Indiana Health Care Association

CMS Approves Indiana’s Nursing Facility State Plan Amendment

2012-05-24T13:29:00.002-07:00

On May 23rd, 2012, CMS provided notice to Indiana Medicaid that CMS had approved the State Plan Amendment (SPA) submitted by the State in October of 2011. The SPA was submitted as a result of the 2011 State Budget bill that called for maximization of Indiana’s Nursing Facility Quality Assessment Fee (QAF). IHCA supported the effort to maximize the QAF in order to increase reimbursement to nursing facilities and to fund Phase III of the nursing facility quality add-on that will move away from sole dependence on the Report Card Score to a Value Based Purchasing methodology comprised of 12 quality metrics.

IHCA is working to obtain details on the implementation plan for the SPA, specifically to ensure that re-processing of the entire fiscal year’s claims is done correctly and to avoid creation of cash flow issues to nursing facilities. Due to the State having submitted the SPA after October 1, 2011, many of the benefits from the SPA impact claims made as of October 1, 2011 and forward. This means that while the QAF will be increased retroactive to July 1, 2011, benefits will not be seen in claims from that first quarter of the fiscal year.

The benefits that will be realized in State Fiscal Year 2012 from the approved SPA include an increase to the Quality Assessment Add-on (by virtue of the increase in the QAF), an increased maximum Report Card Score Add-on, a 75-cent add-on to the Administrative Component to recognize a portion of previously disallowed costs related to direct patient care and patient care supports, and a separate increases to the Administrative Component to 110% in 2012 and 108% in 2013.

In addition, starting July 1, 2012 (State Fiscal Year 2013), the approved SPA will permit reimbursement for the following previously disallowed costs:
• Educational seminars for administrative, direct and indirect care staff
• Support license fees for general and administrative software and hardware
• Support and license fees for software used in hands-on resident care
• Rental costs for low air loss mattresses and pressure support devices and oxygen concentrators up to $1.50 PPD
• Denture replacement costs that exceed current Medicaid expenditure limitations
• Legend and non-legend sterile water for any purpose
• Cable or satellite TV
• Pets, pet supplies, maintenance and vet expenses
• Costs related to non-ambulance travel and transportation of residents

The approved SPA will also increase the capitalization threshold from $500 to $1,000.
As details become available regarding implementation of the SPA and retroactive adjustment of claims from State Fiscal Year 2012, IHCA will update member facilities.

If you have questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Changes to Nursing Home Compare & 5-Star Expected This Year

2012-05-24T09:56:00.000-07:00

AHCA recently notified State Affiliates of a meeting between CMS and stakeholder groups regarding upcoming changes to Nursing Home Compare and the 5-Star Rating. AHCA reported the following:

Upcoming changes to the Nursing Home Compare website, expected to be implemented this summer, in addition to updating the look, feel and some functionalities of the website, include:

•    Posting of survey deficiency reports (2567 forms), beginning for surveys conducted in calendar year 2011. Until CMS has access to Plans of Correction electronically, anticipated in 2014, this information will not be reflected on the website.
•    Reporting on the new MDS 3.0-based quality measures, including 2 new measures of off-label use of antipsychotic drugs (long-stay prevalence and short-stay incidence)
•    Inclusion of ownership information.
•    Reporting on physical therapist staffing levels.

Longer-term considerations for future enhancements currently in the early phases of exploration include reporting on special capabilities and services offered by facilities to better support consumer identification of facilities that can meet specialized needs and reporting of consumer satisfaction information. No information was provided as to the expected timeline for potential incorporation of these data.

The Five-Star Rating system will also be modified this summer to incorporate the new quality measures and adjust expected staffing calculations based on MDS 3.0 data. The approach to revising these measures and calculations has been designed to transition with minimal change to the overall distribution of ratings. CMS also reported that overall trends in Five-Star ratings since the debut of the system in 2008 have shown improvement, with an increasing proportion of facilities receiving 4- and 5-star ratings and fewer receiving 1-star ratings.

IHCA will continue to provide updates as CMS shares additional information and firms up their timeline for rolling out these changes. Provider preview reports are currently available via the CASPER system.

Smoking Ban Guidance

2012-05-17T10:22:00.003-07:00

House Enrolled Act 1149, Indiana’s Statewide Smoking Ban, becomes effective on July 1, 2012. The ban applies to most places of employment and public places, including nursing homes and assisted living facilities. IHCA has developed a guidance document for members’ reference when implementing changes to their smoking policies in light of the new law. Click on the link to the Members Only section of the IHCA website to view this document.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 for additional information or with questions.

CMS Issues Inpatient Hospital and LTCH Proposed Rules

2012-05-01T13:36:00.003-07:00

The Centers for Medicare & Medicaid Services has issued a proposed rule that would update Medicare payment policies and rates for inpatient stays to general acute care hospitals paid under the Inpatient Prospective Payment System (IPPS), and long-term care hospitals (LTCHs) paid under the LTCH Prospective Payment System.

In the proposed rule, CMS projects that general acute care hospital payment rates will increase by 2.3 percent in FY 2013. The 2.3 percent is a net update after inflation, improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes. Payments for IPPS hospitals are expected to increase by approximately 0.9 percent or $904 million in FY 2013. CMS also projects that LTCH payments will increase by approximately $100 million or 1.9 percent.

The proposed rule makes a number of changes to payment policies and rates, including:

• Adding the Medicare spending per beneficiary measure to the Hospital VBP Program, which would affect all Part A and Part B payments beginning in FY 2015;

• Establishing a new methodology and the payment adjustment factors for excess readmissions for heart attack, heart failure and pneumonia, and

• Several changes to the LTCH payment system that would:
oExtend the existing moratorium on the “25 percent threshold” policy for one year;

o Apply a 1.3 percent reduction to the first year of a proposed three-year phase-in of a budget neutrality adjustment, so that the proposed adjustment will not apply to discharges occurring on or before Dec. 28, 2012; and,

o Include the IPPS comparable amount payment option for discharges occurring on or after Dec. 29, 2012 in Medicare payments for very short stays in LTCHs.

To read the press release and fact sheets, go to: http://www.cms.gov/Newsroom/Newsroom-Center.html.

The proposed rule can be downloaded from the Federal Register at: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1.

CMS will not require independent LTC pharmacists

2012-04-04T07:35:00.001-07:00

by Ruta Kadonoff, Vice President, Quality & Regulatory Affairs, American Health Care Association

In a welcome response to comments submitted by AHCA and other stakeholder groups, The Centers for Medicare and Medicaid Services (CMS) reported on April 2 that they will not move forward in the immediate term with a proposal to require LTC facilities to hire independent consultant pharmacists, while reserving the possibility of doing so in the future if reductions in “inappropriate prescribing,” including the off-label use of antipsychotic drugs, are not observed. This decision was reflected in a final rule with comment period for the Medicare Advantage and prescription drug benefits programs for Calendar Year 2013.

In an October, 2011 Federal Register Notice, CMS discussed a potential new requirement for LTC consultant pharmacists to be independent of any affiliations with the facility's pharmacies, pharmaceutical manufacturers and distributors, or any affiliates of these entities. CMS reasoned that such a requirement was necessary to ensure that consultant pharmacist decisions were objective, unbiased, and in the best interest of nursing home residents. CMS now indicates that, “From comments received on this issue, we now believe a more targeted and less disruptive approach is warranted.”

