Division of Aging Holds Listening Session on HCBS Transition Plan

On November 10th, IHCA/INCAL staff attended the second of six listening session that have been scheduled by the Indiana Family and Social Services Administration’s Division of Aging (DA). (Click here for a copy of the listening session presentation.) The listening session included the DA’s broad overview of the CMS HCBS Final Rule and the work that the DA has done so far to help Indiana come into compliance with those CMS Rules through the FSSA’s draft HCBS transition plan. Click here for the schedule of the remaining listening sessions that all occur in the next week!  Comments to the DA on the transition plan are due December 1. 

The DA staff mainly addressed two types of waiver settings and providers at the November 10th meeting – Adult Family Care and Assisted Living waiver providers.  The DA recently published the draft statewide transition plan, which is posted at www.in.gov/fssa/4917.htm, and it addresses the issues that the DA has identified with current provider operations and the CMS rules.  The transition plan also includes other divisions of FSSA and HCBS service categories.  The transition plan also sets out timing for providers to meet the new requirements, but leaves a lot of detail out that still needs to be determined.

To develop that detail, the DA is reviewing existing state law and regulation, as well as internal policies, to determine what must be changed to conform with the CMS rule.  Part of the DA’s work has also been a survey of waiver providers.  As you know, the DA surveyed 87 existing AL waiver providers and 62 responded.  These responses were used to develop the transition plan for the AL waiver section.  The DA noted the following areas with AL providers that must be addressed in the years to come through law, rule and policy changes to ensure compliance with the CMS rule:

• Hours of visitation will need to become more resident friendly and broader
• Permitting Secured Units for Alzheimer/Dementia patients will be subject to “heightened scrutiny”
     o A provider, and the DA, must show why secured units for AL are different than secured units for skilled nursing with a focus on patient integration with others in the residential care facility and the greater community.
• 24-hour resident access to food and drink need to be defined and improved
• Putting in place enforceable leases that conform to landlord tenant laws for each resident
• Clarifying roommate choice
• Ensuring medical services are provided in private areas only
• Improving transportation to areas outside of the facility

Many of these issues will require in-depth review of current DA and ISDH regulations to ensure residents receive appropriate services and that providers are not place in a legal/regulatory catch-22.  IHCA/INCAL will continue to participate in the development of the state’s HCBS transition planning and implementation.

For additional information, contact Katie Niehoff at kniehoff@ihca.org or Zach Cattell at zcattell@ihca.org. 

Ebola Virus Resources

Although news of the Ebola outbreak has dissipated a bit in the last week or so and that long term care centers are not regarded as “first receivers” for patient care, we wanted to ensure that our members were aware of the vast resources and guidance available on the CDC’s website concerning the Ebola virus.  Many public health departments and local hospitals have been working tirelessly to gear up for any potential signs of Ebola in Indiana, and long term care has been tacitly aware of those preparations but not necessarily directly involved.

•    CDC

The CDC’s Ebola Virus Disease website is at http://www.cdc.gov/vhf/ebola/index.html and contains a number of helpful topics and infographics that can be printed and used with your staff.  Specific guidance for healthcare workers, which focuses on Emergency Departments, Ambulatory Care, Hospitals, Medical Transports and Labs can be found at http://www.cdc.gov/vhf/ebola/hcp/index.html.  While the focus are on those acute care settings, the infographics and treatment algorithms may be helpful for you to review.  At the bottom of the healthcare worker’s guidance page are a series of PDFs discussing preparedness in healthcare settings.

In particular, documents that discuss Ebola Basics, a infographic on the differences between Ebola and Flu, and information about the West Africa breakout are particularly helpful in answering questions from residents, families or the general public.

•    ISDH

In addition, the Indiana State Department of Health (ISDH) has re-posted CDC resources on its website, but also has opened a call center to handle question from the public and providers concerning the outbreak. The call center number is 877-826-0011 (hearing impaired 888-561-0044).  Health representatives are available to answer questions regarding symptoms, screening and diagnosis of Ebola. It is open 24 hours.   The ISDH just updated it’s quick factsheet on Ebola on Nov. 10, 2014.

For the ISDH website click here:  http://www.in.gov/isdh/26447.htm. 

