Indiana to Launch the State’s First PACE Program

Beginning on November 1, 2014 Indiana will begin enrollment for the State’s first PACE program.  The Program for All-inclusive Care for the Elderly (PACE) is a risk-based managed care program for both Medicaid and Medicare benefits.  Participants must be at least 55 years of age or older, required nursing home level of care, be in a PACE service area, and be to safely live in the community at time of enrollment.  The program provides a wide-range of benefits from hospital and physician care to nursing care, home care, social services, meals and adult day care, and more.  When a participant enrolls they are required to sign an agreement indicating they understand the PACE organization is their sole service provider.

The Franciscan Alliance in Indianapolis will be the first PACE program service provider and the Indiana Division of Aging will handle the enrollemnet process.  Providers of all types will need to be sure the check a patient’s Medicare and Medicaid card to see if that person is a PACE enrollee.  Indiana Medicaid will deny payment for any fee-for-service claims submitted by non-PACE providers for PACE members.  Additional information will be distributed by Indiana Medicaid in the near future.  To read the latest IHCP Bulletin click here.

Division of Aging and Press Ganey to Announce Webinars on 2014 Satisfaction Survey Results

Nursing facilities should be on the lookout for invitations that are to be sent in early October from Press Ganey for participation in webinars to review the 2014 Satisfaction Survey results.  Recall that the Indiana Division of Aging contracted with Press Ganey in 2013 to conduct satisfaction surveys of residents, resident family or friends, and facility staff with the aim at determining whether such data could be mixed into the Indiana Medicaid nursing facility reimbursement Value Based Purchasing program.  The dates for the webinars are as follows and more details are to come:

•         October 24th  at 9:00 a.m.
•         October 29th 2:00 p.m.
•         October 30th  9:00 a.m. and 2:00 p.m.

Indiana Medicaid Rate Update

Discussions have continued with Indiana Medicaid and the Division of Aging concerning future changes to Indiana’s Medicaid reimbursement system.  In particular, a move from RUGs III to RUGs IV is still being debated, in particular which grouper to utilize, and whether or not the Special Care Unit add-on will remain.  In a new twist to the discussions, Indiana Medicaid indicated it was concerned with the growth in the overall percentage of residents that are categorized in the Rehabilitation groupers.  As of the last reported data, 36% of all Medicaid residents were in a Rehabilitation RUG, which is up 6% in just the past 4 quarters.  Indiana Medicaid seems to be making overtures that a return of an end of therapy assessment may be coming.  However, the data presented to the association by Indiana Medicaid is not exactly clear and we will be having more detailed discussions with the agency on this issue.  Also, as mentioned last month, IHCA has been working on an outline of a LTC policy plan that Indiana Medicaid requested our engagement on.  The plan is meant to develop a road map to follow related to reimbursement changes, home and community based services rebalancing, quality initiatives, and overall funding.  IHCA has presented a draft of this outline to the IHCA Board of Directors and general support was given to the IHCA staff to proceed with the discussion with the state.

Indiana Division of Aging Announces Provider Training and Public Comment Session on HCBS Transition Plan

As reported last month Indiana’s Medicaid office, Division of Aging, and other divisions of the Indiana Family and Social Services Administration are quickly preparing a transition plan that meets CMS’s new regulations for delivery of Home and Community Based Services in the Medicaid program.  The Division of Aging has announced its next Provider Training that will also include a formal Public Comment session on the proposed transition plan.  The formal Public Comment session is a requirement of CMS that states must meet in the development of the transition plan.

The training and comments session will take place on Nov. 10th from 9am-3pm at the Indiana Government Center, 402 West Washington Street in Indianapolis.  This session will be particularly important for providers of Assisted Living and Adult Family Care waiver services, or those who wish to provide such services in the future.  Anticipated topics for the day are:

•    HCBS Final Rule:  An overview of Indiana’s strategy to implement the new HCBS Final Rule and Public Comment session.  While all providers need to be aware of the new requirements, providers of Assisted Living and Adult Family Care will be the most impacted.

•    Fair Labor Standards Act (FLA):  The “Companionship Exemption” - widely used in home health services, is being cancelled for most situations January 2015.  This can substantially affect your business’ bottom line by requiring overtime and pay for travel between work sites.  While we cannot give legal advice, you need to be aware of the new requirements.