In December 2011, AHCA submitted comments to CMS on this proposal, which the AHCA Pharmacy Workgroup was instrumental in shaping. In those comments, AHCA agreed that it is important to minimize the potential for a conflict of interest on the part of the consultant pharmacist and argued that current regulations and Guidance to Surveyors provides adequate support for CMS to deal with potential conflicts. AHCA also provided 6 alternative suggestions to minimize potential conflict of interest, provided data from the one state that requires an independent pharmacist that suggests “independence” does not necessarily result in reduction of use of antipsychotics and listed (with supporting information) advantages to having the consultant pharmacist associated with the dispensing pharmacy.

CMS is now soliciting additional comments to help determine a more comprehensive approach to eliminate overprescribing and reduce the use of antipsychotic drugs in LTC. CMS also strongly encourages the LTC industry to voluntarily adopt the following changes to increase transparency:

• Separate LTC consultant contracting for dispensing and other pharmacy services;

• Pay fair market rates for consultant pharmacist services; and

• Disclose to LTC facilities any affiliations of consultant pharmacists that pose potential conflicts of interest (this may include the execution of consultant pharmacist integrity agreements.)

CMS adds that if the expected improvements in prescribing behavior and antipsychotic drug use do not occur through voluntary practice changes, they will use a future notice and comment rulemaking to propose requirements to comprehensively address these concerns.

The AHCA/NCAL Quality Initiative

2012-03-22T12:34:00.002-07:00

Long term and post-acute care leadership from the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) have announced a multi-year initiative to meet new quality goals, including reducing hospital readmission rates and improving staff retention.

The Quality Initiative focuses on four goals designed to improve quality of care in America's skilled nursing centers and assisted living communities.

1. Reduce Hospital Readmissions: By March 2015, reduce the number of hospital readmissions within 30 days during a SNF stay by 15 percent.
2. Increase Staff Stability: By March 2015, reduce turnover among nursing staff (RN, LVN, CNA) by 15 percent.
3. Reduce the Off-Label Use of Antipsychotics: By December 2012, reduce the off-label use of antipsychotics by 15 percent.
4. Increase Customer Satisfaction: By March 2015, increase the number of customers who would recommend the facility to others up to 90 percent.
(Please note: NCAL is currently developing its specific measures and targets.)

The Quality Initiative goals have been defined for the next three years to foster sustainable change and set specific benchmarks for the long term and post-acute care profession to build upon. AHCA/NCAL is challenging its membership to hold itself accountable in ensuring a higher quality, lower cost health care system.

"The quality initiatives goals set forth by the AHCA compliment our efforts in Indiana as we move towards the most robust value-based purchasing program in the country," said Scott Tittle, President of the Indiana Health Care Association. "The combined focus of these measures and those in the VBP program relating to reducing employee turnover, improving staff retention, and achieving high marks in employee, resident, and family satisfaction should result in improving the experiences of residents and staff in our member facilities. Indiana members want to thank the AHCA for taking this very important step and being the leader nationally in improving resident care."

Reaching the targets set in each goal in the Quality Initiative will improve the health of thousands of seniors and people with disabilities, while at the same time driving down health care costs. When AHCA members achieve the goal of reducing hospital readmissions by 15 percent, 26,000 fewer people will go back to the hospital each year. Improving staff satisfaction will result in more consistent staffing in long term and post-acute care settings, keeping more than 615,000 in their jobs. Less off-label use of antipsychotic medications will help patients avoid the health complications that come with the drugs. More satisfied residents and families means that AHCA member facilities are fulfilling the mission of providing quality care.

AHCA/NCAL has created a volunteer-led Quality Cabinet to coordinate and monitor the progress of the Quality Initiative. More information about the Initiative is available online at qualityinitiative.ahcancal.org.

GAO Issues Study on Implementation of the Quality Indicator Survey

2012-03-08T07:16:00.002-08:00

by Lyn Bentley, AHCA Senior Director of Regulatory Services

This week the GAO issued a study: Nursing Home Quality: CMS Should Improve Efforts to Monitor Implementation of the Quality Indicator Survey. The study states that CMS has not done an adequate job of monitoring the implementation of the Quality Indicator Survey (QIS). While CMS has taken some steps to monitor implementation progress of the QIS, the monitoring has not been systematic nor is it consistent with federal internal control standards.

Of particular interest is the GAO position that “In the case of the QIS-based routine survey process, information collected through performance goals and measures could help CMS routinely monitor the extent to which the objectives of the QIS are being achieved. This information could also inform future efforts by CMS to modify and improve the QIS process as needed.” CMS agreed with the need for certain performance measures – particularly with regard to examining the effect of the QIS on surveyor consistency.

GAO Recommendations to CMS
• Develop a means – such as performance goals and measures – to routinely monitor the extent to which CMS is making progress in meeting the objectives established for the QIS;

• Develop and implement a systematic methodology to track state survey agencies’ progress with implementation activities; and

• Develop and implement a systematic method for obtaining, compiling, and sharing information from state survey agencies about their implementation experiences.

CMS Responses to the GAO Recommendations
CMS concurred with these recommendations and intends to:

• Establish new or modify existing measures or processes to more effectively monitor CMS’s progress towards meeting QIS goals and objectives. CMS is already reviewing available data related to the QIS (for example, data on survey workload, survey deficiencies, and the number of surveys performed) to more effectively monitor the QIS and guide improvement efforts.

• Formalize the data collection method used to track states’ progress with QIS implementation activities. CMS will institute an automated process to obtain updated information on states’ progress with training surveyors which, when combined with existing data, could provide a more accurate assessment of implementation activities in any state.

• Enhance existing and add new methods of sharing information on the QIS with states. CMS plans to expand existing information sharing opportunities (for example, quarterly calls and presentations at annual meetings) to be available to all states, not just those in the process of implementing the QIS. CMS is also considering using a web-based capability to facilitate sharing information on QIS implementation.

OIG issues memorandum report on Nationawide Program for Background Checks

2012-02-01T12:14:00.000-08:00

In January, the Department of Health and Human Services Office of the Inspector General (OIG) issued a report entitled Nationwide Program for National and State Background Checks for Long-Term-Care Employees – Results of Long—Term-Care Provider Administrator Survey. As you may recall, this nationwide program is a voluntary program identified in and funded by the Affordable Care Act provides grants to states to implement programs to conduct federal background checks on prospective long-term-care employees. According to the OIG, the purpose of the survey was to collect baseline data on current practices regarding conducting background checks on potential employees and the effects on the long-term-care workforce.

This report focused on the impact national background checks have on the availability and quality of long-term-care employees. To determine the impact, a sample of long-term-care administrators in states participating in this program were surveyed. According to the OIG, the survey results indicate that 81 percent of the administrators had a sufficient pool of applicants for job vacancies. Those administrators who had an insufficient pool of applicants “cited prospective employees’ preferences for working in health care settings other than long-term care, low pay, and lack of desire to work in a rural area.”

Based on the timeline for development of this report, it is important to note that administrators from 10 of the 17 states that are currently participating in this program were surveyed. It is possible that results will differ when more states are included in the survey.

IHCA Chooses Silverchair Learning Systems as Its Online Training Partner

2012-01-24T09:09:00.000-08:00

IHCA has chosen Silverchair Learning Systems as its partner to provide effective online training solutions that will help improve operations and reduce costs to members.

