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.
Tuesday, September 1, 2015
CMS Midwest Division of Survey and Certification LTC Update
CMS has made revisions to the QIS training procedures for State Survey Agencies (SA) and Regional Offices (RO). There are four revisions for the QIS to follow. 1) Eliminate the mock survey and replace it with a survey for record; 2) Eliminate the T3.5 process formerly called “The Trainer Instructor Training”; 3) Update the compliance process and associated tool used for evaluating surveyors; and, 4) Clarify the role of Certified Trainers. Please note that these revisions do not replace the structure programs each SA and RO is required to have as outlined in Exhibit 42 of the State Operations Manuel (SOM). To read the entire revision, please click here.
CMS has also sent a guidance to clarify policies regarding SA release of data and documents to Medical Fraud Control Units (MFCU). The guidance reiterates the legal requirements SA has in regards to share Automated Survey Processing Environment (ASPEN) Complaint Tracking System (ACTS) data, Long-Term Care Minimum Data Set (MDS) data, and survey documents with their state MFCU upon receipt of a written request. The CMS new guidance memorandum and MFCU letter to SA can be found by clicking here.
CMS has also sent a guidance to clarify policies regarding SA release of data and documents to Medical Fraud Control Units (MFCU). The guidance reiterates the legal requirements SA has in regards to share Automated Survey Processing Environment (ASPEN) Complaint Tracking System (ACTS) data, Long-Term Care Minimum Data Set (MDS) data, and survey documents with their state MFCU upon receipt of a written request. The CMS new guidance memorandum and MFCU letter to SA can be found by clicking here.
Nursing Facility and Residential Care Facility Occupancy
As mandated by legislature as part of the recent moratorium bill, ISDH must determine occupancy rates for January 1 and July 1 of each year. The ISDH did a test run of the system for this past July 1, 2015 and those results are attached in five reports. The first official count from which additional nursing facility beds/facilities could be added in a county that exceeds 90% will be this coming January 1.
Statewide NF occupancy as of July 1, 2015 was 75%. Residential care facility occupancy was 63% (residential care is not impacted by the moratorium, but the ISDH decided to collect data anyway). The five reports are:
• Comprehensive Care Facility Bed Count Report 7-1-2015.pdf
• Comprehensive Care Facility Occupancy Report 7-1-2015.pdf
• Residential Care Facility Bed Count Report 7-1-2015.pdf
• Residential Care Facility Occupancy Report 7-1-2015.pdf
• Comprehensive Care Facility Count Report 7-1-2015.pdf
The ISDH has dedicated the page Reports on Health Care Facilities to serve as a central site for all facility reports. To access this page, please click here.
Statewide NF occupancy as of July 1, 2015 was 75%. Residential care facility occupancy was 63% (residential care is not impacted by the moratorium, but the ISDH decided to collect data anyway). The five reports are:
• Comprehensive Care Facility Bed Count Report 7-1-2015.pdf
• Comprehensive Care Facility Occupancy Report 7-1-2015.pdf
• Residential Care Facility Bed Count Report 7-1-2015.pdf
• Residential Care Facility Occupancy Report 7-1-2015.pdf
• Comprehensive Care Facility Count Report 7-1-2015.pdf
The ISDH has dedicated the page Reports on Health Care Facilities to serve as a central site for all facility reports. To access this page, please click here.
Monday, August 31, 2015
CRE Case Reporting in Marion County
Effective July 1st 2015, all nursing facilities in Marion County will be required to immediately report confirmed or suspected cases of Carbapenem-resistant Enterobacteriaceae (CRE) to the Marion County Public Health Department. The new requirement stems from an amendment to The Health and Hospital Corporation of Marion County code that adds CRE as a reportable communicable disease. Section 7-201 requires any physician or other health care provider who has knowledge of or diagnoses or treats a communicable disease case, and every manager of an extended care facility in which there is a communicable disease case to report that case or suspected case to Marion County Public Health Department in accordance with Section 7-202. Section 7-202 requires CRE to be reported immediately. Laboratories are also required to report evidence of a communicable disease under Section 7-301. Section 7-601 states failure to properly report could be up to a $1,000 fine, upon conviction. In addition to the fine, The Health and Hospital Corporation of Marion County may seek to abate the public health nuisance or violation of this ordinance in any court of competent jurisdiction. The code can be found at https://www.hhcorp.org/hhc/images/HHCcode/codechapter7.pdf
Nursing Facilities are required to report when they know there is a case or a suspected case in the facility. Consulting with clinicians to know what the signs of CRE and all other communicable diseases, as defined in the ordinance, would be necessary to properly suspect cases. In terms of known CRE cases the facility should still report even if the laboratory has already reported to be safe, to avoid penalty. IHCA expects the Indiana State Department of Health to amend its communicable disease rule later this year to require this same reporting statewide.
