IHCA
MLN Matters posted an article September 11, 2015 regarding the related change request for CR 9340. This change is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice (HH&H) MACs and Durable Medical Equipment (DME) MACs, for services provided to Medicare beneficiaries who are in a Part A covered Skilled Nursing Facility (SNF) stay. This change request is scheduled to be implemented January 4, 2015. To read the entire article, please click here.
MLN Matters posted another article on September 11, 2015 revising SE0434. The revision is to reflect the updated regulation reference in the first paragraph of the Background section of the article and to update several Web addresses. All other information remains the same. To read the revision, please click here.
Thursday, October 8, 2015
ASPE Compendium of Residential Care & Assisted Living Regulations and Policy
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) has published its 2015 Compendium of Residential Care and Assisted Living Regulations and Policy. The report provides an overview of state approaches to residential care policy, including assisted living, and provides state summaries for the 50 states and the District of Columbia.
Links to the compendium are as follows:
• Executive Summary: http://aspe.hhs.gov/execsum/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition-executive-summary
• Full Compendium: http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition
• State Summaries: http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition-continuation
Links to the compendium are as follows:
• Executive Summary: http://aspe.hhs.gov/execsum/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition-executive-summary
• Full Compendium: http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition
• State Summaries: http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition-continuation
August Residential Tags
In August 2015 the ISDH issued 6 offense tags and 26 deficiency tags totaling 32 citations to Residential Care Facilities. Five citations were issued to tag 0273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation standards. The total for this tag is now 55, making it the highest cited tag in 2015. Tag 0241 (Offense tag) concerning the administration of medications by licensed nurses or QMAs, was also cited five times this month. This tag has been cited every month this year. Tag 0144 concerning proper maintenance of the building and grounds was issued three times. In the past six months this tag has been cited every month.
A few tags have been frequently cited this year. Tag 0154 concerning maintenance of good and clean kitchen and dining areas and equipment and tag 0217 concerning have trained staff complete a resident’s evaluation, have both been cited every month in 2015. Tag 0090 regarding failure to ensure administrator maintained management of the overall facility has been cited seven out of the past eight months as has tag 0117. Tag 0117 is failure to ensure staff is sufficient in numbers, qualifications, and training. Tag 0214 concerning the evaluation prior to admission and upon admission by a license nurse evaluating each resident’s need for nursing care, has been cited six of the last seven months. Five of the last six months tag 0246 regarding proper authorization and documentation when administering PRN medications by a QMA, has been cited. Tag 0414 concerning staff washing hands after contact with each resident has been cited four of the past five months. In the past four months offensive tag 0242 concerning observation of resident for the effect(s) of medications, documentation of effects, notification to physician, and documentation of notifying physician in resident’s clinical record, has been cited. Prior to this current trend this tag had not been cited since October 2014. For the second time this year tag 0191 concerning inadequate kitchen in complying with 410 IAC 7-24 (Sanitary Standards for the Operation of Retail Food Establishments), was cited. This tag popped up for the first time in IHCA history in June.
Click here to review a summary of August’s Residential Care Facility citations.
A few tags have been frequently cited this year. Tag 0154 concerning maintenance of good and clean kitchen and dining areas and equipment and tag 0217 concerning have trained staff complete a resident’s evaluation, have both been cited every month in 2015. Tag 0090 regarding failure to ensure administrator maintained management of the overall facility has been cited seven out of the past eight months as has tag 0117. Tag 0117 is failure to ensure staff is sufficient in numbers, qualifications, and training. Tag 0214 concerning the evaluation prior to admission and upon admission by a license nurse evaluating each resident’s need for nursing care, has been cited six of the last seven months. Five of the last six months tag 0246 regarding proper authorization and documentation when administering PRN medications by a QMA, has been cited. Tag 0414 concerning staff washing hands after contact with each resident has been cited four of the past five months. In the past four months offensive tag 0242 concerning observation of resident for the effect(s) of medications, documentation of effects, notification to physician, and documentation of notifying physician in resident’s clinical record, has been cited. Prior to this current trend this tag had not been cited since October 2014. For the second time this year tag 0191 concerning inadequate kitchen in complying with 410 IAC 7-24 (Sanitary Standards for the Operation of Retail Food Establishments), was cited. This tag popped up for the first time in IHCA history in June.
