REGULATORY HOT TOPICS INDEPENDENT OWNERS CONFERENCE May 2, 2012 La Costa Resort Carlsbad, CA
STAYING IN THE “NOW” 2012 HOT TOPICS
3.2 NHPPD STAFFING AUDITS Current Audit Period: July 1, 2011 through June 30, 2012 425+ audits completed CDPH projects all audits will be completed by August 80% of audits = facility in full compliance 10 penalty notices have been issued
3.2 NHPPD Audit Process On entrance auditor will provide contact information for supervisor. Auditor will utilize payroll data Length of audit: average is 3 days
Audit Staff Hierarchy Amy Blandford: 916-552-8971 Amy.email@example.com Tina Kruthoff: 916-319-9036 Tina.firstname.lastname@example.org Leslie Fullerton: 440-7083 Leslie.email@example.com Pam Power: 916-552-8967 Pam.firstname.lastname@example.org Evelyn Schaeffer: 916-445-8567 Evelyn.email@example.com
3.2 NHPPD Audit Clarifications Counting of DON in buildings with 59 or fewer licensed beds- no sign-in of DON required. - Corporate payroll- negative deductions, vacation, etc. - Vacation, sick leave, PTO requests, etc. - Work hour agreements for salaried staff. - Leave balance reports indicating paid time off, sick or PTO requests - Training requests and records. Nurse Assistants - HS 280 is key - NA is employee - “Counted Hours” are those worked beyond clinical and NA is “checked off” on related competencies
3.2 NHPPD Audit Clarifications Actual Hours Worked – Audit process calculates nursing staff time by the minute Activity Staff- CNAs who are activity staff and implementing the resident’s plan of care are “countable”. ( Activity Program Director excluded) Dual Role Employees- Must document time providing nursing services on CDPH 530
3.2 NHPPD Audit Clarifications RN Supervisor- Hours are countable as nursing services ADON- ADON hours will be excluded ONLY WHEN ADON is acting for the DON. ( Does not apply to facilities of 59 beds or less). Re-capping Physician Orders – This is “countable” time.
3.2 NHPPD Audit Issues Staff work in lieu of meal period- must have waiver in place Census- When staff out of building with resident- staff time “countable” for 3.2 NHPPD calculation CDPH “FAQ” document remains pending
Check Your Staffing Data! What do your staffing numbers say? OSHPD-submitted staffing data CDS 671 – Five Star CDPH 3.2 NHPPD audit determination
Independent Informal Dispute Resolution (IIDR) Conducted by staff within the Center For HealthCare Quality. One year approval of process by CMS CAHF goal = independent entity conducts reviews
Facility offered IIDR and formal appeal rights (MUST ASK FOR IIDR within 10 calendar days of receipt of notice) IIDR conducted and completed within 60 days of request and a formal written record is generated Facility has G or above deficiencies and a CMP will be Imposed, collected, and put in escrow Ombudsman and resident or family rep allowed to comment Facility is cited for deficiencies In a standard or complaintsurvey Initiated after 1/1/12 facility wishes to Informally appeal these deficiencies Collection of CMP at time of IIDR completion or within 90 days of date of notice of imposition Which IDR process Is appropriate to Consider? Final changes if any made and new 2567 issued Facility offered IDR and formal appeal rights Facility has deficiencies that are D, E, or F in scope and severity Formal appeal available if requested timely IIDR Process Flow
Elder Justice Act (EJA) • Surveyors are now being trained to evaluate facility compliance: • Covered individuals are notified of reporting obligations annually. • Posted notice is accessible ( in area(s) used by covered individuals. • Abuse reporting processes are inclusive of EJA requirements. https://member.cahf.org/Operations/Regulatory/tabid/160/Default.aspx#REPORTING_REQUIREMENTS
September 2011 OIG Report Leads To Change in Complaint Process Effective Immediately: CDPH directed by CMS to use federal complaint process Will impact Five Star Scores Onsite complaint visits are now conducted using the federal abbreviated standard survey process P&P and AFL “pending” http://oig.hhs.gov/oas/reports/region9/90900114.pdf
February 2012 OIG Report Criticizes California Plan of Correction Oversight Deficiency ratings understated for 23 of 178 deficiencies (13 percent); Did not ensure that 40 of 52 correction plans (77 percent) contained specific information addressing the 5 corrective action elements; and Did not verify the correction of identified deficiencies by obtaining evidence of correction. http://oig.hhs.gov/oas/reports/region9/91102019.pdf
April 2012 OIG Report Finds Gaps IN SNF Disaster Preparedness Unreliable transportation contracts, Lack of collaboration with local emergency management, and; Residents who developed health problems. LTC ombudsmen were often unable to support nursing home residents during disasters; SAs reported making some efforts to assist nursing homes during disasters, mostly related to nursing home compliance issues and ad hoc needs.
CAHF DISASTER PREPAREDNESS RESOURCES http://www.cahfdisasterprep.com/ Jocelyn Montgomery, CAHF Director of Clinical Affairs and Manager of Disaster Preparedness Grant firstname.lastname@example.org 916-441-6400 X 214
Antipsychotic Drug Use in Long-Term Care California Advocates for Nursing Home Reform CANHR’s lawyer referral service currently has 125 participating attorney’s all of whom agree to accept at least two pro bono and two reduced fee cases per year.
Antipsychotic Drug Use in Long-Term Care California Advocates for Nursing Home Reform CANHR receives 15% of attorneys’ fees to support its advocacy work. In 2009-10, the lawyer referral service referred 657 clients to panel attorneys in California.