“We are very excited about the vast resources and experience that Silverchair will bring to our members through high-quality and cutting-edge online training,” said Scott Tittle, President of IHCA.

This partnership gives IHCA members access to a highly effective and affordable turn-key learning program that delivers, tracks, and reports on educational programs for their entire organization. Silverchair’s training program provides a complete curriculum of in-service and regulatory courses required by CMS and OSHA, as well as important resident care topics that specifically address the needs of senior care providers and their employees. The program can also be customized to include material specific to an organization.

“As a native Hoosier, I’m especially glad to have the opportunity to partner back home again in Indiana,” said Mike Mutka, President and COO of Silverchair Learning Systems. “We are excited to see how Silverchair will enhance the training of members at the more than 200 facilities that are partnered with IHCA.”

IHCA joins eight other American Health Care Association state chapters who have chosen Silverchair as their online learning partner. IHCA has negotiated exclusive pricing with Silverchair, making the learning management and online training system available to its members at a substantial discount.

Please visit the IHCA website for details on free courses and other benefits of this new partnership!

ISDH Establishes a New Independent Informal Dispute Resolution Process for Long Term Care Facilities

2012-01-04T10:51:00.000-08:00

by Zach Cattell, JD, IHCA General Counsel

On December 30, 2011 the ISDH issued a new ISDH Division of Long Term Care Policy and Procedure implementing the Federal requirement to establish an Independent Informal Dispute Resolution (IIDR) process for long term care facilities. The new IIDR process has been established to provide long term care facilities an opportunity, without cost to facilities, for an entity independent of the State Survey Agency to review certain aspects of survey deficiencies.

The ISDH IIDR Policy and Procedure includes two attachments, one with contact information for the ISDH IIDR lead and one with a timeline of the IIDR process (click here for the documents: IIDR Policy and Procedure; Attachment A – Contact Information; Attachment B – Timeline). The ISDH has also established a Informal Dispute Resolution Information Center at http://www.in.gov/isdh/25304.htm.

Applicability of the New IIDR Process

The new IIDR process is an option for facilities to elect if the facility is the subject of a Civil Money Penalty (CMP) that may be collected and placed in an escrow account. Until further notice from Federal and State regulators only those deficiencies that cite actual harm or immediate jeopardy (G or above) will be subject to the CMP collection and escrow and only those deficiencies will trigger the opportunity for IIDR. Any CMPs imposed for D, E and F deficiencies will be collected under the current informal dispute resolution process run by the ISDH and are not subject to the new IIDR process.

In the December 30, 2011 ISDH Newsletter, the ISDH provided the following key components to the ISDH-developed IIDR process:

1. The new ISDH Informal Dispute Resolution Policy and Procedure is effective January 1, 2012.

2. The ISDH will continue to offer traditional informal dispute resolution for all licensing and certification surveys conducted at comprehensive care facilities. The "informal dispute resolution" process refers to the review process conducted by ISDH Long Term Care Supervisors. The informal dispute resolution process may be either a paper review or a face-to-face review as requested by the facility. There is no fee to the facility for the informal dispute resolution process.

3. Effective January 1, 2012, an independent informal dispute resolution process is available to skilled nursing facilities (SNF) and nursing facilities (NF) that meet certain requirements related to a civil money penalty (CMP) imposed by the Centers for Medicare and Medicaid Services (CMS). The process is conducted by a CMS-approved "independent entity" that has contracted with the ISDH to provide this service. There is no fee to the facility for the independent informal dispute resolution process.

4. The Independent Informal Dispute Resolution process will only apply to standard (annual) and/or complaint surveys begun on or after January 1, 2012, that initiate an enforcement action for which a civil money penalty is imposed and subject to being placed in escrow. Any revisit survey conducted on or after January 1, 2012, that is associated with standard or complaint surveys begun prior to January 1, 2012, will not be subject to the Independent Informal Dispute Resolution Process.

5. Only civil money penalties which are imposed based on a deficiency or deficiencies cited for actual harm or immediate jeopardy to resident health or safety (i.e., at a scope and severity level of G or above) will be subject to civil money penalty collection and escrow provisions. Those deficiencies which result in the imposition of such civil money penalties will trigger a facility's opportunity to participate in the independent informal dispute resolution process. CMS will provide notice of the opportunity to participate in the independent informal dispute resolution process. The facility will request an independent informal dispute resolution through the ISDH.

6. The ISDH will be contracting with an independent entity for the independent informal dispute resolution process. The ISDH will provide contact and process information for that entity when a facility requests the independent process.

Independent Informal Dispute Resolution Entity

As noted by the ISDH in item #6 above and in the December 30, 2011 ISDH Newsletter, the State has not yet awarded a contract as proposals to the State were due on January 5, 2012. The ISDH believes that the independent entity will be in place in time for use by facilities.

Additional Considerations

The new IIDR process, with its requirements and timing limitations, is untested in Indiana or anywhere else in the country and there will undoubtedly be questions that arise. Due to the timing limitations (the process must be completed within 60 days from a facility’s request for IIDR), the new IIDR process for Indiana facilities will be entirely paper-based and no in-person meetings will occur. For the traditional ISDH-led informal dispute resolution process, a facility can choose either paper-based review or in-person review.

Because the ISDH will continue to administer the ISDH-led informal dispute resolution process and because facilities will not be able to go through both the ISDH-led process and the new IIDR process for the same deficiencies, the ISDH will not schedule an ISDH-led informal dispute resolution process, if requested, until a determination of whether CMP will be imposed that can trigger a facility’s right to the new IIDR. It will be key that a facility submit all supporting documentation to the ISDH through the ISDH Survey Report System when electing the ISDH-led process as requests for that process will not be considered until all documentation is submitted. Once it is known whether CMP is to be imposed for a deficiency, then a facility can choose either the ISDH-led process or the new IIDR process.

In addition, facilities and their counsel should consider how the IIDR process will impact any decision to request or waive a formal hearing on cited deficiencies. CMS and ISDH have been clear that the new IIDR process is not and will not be used to delay timing of the formal hearing process. Request for a formal hearing will likely have to occur near the same time that an IIDR is requested due to timing requirements.

IHCA will continue to monitor the development of Indiana’s IIDR process. For additional information please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Congress Agrees on Two-Month Extension to Payroll Tax Cut and Extended Unemployment Compensation: "Doc Fix" and Outpatient Therapy Caps Exceptions Process Receive Similar Reprieve

2012-01-03T10:19:00.001-08:00

The U.S. Congress passed a two-month payroll tax cut extension just eight days before its scheduled January 1, 2012 expiration after House Republicans dropped their objections under growing political pressure. President Obama signed the extension, guaranteeing that 160 million workers will continue to receive a two percent cut in their social security payroll taxes. Also included in the package was a freeze in physician Medicare payments, which avoided a massive 27.4% cut set for January 1, 2012; an extension of expanded unemployment compensation benefits; and an extension of the Medicare Part B outpatient therapy cap exceptions process under which SNFs and other providers can avoid therapy caps for certain patient diagnoses.

Congress will use the two-month reprieve to try to come to a full year agreement on the “extenders” package. The Senate and the President had supported a one-year extension, but the House had originally balked at the idea, accusing them of “kicking the can down the road” and failing to enact any long range deficit reduction legislation. A one or two-year extension will hinge on the ability of Congress to come to an agreement about how to pay for the various program extensions. Congress has appointed a conference committee to resolve the controversy. The committee has until March 1 to decide what to fix, for how long, and how to pay for it. None of the conferees named to date are from Indiana.

