National Association for Regulatory Administration

1. National Association for Regulatory Administration Brian Hortert Concordia Lutheran Ministries Beth Greenberg, MPA, MA Regulatory Affairs and Research Manager Nick Luciano, Esq. Legislative Council September 13, 2011 8:30-10:00 AM

2. Objectives

3. Brian HortertExecutive Director, Concordia of South Hills September 13, 2011

4. Work History • 1986 - Started first Personal Care Home • 1992 - Purchased a 2nd home in 1992 • 1995- Home Health Social Services • 1998- Skilled Nursing Social Services and NHA • 2001- Present - VP of Personal Care (705 Licensed beds) and CEO of Concordia Lutheran Ministries of Pittsburgh, a CCRC in Mt. Lebanon.

5. 130 year old not for profit, providing: Concordia Lutheran Ministries Organization

6. Appointments to Boards of Directors

7. Provider Frustrations / Viewpoints • Perception that Surveyors are unreasonable • Survey process is punitive • Difference between regulation and interpretation

8. Surveyor frustrations (as related to providers) • Providers view you as the enemy • Disorganization of providers during the survey process • Staff hide during the survey

9. Surveyor Frustrations (as related to outside forces / directors) • Used for litigation • Used by politicians during election time • Chastised for not finding enough deficiencies

10. Systemic Frustrations Providers and Surveyors • Care delivery in U.S. is in silos (SNF, PC, Hospital, Home Health) • Increased demands with decreased resources • Political environment – Change in Administration

11. Improving Quality • Director of Education and Compliance • Mock survey process • “Call your friendly neighborhood inspector”

12. How do we effect change together? • Help develop a system for worry free self-reporting • Team approach for effecting change • Move the silos.

13. Common Goals, Different Perspectives Beth GreenbergRegulatory Affairs & Research ManagerLeadingAge PA September 13, 2011

14. About LeadingAge PA LeadingAge PA’s mission is to promote the interests of our members by enhancing their ability to provide quality services efficiently and effectively; and by representing our members through cooperative action.

15. …Who Are LeadingAge PA Members?

16. Profile of Services – A Sample

17. The Promise of OBRA ’87… • OBRA ‘87 legislation, based on a 1986 report by the Institute of Medicine, strove to: • create an oversight system that ensured sustained compliance of nursing homes with regulations. • foster a high quality of care and high quality of life for residents.

18. Difficult, But Worthwhile • Challenges occurred from the outset and remain in implementing ‘OBRA • There have been a series of studies; this one in 2005 found that improvement has been made but more needs to be done

19. LeadingAge Task Force on Survey, Certification and Enforcement • In late 2006, LeadingAge (formerly AAHSA) convened a Task Force to examine the current oversight system for nursing facilities. • 20 individuals served on the Task Force including LeadingAge PA’s Executive Director, Ron Barth. • Task Force Report, Broken and Beyond Repair was issued in June 2008.

20. What Went Wrong? • Why were providers so angry and frustrated? • A plethora of personal stories about the survey process, hauntingly similar across geography: • Negative and adversarial encounters with surveyors intent on “finding something wrong” • By the end of the survey providers were angry and staff were demoralized and ready to quit • …In spite of the provider’s commitment and ongoing efforts to provide high-quality care

21. What Isn’t Working? • Focus on punishment rather than quality improvement (guilty until proven innocent; surveyors and providers both support a more consultative role) • Complexity breeds inconsistency • Idiosyncratic interpretations of CMS guidelines • Informal Dispute Resolution (IDR) values expediency over fairness/cannot change scope and severity

22. What Isn’t Working? • Inconsistency signals deeper flaws • The survey system inevitably leads to inconsistent results and poor feedback regarding real quality issues because it is characterized by: “unrealistic expectations about how many recommended care processes can be measured; poor definition of measures and methods of measurement; confusing rules linking measures to deficiency statements; and a survey culture that depends on expert judgment.” Dr. Jack Schnelle, Vanderbilt University • State Operations Manual (SOM) for example

23. What Isn’t Working? • Regulations that don’t encourage culture change or person-centered innovations; do POCs bring about compliance or just increase paperwork? • Poor communication – strained during survey; nonexistent between surveys

24. Series of Recommendations • 31 recommendations • S. 3407 in last Congress (not enacted): Institute of Medicine to study nursing home survey • Many of the state-level recommendations are reflected in LeadingAge PA’s 2011-12 Public Policy Objectives

25. Summary of Task Force Recommendations • Improve the quality of survey teams; • Foster effective communication among regulators, surveyors and providers; • Improve consistent application of regulations; • Encourage providers to strive for excellence; • Facilitate accurate reporting to consumers; • Improve fairness of enforcement and dispute resolution.

