CRE Case Reporting in Marion County

Effective July 1st 2015, all nursing facilities in Marion County will be required to immediately report confirmed or suspected cases of Carbapenem-resistant Enterobacteriaceae (CRE) to the Marion County Public Health Department.  The new requirement stems from an amendment to The Health and Hospital Corporation of Marion County code that adds CRE as a reportable communicable disease. Section 7-201 requires any physician or other health care provider who has knowledge of or diagnoses or treats a communicable disease case, and every manager of an extended care facility in which there is a communicable disease case to report that case or suspected case to Marion County Public Health Department in accordance with Section 7-202.  Section 7-202 requires CRE to be reported immediately. Laboratories are also required to report evidence of a communicable disease under Section 7-301. Section 7-601 states failure to properly report could be up to a $1,000 fine, upon conviction. In addition to the fine, The Health and Hospital Corporation of Marion County may seek to abate the public health nuisance or violation of this ordinance in any court of competent jurisdiction.  The code can be found at https://www.hhcorp.org/hhc/images/HHCcode/codechapter7.pdf 

Nursing Facilities are required to report when they know there is a case or a suspected case in the facility. Consulting with clinicians to know what the signs of CRE and all other communicable diseases, as defined in the ordinance, would be necessary to properly suspect cases. In terms of known CRE cases the facility should still report even if the laboratory has already reported to be safe, to avoid penalty.  IHCA expects the Indiana State Department of Health to amend its communicable disease rule later this year to require this same reporting statewide.
Marion County Public Health Department sent a letter to All Marion County Medical Providers and Infection Preventionists about CRE Reporting. That letter can be found by clicking here.

The CRE report form that needs to be submitted per patient per admission within 72 hours and faxed to Marion County Public Health Department Infectious Disease at (317)221-2076 can be found by clicking here.

Division of Aging Introduces Email Address and Hyperlink to Address Duplicate e450B Requests

The Division of Aging (DA) continues to receive many emails from the same nursing facility regarding the same issue. This results in multiple DA staff researching the same information, which is very inefficient for response time between the DA and the facility. In an attempt to improve response time, the DA has created an email specifically designed for e450b and/or SADE process questions/concerns only. The email is DA.NFinforequest@fssa.in.gov and is effective immediately.

As you are aware, an authorized e450b is available for download for up to thirty (30) days from Da’s authorization. If the nursing facility does not complete the download in that time period or the download is interrupted/not completed, the nursing facility must contact the DA to re-download the authorized e450b. There has also been a high demand for additional downloads, so the e450b web page now contains a hyperlink to request addition downloads for e450b’s that have previously been downloaded. The hyperlink, NEW Request a duplicate Form 450B ONLINE, is located just above the reference material section on the e450b webpage.

Hopefully the enhancements listed above will be helpful for all nursing facilities as well as improve the DA’s response time to the facilities.

CMS Releases Phase Two of Initiative to Reduce Avoidable Hospitalization Among Nursing Facility Residents

Since September 2012, under Phase One of theInitiative to Reduce Avoidable Hospitalization Among Nursing Facility Residents, CMS has partnered with seven Enhanced Care and Coordinator Providers (ECCP) organizations in seven states, as an effort to improve care for nursing facility’s long-term residents. Indiana is one of those seven states included in this initiative. In conjunction with Phase One, Indiana University created OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care), which includes the deployment of Registered Nurses (RNs) and Advanced Practice Nurses (APNs) to be on-site at nursing facilities, allowing for enhanced recognition and management of acute changes in medical conditions. IHCA has learned that OPTIMISTIC is currently evaluating Phase Two of the initiative. To read about Phase One, click here.

On August 27, 2015 CMS release Phase Two, which includes the four-year funding opportunity that will be implemented in current ECCP facilities and newly recruited facilities. The payment model incentivizes nursing facilities to expand internal resources to treat and/or manage residents in six defined acute conditions (Pneumonia, Dehydration, Congestive Heart Failure (CHF), Urinary Tract Infection (UTI), Skin Ulcers/Cellulitis, and COPD/Asthma). This would allow facilities to treat residents on site, rather than sending them to a hospital.