The original House version of the “extenders” package had called for a cut in federal reimbursement for public and private Medicare “bad debts” to 55 percent. Such a cut would have had a huge impact in states, like Indiana, whose Medicaid programs do not reimburse SNFs for Medicare Part A co-payments. We understand in this two month review, our industry is once again in Congress’ sights as potential “pay for” solution. Our national affiliate, the American Health Care Association, is following the issue closely and advocating for alternative funding sources such as savings from reduced re-hospitalizations.

We will bring you more information on the issue as it becomes available. Meanwhile, members with questions may call (317-616-9031) or email IHCA President Scott Tittle at stittle@ihca.org for additional information.

CMS Region V Updates

2012-01-03T10:12:00.000-08:00

by Zach Cattell, IHCA General Counsel

IHCA recently had the opportunity, along with several other states’ long term care associations, to meet with the survey and certification staff of CMS Region V. The following information was discussed:

• Citation patterns by state and by region. See attached charts that summarize the top ten citations for Region V as well as a total deficiencies cited by severity level. F441, F371, F323 and F279 were in the top ten for all states in Region V.

• QIS will continue to be implemented in the states where training has started, but no new states will begin QIS training until further funding is identified. In addition, QIS will continue to only apply to annual surveys and there is no word at the current time as to if or when QIS will apply to complaint surveys.

• Elder Justice Act – Crimes Reporting

     1. Unfortunately, no new guidance or insights were discussed by CMS as to the rollout of the      reporting requirement. CMS stands by its last issued guidance

     2. The Region V staff was unsure as to when CMS Central Office would be issuing any additional guidance or promulgating regulation to implement the CMP and excluded individual provisions of the law

     3. Facilities should continue to follow the guidance issued by CMS and the ISDH to implement the crimes reporting requirement

• Independent Informal Dispute Resolution (IIDR)

     1. A new CMS S&C Memorandum was published on December 2, 2011 that superseded the October 14, 2011 memorandum on the implementation of IIDR. The new Memorandum is attached and includes the Interim Advance Guidelines that will be placed in the State Operations Manual regarding the IIDR process.

     2. The ISDH is working on its own guidance regarding IIDR since it is required by CMS to implement the IIDR program for Indiana. The ISDH is expected to release guidance when the new IIDR process goes into effect on January 1, 2012.

     3. The new IIDR process will only apply to all standard or complaint surveys begun on or after January 1, 2012 and include enforcement action on a G-level deficiency or higher for which Civil Money Penalty may be assessed and escrowed.

     4. IHCA is analyzing the CMS and ISDH guidance.

• Life Safety Code citation history for 2011. See attached charts regarding Life Safety Code citations for Region V states, comparisons of the top ten citations from 2010 to 2011, as well as CMS’s tips on how to avoid the top ten deficiencies. Indiana’s #1 Life Safety Code deficiency was K144 – Emergency Generators for the second year in a row.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.

ISDH Long Term Care Bed and Personnel Tracking System

2011-12-01T11:13:00.000-08:00

by Katie Eller, IHCA Director of Education and Member Services

The ISDH has created a Long Term Care Bed and Personnel Tracking System that will be effective on
December 1, 2011. The ISDH has several purposes behind the implementation of tracking system. This system will be used to track available beds in long term care facilities and track key facility personnel.

The following are the purposes behind this system.

1. EMERGENCY PREPAREDNESS: The purpose behind the system is to improve state
emergency preparedness. In the case of emergencies, there is a need to know the location of
available beds in case there is a need for evacuation. This system is intended to provide reliable
current information on available nursing home beds.

The ISDH currently tracks the number of licensed and certified beds for each facility. That
information is recorded at the time of licensing and does not reflect the number of occupied beds.

The ISDH obtains a bed census at the time of a survey. Because surveys may not occur for up to
fifteen months apart, that data is not current and therefore not reliable in an emergency. It also
does not provide the detail as to type of available beds that is needed for appropriate placement
determinations.

In the mid-2000’s, the ISDH created an online system to track available hospital beds throughout
the State. That system, in partnership with the Indiana Department of Homeland Security, was
intended to provide improved information for emergency responders in emergency situations.That system was implemented and has been a valuable asset in emergency situations.

As a next preparedness step, the Centers for Medicare and Medicaid Services (CMS) included
the development of a bed tracking system for long term care facilities as one of its priorities to be
implemented by state survey agencies by July 2009. CMS developed a pilot tracking system for
that purpose but did not implement the system. In 2011, the ISDH therefore began development
of a state system.

The need for such a system can be readily demonstrated by recent emergency situations in
Indiana. In the summer of 2009, Indiana experienced significant flooding. One nursing home that
had to be totally evacuated had planned to evacuate to sister facilities. Those facilities were no
longer accessible because of the flood waters. The facility therefore needed to know where there
were nearby available beds. There was no ready source for current bed availability information
and local communications were out. Had this system existed, the ISDH could have provided the
information to local emergency responders through the state emergency communications system.

Another large facility had to evacuate nearly 200 residents. The nursing homes in the area were
at capacity so there was a need to find appropriate beds in surrounding counties. There again
was no ready source for current bed availability information. Because phone lines were
accessible, the ISDH wound up calling facilities to determine bed availability but that resulted in
delays in getting residents placed. The ISDH also learned that there was a need to know not only
the availability of a bed but the classification and purpose of the bed.

Earthquakes, tornadoes, and flooding are all realistic potential emergency situations in Indiana.
The ISDH believes that reliable bed tracking data is essential to improving the state’s emergency
preparedness and response capacity. This new bed tracking system has been designed to meet
those emergency preparedness needs.

2. FACILITY CLOSINGS AND ROUTINE PLACEMENTS: One of the challenges faced by families, facilities, and the State is the appropriate placement of residents. When families or State
Ombudsman are trying to find available beds in an area, they often spend lots of time calling
facilities trying to identify available beds. Even more critical is when a facility is closing and there
is a need to place a large number of residents. The bed tracking system is intended to be an
efficient resource to assist in the appropriate placement of residents.

3. DETERMINATION OF STATE OCCUPANCY RATES: The ISDH is required to determine
nursing home occupancy rates. The Indiana General Assembly adopted statutes that refer to
nursing home occupancy rates. For instance, Indiana Code 16-28-16 states that the ISDH may
not approve the certification of new or converted comprehensive beds for participation in the state
Medicaid program unless the statewide comprehensive care bed occupancy rate is more than
ninety-five percent as calculated annually on January 1 by the ISDH. Other legislative proposals
have referred to a monthly occupancy rate by county and the legislature has requested that the
ISDH be able to provide monthly occupancy rates.

In order to implement state statutory requirements, the ISDH must be able to determine accurate
nursing home occupancy rates. At the present time, the ISDH is unable to comply with the
statute because the ISDH does not have a data source that provides occupancy on a given date.
While the ISDH collects occupancy data at the time of licensing surveys, the data does not allow
for determination of an occupancy rate on a given date because surveys may occur up to fifteen
months apart for a given facility.

The bed tracking portion of the new system will allow the ISDH to track bed occupancies on a
monthly basis in fulfillment of state statutory requirements. The database will also allow for
further study of occupancy rates by various criteria as requested by legislative studies.