•    Billing: Avoiding Denials and Resolving Problems – This was our most popular session during the last training and it has been updated based on the feedback and experience gained from that session.

•    Incident Reporting: This session is required for new waiver providers and is a good refresher for existing providers.   The session will cover the basics of what is required to be reported, and how to file a report

•    Person-Centered Compliance Reviews – Policy - What to Expect when one of your consumers is selected to undergo a review. 

CMS Announces New Goals with National Partnership to Improve Dementia Care

CMS issued a press release (click here to view) announcing the new national goal to reduce use of antipsychotic medications in long-stay nursing home residents by 25% by the end of 2015 and 30% by the end of 2016.  Between the end 2011 and the end of 2013, the national antipsychotic use rate in long-stay residents was reduced by just more than 15%.  CMS also plans to add the antipsychotic measure to the Five Star Quality Rating calculation.  Indiana has seen a reduction of 17.4% through the first quarter of 2014 since the tracking began in 2011.    Click here for a the CMS Fact Sheet that includes data on the initiative.

Residential Care Facility Citation Update

In August 2014 the ISDH issued 38 Deficiency tags and 6 Offense tags to Residential Care Facilities.  Of note in August, Tag 273 continues to be the most cited tag due to allegations of facility failure to maintain food preparation areas and service areas in accordance with state and local laws.  Tag 414 is also trending in 2014 as the ISDH cites more facilities for staffs’ failure to wash hands after each direct contact with a resident.  Tag 414 has been cited nearly twice as often in 2014 (11) than it was in 2013 (6) and 2104 is not yet over.  Lastly, Tag 241 continues to be cited with regularity for alleged failure by the facility to ensure physician ordered medications are administered to residents by a QMA or licensed nursing personnel.

To review a summary of the August residential care citations, click here.

DEA issues Final Rule on Disposal of Controlled Substances

On September 8, 2014 the Drug Enforcement Administration (DEA) released their final rule regarding the disposal of controlled substances which takes effect October 9, 2014.  This rule governs the secure disposal of controlled substances by registrants and ultimate users. These regulations will implement the Secure and Responsible Drug Disposal Act of 2010 by expanding the options available to collect controlled substances from ultimate users for the purpose of disposal, including: take-back events, mail-back programs, and collection receptacle locations.  Significant changes are made in this final rule which the DEA states are to help ensure that long term care centers have adequate disposal options.  These changes are outlined below:
•         Expands authority of authorized hospitals/clinics and retail pharmacies to voluntarily maintain collection receptacles at long-term care centers. 
o   (1301.51 Modification in registration) A hospital/clinic with an onsite pharmacy or retail pharmacy applying for a modification in registration to authorize such registrant to be a collector to maintain a collection receptacle at a long term care facility in accordance with 1317.80, shall also include the name and physical location of each long term care facility at which the hospital/clinic with an onsite pharmacy, or the retail pharmacy, intends to operate a collection receptacle.
•         Alleviates two security requirements proposed to apply to collection receptacles at long term care centers:
o   DEA is permitting authorized hospitals/clinics and retail pharmacies to store inner liners that have been sealed upon removal from collection receptacle at long term care centers in securely locked, substantially constructed cabinet or securely locked room with controlled access for up to three business days until liners can be transferred for destruction.
o   DEA relaxed the two employee integrity requirement for inner liner installation, removal, storage, and transfer at long term care centers.  Collectors will retain the option to authorize two of their own employees to install, remove, store, and transfer inner liners; however, the DEA is permitting collectors the option to designate a supervisor-level employee of the long term care center (e.g., a charge nurse, supervisor, or similar employee) to install, remove, store, or transfer inner liners with only one employee of the collector.
o   With this rule, the DEA allows all pharmaceutical controlled substances collected through take-back events, mail-back programs, and collection receptacles to be comingled with non-controlled substances, although such comingling is not required.
o   Collection receptacle must be located in an area regularly monitored by long term care center personnel.