Click here to review a summary of August’s Residential Care Facility citations.
IJ/SSQC Citation Update
There was one IJ citation issued by the ISHD in August. F 155 was issued for failure to have a system in place to determine code status and failure to perform CPR on a resident in full code. The facility also failed to ensure advanced directive/code status that was clearly and consistently documented for 4 of 6 residents reviewed with advanced directives. This is the fourth time F 155 has been cited as the IJ level in 2015, and the sixth time in the last 7 months that a citation has been issued at the IJ level for failures surrounding advance directives and administration of CPR.
In the August event, a resident was found deceased in her bed by a CNA. The CNA immediately got an RN, who determined that the resident was cold, stiff, and mottled half way up and deemed calling the ambulance unnecessary as it would just result in the EMTs telling the RN to contact the coroner. The RN indicated the resident had no pulse, no respirations, and no blood pressure. The POST for this resident was to administer CPR even if pulse and breathing are not detected.
The other event documented was the facility failed to ensure clear and consistent documentation of advanced directives, 4 of 6 residents were affected by this. The inconsistent documentation included not updating current POST, no updating proper stickers that indicate directives, miscommunication between the POST and the computerized profile, and RN not being CPR certified. The immediate jeopardy began on 4/5/15 and was removed on 8/10/15 when the facility began to in-service staff on CPR and how to determine resident’s codes. The facility has also mention discussion of replacing the stickers with a sheet of colored paper for a quick reference on resident’s proper POST.
To review a summary of the 2015 IJ/SSQCs and the August 2567, click here.
In the August event, a resident was found deceased in her bed by a CNA. The CNA immediately got an RN, who determined that the resident was cold, stiff, and mottled half way up and deemed calling the ambulance unnecessary as it would just result in the EMTs telling the RN to contact the coroner. The RN indicated the resident had no pulse, no respirations, and no blood pressure. The POST for this resident was to administer CPR even if pulse and breathing are not detected.
The other event documented was the facility failed to ensure clear and consistent documentation of advanced directives, 4 of 6 residents were affected by this. The inconsistent documentation included not updating current POST, no updating proper stickers that indicate directives, miscommunication between the POST and the computerized profile, and RN not being CPR certified. The immediate jeopardy began on 4/5/15 and was removed on 8/10/15 when the facility began to in-service staff on CPR and how to determine resident’s codes. The facility has also mention discussion of replacing the stickers with a sheet of colored paper for a quick reference on resident’s proper POST.
To review a summary of the 2015 IJ/SSQCs and the August 2567, click here.
HEA 1391 Final Report
Since the passage of House Enrolled Act 1391 by the 2014 General Assembly, 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 have been working on a written report regarding various issues concerning delivery of long term services and support in Indiana. That final report has been be submitted to the Indiana General Assembly as of October 1, 2015. To view the final report, please click here. You can also find previous drafts for HEA 1391 under the Newsletter Materials section on the website. For more information or any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
NF Capacity Reduction Update
Throughout the year 2015 IHCA has been in discussion with the Indiana Family and Social Services Administration (FSSA), as well as the two other nursing facility trade associations Leading Age Indiana (LAI) and Hoosier Owners and Providers for the Elderly (HOPE), concerning the future of Long Term Care in Indiana. FSSA has emphasized the rebalancing of spending between institutional care and home and community based services (HCBS) using a 5 to 8 year plan. The effort to rebalance is driven by future budgetary concern and because the current Indiana ratio of spending is 67% on institutional and 33% on HCBS, whereas nationally spending is 51% institutional and 49% HCBS.