4. EDUCATION AND TRAINING: The ISDH periodically provides education and training on
healthcare quality of care issues. Examples include state leadership conferences as well as the
pressure ulcer and healthcare associated infection initiatives. As part of these initiatives, the
ISDH often provides resource materials or information on educational opportunities.

The ISDH does not currently have contact information for key healthcare providers related to
topics in their area of expertise and responsibility. The result is that healthcare quality
improvement information often does not reach the relevant healthcare providers.

For example, there has been interest in developing programs to improve care coordination.
While the ISDH tracks the name of the facility medical director, we do not necessarily have
contact information for those individuals. Furthermore, the ISDH does not have any contact
information for attending physicians. With improved contact information for key healthcare
providers, the goal of the ISDH is to use this information to improve dissemination of information
to appropriate sources and create improved partnerships towards quality improvement.

5. SURVEY EFFICIENCY: The ISDH is always looking for ways to improve survey efficiency.
When the ISDH begins a survey, surveyors spend time identifying beds and key facility staff.
With the new tracking system, surveyors will have a copy of the facility’s bed census and key
staff. Surveyors will simply verify the list with the facility at the time of entrance. Surveyors often
spend time trying to identify the key staff not a part of current reporting. For instance, many
health care facilities are required to have an Alzheimer’s Director. The ISDH does not currently
track that information so having the information in the system assist surveyors in identifying
required staff and thus reduce survey time.

6. IMPROVED ACCURACY OF PERSONNEL TRACKING: Healthcare rules require facilities to
provide the ISDH with a change of the facility’s administrator, director of nursing, and medical
director. An example of a regulatory reporting requirement is 42 CFR 483.75(p). The ISDH
frequently finds that information is out of date and has not been appropriately updated. The
system is intended to improve the accuracy of tracking.

The system will be housed and accessed through the same ISDH Gateway System as the new
Survey Report System that was implemented earlier in 2011. The facility should expect to receive
an email on or about November 30 requesting the facility to submit their monthly report. The email
will be sent to the same email address used in the Survey Report System. The facility should then
log in to the system and provide the requested information. The facility will then subsequently
receive a reminder each month via email to update their data.

What Information Will be Tracked

The following available bed information will be tracked on a monthly basis:

• Facility census on last day of month
• Total bed occupancy
• Subcategories of bed availability
• Bed availability: male and female
• Bed availability: Alzheimer's Unit
• Ventilator beds available

Facilities will be asked to provide contact information for the following individuals:

• Administrator(s)
• Director(s) of Nursing
• Medical Director(s)
• Attending Physicians
• Nurse Practitioners
• Physician Assistants
• Minimum Data Set (MDS) Coordinator
• Wound Care Specialist(s)
• Alzheimer's/Dementia Unit Director(s)
• Social Services Director(s)

For More Details
For more details about the tracking system and the facility’s responsibility, please review:

ISDH LTC Advisory Letter LTC-2011-02

ISDH LTC Advisory Letter LTC-2011-02 Attachment A

CMS Retracts Guidance on F322 - Feeding Tubes

2011-11-03T06:15:00.000-07:00

by Zach Cattell, JD, IHCA General Counsel

Guidance issued by CMS this past September that was to be effective this November has been retracted. Survey & Certification Memorandum 11-37-NH is no longer valid and CMS is revising the guidance to incorporate information from the Quality Indicator Survey process. CMS anticipates releasing revised guidance during the first six months of 2012.

If you have any questions about this topic, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Physician Signatures Not Required for Clinical Labs Under Clinical Laboratory Fee Schedule

2011-11-02T08:35:00.000-07:00

by Zach Cattell, JD, IHCA General Counsel

CMS released its final rule making Revisions to Payment Policies to the Physician Fee Schedule for CY 2012 and CMS has officially retracted the proposed physician or non physician practitioner signature requirement on clinical lab test requisition policy. CMS had proposed for January 1, 2011 implementation of a rule which would have required a physician’s or qualified non physician practitioner’s signature on all requisitions for clinical diagnostic laboratory tests paid for on the basis of the Clinical Laboratory Fee Schedule (CLFS). The American Health Care Association, along with State affiliates, fought the proposal. CMS had first delayed the implementation and then had indicated that it would eliminate the requirement. The release of the final rule confirms the elimination of the proposal.

The final rule states “After consideration of the public comments received, we are finalizing our proposal to retract the policy that was finalized in the CY 2011 PFS final rule with comment period, which required a physician's or NPP's signature on a requisition for clinical diagnostic laboratory tests paid under the CLFS (75 FR 73483) and to reinstate our prior policy that the signature of the physician or NPP is not required on a requisition for a clinical diagnostic laboratory test paid under the CLFS for Medicare purposes.”

If you have any questions or for additional information, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

CMS Issues Guidance to States for an Independent Informal Dispute Resolution Process for Long Term Care Facilities

2011-11-02T08:29:00.000-07:00

by Zach Cattell, JD, IHCA General Counsel

Section 6111 of the Patient Protection and Affordable Care Act (ACA), in part, formed the basis for the establishment of a new Independent Informal Dispute Resolution (IIDR) process within the Civil Money Penalty scheme. Per Federal Regulations at 42 CFR 488.431, the new IIDR process has specific timelines and requirements for facilities to meet in order to take advantage IIDR. On October 14, 2011, CMS issued Survey & Certification Memorandum 12-02-NH (click here for a copy) that provides further guidance on the new IIDR process.

The new IIDR process is an option for facilities to elect if the facility is the subject of a Civil Money Penalty (CMP) that is subject to being collected and placed in an escrow account. CMS is phasing in the CMS collection and escrow provisions of the ACA and attendant regulations and will only be applying the CMP collection and escrow authority on the most serious deficiencies. Until further notice from CMS only those deficiencies that cite actual harm or immediate jeopardy (G or above) will be subject to the CMP collection and escrow and only those deficiencies will trigger the opportunity for IIDR. Any CMPs imposed for D, E and F deficiencies will be collected under the current process and are not subject to the new IIDR process.

Federal funding is available to States, through the State Survey Agency, for development of the IIDR process. The Indiana State Department of Health (ISDH) recently issued an alert indicating that the department is in the process of developing a new IIDR process according to the CMS guidance. The new IIDR process must:

1. Offer a facility the opportunity for IIDR within 30 calendar days of notice of imposition of CMP that will be collected and placed into escrow. A facility has 10 calendar days to request IIDR after receiving notice.

2. Be completed within 60 calendar days of receipt of the facility request for IIDR. “Completed” IIDR means that (a) a final decision has been rendered, (b) a written report has been generated, and (c) the ISDH has provided written notice to the facility of the decision.

3. Generate a written record of the decision before the CMP is collected. Such written record must include (a) each disputed deficiency/survey finding, (b) a summary of the IIDR recommendation with rationale for the result, (c) documents submitted by the facility, and (d) comments submitted to the IIDR by the Ombudsman and/or residents and their representatives.

4. Notify the Ombudsman, resident and resident’s representative of the opportunity to submit comments to the IIDR entity prior to the completion of the IIDR process.

5. Be administered by an entity that does not have a conflict of interest with the ISDH (State Survey Agency) and that has specific understanding of Medicare and Medicaid program requirements.

