2014 IHCP Annual Provider Seminar – October 14-16 in Indianapolis

The Indiana Family and Social Services Administration (FSSA) and HP Enterprise Services invite Indiana Health Coverage Programs (IHCP) providers to attend the 2014 IHCP Annual Provider Seminar October 14-16, 2014, in Indianapolis. There is no cost for the seminar.  The seminar features three full days of important information. Topics  include program overviews and specific program billing guidelines, as  well as tips and reminders on various session topics.  For more details and registration links, see IHCP Bulletin BT201441.

WPS Medicare Full Day Training

WPS Medicare, the Medicare carrier for Indiana and Michigan , is offering a full day educational event designed for providers and suppliers of all types.  The multi-breakout sessions will allow providers to choose from 20 different topics of interest.  This exciting program, A Day with Medicare, is coming to Indianapolis, IN on October 7, 2014.  This event includes both Part A and Part B topics to gain insight into the cause for errors and the best ways to avoid them in the future.  The agenda includes a general session, 20 breakout sessions, and opportunities to meet with WPS Medicare staff. WPS Medicare is able to offer this event free of charge due to special funding from the Centers for Medicare & Medicaid Services.  The event capacity is limited to 200 people, so register today. 

To register, go to the WPS Medicare J8 website for Part A or Part B, click on the Training tab, choose Live Training, and click on the "Live training event catalog" link
October 7, 2014 - Indianapolis, IN - Click here for more information
October 9, 2014 - Detroit, MI - Click here for more information
For the schedule, a list of breakout sessions and speakers, please click here to access the program brochure.

Indiana Begins Work to Implement CMS Home and Community Based Settings Rule

In March 2014 CMS released a toolkit to state agencies to use as they move forward with creating or amending Home and Community Based Services (HCBS; also referred to as Home and Community Based Settings) programs within Medicaid.  CMS’s website devoted to the CMS HCBS rule and guidance is great resource to understand the agency’s direction for the Medicaid waiver programs that serve persons with mental illness, intellectual or developmental disabilities, and/or physical disabilities.  The CMS rule and interpretive guidance spell out a significant shift in the way CMS will support state HCBS program with federal funding.  Only those programs that meet specific criteria, much of which differs substantially from prior rule and guidance, will be eligible for federal funding.  Transition to compliance may take up to 5 years in each state, depending on specific state circumstances.

One of Indiana’s HCBS waivers is the Aged & Disabled Waiver (A&D Waiver) that includes the Assisted Living Services (amongst many others – see FSSA’s Medicaid Waivers page).  Approximately 1,500 Medicaid recipients currently reside in licensed Residential Care Facilities through the AL services wavier, and more than 16,000 Medicaid recipients receive one of the services listed under the A&D waiver.  All of these recipients quality for institutional care but are being served in the community under one of the waiver programs.  The Indiana Division of Aging (DA) manages the A&D Waiver and will be applying later this year to increase the number of slots available so that more Medicaid recipients can access these services.  A well known goal of federal and state governments is to increase the number and level of spending for HCBS so that more recipients can be cared for, when appropriate, in a lower cost community setting.

The CMS rule and guidance set out a number of new requirements and limitations for HCBS programs, and a new option to add HCBS into a state’s Medicaid plan rather than operating it as a waiver to the state plan.  More guidance is expected to be released in order to distinguish application of the requirements on the very different populations covered, but as they read now the rules and guidance are likely to result in significant change to Indiana’s HCBS programs.  CMS’s guidance titled Regulatory Requirements for Home and Community Based Settings spells out CMS’s expectations that states design programs that integrate recipients with the broader community, promote choice and person-centered care, provides autonomy and ensure protection of individual rights, and excludes settings that are de-facto institutions (like Nursing Facilities, ICF-IIDs, and Hospitals), or that have qualities of institutions or qualities that isolate HCBS recipients.

Impact on Indiana Providers
There will be impact on Indiana’s AL services providers – licensed Residential Care Facilities. Under CMS’s guidance, any provider-owned or controlled residential setting, in addition to the qualities discussed above (qualities which are evaluated based on other extensive guidance), must permit or provide:

-    The unit/dwelling is a specific space that can be owned, rented, or occupied under a legally enforceable agreement and provides the same protections that tenants would have under landlord/tenant laws of a state or other municipality.
-    Each unit must provide for privacy and have entrance doors that are lockable by the individual, with only appropriate staff having keys to doors; individuals must have a choice of roommate; individuals must have the freedom to decorate and furnish the unit within the lease or other agreement.
-    Individuals must have the freedom to control their own schedules and have access to food at any time.
-    Individuals must be able to have visitors of their choosing at any time.
-    The setting must be physically accessible to the individual.
-    Any modification to the above must be done through a person-centered service plan that meets specified requirements.