Successful ECCP applicants will implement the new payment model with both their existing facilities and newly recruited facilities in October 2016. This payment structure is intended to allow CMS to continue to 1) Identify the impact of the clinical interventions, 2) evaluate the impact of a new payment model, and 3) Assess the impact of both these models combined. Relative dates and time for application process are below.

· Notice of Intent to Apply: September 9, 2015
· Electronic Application Due Date: October 29, 2015, by 5:00 p.m. Eastern Time
· Anticipated Notice of Award: January 15, 2016
· Anticipated Project Period of Performance: January 15, 2016 to October 23, 2020

To read about Phase Two, click here.

Indiana Division of Aging Update for HEA 1391

In 2014, the General Assembly passed House Enrolled Act 1391. Section 7 of the bill requires the Office of the Secretary of Family and Social Services, in conjunction with the State Department of Health, and the Office of Management and Budget, to provide a written report to the Indiana General Assembly before October 1, 2015, regarding various issues concerning delivery of long term services and support in Indiana (click here for details). The report is not yet complete, but there have been multiple drafts, and the latest draft was just released for review.

The latest draft supports reliance on a two-year CHOICE (Community and Home Options to Institutional Care for the Elderly and Disabled) pilot program, for which will be available in 2017. The CHOICE pilot program is a two-year program implemented in four regions of the state, Ares 1, 4, 13 and 14. The pilot program is intended to evaluate the impact of changes in the CHOICE program. The changes include lessening eligibility requirements to one Activity of Daily Living (ADL) impairment, which will allow individuals to receive services before their needs become extensive. The asset limit is reduced to $250,000 and an increase in cost share participation by basing it on assets as well as income in an attempt to be applicable to more individuals. The pilot program also puts focus on a needs based assessment process to identify community and personal resources for the individual’s needs, potentially without the use of public dollars. There is also more flexibility in the utilization of case management dollars for the initial assessment and screening stages. This pilot program could potentially change performance metrics such as: nursing facility admission rate in pilots versus non-pilots; reduction of wait lists or time spent on wait list; reduction of expenditures per person served; increased informal supports; and improved quality of life as measured in a new survey tool. The draft does address the issue of low occupancy rate in nursing facilities and credits the passage of the moratorium to help occupancy rates rise. The draft also discusses the FSSA’s perspective that Indiana needs to rebalance long term services and supports spending towards more Home and Community Based services. Tennessee’s managed care was used as a positive example for how nursing facility and long-term care costs can be contained relative to growth in the population over age 65. There is also an entire section dedicated to telemedicine physician coverage in nursing facilities. Telemedicine provides numerous ways in which to improve health outcomes through the use of two-way, real-time interactive communication between the patient and a remotely located physician or medical practitioner using audio and video equipment. Although Telemedicine is being used in some nursing facilities, it is not yet required, but possibly could be in the future. To see the entire draft please click here.

Residential Care Citation Update

The ISDH issued 12 offense tags and 71 deficiency tags totaling 83 citations to Residential Care Facilities in the month of July. This is the highest month of citations issued, it’s even higher than when ISDH was only issuing Residential Tags due to the government shutting down in October 2013. Ten citations were issued to tag 0273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation standards. This marks the second time in 2015 that this Tag received ten citations, creating a total of 50 citations issued this year. Tag 0241 (Offense tag) concerning the administration of medications by licensed nurses or QMAs, was the second highest citation issued in July with nine citations. It has been cited every month with a total of 26 citations for 2015. Tag 0217 concerning resident evaluation and services plan was cited eight times. This citation has been issued every month in the year 2015 for a total of 23 citations. Tag 0148, Tag 0154, and Tag 0272 were issued five citations making it the highest month for those Tags to be cited in 2015.

There were three Tags that were issued for the first time in 2015: Tag 0058 for Patients’ Rights when a facility fails to grant immediate access for authorized public personnel or an individual’s physician; Tag 0149 for Sanitation & Safety Standards for failure to comply with 410 IAC 7-24 requiring a pest control program; Tag 0193 for Physical Plan Standards in failure to have proper laundry services. There was also a new Tag issued that had not been reported before, Tag 0179. This involves failure for an adequate air conditioning system in compliance with 675 IAC (Fire Prevention and Building Safety Commission).