More To Come…. CANHR is co-sponsoring back-to-back full day dementia care trainings in San Diego and Los Angeles. June 4 – San Diego – only $30 for lunch and materials. Co-sponsored by San Diego County Long-term Care Ombudsman and Elder Law & Advocacy. June 5 – Los Angeles – only $30 for lunch and materials. Co-sponsored by Wise and Healthy Aging, Senior Care Training, and Bet Tzedek.
Antipsychotic Drug Use in Long-Term Care “Cause for Alarm: Antipsychotic Drugs for Nursing Home Patients” “Nursing homes should be penalized for overuse of antipsychotic medications for dementia residents, federal investigator says”
Antipsychotic Drug Use in Long-Term Care “Nursing Home Investigation Finds Errors by Druggists” “Alzheimer's and Psychoactive Medications -- A Controversial Decision for Caregivers” Huffington Post
Antipsychotic Drug Use in Long-Term Care Located at www.cahf.org “Members Only” Section Under “Hotlinks” ANTI-PSYCHOTIC MEDICATION WORKSHOP A Template for CAHF Chapters Format Panelists Suggested Questions Draft Press Release Talking Points CEU information
CDPH Antipsychotic Collaborative with Department of Health Care Services • Collaborative goal: • Promote appropriate use of antipsychotic medication by: • Identifying inappropriate antipsychotic use in SNF residents with a diagnosis of dementia. • Provider education. • Interagency agreement – Started May 2010 • Data provided by MediCal Pharmacy Benefits Division
Antipsychotic Collaborative “Target” Criteria Residents currently prescribed either: • Two antipsychotic medications concurrently OR • One ( or more) antipsychotic medication(s) with a primary diagnosis of Alzheimer’s or dementia with or without a co-existing diagnosis of SMI
CDPH Investigative Process • Complaint investigation process: • Survey team limited to Pharmaceutical Consultants on LTC Task in these District Offices: • Chico • East Bay Fresno • Sacramento • San Diego • San Jose • Santa Rosa/ Redwood Coast
Investigations FindingsMay 2010 through January 24, 2011 • Investigations completed: 11 • Regulatory violations cited per investigation: on average five. • Inappropriate antipsychotic polypharmacy (54%); • Consultant pharmacist's failure to identify antipsychotic polypharmacy (54%); • Care plan related issues (64%) • Informed consent related issues (27%)
Antipsychotic Use Reduction Initiatives AHCA Quality Initiative- charges members to safely reduce the off-label use of antipsychotics by 15 percent by December 31, 2012 CMS Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Homes Residents - aims to reduce the use of these drugs by 15 percent before the end of 2012
MDS 3.0 and New Public QM Psychoactive Medication Use in Absence of Psychotic or Related Condition Check coding at Section I ( Active Diagnosis) - Schizophrenia and Bipolar disease are exclusions - Review RAI manual for other related exclusions
Resources Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) Website https://www.healthcare.uiowa.edu/igec/IAADAPT AHCA http://www.ahcancal.org/quality_improvement/qualityinitiative/Pages/default.aspx
CMS Delivers Antipsychotic Reduction Message Via You Tube • Surveyors have a template for evaluating antipsychotic Rx use in persons with dementia who do not have psychiatric diagnosis • Key areas of emphasis: • Consistent assignment • Non-pharmacological interventions • Consultant pharmacist role • Enough staff?
Beyond Verifying Informed Consent Was Obtained New surveyor focus: F 154- Resident/family are fully informed in advance about care and treatment and of any changes in same that might affect the resident’s well-being. - Care planning processes document res/family agreement with plan of care - Need to reflect in record how resident/family informed of plan of care- including medications
CMS Initiative If antipsychotic Rx needed in emergent situation were underlying causes considered? Was dose one time with further follow-up? If weekend/night- any evidence Rx ordered for staff convenience? Was family notified? How is Rx use evaluated via QAA process?
CMS Initiative Five Star will display use of antipsychotic Rx for residents with dementia. (Long Stay) State survey agency will be provided with the same data. Video release set for this summer: “Hand in Hand” CMS You Tube Posting: http://www.youtube.com/watch?v=U1_rpO0bwbM&list=UUhHTRPxz8awulGaTMh3SAkA&index=3&feature=plcp
CMS Initiative Care planning and antipsychotic medication use: - How will staff monitor to determine if target symptoms are reduced? - What side effects will be monitored? - On interview can nursing staff demonstrate they know what side effects to watch for? - Does consultant pharmacist have role in care planning?
What’s on Your Surveyor’s I Pad? This CMS broadcast was designed as an educational video for state and federal surveyors. It is 2 hours and 30 minutes in length, and provides an introduction to the 2006 revisions of the Unnecessary Drugs and Pharmacy Services regulations. http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1055
What’s on Your Surveyor’s I Pad? This presentation was produced by the Centers of Medicare and Medicaid Services (CMS). This guidance training includes a slide show presentation, notes for the instructor, and the general message on each slide. Some of the goals of this training presentation include describing the MRR regulation, identifying compliance with the regulation and issues that lead to an F428 investigation, and categorizing the severity of non-compliance issues. http://www.aging.pitt.edu/professionals/resources/S&C-06-29-11-F428MedRegReviewInstructorGuide.pdf
CHA Patient Safety Committee CAHF Staff now members of this committee Focus is safe hand-offs during care transitions from acute to SNF; - medication reconciliation - informed consent
Health Care Acquired Infections ( HAI) • F441- Surveyors are receiving additional training on HAI HAI = symptoms emerge more than 72 hours post-admission. • Antimicrobial Stewardship- CMS is now holding facilities accountable for physician prescribing. • CAUTI, CLABSI
CMS Scrutinizing Room Size Waivers Triage residents placed in smaller spaces Probe and Document routinely- are residents: - Able to move about room; - Is path of travel clear; - Is adaptive/personal equipment accommodated ? Evaluate resident/family satisfaction