Settings that are presumed to have qualities of institutions, as defined by CMS, will require special attention by each state if these settings are to continue participate in HCBS programs.   Such settings are required to be identified by the state with a plan as to what changes to licensing or certification standards may be necessary to use such settings in a HCBS program.  Settings that are presumed to have qualities of institutions that are included in a HCBS waiver plan will go through a “heightened scrutiny” process (see also Steps to Compliance for HCBS Setting Requirements).  Settings that are presumed to have qualities of institutions are:

-    Any setting located in a building that is also a publically or privately operated facility that provides inpatient institutional treatment;
-    Any setting that is located in the building on the grounds of, or immediately adjacent to, a public institution; or
-    Any other setting that has the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS (see CMS Guidance on Settings That Have the Effect of Isolating Individuals).

Indiana Division of Aging Work To Date
The Indiana DA has begun work, along with its sister divisions at FSSA, to develop a transition plan that includes timeframes and benchmarks for developing/changing Indiana’s programs to comply with the CMS rule and guidance.  The first draft of a transition plan is due to CMS in December 2014.  The state will have one year to submit a final transition plan and the transition period may be up to 5 years depending on circumstances discovered in the planning process (required statutory/regulatory changes that may be necessary, etc.).

As it relates to the Assisted Living Services component of the Indiana A&D waiver, the DA is developing a survey tool that will be sent to current AL service waiver providers in order for the DA to have hard data on the housing stock and operations of Residential Care Facilities.  This data is essential to gather in order to allow the DA to develop a transition plan that can include Residential Care Facilities and/or design alternative programs to continue Assisted Living Services in Indiana’s HCBS waiver program.  This survey is to be sent later this summer.  This entire process will be a long one, but it is critically important to follow and provide input into.

IHCA/INCAL will continue to monitor Indiana’s implementation of the CMS rule.  Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with questions or comments.

Indiana Medicaid Issues Home Health Telehealth Proposed Rule

Pursuant to legislative action in the past 2014 session of the Indiana General Assembly, Indiana Medicaid issued a proposed rule to provide reimbursement for home health agencies providing telehealth services.   A public hearing on the proposed rule was held on August 28, 2014.  The rule defines telehealth services and establishes rates of $14.45 per client for the initial client visit to train and orient the client on use of the equipment and a rate of $9.84 for each date the telehealth equipment is used by an RN to monitor and managed the client’s care in accordance with physician orders.  In addition, the rule removes the current 20 mile geographic limitation for telemedicine services for FQHCs, rural health clinics, community mental health centers and critical access hospitals.  To review the rule, click here.

Indiana Medicaid Rate Update

As reported last month the State has begun to reprocess rates to implement a 2% increase and to implement a slightly increased Quality Assessment Fee, both effective 1/1/14.  Also reported in the past, IHCA has been in discussions with Indiana Medicaid and the Division of Aging concerning a transition to RUGS IV, as well as the ongoing payment of the Special Care Unit add-on.  IHCA recently met again with the State on these matters and no decisions have been made.  The state has asked the IHCA and other long term care associations to engage assembling a 5-8 year plan concerning nursing home reimbursement, home and community based services, and quality initiatives.  As part of that planning process, the RUGs IV and Special Care Unit add-on will be addressed.  IHCA will be working internally with our Board of Directors, and externally with our fellow trade associations to determine next steps.

CMS Issues New Survey & Certification Memos for Nursing Homes

The below S&C Memos have been issued by CMS that are applicable to nursing homes:
-    S&C 14-42-NH – Release of Learning Tool on Building Respect for Lesbian, Gay, Bisexual, Transgender (LGBT) Older Adults.  CMS has developed and released a free learning tool designed to educate nursing facilities on the needs and right of older LGBT adults.  The program presented in six online training modules.  There are approximately 1.5M older adults over the age of 65 that identify as LGBT, and estimates indicated that number will double by 2030.  To access the learning tool go to http://lgbtagingcenter.org/training/buildingRespect.cfm.
-    S&C 14-43-NH - Completion of Minimum Data Set (MDS) 3.0 Discharge Assessments for Resident Transfers from a Medicare- and/or Medicaid-Certified Bed to a Non-Certified Bed.  CMS reminds nursing homes of the requirement for MDS 3.0 discharge assessments to be completed  when a resident transfers from a Medicare or Medicaid certified bed to a non-certified bed.  The requirement is based in federal regulation and law.  To read more, click on the above linked memo.

QIO Changes Update

As reported last month two new QIO entities have begun work in Indiana.  KEPRO is in charge of beneficiary complaints and appeals, and quality of care reviews, while QSource will be responsible for working with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm, and improve clinical care at their local and regional levels.

Providers have experience some transition pains with KEPRO in the area of processing beneficiary appeals.  It appeared that KEPRO was not able to handle the volume of appeals, which has created problems for beneficiaries and providers alike with obtaining appropriate Medicare coverage.  To assist with the appeal process, providers are encouraged to use the Expedited Determination Contact Information for Discharge Appeals for appeals that are time sensitive.

