CMS Releases Guidance on Medicaid Funding for LTC Ombudsman Functions

On May 18, 2013, CMS released guidance to State Medicaid Agencies and State Units on Aging on the availability of federal Medicaid administrative matching funds for the LTC Ombudsman program.  In prior years, CMS has indicated the Medicaid matching funds were not available for the LTC Ombudsman program.

The guidance lists the following activities that may be eligible for Medicaid administrative matching (50% match rate):

• Information provided to potential enrollees regarding Medicaid eligibility and facilitation of the enrollment process;
• Identifying and referring individuals who may be eligible for and in need of Medicaid services;
• Tracking and reporting to the Medicaid agency consumer requests for assistance in obtaining medical, dental, mental health, or long-term care (including home and community based) services that are covered by Medicaid;
• Providing ombudsman services to assist beneficiaries in transitioning from Medicare Part A coverage into the Medicaid nursing facility benefit or from private pay status into Medicaid funded nursing facility, home and community based services, or other Medicaid service categories;
• Consultation and direct case advocacy to assist individuals participating in home and community-based waiver programs;
• Identifying Medicaid-eligible residents who want to transition out of nursing home facilities and then connecting them with the appropriate local contact agency or other services to assist them in returning to the community.
Identifying and reporting suspected instances of Medicaid fraud to federal and state agencies for investigation and action; and
• Other LTCO activities which are determined by the Secretary of DHHS to be necessary for proper and efficient administration of the Medicaid state plan.
• State Medicaid Agencies will submit State Plan Amendments to begin to draw down such funding.  And, the CMS Regional Offices will lead in working with interested states as well as Administration for Community Living regional offices. 

In order to draw down the federal Medicaid matching funds, States must meet a number of complex requirements, including documentation of direct benefits to the Medicaid program and consistency with federal cost allocation principles.  It is unclear at this time if Indiana will utilize this new guidance, and IHCA has contacted the Indiana Division of Aging and Office of Medicaid Policy and Planning to inquire about their potential use of the potential funding.  Increased funding to the LTC Ombudsman program may help consumers and facilities in a number of ways, including better support with discharges and transfers and assisting with resident access to specialty services.

CMS Alters SNF/NF Medication Pass Survey Protocol

IHCA members may have seen that CMS released a memorandum changing the survey protocol for Medication Pass.  This change only impacts the Traditional Survey process.  The change will now make the Traditional Survey procedure for Medication Pass the same as the QIS Medication Administration Observation protocol.  If you’d like to read more, click here.

CMS Releases Introductory QAPI Materials

CMS announced the release of several QAPI tools for providers to use, and a new webpage to hold these resources.  S&C 13-37-NH, accessible in the Members Only section of the IHCA website briefly discusses the following introductory materials:

o   QAPI at a Glance – a guide for understanding and implementing QAPI in nursing homes
o   QAPI Tools – process tools, within QAPI at a Glance, to help providers establish a foundation in QAPI
o   QAPI News Brief – newsletter describing basic principles of QAPI
o   Video – Nursing Home QAPI – What’s in it for you? -  introduces QAPI, its value to residents, their families and caregivers, and what is in it for nursing homes that embrace QAPI

Moving forward, CMs plans to expand its QAPI efforts by developing resources for consumers.  Visit the QAPI website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html.

ISDH Updates Advance Directives Brochure and Creates an Advance Directives Resource Center

The Indiana State Department of Health (ISDH) has released an updated version of their Advance Directives – Your Right to Decide brochure.  You may access at the following link:  http://www.in.gov/isdh/files/advanceddirectives.pdf.  The updated version revises guidance concerning Out of Hospital Do Not Resuscitate Orders, and includes a description of the new Physician Orders for Scope of Treatment (POST) form, which is due out on or around July 1, 2013 (for a summary of the POST form and law, see http://blog.ihca.org/2013/06/indiana-physician-orders-for-scope-of.html).   

In addition, the ISDH has created a new Advance Directives Resource Center website with links to the several advance directives authorized under Indiana law.  See http://www.in.gov/isdh/25880.htm for more information.

Nursing Home Resident Satisfaction Surveys to Begin in July

A friendly reminder that contractors from the Office of Medicaid Policy and Planning, GoResource Link and Knowledge Services, will begin performing satisfaction surveys of residents in Indiana Nursing Facilities during the month of July.  These interviews are part of the Indiana Medicaid Value Based Purchasing (VBP) program. For more on the VBP program, click here. 

IHCA was invited to observe one of the training sessions conducted for the persons that will be interviewing the residents in your facilities.  IHCA passed along the following observations and recommendations:

• The training sessions were thorough and discussed the nursing home environment, the need to be neutral during the surveys, HIPAA training and confidentiality of resident information
• The interviewers had a range of backgrounds, including some that have had prior long term care experience.  Others were retired individuals or home-makers working part time.
• There will likely be 2 to 4 interviewers in each facility and they may have questions or need assistance with locating residents.   IHCA recommends you assign a point-person to that interview team during their visit to your facility in order to field questions and assists as necessary.
• Interviewers are aware of the need to immediately report to the Administrator any specific information that could be an allegation of abuse, neglect, or misappropriation of resident property. 

