10/03/2017 Mi Midw dwes est Divisio Division of of Sur Survey - - PDF document

10/03/2017 1

Mi Midw dwes est Divisio Division of

• f Sur

Survey & Certif rtificatio ion Policy licy Upda Updates

LeadingAge Kansas Policy & Leadership Conference October 4, 2017 LCDR Marsophia Ruth Powers, LTC Branch Manager – Kansas City Regional Office

Agenda Agenda Agenda Agenda

• New Long Term Care (LTC) Survey Process/Phase II Implementation
• Emergency Preparedness Requirements
• Civil Money Penalty (CMP) Policies & Analytic Tool
• Quality and Certification Oversight Reports (QCOR)

New New LT LTC Sur Survey Process/P

• cess/Phase

ase II II Im Implem ementation New New LT LTC Sur Survey Process/P

• cess/Phase

ase II II Im Implem ementation

• Effective November 28, 2017
• Combining strengths from the Traditional and Quality Indicator Survey

(QIS) process

• Same computer-based survey for entire country
• Onsite survey time expected to be unchanged
• Incorporates new regulatory requirements

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New New LT LTC Sur Survey Process:

• cess: Appe

Appendix ix PP PP New New LT LTC Sur Survey Process:

• cess: Appe

Appendix ix PP PP

• Interpretive Guidelines (IGs) revisions made for new Phase II

requirements

• Improvements made were needed for some existing tags
• Ensures that standards and examples are clear
• Most of the IGs have not been changed
• Revised format with consistent sections
• References to the revised survey process and protocols
• Information about new survey process embedded within revised

Interpretive Guidelines

• Revision of Nursing Facility F-Tags

Pha Phase II II Implemen plementation: tion: Enforcemen ement Pha Phase II II Implemen plementation: tion: Enforcemen ement

• Phase I Requirements and other existing standards: Enforcement remains

unchanged

• Phase II Requirements:
• One-year restriction for specific Phase II requirements
• Will not utilize civil money penalties, denial of payment, and/or termination
• May utilize Directed Plan of Correction, Directed In-Service Training
• Focus: Education (e.g. antibiotic stewardship, facility assessment, QAPI plan
• Five Star Quality Rating System:
• No change to facility health inspection rating for any surveys conducted after

11/28/17

• Facilities with serious quality concerns will be separately flagged

New New LT LTC Sur Survey Process:

• cess: Pro

Provider Traini ning ng New New LT LTC Sur Survey Process:

• cess: Pro

Provider Traini ning ng

• Provider training can be

accessed through the Integrated Surveyor Training Website (ISTW)

• Webpage:

https://surveyortraining.c ms.hhs.gov/index.aspx

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New New LT LTC Sur Survey Process:

• cess: Pro

Provider Traini ning ng New New LT LTC Sur Survey Process:

• cess: Pro

Provider Traini ning ng

Webpage: https://www.cms.gov/Medicare/Provider‐Enrollment‐and‐Certification/GuidanceforLawsAndRegulations/Nursing‐Homes.html

Emer Emergency ncy Pre Preparedne ness Requir iremen ements Emer Emergency ncy Pre Preparedne ness Requir iremen ements

• Effective November 15, 2017
• Interpretive Guidelines: Appendix Z
• Four core elements of the Emergency Preparedness Program
• Risk Assessment and Planning
• Policies and Procedures
• Communication Plan
• Training and Testing Program

Emer Emergency ncy Pre Preparedne ness Requir iremen ements Emer Emergency ncy Pre Preparedne ness Requir iremen ements

• All Hazards Approach
• Specific to the location of the provider/supplier and considers the particular type
• f hazards most likely to occur in their areas

http://www.cnn.com/2017/09/20/health/florida‐nursing‐home‐ninth‐death/index.html

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Emer Emergency ncy Pre Preparedne ness Requir iremen ements: Com Complian liance Emer Emergency ncy Pre Preparedne ness Requir iremen ements: Com Complian liance

• All facilities expected to be in compliance with the requirements by 11/15/17
• Survey Process
• Life Safety Code & Health surveyors trained on requirements prior to the 11/15/17

compliance date

• Survey process for requirements embedded within current practices (to include new

survey process)

• Enforcement Practices
• Unchanged - Same process will occur when non-compliance is cited.
• Emergency Preparedness Webpage:
• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html

Ci Civil vil Money Money Pe Penalty (CM (CMP) Polic licie ies & Analytic Analytic Tool

• ol

Ci Civil vil Money Money Pe Penalty (CM (CMP) Polic licie ies & Analytic Analytic Tool

• ol
• Revisions to the following areas:
• Past Noncompliance
• Per Instance CMP is the default for Noncompliance existed before the survey
• Per Day CMP is the default for noncompliance existing during the survey and

beyond

• Revisit Timing
• Review of High CMPs

Quality ality and and Certi Certific icatio ion Ov Over ersigh sight Re Reports (Q (QCOR) R) Quality ality and and Certi Certific icatio ion Ov Over ersigh sight Re Reports (Q (QCOR) R)

• CMS Initiative: Increased transparency and access to data
• Summarized Survey & Certification data
• Includes results of on-site inspections of providers and suppliers
• Access: https://qcor.cms.gov or https://pdq.hhs.gov/main.jsp
• Demonstration
• Provider Reports
• Survey Reports
• Deficiency Reports
• Enforcement Reports
• Abuse Reports