CMS indicates that for States to receive Federal funds for IIDR in FY 2012, States must have a process and estimated budget submitted to CMS by November 30, 2011. Furthermore, the new IIDR process is set to begin on January 1, 2012. It is unclear at this time whether the ISDH will meet either deadline. Given that Indiana law regarding state agencies contracting for services requires a fairly lengthy procurement process, it does not seem likely that the ISDH process will be finalized and ready by January 1, 2012. For deficiencies that are subject to the new IIDR process, States may not charge facilities for the IIDR process. For situations that do not require the new IIDR (deficiencies that do not require escrowing of CMP), the State may develop and charge for its own resolution process.

IHCA will continue to monitor the development of Indiana’s IIDR process. For additional information please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Changes in Interpretive Guidelines for the Use of Feeding Tubes

2011-10-06T10:51:00.000-07:00

by David Bufford, Hall Render, IHCA Associate Member

CMS released a Survey & Certification letter in September announcing revisions to surveyor guidance related to the use of feeding tubes in facilities, effective November 30, 2011. The revisions include the deletion of tag F-321, which addressed not utilizing a feeding tube unless it was unavoidable, and rolled the interpretive guidance for that tag into tag F-322.

The guidance for tag F-322 has been revised to provide clarification to nursing home surveyors when determining compliance with the regulatory requirements for feeding tubes. The actual federal regulation at issue, 42 CFR 483.25(g), has not changed. The guidance now better reflects the intent of the regulation to ensure the feeding tube is utilized only after an adequate assessment determines that the resident's clinical condition makes the intervention medically necessary. The feeding tube must be utilized in accordance with current clinical standards of practice and services are provided to prevent complications to the extent possible. Additionally, the facility must provide services to restore normal eating skills, to the extent possible.

The new guidance will address identify the key elements for tag F-322 that determine the level of severity. Severity Level 1 is not applicable to this tag.

CMS Provides Guidance for Nursing Facility Gardens

2011-10-06T10:47:00.000-07:00

by David Bufford, Hall Render, IHCA Associate Member

CMS released a Survey & Certification letter in September providing guidance for nursing homes that desire to utilize on-site gardens to provide fresh produce for residents. After numerous inquiries from facilities, CMS confirmed that residents can benefit from home-grown foods as long as food-borne illness dangers are mitigated to the greatest extent possible.

The facility should follow safe food handling practices once foods are harvested and brought into the kitchen for preparation. Additionally, the facility must have in place policies and procedures for maintaining the garden. Such actions will permit the facility to remain in compliance with 42 CFR 483.35(i), Sanitary Conditions, and the related survey tag, F371.

In the event of an outbreak of a food-borne illness, surveyors will request the facility’s policies and procedures related to the garden if the facility’s main food source has been ruled out as the cause. The facility must immediately report any outbreak of a food-borne illness, regardless of the cause, to the local health department. The facility must also comply with any local or state requirements related to growing food on-site.

Medicaid RAC Rule Finalized

2011-10-05T07:59:00.000-07:00

Section 6411 of the Patient Protection and Affordable Care Act (PPACA) expanded Federal efforts in the auditing and health care fraud arena by requiring that the Recovery Audit Contractor (RAC) program, which had previously only applied to Medicare, be applied to Medicaid as well. The Medicaid RAC programs will be operated by each individual State, but will be jointly funded by the State and the Federal government.
On September 16, 2001, the Centers for Medicare and Medicaid Services finalized the rule that will implement the health care fraud and abuse program. The Final Rule "provides guidance to States related to Federal/State funding of State start-up, operation and maintenance costs of Medicaid Recovery Audit Contractors (Medicaid RACs) and the payment methodology for State payments to Medicaid RACs." While the framework for the Medicaid RAC program was established in the corresponding proposed rule, the Final Rule sets forth the following important points:

· States may exclude Medicaid managed care claims from review by Medicaid RACs

· States must coordinate the recovery audit efforts of their Medicaid RACs with other auditing entities

· States must set limits on the number and frequency of medical records to be reviewed by the Medicaid RACs subject to requests for exceptions made by the RACs

· RACs must not review claims that are older than 3 years from the date of the claim, unless it receives approval from the State

· RACs should not audit claims that have already been audited or that are currently being audited by another entity

· If a provider appeals a Medicaid RAC overpayment determination and the determination is reversed, at any level, then the Medicaid RAC must return its contingency within a reasonable timeframe as prescribed by the State

· States must adequately incentivize the detection of underpayments and States must notify providers of underpayments that are identified by the Medicaid RACs

· States must provide appeal rights under State law or administrative procedures to Medicaid providers that seek review of an adverse Medicaid RAC determination

The Final Rule becomes effective on January 1, 2012.

"Long-Term Care Providers Must Not Adopt Residents’ Racial Preferences"

2011-09-07T10:34:00.000-07:00

by Laurie E. Martin, Hoover Hull LLP

Long-term care providers may violate federal anti-discrimination law if they have a policy of honoring their resident’s racial preferences in assigning health care providers. A recent opinion from the U.S. Court of Appeals for the Seventh Circuit, Chaney v. Plainfield Health Care Center, 612 F.3d 908 (7th Cir. 2010), found that a provider’s policy of acceding to the racial biases of its residents was an unlawful employment practice that, along with racial animosity from the plaintiff’s co-workers, created a hostile workplace in violation of Title VII of the Civil Rights Act of 1964.

Certain Plainfield residents refused assistance from black CNAs. Plainfield had a policy of honoring its resident’s racial preferences, citing state and federal laws granting residents the right to choose providers, to privacy, and to bodily autonomy. Accordingly, African American plaintiff Brenda Chaney’s daily assignment sheets stated in writing that one of her residents “Prefers No Black CNAs.”

Over the course of three months, co-workers referred to Chaney in derogatory racial terms on multiple occasions. She reported the comments to management, and the comments eventually stopped, but Plainfield’s racial preference policy remained in place.

Chaney was later terminated for using profanity in front of a resident, although Plainfield later claimed other reasons led to her discharge. The court cautioned that a shifting justification for an employment decision can be circumstantial evidence of an unlawful motive. Rudin v. Lincoln Land Cmty. Coll., 420 F.3d 712, 723-34 (7th Cir. 2005).

The Seventh Circuit reversed summary judgment for Plainfield, finding that although Plainfield had acted to stop the racial epithets, it had actually encouraged a racially charged environment through its daily written assignment sheets reminding Chaney and her co-workers that certain residents preferred no black CNAs.

Chaney, 612 F.3d at 913-15. The court explained that, unlike gender, race is never a legitimate reason – a bona fide occupational qualification – for accommodating patients’ privacy interests. “Just as the law tolerates same-sex restrooms or same-sex dressing rooms, but not white-only rooms, to accommodate privacy needs, Title VII allows an employer to respect a preference for same-sex health providers, but not same-race providers.” Id. at 913.

Finally, the court disagreed that an Indiana regulation which gives residents a right to “choose a personal attending physician and other providers of services,” (410 Ind. Admin. Code 16.2-3.1-3(n)(1)), required Plainfield to instruct its employees to accede to the racial preferences of its residents. The court suggested that the regulation may require Plainfield to allow the resident reasonable access to a white aide if she wished to employ one at her own expense, but that it did not trump Plainfield’s duty to its employees to abstain from race-based work assignments. Title VII contains no good faith defense permitting an employer to ignore federal mandates in favor of allegedly conflicting state law. Id. at 914.

The Court suggested several actions a long-term care provider could take to confront a hostile resident without exposing itself to hostile workplace liability:

• Warn residents before admission of the facility’s non-discrimination policy and secure the resident’s consent in writing.