IHCA recommends you discuss this procedure with the interview team when they arrive at the facility.

Timeframe to Report Incidents to the ISDH

State and federal regulations require health care facilities to report certain “incidents” to the Indiana State Department of Health (“ISDH”). Both the ISDH and the Centers for Medicare & Medicaid Services (“CMS”) have expectations of the timing in which a facility must report an incident. The current expectations and rules for both the ISDH and CMS are below; please note, however, that the standards may change once CMS issues the long-awaited memorandum concerning reporting allegations of abuse and neglect. Furthermore, it is likely that the ISDH will alter its guidance to align with CMS once the memo is issued.

According to the ISDH Division of Long Term Care, current CMS regulation concerning incident reporting takes precedent over that of the ISDH policy, and any facility must ensure that incidents are reported to the Administrator and ISDH immediately. The federal regulation, 42 C.F.R. §483.13(c)(2), states the following concerning timeliness of reporting incidents:

The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 
     
The ISDH Division of Long Term Care has indicated that CMS interprets the regulation so that the term “immediately” applies both to reporting to the Administrator and reporting to “other officials in accordance with State law through established procedures.” Id. Furthermore, CMS has maintained that “immediately” means “as soon as possible, but ought not exceed 24 hours after discovery of the incident.”

Guidance from the ISDH Reportable Incidents Policy, accessible in the Members Only section of the IHCA website, is the main source of confusion on whether the Indiana standard for reporting is immediately or within 24 hours. The first sentence of the Indiana guidance states, “Facilities are required by law to report unusual occurrences within 24 hours of occurrence to the Long Term Care Division.” Through discussions with the ISDH Division of Long Term Care, this sentence is not accurate and needs to be revised. However, the language in the Reportable Incidents Policy will not likely change until CMS issues the memo regarding F 223.

CMS surveyors are beginning to cite facilities for alleged failures to report incidents immediately through look-behind surveys. Because of the increased CMS oversight, the ISDH may be changing its approach and begin to more aggressively cite facilities for not reporting incidents immediately. An example of a citation concerning incident reporting in which a facility was cited for failing to report immediately is also available in the Members Only section. Please note that the facility in this example reported 24 hours after the incident occurred, and referenced the ISDH guidance on the 24 hour reporting requirement.  This incident should have been reported sooner.

Below are best practices and key points regarding the current legislation and requirements to comply with ISDH and CMS guidelines for incident reporting.

• “Immediately” does not mean a 24 hour grace period exists to report an incident.
• “Immediately” means as soon as possible once the resident is safe and protected.
    o An example of the immediacy required: If an allegation of abuse has been made and the resident is bleeding, stop the bleeding and then immediately notify the ISDH. You do not stop the bleeding, suspend the employee(s), take witness statements, draw conclusions, and then finally notify the ISDH.
• Use best judgment and report as soon as possible when dealing with “degrees” of incidents, including the time of day in which incidents take place. A common concern is immediate reporting in the middle of the night when the alleged incident is not especially grave or injurious (for example: a bruise of unknown origin discovered at 2a.m.). Immediate in this circumstance may not require an ISDH report by 2:30 a.m.. However, if an allegation of an employee hitting a resident is made at 2 a.m., a report to the ISDH as soon as possible once the resident is safe and protected (which may also require the removal and suspension of the employee) is required. A reasonable time to do this may be an hour, or perhaps a bit more.
• Educate facility staff. The 24 hour window that most believe exists before an incident report must be submitted does not likely exist at all.

If you have questions or would like more information about this, contact Zach Cattell at (317) 616-9001.

Indiana Physician Orders for Scope of Treatment (POST)

During the 2013 session of the Indiana General Assembly, House Enrolled Act 1328 was passed by the legislature and signed into law by Governor Pence.  The bill establishes the framework for use of the Physician Orders for Scope of Treatment (POST) form and requires the Indiana State Department of Health to develop the official form and place it on the department's website.  The law becomes effective July 1, 2013, and it is expected that the ISDH will have a form available on its website that day.

The initiative to adopt the POST form in Indiana was born from a national effort, started in Oregon, to develop a new and more effective approach to end of life care planning.  The form captures a patient's treatment preferences in specific medical orders that health care providers can act upon.   A POST form "is built upon conversations between patients, loved ones, and health care professionals, during which patients can determine the extent of care they wish to receive."   A patient may elect to execute a POST form as a result of the conversations and guidance concerning end of life care, and those care preferences then become medical orders that are carried out by health care providers.
A POST form, once properly executed, results in the creation of medical orders that by law are actionable across all medical settings.  As with any new health care treatment tool, it will take time and communication for health care providers to implement use of POST within their own facilities and amongst health care settings.

For your information, IHCA has developed the following summary of the POST law along with some practical and operational considerations.  IHCA will continue to update its members on the implementation of POST as information becomes available. Read More.

The remainder of this article is located in the Members Only section of the IHCA website. To request access to that section, click here. If you have already assigned yourself a password but have difficulty logging in to the Members Only section, please contact Kate Vaulter at kvaulter@ihca.org.