Click here to review a summary of July’s Residential Care Facility citations.

CMS Issues Two Survey & Certification Memos Related to LTC

On July 17, 2015 CMS issued one new Survey & Certification memo and updated a previously released memo.

• CMS S&C 15-47 -  Medication-Related Adverse Events in Nursing Homes
CMS states that adverse events related to high risk medications can have devastating effects on nursing home residents, and is concerned with the prevalence of adverse drug events.  CMS has begun pilot testing a Focused Survey on Medication Safety Systems to look at nursing home systems around high risk and problem-prone medications using an Adverse Drug Event Trigger Tool.  The CMS is making the draft tool available to assist surveyors in investigating medication related adverse events and to nursing home providers as a risk management tool. Click here to access the memo and an attachment.

• CMS S&C 14-42  - Release of Learning Tool on Building Respect for Lesbian, Gay, Bisexual, Transgender (LGBT) Older Adults (NH – Original version released 8/22/14; Revised version released 7/17/15)
The original memo announced the release of a free learning tool on Building Respect for LGBT Older Adults. The revised memo  updates the Training Tool website link. Click here to see the revised memo.

CMS Releases the FY 2016 SNF PPS Final Rule

On July 30th, 2015, CMS released the FY 2016 SNF PPS final rule, which also included language on value-based purchasing (VBP) as well as the recently-enacted IMPACT law. AHCA will provide additional details in the coming days. For now, please see below for an outline of the specifics behind the market basket update.

SNF payments to increase $430 million

CMS projects within the final rule that aggregate SNF payments in FY 2016 will increase by $430 million - or 1.2 percent - from payments in FY 2015.

This final increase is 0.2 percent less than what was outlined in the proposed FY 2016 rule released earlier in April, which included a 1.4 percent net market basket increase ($500 million) for SNFs beginning on October 1 of this year.

CMS justifies the reduction via a caveat in the FY 2016 proposed rule that if more recent data became available and was appropriate to consider, the agency would use such data to determine the final FY 2016 SNF rate. That explains the change from the original $500 million estimate to $430 million. CMS used more recent data from the second quarter 2015 IHS Global Insight forecast of the FY 2010-based SNF market basket to calculate the reduced market basket increase of 1.2 percent.

Tables 1 and 2 below reflect the updated components of the unadjusted federal rates for FY 2016 prior to adjustment for case-mix. CMS further adjusts the rates by a wage index budget neutrality factor.

Table 1 - FY 2016 Unadjusted Federal Rate Per Diem
Urban
  

Table 2 - FY 2016 Unadjusted Federal Rate Per Diem
Rural
 

Quality Measures Finalized

CMS also finalized the rehospitalization measure to be used in the SNF VBP program that applies a 2 percent withhold to all SNF Part A payments. SNFs can "earn" some of the withhold back based on its rehospitalization rate. The measure, which was unchanged from the proposed rule, will use the SNF RM, a National Quality Forum-endorsed risk adjusted measure based on SNF and Hospital Part A claims.

In addition, CMS finalized the specifications for three quality measures to comply with the IMPACT Act. In the coming days, AHCA will release a more detailed summary of the final rule, including the VBP language as well as details on the quality reporting and staff reporting measures found in IMPACT. You are encouraged to review the final rule, as well as the CMS fact sheet.

AHCA will continue to advocate on your behalf as we meet with CMS in the coming weeks about the provisions in the final rule.

RUGs IV 48 Grouper

IHCA has received a number of questions about the RUGs IV 48 grouper change that is set to occur on July 1, 2016.  Many questions are being generated by the recent release of CMI rosters with the residents converted to the RUGs IV 48, and many facilities are seeing drops in both the all facility and Medicaid only CMIs.  In discussions with the State and Myers & Stauffer, the projections given to providers in late 2014 are still on track in that the RUGs IV 48 grouper will add a small amount of reimbursement to the overall system (approx. $6.9M).  Projected Medians for the RUGs IV 48 grouper are due to be released by August 31st, and once released payment modeling will be able to be performed more accurately.

