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.

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.

CRE Case Reporting in Marion County

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

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

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

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

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

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

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

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

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

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

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

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

To read about Phase Two, click here.

Indiana Division of Aging Update for HEA 1391

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

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

Residential Care Citation Update

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

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

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