26. Policy Objectives 2011-12 • Promote meaningful changes to the nursing facility survey process to create a resident-focused, outcome-related system.

27. This system must: • Promote and encourage consumer-focused care; • Take swift and appropriate actions where poor care is found; • Apply a standard of reasonableness and proportionality to punitive actions; • Introduce an effective appeals process; • Provide for an impartial dispute resolution process; • Encourage and complement exemplary care; • Mandate joint provider-surveyor training; and • Require government surveyors to understand the entity they are reviewing and the consumers being served.

28. So what are we doing about this? • QI initiatives • Data initiatives • Regulation and Survey Initiatives • Legislation • HB 1052 and SB 1095 (Reform of Nursing Home IDR Process)

29. Some Examples - Good Survey Experiences • Inappropriate behavior/treatment of staff – reported and corrected. • Surveyors addressed issues during survey that encouraged us on our journey toward person centered care • Surveyors actually commented that we made good progress at minimizing incidence of pressure areas. • Field Office uses this location to orient new team leaders/surveyors.

30. Examples – Bad Survey Experiences • Continuing difficulty with surveyors through many years regarding physiological need regarding positioning devices or wheelchair positioning. • Non-nurse surveyors conducting chart reviews have difficulty interpreting charts. • At Exit Interview, always state: “We are not here to find the good things you are doing…” Why not?

31. Member Feedback on Surveys • Sense that existence of poor quality nursing homes lead surveyors to believe all homes are poor quality. • Would like more advice on how to comply when the surveyors find a home out of compliance. • Joint training is essential – we could learn so much from each other. • Indicator survey, done in PCHs with good history of compliance…appreciated and a good way to direct more resources where needed.

32. Quality Improvement Initiatives • Regulation and Survey • CMS Quality Assurance/Quality Improvement and Patient Safety Initiatives • Quality Improvement Organizations (QIOs) • Advancing Excellence • Focused initiatives such as PA Restraint Reduction Initiative (PARRI) • PA Patient Safety Authority • Accreditation • Consumer Education/Involvement

35. http://www.healthcare.gov/center/programs/partnership/index.htmlhttp://www.healthcare.gov/center/programs/partnership/index.html

38. http://www.nhqualitycampaign.org/

45. Goal: Quality of Life for Each Nursing Facility Resident • We have different roles but same goal. • The work is difficult but worthwhile. • We are making progress… • But we are not there yet. • We must continue to work together and achieve this goal, for the benefit of the residents.

46. September 13, 2011

47. A Case Study of Regulatory Change Nick Luciano, Esq.Legislative CounselLeadingAge PA September 13, 2011

48. Landscape of Licensed Community DPW licenses Personal Care Homes for the Commonwealth of Pennsylvania. As of August 31, 2011 there are: • 1336 Licensed Personal Care Homes • 67,344 Licensed Personal Care Beds • 47,355 Residents in PCH’s (70.3% Occupancy)

49. Landscape of Licensed Community Snapshot of Residents by Age, Need, and Income Resident Description of Resident Number % of Pop. Residents 60 Years of Age or Older 42,016 87.06% Residents with a Mobility Need 8,806 18.25% Residents with Mental Illness 6,890 14.27% Residents with Dementia 4,398 9.11% Residents with a Physical Disability 3,751 7.77%

50. Landscape of Licensed Community Total Capacity and Number of Licensed Personal Care Homes Month/Year Homes Capacity Homes % Capacity Change % Change • December 2010 1,362 68,012 - 4.36% - 1.77% • December 2009 1,424 69,237 - 0.14% +0.12% • December 2008 1,426 69,151 - 4.42% - 2.46% • December 2007 1,492 70,154 - 7.96% - 5.60% • December 2006 1,621 74,316 +1.44% +2.53% • December 2005 1,598 72,479 - 5.44% - 3.00%