ISDH Report Card Score Proposed Changes

IHCA met with the ISDH last month to continue discussions about the proposed changes to the ISDH Report Card Score methodology. After receiving positive and negative feedback, the ISDH is going to revise the proposal by examining the point allocation for each tag cited.  Under the original proposal, points were assigned to each tag only with respect to the severity component and did not take into consideration the scope component.  In addition, ISDH is ensuring that tags are not double counted when a complaint survey is conducted at the same time an annual survey is conducted.  A new data run on the proposed methodology should be available soon, and IHCA will get that out to members asap.

QIO Nursing Home Change Package

The March 2015 v.2.0 Change Packages from the National Nursing Home Quality Care Collaborative released the Change Packages in bite-size strategies and with change bundles to help facilities use the resources available.  The National Nursing Home Change Package shares and organizes best practices into seven strategies. Now, you can download each bite-sized strategy of the change package, along with supporting action items, to share with your teams to create measurable change in your facilities.  Click here for more information.

Learn More About Proposed Changes to the Requirements of Participation and Submitting Comments to CMS

CMS issued a proposed rule change for the SNF/NF Medicare and Medicaid Requirements for Participation on Monday July 13th 2015. The rule is very large in scope and contains both new requirements and some requirements that have already been issued by CMS via Survey & Certification memoranda. The formatted version of the NPRM proposing changes to the SNF Requirements for Participation is available in the Federal Register, with a deadline for comments submission of 5:00 pm on September 14, 2015.

To provide you with a "Cliff's Notes" version, as well as AHCA comments regarding some of the changes, AHCA has developed a summary of all the proposed changes. Click HERE to view the summary. The actual language in the Requirements for Participation CMS is proposing are contained on pages 42246 to page 42269. Although CMS will review comments on all components of the rule, CMS has requested specific "solicitation for comments" from stakeholders for areas that CMS has not made a specific proposal or recommendation about implementation timelines. These requests appear on pages 10-11 of the summary.

Some of the proposed changes/requirements that stand out:

1. Quality Assurance and Performance Improvement (QAPI) programs;
2. Baseline care plan for each resident within 48 hours of admission;
3. Compliance and ethics programs;
4. Discharge planning;
5. Facility assessment which aims to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies; and
6. A more comprehensive Infection Prevention and Control Program including an Infection Prevention and Control Officer.
7. Comments on the use of arbitration agreements.

Given the impact these changes will have on nursing centers, members are encouraged to submit comments themselves to show the importance and concerns raised by CMS. Tips on how to submit comments are below.

Additionally, members are encouraged to send their concerns and any suggested changes to this rule no later than August 6th to Lyn Bentley, so they can be considered for inclusion in AHCA's comments to CMS.

 If you send comments directly to Lyn, please copy Zach Cattell at zcattell@ihca.org. You can also submit comments to IHCA to Zach's email as well. IHCA has engaged its Regulatory/Clinical committee and Board of Directors to consider submitting comments in addition to those submitted by AHCA.

Tips to Submit Comments to CMS

* When submitting comments you need to refer to file code CMS-3260-P.

* Organize your comments by major section heading in the proposed rule (see below for list) and then by the outline format used in the rule. For example if you wanted to comment on part of the proposed changes to Resident Rights you would say: "In section Residents Rights (483.10), we have comments about the proposed language in (a) 3. (i.) about "The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative."

* Organize each of your comments in into three sections: First site the section of the proposed rule change, followed by your comments/discussion about the rule change, followed by your recommendation or suggested changes to CMS's proposed changes.

* Section of proposed rule (site Federal Registry page number and section headings - see list of section headings below). It is also ok to copy specific language you are commenting on.
* Comments/Discussion
* Recommendations/suggestions

* General comments about the changes in general or that do not contain recommended changes often have little impact on the final rule issued by CMS.

Section Reference of the Proposed Rule
* Resident rights (§483.10)
* Facility responsibilities (§483.11)
* Freedom from abuse, neglect, and exploitation (§483.12)
* Transitions of care (§483.15)
* Resident assessments (§483.20)
* Comprehensive resident-centered care plans (§483.21)
* Quality of care and quality of life (§483.25)
* Physician services (§483.30)
* Nursing services (§483.35)
* Behavioral health services (§483.40)
* Pharmacy services (§483.45)
* Laboratory, radiology, and other diagnostic services (§483.50)
* Dental services (§483.55)
* Food and nutrition services (§483.60)
* Specialized rehabilitative services (§483.65)
* Administration (§483.70)
* Quality assurance and performance improvement (§483.75)
* Infection control (§483.80)
* Compliance and ethics program (§483.85)
* Physical environment (§483.90)
* Training requirements (§483.95)

Where and How to submit your comments:
* When submitting comments you need to refer to file code CMS-3260-P.