AHCA/NCAL would like to highlight three aspects of this rule that are important considerations from an operational perspective:

1.      Definition of long term care facilities (LTCFs) - DEA’s definition of long term care facilities is broad and seems to include assisted living.  LTCF is defined at 1300.01(b) and “means a nursing home, retirement care, mental care or other facility or institution which provides extended health care to resident patients.” (see page 53540 of Federal Register)

2.      Definition of ultimate user - An ultimate user is defined by the CSA as a “person who has lawfully obtained, and who possesses, a controlled substance for his own use or for the use of a member of his household or for an animal owned by him or by a member of his household.”…Individuals lawfully entitled to dispose of an ultimate user decedent’s property are authorized to dispose of the ultimate user’s pharmaceutical controlled substances by utilizing any of the three disposal options.  All of the collection methods are voluntary and no person is required to establish or operate a disposal program.  The rule also does not require ultimate users to utilize any of these three methods for disposal of controlled substances…this rule does not prohibit ultimate users from using existing lawful methods.  (see page 53521 of Federal Register)

3.      Exposure to DEA inspection - The location of the collection receptacle is both a registered location and a controlled premise…LTCFs with authorized collection receptacles are “controlled premises” pursuant to 21 U.S.C. 880(a) and 21 CFR 1316.02(c); accordingly, the DEA may enter LTCFs and conduct administrative inspections in furtherance of, and in carrying out, the responsibilities charged to the DEA by the CSA pursuant to 21 U.S.C. 880 (b) and 21 CFR 1216.03. (see page 53541 of Federal Register)

Under the Secure and Responsible Drug Disposal Act of 2010, DEA already has the authority over disposal of controlled drugs (including in long term care centers), and they also have the authority to issue regulations governing disposal of drugs in long term care centers and to ensure compliance with those regulations.  It is not clear how frequently DEA will visit centers if they do or do not have collection receptacles. 

While the rule states it is voluntary to maintain collection receptacles at long term care centers, AHCA/NCAL recommends members seek advice of their legal counsel.

Health Facility Administrators Board Listens to Proposal to Create HFA Bachelors and Masters Programs

At its September 23rd meeting the Indiana Chapter of the American College of Health Care Administrators briefly addressed the members of the Indiana Health Facility Administrators Board to describe recent discussions with universities in Indiana, including St. Francis in Ft. Wayne and Indiana University, to create 4-year baccalaureate programs and a masters program in Health Facility administration.  The focus of the presentation was to test the Board’s interest in creating a more flexible regulatory structure within the AIT program so that the requisite AIT hours could be partially satisfied during the academic process and completed at the end of the academic program with a “capstone” AIT program.  This flexibility would be critical to universities developing any baccalaureate or masters level programs in order to attract students.  Any change to the AIT program in this fashion would require changes to the regulations, which is at best a year-long process.  IHCA is coordinating with the Indiana ACHCA Chapter, as well as colleagues at LeadingAge and HOPE.  We will keep membership up to date on any progress.

Tuberculin Guidelines Rescinded Effective September 5, 2014

Per and ISDH Long Term Care Newsletter the ISDH TB Program has rescinded its recommendations to deal with a Tuberculin shortage that began last year.  Facilities should return to pre-shortage practices, but not do any testing to “catch-up” and rather begin any required testing on the next due date.  For more information and to read the ISDH announcement, click here.

ISDH IJ/SSQC Update

In the month of August 2014 there were two events that were both IJ and SSQC, leading to 4 tags being cited.

The first event involved allegations of verbal, physical, and mental abuse of a resident that were not thoroughly investigated and for which the facility’s policies and procedures were not followed, for which F223, F225 and F226 were cited.   The issue stemmed from a resident being given a shower against her will, and the resident’s complaints to other staff members of being given a shower against her will and the staff’s failure to immediately report allegation of abuse to the administrator.  The resident had experienced a large bowel movement overnight and was in need of a shower, even though it was known she did not like them.   The DON determined that it was in the resident’s best interest to receive a shower and, even though the resident was known to be difficult (though documentation was lacking on this point), the staff was directed to give the resident a shower.  During the shower the resident complained of the water temperature being too  hot and scalding and the verbal abuse of staff. 

The second event involved the alleged failure of a facility to prevent progress of a pressure ulcer that developed into a stage 4 ulcer, for which F314 was cited.  Upon review of the clinical record, the ISDH took issue with the facility’s failure to provide treatment to the ulcer twice daily as ordered by a physician.  The clinical record lacked documentation to support physician ordered treatment.

To read the 2567s from August and for a summary of the 2014 IJ/SSQC citations, click here.