•    Individual Legal Counsel

Several concerns have been raised about staff or visitor restrictions due to travel to West Africa or contact with persons that have traveled to West Africa.  It is important to remember that Ebola is only spread through close contact with those that are infected via blood or bodily fluids.  Neither the CDC nor the ISDH are recommending avoidance of contact with people that have recently traveled to West Africa unless they have symptoms of the disease, in which case that person should be referred to their personal health care provider or a hospital emergency room.

There are a host of laws that must be considered in the employment context that govern how employers can, or more accurately cannot, screen employees.  For example, an employer would not be correct to refuse to hire or prohibit an employee from coming to work just because they recently traveled to West Africa or is of West African decent as this could be a discriminatory practice banned by Title VII of the Civil Rights Act of 1964.  Laws governing medical examinations of employees, such as the Americans with Disabilities Act should also be considered if medical examinations of employees are desired.   Also, if your facility is covered by FMLA, how a facility handles any mandatory leave requires specific analysis to minimize risk to the employer.  Visitor restrictions also need to be carefully considered in the context of resident rights both the resident being visited and the protection of all other residents in the facility.  Special consideration for the patients within nursing facilities and regulatory requirements for nursing facilities do make some of these challenges more straight forward to handle, but individual legal counsel should be sought to determine your facility’s compliance with applicable law.

FSSA Releases Draft HCBS Transition Plan

The Indiana Family and Social Services Administration (FSSA) has released a draft statewide transition plan regarding its Home and Community Based Services (HCBS) programs.  Following a new regulation from CMS in January 2014 that redefined what settings can qualify for reimbursement for HCBS, Indiana is reviewing all of FSSA’s HCBS programs to ensure compliance with the new CMS regulations.  FSSA has developed a website at www.in.gov/fssa/4917.htm that includes information on the CMS final rule and the Indiana draft transition plan.

The transition plan assesses all of FSSA’s HCBS program to identify where Indiana’s programs are already in-line with the new CMS regulations and where changes and improvements are needed to meet the new CMS regulations.  The plan sets out strategies and timelines for Indiana’s compliance with the CMS regulations, which must be no later than March 2019.

Indiana FSSA is seeking public comment on the transition plan, and will hold the comment period open from November 1st to December 1st.  The above FSSA website includes instructions on how to submit comment, including attending one of the scheduled stakeholder forums and listening sessions. 

Indiana Medicaid Rate Update

The Indiana Office of Medicaid Policy and Planning (OMPP) indicates that the July 1, 2014 rate letters will be released in early December.  Updated median data will not be released before the rate letters are released.

Discussions with OMPP and Indiana Division of Aging concerning changes to Indiana’s Medicaid rate setting methodology, particularly concerning RUGs IV, the Special Care Unit add-on, and end of therapy RUG re-categorization will pick back up in November.  IHCA staff have had informal discussions with agency officials on these subjects in the month of October, however the next formal meeting to discuss and ascertain the direction of these issues is set for the middle of November.  Click here to review past months’ Indiana Medicaid Rate Updates.

President Obama Signs the IMPACT Act of 2014

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 was signed into law in October 2014.  The act will standardize assessments for critical care issues across post-acute care providers.  AHCA has assembled a summary of the 5 parts to the IMPACT Act and a timeline. Click here for the AHCA summary.

ISDH Updating Provider Change of Ownership Packets

The ISDH has announced that it is in the process of updating all of the packets on the ISDH website for provider changes.  The goal is to have all of the packets for both comprehensive care and residential care facilities reviewed and updated by the end of the year.  The first packet that has been updated and is currently available on the website is the CHOW packet for Medicare or Medicare/Medicaid facilities.  The link for the updated packet is http://www.in.gov/isdh/files/Change_of_Ownership_Medicare_or_Medicare_-_Medicaid.pdf

In the future, please check the below websites for packet updates.

The comprehensive care facility packets can be found under the forms section on the comprehensive care facility website at http://www.in.gov/isdh/20511.htm

The residential care facility packets can be found under the forms section on the residential care facility website at http://www.in.gov/isdh/20227.htm

Contact Miriam Buffington at the ISDH for any questions.