* CMS will NOT accept comments by facsimile (FAX) transmission.

* You may submit comments in any one of three ways but only need to use one method (we recommend submitting comments electronically):

1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the ''Submit a comment'' instructions.

2. By regular mail. You must allow sufficient time for mailed comments to be received before the close of the comment period (NOT postmarked). You can mail written comments to the following address:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-3260-P

P.O. Box 8010

Baltimore, MD 21244.

3. By express or overnight mail. You must allow sufficient time for mailed comments to be received before the close of the comment period (NOT postmarked). You may send written comments to the following address only:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-3260-P

Mail Stop C4-26-05

7500 Security Boulevard

Baltimore, MD 21244-1850.

CRE Case Reporting in Marion County

Effective July 1, 2015, all nursing facilities in Marion County will be required to immediately report confirmed or suspected cases of Carbapenem-resistant Enterobacteriaceae (CRE) to the Marion County Public Health Department. The new requirement stems from an amendment to The Health and Hospital Corporation of Marion County code that adds CRE as a reportable communicable disease. Section 7-201 requires any physician or other health care provider who has knowledge of, diagnoses or treats a communicable disease case and every manager of an extended care facility in which there is a communicable disease case to report that case or suspected case to the Marion County Public Health Department. Section 7-202 requires CRE be immediately reported. Laboratories are also required to report evidence of a communicable disease. Failure to properly report could be up to a $1,000 fine, upon conviction. Additionally, The Health and Hospital Corporation of Marion County may seek to abate the public health nuisance or violation of this ordinance in any court of competent jurisdiction. The code can be found at https://www.hhcorp.org/hhc/images/HHCcode/codechapter7.pdf.

Nursing facilities are required to report a case or suspected case of CRE. Consulting with clinicians to learn the signs of CRE and other communicable diseases, as defined in the ordinance, is necessary to properly identify cases. The facility should still report known CRE cases even if the laboratory has already reported them to avoid any possibility of penalty. IHCA expects the Indiana State Department of Health to amend its communicable disease rule later this year to require this same reporting statewide.

Residential Care Citation Update

The ISDH issued 5 Offense Tags and 31 Deficiency Tags to Residential Care Facilities in June. Tag 0273, which involves maintenance of food preparation and service areas in accordance with state and local sanitation standards, was cited five times. Tag 0273 has been cited 40 times so far in 2015. Additionally, Tag 0241, which deals with the administration of medications by licensed nurses or QMAs, was cited 4 times in June, raising the total number of times this citation has been issued in 2015 to 17.

Four citations were issued for Tag 0144 which involves building and grounds maintenance. Tag 0144 has been cited in five of the past six months, with June receiving the highest number of this particular citation since October 2013. One citation for Tag 0217 was issued in June, for a total of 15 citations in 2015. Tag 0217 concerns resident evaluation and services plan.

A citation was issued for Tag 0191 which deals with inadequate kitchen in complying with 410 IAC 7-24 (Sanitary Standards for the Operation of Retail Food Establishments). Tag 0191 has not been cited before.

To review a summary of the June citations, click here.

IJ/SSQC Citation Update

Following IJ citation issued in May, no IJs were cited in June. There was one SSQC citation cited for the month of June. The event involved failing to properly report and implement abuse policy for several allegations. The administrator was not in the building at the time of the incident. The DON was present and followed all proper steps to report the incident but failed to fully report it by sending it to the ISDH. It is important to know who is responsible for filing reports in case the administrator or second in command is not currently there.

Another situation occurred where the administrator filed the abuse allegation, yet failed to alert law enforcement until several days later. There was also a report made by a surveyor who allegedly witnessed an RN become verbally aggressive with a patient when attempting to administer medication. To review a summary of the 2015 IJ/SSQCs and the June 2567, click here.