Marion County Public Health Department sent a letter to All Marion County Medical Providers and Infection Preventionists about CRE Reporting. That letter can be found by clicking here.
The CRE report form that needs to be submitted per patient per admission within 72 hours and faxed to Marion County Public Health Department Infectious Disease at (317)221-2076 can be found by clicking here.
Nursing Facilities are required to report when they know there is a case or a suspected case in the facility. Consulting with clinicians to know what the signs of CRE and all other communicable diseases, as defined in the ordinance, would be necessary to properly suspect cases. In terms of known CRE cases the facility should still report even if the laboratory has already reported to be safe, to avoid penalty. IHCA expects the Indiana State Department of Health to amend its communicable disease rule later this year to require this same reporting statewide.
Marion County Public Health Department sent a letter to All Marion County Medical Providers and Infection Preventionists about CRE Reporting. That letter can be found by clicking here.
The CRE report form that needs to be submitted per patient per admission within 72 hours and faxed to Marion County Public Health Department Infectious Disease at (317)221-2076 can be found by clicking here.
Division of Aging Introduces Email Address and Hyperlink to Address Duplicate e450B Requests
The Division of Aging (DA) continues to receive many emails from the same nursing facility regarding the same issue. This results in multiple DA staff researching the same information, which is very inefficient for response time between the DA and the facility. In an attempt to improve response time, the DA has created an email specifically designed for e450b and/or SADE process questions/concerns only. The email is DA.NFinforequest@fssa.in.gov and is effective immediately.
As you are aware, an authorized e450b is available for download for up to thirty (30) days from Da’s authorization. If the nursing facility does not complete the download in that time period or the download is interrupted/not completed, the nursing facility must contact the DA to re-download the authorized e450b. There has also been a high demand for additional downloads, so the e450b web page now contains a hyperlink to request addition downloads for e450b’s that have previously been downloaded. The hyperlink, NEW Request a duplicate Form 450B ONLINE, is located just above the reference material section on the e450b webpage.
Hopefully the enhancements listed above will be helpful for all nursing facilities as well as improve the DA’s response time to the facilities.
As you are aware, an authorized e450b is available for download for up to thirty (30) days from Da’s authorization. If the nursing facility does not complete the download in that time period or the download is interrupted/not completed, the nursing facility must contact the DA to re-download the authorized e450b. There has also been a high demand for additional downloads, so the e450b web page now contains a hyperlink to request addition downloads for e450b’s that have previously been downloaded. The hyperlink, NEW Request a duplicate Form 450B ONLINE, is located just above the reference material section on the e450b webpage.
Hopefully the enhancements listed above will be helpful for all nursing facilities as well as improve the DA’s response time to the facilities.
CMS Releases Phase Two of Initiative to Reduce Avoidable Hospitalization Among Nursing Facility Residents
Since September 2012, under Phase One of theInitiative to Reduce Avoidable Hospitalization Among Nursing Facility Residents, CMS has partnered with seven Enhanced Care and Coordinator Providers (ECCP) organizations in seven states, as an effort to improve care for nursing facility’s long-term residents. Indiana is one of those seven states included in this initiative. In conjunction with Phase One, Indiana University created OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care), which includes the deployment of Registered Nurses (RNs) and Advanced Practice Nurses (APNs) to be on-site at nursing facilities, allowing for enhanced recognition and management of acute changes in medical conditions. IHCA has learned that OPTIMISTIC is currently evaluating Phase Two of the initiative. To read about Phase One, click here.
On August 27, 2015 CMS release Phase Two, which includes the four-year funding opportunity that will be implemented in current ECCP facilities and newly recruited facilities. The payment model incentivizes nursing facilities to expand internal resources to treat and/or manage residents in six defined acute conditions (Pneumonia, Dehydration, Congestive Heart Failure (CHF), Urinary Tract Infection (UTI), Skin Ulcers/Cellulitis, and COPD/Asthma). This would allow facilities to treat residents on site, rather than sending them to a hospital.
