ISDH Long Term Care Bed and Personnel Tracking System

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

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

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

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

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

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

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.