Although this conversation has been going on for many months, in recent weeks FSSA has included a proposal to incentive the closure of nursing facilities as a method for increasing overall operational efficiency and save long term dollars. The proposed incentive plan is to withhold some amount of the supplemental payments county hospitals currently receive and only give that withheld amount back if a targeted number of nursing facilities close. The proposal would be effectuated by changing the quarterly agreements that each county hospital signs with Indiana Medicaid when drawing down supplemental payments.
According to a report released by the Indiana State Department of Health (ISDH) in July 2015, there are 540 facilities with a total of 52,624 comprehensive beds in the state of Indiana, averaging 97 beds per facility. The report also found that statewide occupancy is at 75%. FSSA has a target statewide occupancy rate of 85-90%, which means the closure of 54-81 facilities total and about 15-25 facilities annually. IHCA agrees that there is a need to increase the occupancy rate and that reduction in capacity could be a part of that, but the FSSA proposal is very complicated and has generated many concerns from IHCA members and partners.
IHCA and LAI sent a letter to Chris Fletcher, OMPP Reimbursement Section Director of FSSA, on September 18, 2015 concerning the 5-8 year plan and the state’s idea concerning facility closure. The letter explained concerns with the FSSA proposal, as well as providing a proposed 5 to 8 year plan timeline and alternative concepts. To read the entire letter, please click here.
The state’s plan to rebalance is progressing rapidly after months of little action. This rebalancing plan will have a major impact to the LTC community, please remain engaged for updates. Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 for more information.
Although this conversation has been going on for many months, in recent weeks FSSA has included a proposal to incentive the closure of nursing facilities as a method for increasing overall operational efficiency and save long term dollars. The proposed incentive plan is to withhold some amount of the supplemental payments county hospitals currently receive and only give that withheld amount back if a targeted number of nursing facilities close. The proposal would be effectuated by changing the quarterly agreements that each county hospital signs with Indiana Medicaid when drawing down supplemental payments.
According to a report released by the Indiana State Department of Health (ISDH) in July 2015, there are 540 facilities with a total of 52,624 comprehensive beds in the state of Indiana, averaging 97 beds per facility. The report also found that statewide occupancy is at 75%. FSSA has a target statewide occupancy rate of 85-90%, which means the closure of 54-81 facilities total and about 15-25 facilities annually. IHCA agrees that there is a need to increase the occupancy rate and that reduction in capacity could be a part of that, but the FSSA proposal is very complicated and has generated many concerns from IHCA members and partners.
IHCA and LAI sent a letter to Chris Fletcher, OMPP Reimbursement Section Director of FSSA, on September 18, 2015 concerning the 5-8 year plan and the state’s idea concerning facility closure. The letter explained concerns with the FSSA proposal, as well as providing a proposed 5 to 8 year plan timeline and alternative concepts. To read the entire letter, please click here.
The state’s plan to rebalance is progressing rapidly after months of little action. This rebalancing plan will have a major impact to the LTC community, please remain engaged for updates. Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 for more information.
IHCA Presents to Indiana House Ways & Means Committee Concerning Nursing Facility Policy
On September 29, 2015, the Indiana House Ways & Means Committee held a briefing for a select group of committee members with the aim to better understand the funding of and reimbursement for nursing facility services, as well as issues surrounding efforts to rebalance Indiana Medicaid’s Long Term Services and Supports spend. Representatives from the Indiana Family and Social Services Administration (FSSA), IHCA, LeadingAge Indiana, and HOPE were invited to make presentations to the committee. The briefing resulted in an open conversation concerning current NF Medicaid reimbursement, the State’s policy objectives in rebalancing Long Term Services and Supports (LTSS) spending, and the NF trade associations’ perspectives on these issues.