Successful ECCP applicants will implement the new payment model with both their existing facilities and newly recruited facilities in October 2016. This payment structure is intended to allow CMS to continue to 1) Identify the impact of the clinical interventions, 2) evaluate the impact of a new payment model, and 3) Assess the impact of both these models combined. Relative dates and time for application process are below.
· Notice of Intent to Apply: September 9, 2015
· Electronic Application Due Date: October 29, 2015, by 5:00 p.m. Eastern Time
· Anticipated Notice of Award: January 15, 2016
· Anticipated Project Period of Performance: January 15, 2016 to October 23, 2020
To read about Phase Two, click here.
Indiana Division of Aging Update for HEA 1391
In 2014, the General Assembly passed House Enrolled Act 1391. Section 7 of the bill requires the Office of the Secretary of Family and Social Services, in conjunction with the State Department of Health, and the Office of Management and Budget, to provide a written report to the Indiana General Assembly before October 1, 2015, regarding various issues concerning delivery of long term services and support in Indiana (click here for details). The report is not yet complete, but there have been multiple drafts, and the latest draft was just released for review.
The latest draft supports reliance on a two-year CHOICE (Community and Home Options to Institutional Care for the Elderly and Disabled) pilot program, for which will be available in 2017. The CHOICE pilot program is a two-year program implemented in four regions of the state, Ares 1, 4, 13 and 14. The pilot program is intended to evaluate the impact of changes in the CHOICE program. The changes include lessening eligibility requirements to one Activity of Daily Living (ADL) impairment, which will allow individuals to receive services before their needs become extensive. The asset limit is reduced to $250,000 and an increase in cost share participation by basing it on assets as well as income in an attempt to be applicable to more individuals. The pilot program also puts focus on a needs based assessment process to identify community and personal resources for the individual’s needs, potentially without the use of public dollars. There is also more flexibility in the utilization of case management dollars for the initial assessment and screening stages. This pilot program could potentially change performance metrics such as: nursing facility admission rate in pilots versus non-pilots; reduction of wait lists or time spent on wait list; reduction of expenditures per person served; increased informal supports; and improved quality of life as measured in a new survey tool. The draft does address the issue of low occupancy rate in nursing facilities and credits the passage of the moratorium to help occupancy rates rise. The draft also discusses the FSSA’s perspective that Indiana needs to rebalance long term services and supports spending towards more Home and Community Based services. Tennessee’s managed care was used as a positive example for how nursing facility and long-term care costs can be contained relative to growth in the population over age 65. There is also an entire section dedicated to telemedicine physician coverage in nursing facilities. Telemedicine provides numerous ways in which to improve health outcomes through the use of two-way, real-time interactive communication between the patient and a remotely located physician or medical practitioner using audio and video equipment. Although Telemedicine is being used in some nursing facilities, it is not yet required, but possibly could be in the future. To see the entire draft please click here.
The latest draft supports reliance on a two-year CHOICE (Community and Home Options to Institutional Care for the Elderly and Disabled) pilot program, for which will be available in 2017. The CHOICE pilot program is a two-year program implemented in four regions of the state, Ares 1, 4, 13 and 14. The pilot program is intended to evaluate the impact of changes in the CHOICE program. The changes include lessening eligibility requirements to one Activity of Daily Living (ADL) impairment, which will allow individuals to receive services before their needs become extensive. The asset limit is reduced to $250,000 and an increase in cost share participation by basing it on assets as well as income in an attempt to be applicable to more individuals. The pilot program also puts focus on a needs based assessment process to identify community and personal resources for the individual’s needs, potentially without the use of public dollars. There is also more flexibility in the utilization of case management dollars for the initial assessment and screening stages. This pilot program could potentially change performance metrics such as: nursing facility admission rate in pilots versus non-pilots; reduction of wait lists or time spent on wait list; reduction of expenditures per person served; increased informal supports; and improved quality of life as measured in a new survey tool. The draft does address the issue of low occupancy rate in nursing facilities and credits the passage of the moratorium to help occupancy rates rise. The draft also discusses the FSSA’s perspective that Indiana needs to rebalance long term services and supports spending towards more Home and Community Based services. Tennessee’s managed care was used as a positive example for how nursing facility and long-term care costs can be contained relative to growth in the population over age 65. There is also an entire section dedicated to telemedicine physician coverage in nursing facilities. Telemedicine provides numerous ways in which to improve health outcomes through the use of two-way, real-time interactive communication between the patient and a remotely located physician or medical practitioner using audio and video equipment. Although Telemedicine is being used in some nursing facilities, it is not yet required, but possibly could be in the future. To see the entire draft please click here.