ACIP Recommends Pneumococcal Conjugate Vaccine for Adults 65 Years and Older

As reported by the ISDH Long Term Care Newsletter, The Advisory Committee on Immunization Practices (ACIP) now recommends a dose of PCV13 (Prevnar 13®) in addition to the currently recommended PPSV23 (Pneumovax®) in persons 65 years and older.

Those who have not previously received pneumococcal vaccine or whose vaccination history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23 6-12 months later. The two vaccines should not be co-administered. The minimum acceptable interval between PCV13 and PPSV23 is 8 weeks.

Adults aged 65 years who have previously received 1 dose of PPSV23 and who have not yet received PCV13 should receive a dose of PCV13 at least 1 year after receipt of their most recent PPSV23 dose. When an additional dose of PPSV23 is indicated, it should be given 6 -12 months after PCV13 and 5 years after the most recent dose of PPSV23.

ACIP recommendations remain unchanged for the routine use of PCV13 in adults aged 19 years with high risk conditions including:
•             immunocompromising conditions
•             functional or anatomic asplenia
•             cerebrospinal fluid leak
•             cochlear implants

New Indiana QIO Ramps-Up Work

The Atom Alliance, which is an umbrella organization that encompasses the new Indiana QIO, QSource, is ramping up it’s activities in Indiana.  They have provided a fact sheet concerning the Atom Alliance as well as a fact sheet concerning their work on reducing Health Care Acquired Conditions in Nursing Homes.  CMS has issued a letter concerning the next QIO scope of work and the focus on the National Nursing Home Quality Care Collaborative that has already begun in Indiana.  The effort is aimed at bringing together nursing  homes to “instill quality and performance improvement practices”.  QSource will be asking nursing homes from all across the state to participate in the NNHQCC and specifically ask for the facility to sign a Participation Agreement.  The goal is to recruit 75% of all nursing homes in Indiana to participate with an oversampling of 1-Star facilities.  The focus of the NHCQCC will be on reduction of anti-psychotic medications, improvement of mobility and reduction in falls, reduction in readmissions, HAIs and HACs.

Residential Care Facility Citation Update

In September 2014 the ISDH issued 17 Deficiency tags and 4 Offense tags to Residential Care Facilities.  Leading the way in September is the most often cited Deficiency tag – Tag 273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation standards.  The tag was cited 6 times in September.  Two facilities were cited Tag 241 for failing to administer physician ordered medications by licensed nurses or by a QMA and one facility was cited Tag 242 for failing to observe, document, and immediately notify the physician of any undesirable medication effects.

Click here for a summary of the September tags.

ISDH IJ/SSQC Update

There were four events in September leading to four IJ citations, three of which were also SSQC.  The first issue involved the failure of a facility to put in place appropriate interventions to prevent non-consensual sexual contact between two residents with diagnoses of dementia, and known wanderers, amongst other issues.   F323 was cited when the male resident was transferred to a psychiatric unit for evaluation and the female resident was placed on 1:1 care with 15 minute checks.  The male resident was found undressed in his room (which according to his care plan is normal for when he was sleeping) and the female resident wandered into the male resident’s room.  The male resident was reported to have his hand up the female resident’s gown.  A staff investigation occurred, including medical examinations of the female resident, and the staff did not find any abuse, however there was uncertainty concerning the consensual or non-consensual nature of the contact.  Due to cognitive status surveyors determined this to be non-consensual sexual contact.

A second F323 citation was issued for failure of a facility to provide supervision and interventions to reduce risk of harm to other residents to a resident who was a known wanderer and that had a history of physical and verbal abuse.  Several residents reported that they were afraid of the resident in question.  The surveyors noted that the resident had been in a dementia unit before and the resident’s daughter was aware of the behavior, however the SSD indicated that the family member had not been contacted prior to survey about placing the resident on a secured dementia unit.

A citation was also issued for F414 for the facility’s failure to ensure proper sanitation procedures for the cleaning of reusable glucometers.  The staff mistakenly used non-manufacturer approved, or non-bleach based, wipes for cleaning the glucometers.   Also in September, F314 was issued concerning failure to prevent development of a State 4 pressure ulcer (this tag was reported last month as well as it was included in the August report even though it occurred on September 2).

Click here for a summary of the 2014 IJ/SSQCs and for the September 2567s.