The FSSA’s presentation began by discussing the agency’s desire to rebalance the LTSS spend towards more spending on Home and Community Based Services (HCBS) and less spending on institutional services. The agency, through its contractor Myers & Stauffer, provided a detailed explanation of the Medicaid rate setting system, as well as an overview of the supplemental payment program that county hospitals have engaged in by being licensed to operate nursing facilities across Indiana. The presentation continued with financial projections of Indiana’s Medicaid program based on current spending levels for institutional and HCBS service spending, with reference of managed care as an often utilized method to achieve LTSS rebalancing. FSSA also discussed an idea related to reducing nursing facility capacity that implicates the supplemental payment program. The State’s discussion ended with the topic of HCBS waiver redesign to serve more Medicaid members in the community.
IHCA collaborated with LeadingAge Indiana and HOPE on the presentation made to the committee. Zach Cattell, IHCA President, began the presentation by discussing patient care and providing specific clinical examples of the types of patients that nursing facilities care for. Jim Leich, LeadingAge Indiana President, then provided an overview of the challenges that nursing facilities face with Medicare and discussed the importance of taking these challenges into consideration when discussing the rebalancing of LTSS spending. Terry Milller, HOPE President, provided insight on the changes of resident acuity and payment policy over the past 30 years. Zach Cattell from IHCA finished the presentation by explaining that a thorough plan is needed in order to correctly rebalance the system. The plan must focus on the needs of Hoosiers, and not simply on a budget target. IHCA focused on three key issues: 1) maintaining a direct relationship with the State for provision of NF services; 2) helping rebalance LTSS; and 3) stabilizing reimbursement and addressing nursing facility capacity.
The meeting was very productive for all that attended. It is clear that FSSA is serious about moving the needle on LTSS spending towards more Home and Community Based Services. It is also clear that the nursing facility profession must be proactive in providing the right solutions to this challenge. Sometime in October FSSA will be finalizing its LTSS rebalancing plan, so be on the lookout for that as the month continues. To access the two presentations from the State and the PowerPoint from IHCA, LeadingAge Indiana and HOPE, click here. For more information or any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
The FSSA’s presentation began by discussing the agency’s desire to rebalance the LTSS spend towards more spending on Home and Community Based Services (HCBS) and less spending on institutional services. The agency, through its contractor Myers & Stauffer, provided a detailed explanation of the Medicaid rate setting system, as well as an overview of the supplemental payment program that county hospitals have engaged in by being licensed to operate nursing facilities across Indiana. The presentation continued with financial projections of Indiana’s Medicaid program based on current spending levels for institutional and HCBS service spending, with reference of managed care as an often utilized method to achieve LTSS rebalancing. FSSA also discussed an idea related to reducing nursing facility capacity that implicates the supplemental payment program. The State’s discussion ended with the topic of HCBS waiver redesign to serve more Medicaid members in the community.
IHCA collaborated with LeadingAge Indiana and HOPE on the presentation made to the committee. Zach Cattell, IHCA President, began the presentation by discussing patient care and providing specific clinical examples of the types of patients that nursing facilities care for. Jim Leich, LeadingAge Indiana President, then provided an overview of the challenges that nursing facilities face with Medicare and discussed the importance of taking these challenges into consideration when discussing the rebalancing of LTSS spending. Terry Milller, HOPE President, provided insight on the changes of resident acuity and payment policy over the past 30 years. Zach Cattell from IHCA finished the presentation by explaining that a thorough plan is needed in order to correctly rebalance the system. The plan must focus on the needs of Hoosiers, and not simply on a budget target. IHCA focused on three key issues: 1) maintaining a direct relationship with the State for provision of NF services; 2) helping rebalance LTSS; and 3) stabilizing reimbursement and addressing nursing facility capacity.