Residential Care Citation Update
The ISDH issued 12 offense tags and 71 deficiency tags totaling 83 citations to Residential Care Facilities in the month of July. This is the highest month of citations issued, it’s even higher than when ISDH was only issuing Residential Tags due to the government shutting down in October 2013. Ten citations were issued to tag 0273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation standards. This marks the second time in 2015 that this Tag received ten citations, creating a total of 50 citations issued this year. Tag 0241 (Offense tag) concerning the administration of medications by licensed nurses or QMAs, was the second highest citation issued in July with nine citations. It has been cited every month with a total of 26 citations for 2015. Tag 0217 concerning resident evaluation and services plan was cited eight times. This citation has been issued every month in the year 2015 for a total of 23 citations. Tag 0148, Tag 0154, and Tag 0272 were issued five citations making it the highest month for those Tags to be cited in 2015.
There were three Tags that were issued for the first time in 2015: Tag 0058 for Patients’ Rights when a facility fails to grant immediate access for authorized public personnel or an individual’s physician; Tag 0149 for Sanitation & Safety Standards for failure to comply with 410 IAC 7-24 requiring a pest control program; Tag 0193 for Physical Plan Standards in failure to have proper laundry services. There was also a new Tag issued that had not been reported before, Tag 0179. This involves failure for an adequate air conditioning system in compliance with 675 IAC (Fire Prevention and Building Safety Commission).
Click here to review a summary of July’s Residential Care Facility citations.
There were three Tags that were issued for the first time in 2015: Tag 0058 for Patients’ Rights when a facility fails to grant immediate access for authorized public personnel or an individual’s physician; Tag 0149 for Sanitation & Safety Standards for failure to comply with 410 IAC 7-24 requiring a pest control program; Tag 0193 for Physical Plan Standards in failure to have proper laundry services. There was also a new Tag issued that had not been reported before, Tag 0179. This involves failure for an adequate air conditioning system in compliance with 675 IAC (Fire Prevention and Building Safety Commission).
Click here to review a summary of July’s Residential Care Facility citations.
Tuesday, August 4, 2015
CMS Issues Two Survey & Certification Memos Related to LTC
On July 17, 2015 CMS issued one new Survey & Certification memo and updated a previously released memo.
• CMS S&C 15-47 - Medication-Related Adverse Events in Nursing Homes
CMS states that adverse events related to high risk medications can have devastating effects on nursing home residents, and is concerned with the prevalence of adverse drug events. CMS has begun pilot testing a Focused Survey on Medication Safety Systems to look at nursing home systems around high risk and problem-prone medications using an Adverse Drug Event Trigger Tool. The CMS is making the draft tool available to assist surveyors in investigating medication related adverse events and to nursing home providers as a risk management tool. Click here to access the memo and an attachment.
• CMS S&C 14-42 - Release of Learning Tool on Building Respect for Lesbian, Gay, Bisexual, Transgender (LGBT) Older Adults (NH – Original version released 8/22/14; Revised version released 7/17/15)
The original memo announced the release of a free learning tool on Building Respect for LGBT Older Adults. The revised memo updates the Training Tool website link. Click here to see the revised memo.
• CMS S&C 15-47 - Medication-Related Adverse Events in Nursing Homes
CMS states that adverse events related to high risk medications can have devastating effects on nursing home residents, and is concerned with the prevalence of adverse drug events. CMS has begun pilot testing a Focused Survey on Medication Safety Systems to look at nursing home systems around high risk and problem-prone medications using an Adverse Drug Event Trigger Tool. The CMS is making the draft tool available to assist surveyors in investigating medication related adverse events and to nursing home providers as a risk management tool. Click here to access the memo and an attachment.
• CMS S&C 14-42 - Release of Learning Tool on Building Respect for Lesbian, Gay, Bisexual, Transgender (LGBT) Older Adults (NH – Original version released 8/22/14; Revised version released 7/17/15)
The original memo announced the release of a free learning tool on Building Respect for LGBT Older Adults. The revised memo updates the Training Tool website link. Click here to see the revised memo.