On the quality improvement side, Indiana’s long term care community is thrilled that Kathy Hybarger has been hired by QSource to continue her great work in quality improvement.  Kathy’s contact information is below.  QSource issued this introduction letter to providers about their operations and the name of the territory that they cover, dubbed the Atom Alliance (covering IN, TN, KY, AL, and MS).  Congratulate Kathy as you are able and you’ll be hearing more from her and QSource in the very near future.

Kathy Hybarger  RN, MSN
Task Lead for Nursing Homes, Hospital, and Care Coordination
Phone:765-413-9764
e-mail:  Kathy.Hybarger@hcqis.org

ISDH Announces the Advanced Healthcare Education Project

In partnership with the University of Indianapolis Center for Aging & Community, the ISDH is developing and implementing a series of advanced education programs on geriatric care issues.   The project will provide introductory certification-level educational programs throughout the state on several advanced education topics.  The programs are intended to prepare the participant to be eligible for a level of certification in the specified area.  The programs will offer education in the following areas:

-    Wound Care
-    Infection prevention
-    Alzheimer’s and dementia care
-    Quality/Process improvement

Assessment of the project will be done by monitoring the number of deficiencies cited during long term care surveys, specifically for F314 and F441, and track the percent of Indiana nursing homes with an individual that has “certification level education” in wound care, infection prevention, Alzheimer’s and dementia care, PHI abuse prevention, and yellow and green belt Six Sigma.

The programs are funded by ISDH Civil Money Penalties and are free of charge to participants.  There may be a small charge for cost of food and beverage during the education sessions.

The training schedule has already been developed for the Quality/Process Improvement trainings that begin in September and go through January in different areas of the State.  For additional details on the ISDH project and the training schedule please see the ISDH Long Term Care Newsletter from August 25, 2014.

Changes Approved to the Indiana Medicaid Formulary

On August 15th the Indiana Drug Utilization Review (DUR) Board approved changes to the preferred drug list for Indiana Medicaid recipients.  In addition, the DUR Board approved utilization edits reviewed by the Mental Health Quality Advisory Committee.  Changes to the formulary and utilization edits are effective for dates of service on or after Oct. 1, 2014.  See IHCP Bulletin BT 201440 for additional detail.

Residential Care Citation Update

In July 2014 the ISDH issued 59 Deficiency tags and 4 Offense tags to Residential Care Facilities.  This is the high mark in 2014 for Deficiency and Offense tags by the ISDH.  Leading the way is Tag 0273, which was cited 11 times in July, concerning maintenance of food preparation and service areas in accordance with state and local standards.  Tag 0217 was cited 7 times in July, and having been cited 8 times in the first 6 months of the year, ISDH surveyors appear to be paying extra attention to the use of appropriately trained staff to complete evaluations and resident service plans.  Another trend that has appeared in the last few months is citation of Tag 0214, another resident evaluation tag, concerning initiation of an evaluation prior to admission and upon a change of condition with a licensed nurse evaluating the resident’s need for nursing care.   Tag 0214 was cited 5 times in July, 2 times in June, and 3 times in May.

For a summary of all Deficiency and Offense tags issued in July, click here.

ISDH IJ/SSQC Update

There were three events in the month of July that led to 7 IJ citations being issued all of which were also SSQC.

The first event, citing F225 and 226, involved the lack of investigation and reporting of allegations of sexual abuse by a staff member of a resident.   In this particular case, a resident who apparently had a history of making false accusations reported that a female staff member was having sex with a male resident in the resident’s room (the resident making the accusation was the roommate).  The Administrator did not take the accusation as credible due to the resident’s history and the details of the accusation.  However, the ISDH took exception with the lack of investigation and reporting to the ISDH of this allegation. 

The second event involved the failure to order and monitory lab values for 2 residents receiving Warfarin.  The failure resulted in citation of F329 and was cited as past noncompliance as the facility caught its error and corrected it prior to survey.  The error was due to miscommunication during a conversion of physician orders to a new computer system.

The third event involved the failure of the facility and the facility’s management to address and report verbal abuse by the Administrator to residents and staff.  Citations were issued for F223, F225, F225, and F490, all related to the alleged verbal abuse by the Administrator.  Behavior of the Administrator was described as demeaning, humiliating, and threatening to residents and staff.  Staff reported to ISDH that they had called the corporate hotline several times concerning the Administrator.  F490 was issued due to the management’s alleged failure to ensure the facility was administered to attain or maintain the highest practicable mental and psychosocial well-being of each resident based upon the behavior of the Administrator.

To review the 2567s for the July IJs/SSQCs and for a summary of all IJs/SSQCs in 2014, click here.