The meeting was very productive for all that attended. It is clear that FSSA is serious about moving the needle on LTSS spending towards more Home and Community Based Services. It is also clear that the nursing facility profession must be proactive in providing the right solutions to this challenge. Sometime in October FSSA will be finalizing its LTSS rebalancing plan, so be on the lookout for that as the month continues. To access the two presentations from the State and the PowerPoint from IHCA, LeadingAge Indiana and HOPE, click here. For more information or any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
July 1, 2015 Medicaid Rate Update
On October 2, 2015 Myers & Stauffer began to issue the 7/1/2015 Medicaid rates. As of October 8, 2015 there are 187 facilities that have yet to receive their annual Medicaid rate and there are several reasons for the delay. For a majority of these facilities (100+), a request for information was sent and the provider has not yet responded to this request. Once the response is received, the information will be reviewed and the rates will be established. The remainder of the facilities are either on hold due to a pending change of ownership transaction review, the annual rate was delayed due to failure to timely file the cost report, the facility is newly Medicaid certified and still in the initial rate process, or the facility does not have the necessary data to establish an individual facility Total Quality Score (TQS). When a facility does not have the necessary data for an individual facility TQS, a Statewide Average Total Quality Score would be used in the calculation. With over 100 facilities still waiting information, establishing the Statewide Average Total Quality Score is not feasible at this time. Once more of the 7/1/15 rates have been established, the TQS averages can be determined and subsequently the 7/1/15 rates awaiting these averages can be established. To see the current Cumulative Rate Listing, please click here.
For more information or any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
For more information or any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
CMS Call - Implementation of the IMPACT Act
On October 21, 2015, CMS is hosting a provider call to discuss the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The call will cover:
CMS suggests that the call will be “more meaningful” if the audience read the entire bill text prior to session. For details, including a link to the registration page, see https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2015-10-21-Post-Acute-Care.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending.
- Legislative requirements of the IMPACT Act related to the use of standardized data, quality measures, and resource use and other measures for skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals, and home health agencies;
- Participation in the quality measure and assessment instrument development process; and
- Opportunities for stakeholder engagement and input.
CMS suggests that the call will be “more meaningful” if the audience read the entire bill text prior to session. For details, including a link to the registration page, see https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2015-10-21-Post-Acute-Care.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending.
Ombudsman Acting Director
Karen Gardner Gilliland has been appointed Acting Director of the State Long Term Care Ombudsman Program. Karen has been with the Division of Aging for eight years and most recently served as Deputy Director for Policy and Planning. As a gerontologist, she has 40 years in services for the older adults, having served as an Area Agency on Aging Director in Muncie, President/CEO of a joint venture with Parkview and Lutheran Hospitals and the Visiting Nurse Services and Hospice of Fort Wayne, and as LTC Program Development Director for Mercy Health System in Cincinnati. In May of 2015, Karen was awarded the "Advocate of the Year" award by the Indiana Association of Home and Hospice Care for client advocacy.
The Ombudsman program serves to advocate for the needs of long term care residents by investigating and resolving their problems and complaints. The program provides information and education on long term care services, programs and advocacy on regulations and policies affecting long term care. Karen will oversee twenty-two full and part time Ombudsman located throughout the state.
The Ombudsman program serves to advocate for the needs of long term care residents by investigating and resolving their problems and complaints. The program provides information and education on long term care services, programs and advocacy on regulations and policies affecting long term care. Karen will oversee twenty-two full and part time Ombudsman located throughout the state.
Meeting with CMS
On September 15, 2015, AHCA had a meeting with CMS and participated in a stakeholder meeting convened by CMS. The first meeting included AHCA, LeadingAge and CMS. The second was a larger, invitation only Stakeholder Meeting on Future Changes to Five Star and Nursing Home Compare. Discussion points include issues concerning the Payroll Based Journal, anti-psychotic use rate, “focused surveys” not being categorized as complaint surveys, and coming changes to Five Star/Nursing Home Compare. Notes from both meetings can be accessed by clicking here. For more information or any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
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