CMS Releases the FY 2016 SNF PPS Final Rule
On July 30th, 2015, CMS released the FY 2016 SNF PPS final rule, which also included language on value-based purchasing (VBP) as well as the recently-enacted IMPACT law. AHCA will provide additional details in the coming days. For now, please see below for an outline of the specifics behind the market basket update.
SNF payments to increase $430 million
CMS projects within the final rule that aggregate SNF payments in FY 2016 will increase by $430 million - or 1.2 percent - from payments in FY 2015.
This final increase is 0.2 percent less than what was outlined in the proposed FY 2016 rule released earlier in April, which included a 1.4 percent net market basket increase ($500 million) for SNFs beginning on October 1 of this year.
CMS justifies the reduction via a caveat in the FY 2016 proposed rule that if more recent data became available and was appropriate to consider, the agency would use such data to determine the final FY 2016 SNF rate. That explains the change from the original $500 million estimate to $430 million. CMS used more recent data from the second quarter 2015 IHS Global Insight forecast of the FY 2010-based SNF market basket to calculate the reduced market basket increase of 1.2 percent.
Tables 1 and 2 below reflect the updated components of the unadjusted federal rates for FY 2016 prior to adjustment for case-mix. CMS further adjusts the rates by a wage index budget neutrality factor.
Table 1 - FY 2016 Unadjusted Federal Rate Per Diem
Urban
Table 2 - FY 2016 Unadjusted Federal Rate Per Diem
Rural
Quality Measures Finalized
CMS also finalized the rehospitalization measure to be used in the SNF VBP program that applies a 2 percent withhold to all SNF Part A payments. SNFs can "earn" some of the withhold back based on its rehospitalization rate. The measure, which was unchanged from the proposed rule, will use the SNF RM, a National Quality Forum-endorsed risk adjusted measure based on SNF and Hospital Part A claims.
In addition, CMS finalized the specifications for three quality measures to comply with the IMPACT Act. In the coming days, AHCA will release a more detailed summary of the final rule, including the VBP language as well as details on the quality reporting and staff reporting measures found in IMPACT. You are encouraged to review the final rule, as well as the CMS fact sheet.
AHCA will continue to advocate on your behalf as we meet with CMS in the coming weeks about the provisions in the final rule.
SNF payments to increase $430 million
CMS projects within the final rule that aggregate SNF payments in FY 2016 will increase by $430 million - or 1.2 percent - from payments in FY 2015.
This final increase is 0.2 percent less than what was outlined in the proposed FY 2016 rule released earlier in April, which included a 1.4 percent net market basket increase ($500 million) for SNFs beginning on October 1 of this year.
CMS justifies the reduction via a caveat in the FY 2016 proposed rule that if more recent data became available and was appropriate to consider, the agency would use such data to determine the final FY 2016 SNF rate. That explains the change from the original $500 million estimate to $430 million. CMS used more recent data from the second quarter 2015 IHS Global Insight forecast of the FY 2010-based SNF market basket to calculate the reduced market basket increase of 1.2 percent.
Tables 1 and 2 below reflect the updated components of the unadjusted federal rates for FY 2016 prior to adjustment for case-mix. CMS further adjusts the rates by a wage index budget neutrality factor.
Table 1 - FY 2016 Unadjusted Federal Rate Per Diem
Urban
Table 2 - FY 2016 Unadjusted Federal Rate Per Diem
Rural
Quality Measures Finalized
CMS also finalized the rehospitalization measure to be used in the SNF VBP program that applies a 2 percent withhold to all SNF Part A payments. SNFs can "earn" some of the withhold back based on its rehospitalization rate. The measure, which was unchanged from the proposed rule, will use the SNF RM, a National Quality Forum-endorsed risk adjusted measure based on SNF and Hospital Part A claims.
In addition, CMS finalized the specifications for three quality measures to comply with the IMPACT Act. In the coming days, AHCA will release a more detailed summary of the final rule, including the VBP language as well as details on the quality reporting and staff reporting measures found in IMPACT. You are encouraged to review the final rule, as well as the CMS fact sheet.
AHCA will continue to advocate on your behalf as we meet with CMS in the coming weeks about the provisions in the final rule.
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