• Attempt to reform the resident’s behavior after admission.

• Assign staff based on race-neutral criteria that minimize the risk of conflict.

• Advise employees that they can ask for protection from racially harassing residents.

Id. at 915 (citing Patrick Gavin & JoAnne Lax, When Residents and Family Harass Staff: The Tightrope between Regualtory Compliance, Risk Management and Employment Liability, LONG TERM CARE AND THE LAW 16-18 (Feb. 27, 2008) (American Health Lawyers Association, Seminar Materials.)

Employers can also seek to avoid liability under Title VII by enacting and consistently enforcing the following helpful practices:
• Establish a clear and effective anti-harassment policy

• Respond promptly to any complaints of harassment from employees.

• Provide clear and comprehensive reasons for discharge at termination.

• Seek clarification from the Indiana State Department of Health or legal counsel if a state regulation appears to require actions inconsistent with federal law.

Laurie E. Martin is an associate with Hoover Hull LLP. She represents employers, including long term care facilities and hospitals, in state and federal court and before administrative agencies on all employment and employee-benefit related matters including compliance with the Family and Medical Leave Act (FMLA), Title VII of the Civil Rights Act, the Employee Retirement Income Security Act of 1974 (ERISA), the Americans with Disabilities Act (ADA), Genetic Information Nondiscrimination Act (GINA), wage and hour disputes, wrongful discharge and blacklisting. Visit www.hooverhull.com or contact Laurie E. Martin directly at 317-822-4400, ext. 136, to discuss your employment-related needs.

An Update on Reporting of Crimes in Long Term Care Facilities

2011-09-07T07:35:00.000-07:00

by Zach Cattell, J.D., IHCA General Counsel

On August 12th, 2011, the Centers for Medicare and Medicaid Services (“CMS”) released an update to the June 17th, 2011, Survey and Certification Memorandum 11-30-NH (the “Memorandum”) that provides guidance to State Survey Agencies (“SSA”), the Indiana State Department of Health (“ISDH”) in Indiana, regarding the reporting of reasonable suspicions of crimes in long term care facilities (“LTC”) (click here for the updated Memorandum: Updated S&C 11-30-NH).

The Memorandum was published due to the passage of the Elder Justice Act that, in part, requires certain covered individuals to report reasonable suspicions of crimes in that occur in LTCs to the ISDH and a local law enforcement agency. The revised memorandum includes a Questions and Answers document, at pages 13-18, and guidance on the content of required notice regarding anti-retaliation provisions.

In addition, on August 31st, 2011, the ISDH released guidance of its own in the form of ISDH Program Advisory LTC-2011-01 (the “ISDH Program Advisory”). This ISDH Program Advisory provides additional guidance for facilities, as well as sample forms and an implementation timeline that facilities should follow.
CMS Questions and Answers

The additional CMS guidance provides, unfortunately, only a few new pieces of information. For the most part the Questions and Answers reiterate information that was already communicated in the original Memorandum. That being said, the following are new guidance from CMS:
• Reporting a reasonable suspicion of a crime does not require “first-hand knowledge” of the events giving rise to the reasonable suspicion.

• Continuing Care Retirement Communities must comply with the reporting requirements and, specifically, notices that are required to be posted must be so posted in the SNF/NF portion of the community and not in each building or unit of the entire community.

• To promote a culture of safety, and to encourage reporting of reasonable suspicions of crimes, it is not recommended that facilities require covered individuals report to the facility when a report of a reasonable suspicion of a crime is made. Anti-retaliation provisions of the reporting requirement reinforce this premise.

However, this guidance must be balanced with the requirement for facilities to ensure that all alleged violations involving mistreatment, abuse, neglect, injuries of unknown origin and misappropriation of resident property are immediately reported to the administrator and other officials in accordance with current law.

• The 2-hour and 24-hour reporting requirements for reports of reasonable suspicions of crimes (2-hours when events results in serious bodily injury, and 24-hours for all other reports) are based on actual (clock) time, and not business hours.

• Incidents such as falls, bruising/injuries of unknown origin, resident-on-resident abuse, and other events, may be subject to the crimes reporting requirement, but are case specific. Each of these events would be reportable as an incident, but whether there is a reasonable suspicion of a crime depends on the surrounding circumstances.

Indiana State Department of Health Guidance

The ISDH released ISDH Program Advisory LTC-2011-01, which includes several helpful attachments. The ISDH Program Advisory hits many similar points that the CMS Memorandum discusses, but gives specific guidance on the reporting process and contact information for submitting reports to the ISDH, gives recommendations for implementation of the reporting requirements, includes templates for required and recommended postings, a revised Incident Report Form, and an ISDH Q&A document.

The ISDH materials may be located on the LTC Incident Reporting website at http://www.in.gov/isdh/23638.htm (documents are at the bottom of the page under “Program Guidance and Advisory Letters”). Most notably, the ISDH recognizes that the reporting requirements is current law and is in effect. However, the ISDH sets out an implementation timetable in the form of a checklist (see Implementation Checklist for Facilities) that does provide for some additional time for facilities to get up to speed with the law.

Recommendations

LTC facilities should immediately develop policies and procedures implementing the crimes reporting requirements. According to CMS, the law is in effect and should be enforced by State and Federal Surveyors.

Training of covered individuals (owners, operators, employees, managers, agents or contractors of the facility) regarding their individual duty under the requirement is critical. Each facility will want to be sure that each covered individual understands his/her responsibility, how to make a report, how to join a group report if a group report is being made, that the individual is are not to be retaliated against for making a report to the ISDH or local law enforcement and if retaliation occurs how the individual can make a report regarding such retaliation.

LTC facilities need to reach out to their local law enforcement agency, either the county sheriff or city/town police, as applicable, regarding communication of reports. Establishing a relationship with local law enforcement for purposes of reporting reasonable suspicions and understanding what constitutes a crime in the local jurisdiction are key components to implementation.

If you have any questions about the crime reporting requirements, please contact Zach Cattell at 317-636-4341 or zcattell@ihca.org.

IHCA congratulates American Senior Communities on deficiency-free survey

2011-08-26T05:56:00.000-07:00

The Indiana Health Care Association (IHCA) would like to congratulate one of its members, American Senior Communities, on one of its facilities, American Village, becoming the first and only nursing home in the state to receive a deficiency-free survey by the Indiana State Department of Health using tough new federal criteria.

Indiana is one of more than a dozen states now using the federally mandated Quality Indicator Survey, initiated in January. The new two-stage survey process requires in-depth investigation, interviews with residents, staff and others and a review of residents’ medical records. It is far more comprehensive than previous surveys, making American Village’s deficiency-free status a significant achievement.

“Congratulations to American Village for all of its hard work and recognition,” said Scott Tittle, President of IHCA. “We are very proud of our members’ commitment to high quality care, and that one of our members is leading the way in QIS.”

American Village, 2026 East 54th Street, is a full-continuum campus offering a wide variety of premiere senior living options.

Indiana owned and operated, American Senior Communities is the largest provider of retirement living and senior healthcare in Indiana, serving fellow Hoosiers for over a decade. American Senior Communities operates over 25 locations in the Greater Indianapolis area and 57 across the state. For more information about American Village and American Senior Communities visit http://www.americansrcommunities.com/.

