolis.  The ISDH invites each comprehensive care facility (nursing home) to send two representatives to the conference. Each facility may select the individuals attending the conference on behalf of their facility. The ISDH recommends individuals such as the facility administrator, director of nursing, or compliance officer. Corporate offices of facilities are also invited to send appropriate representatives.  Registration materials are not yet available.

New ISDH Incident Reporting and Reasonable Suspicion of Crimes Against a Resident Forms

On January 15, the ISDH posted new forms for to use for Incident Reporting and reporting Reasonable Suspicion of Crimes Against a Resident.  When the reasonable suspicion of crimes reporting requirement was first implemented, the ISDH simply added those reporting elements to the Incident Report Form.  While thought to be convenient at first, this dual reporting form has led to some confusion and incomplete and/or inaccurate reporting.  The ISDH has now separated these reporting forms and facility employees and covered individuals should use each form for its intended purpose.  If an incident needs to be reported and the incident also gives rise to a reasonable suspicion of a crime, then both forms need to be filled out and submitted to the ISDH.  Conversely, if a reasonable suspicion needs to be reported that also qualifies as a reportable incident, both forms must be completed and submitted to the ISDH.

The ISDH has not publicized this change yet and is accepting both the old and new forms for the time being.  The ISDH expects to announce this change along with announcements about its revised website in the coming weeks.

The new forms can be accessed at on the ISDH website at the following:

Reporting a Crime Against a Resident Information Center: http://www.in.gov/isdh/25766.htm

Incident Reporting: http://www.in.gov/isdh/23638.htm