American Senior Communities is one of the IHCA’s 221 member facilities that care for more than 25,000 of Indiana's geriatric and developmentally disabled citizens, the majority of whom are low-income Medicaid recipients. IHCA is Indiana's largest trade association and advocate representing proprietary, not-for-profit and hospital-based nursing home and assisted living communities, adult foster care and adult day services. For more information on IHCA, visit http://www.ihca.org/.

Memo from AHCA President & CEO Governor Mark Parkinson: "We Must Fight On"

2011-08-03T08:25:00.000-07:00

Friday’s news of the final PPS rule dealt us a severe and unnecessary blow. Severe because of the impact it will have on our members, their employees and most importantly, our residents. Unnecessary because AHCA put forth a solution that would have satisfied the goals of the government without threatening our profession.

How could this happen? Here is the CMS line of thinking: CMS intended to spend $31 billion on post-acute care in Fiscal Year 2011; CMS now believes it will end up spending $35 billion in FY 2011. So, for FY 2012, it is reducing spending back to $31 billion. Further, CMS claims that a large part, if not all, of the reason for the $4 billion overpayment was the profession’s behavior. CMS thinks we up coded, gamed the system, or whatever you want to call it. As a result, CMS just doesn’t see the big deal about immediately reducing payments by nearly $4 billion.

Of course, it is a big deal. Most of us find it insulting that SNFs are accused of incorrectly providing inappropriate care. Many of you have not experienced an increase of the magnitude claimed by CMS. We are all concerned that the CMS rule will over-correct for a flawed payment system and result in the government actually spending less than $31 billion in the sector next year. And none of this accounts for the challenges we face with increased costs, drastic Medicaid cuts and the looming threats of additional cuts.

Despite Friday’s result, we must fight on. We cannot allow the impact of this blow to stop us. Our need to work hard, strategically and as a united front has never been greater.

I have directed AHCA staff to take all possible steps to minimize the impact of the rule. Every idea is on the table, and we will thoroughly examine each option, including our legal and legislative options.

Further, we must make certain that this is the last hit that we take this year. Unfortunately, there are still three serious risks that we face. They are:

1. Attempts on the Hill to claw back any unintended payments we received this year.

2. Specific attempts to cut skilled Medicare rates because of persistent arguments that our margins are too high.

3. General cuts to both Medicaid and Medicare that would impact the sector, like cuts in provider taxes and the blended Medicaid rate proposal.

As we develop specific strategies, we will share more information with the membership. At the time, there are at least two ways that you can help us accomplish our goals. First, please continue your political support and activity. Over the last 60 days, our members’ response to our requests for involvement has been stunning. You have sent over 100,000 emails and letters. We have lobbied virtually every Congressional office. This culminated in significant bipartisan support for our balanced approach on the Hill.

The need to exert our political pressure has not diminished just because the final rule has been announced. We need political pressure now, more than ever.

Second, we need examples from members of the economic impact of this rule. CMS states in its rule that it does not believe we will lay people off, freeze wages, stop construction of new buildings or renovations of older ones. We need real world examples of what you have to do to absorb these drastic cuts. Please send those examples to Julie Painter in AHCA Member Services so that we can ensure policy makers understand the effect of this action.

If we let this rule deflate us, it will have beaten us twice. We can’t let that happen. We can’t give up.

It has been said that adversity doesn't build character, it reveals it. How will we react in the face of adversity? Will we give up, walk away and sulk? Or will we channel our disappointment and frustration into an energy to rise up and fight on?

AHCA is ready to rise to the occasion, and with your help, I have no doubt that we can succeed.

CMS Issues Final Rule on Medicare Payments to SNFs

2011-08-02T09:20:00.000-07:00

The Centers for Medicare & Medicaid Services (CMS) issued its Skilled Nursing Facility Prospective Payment System (SNF PPS) Final Rule for FY 2012 this afternoon. The American Health Care Association (AHCA) is conducting an in-depth analysis of the final rule, but AHCA's initial review shows cause for concern and extreme disappointment. The rule ignores a unified message from members, caregivers, lawmakers and stakeholders to find a responsible solution to Medicare payments.

Similar to what was first proposed by CMS in late April, the agency will cut Medicare payments by 11.1 percent starting October 1, totaling $3.87 billion. As you know, these reductions are an attempt to return the Medicare system back to budget neutrality for CMS after implementing RUG-IV and MDS 3.0.
CMS also implemented modifications to group therapy and to Change of Therapy (COT) and End of Therapy (EOT) Other Medicare Required Assessments (OMRAs), virtually without any modification from the proposed rule.

Unfortunately, CMS has disregarded AHCA's sound and reasonable approach to implement modest reductions to SNF payments over multiple years. AHCA's proposal would have protected long term care for seniors, while also achieving the government's goal of a budget-neutral payment system. CMS' action also failed to acknowledge the tens of thousands of letters, emails, and phone calls all of you made to let the agency know how damaging such a drastic proposal would be to the profession and the economy.

These are only the initial findings, and the AHCA team is combing through the 300 plus page final rule. But AHCA have already issued a strongly-worded statement demonstrating its disappointment with CMS for issuing such irresponsible public policy. In the coming days, AHCA will provide an overview and let you know what this means for the Association and the profession. But one thing is certain - AHCA will continue to work with CMS and lawmakers on Capitol Hill to implement regulations and policies that are fair to all involved.

Please keep watch for more detailed information very soon. If you have any questions, please contact Elise Smith, esmith@ahca.org, or Bill Hartung, whartung@ahca.org.

Accountable Care Organizations

2011-08-01T08:25:00.000-07:00

By Ellen Ferringer, CPA, CAPPM, Katz, Sapper & Miller, IHCA Associate Member
The face of healthcare is changing. "Accountable care organization" is becoming a common term in the industry. What exactly is an accountable care organization? On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, which empowers the Secretary of Health and Human Services to create a shared savings program to promote accountability of patient care through Accountable Care Organizations (ACO). As defined by the Centers for Medicare and Medicaid Services (CMS), an ACO is an "organization of healthcare providers that agrees to be accountable for quality, cost and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.” Ultimately, Medicare is trying to create an incentive program to reduce its costs while increasing the quality of care provided to patients.

The regulations regarding ACOs are still in proposed form and 427 pages in length. At a very high level, these proposed regulations provide the following requirements of ACOs:

• Provide care for at least 5,000 Medicare beneficiaries (based on their primary care physician)

• Participate in the program for three years, beginning Jan. 1, 2012

• Self-report 65 quality measures to the CMS

• Meet various anti-trust regulations

Under the proposed rule, Medicare would continue to pay healthcare providers for specific services under the Medicare payment systems. The ACO would then receive a share of the cost savings based on their Medicare patient population spending compared to benchmarks determined by CMS. The concept is that by better coordinating patient care between the primary care physicians and the specialists, there will be more information sharing and quality of service will increase, thus reducing costs.

Currently, many physician groups and hospitals are weighing the pros and cons of forming an ACO. Included in this mix are also long-term care facilities. Since they play an important role in keeping hospital readmissions down, long-term care facilities appear to be a perfect partner to hospitals and physicians. CMS estimates there will be 75 to 150 ACOs formed by Jan. 1, 2012. Even with this relatively small number, a huge change in patient care is expected as a result of this Act.

Ellen Ferringer is a director in Katz, Sapper & Miller’s Healthcare Resources Group. For more information, contact Ellen at 317.580.2013 or eferringer@ksmcpa.com.