Healt lth F Facili ilities Lic icensing a g and nd Oversi - - PowerPoint PPT Presentation

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Healt lth F Facili ilities Lic icensing a g and nd Oversi - - PowerPoint PPT Presentation

Healt lth F Facili ilities Lic icensing a g and nd Oversi sight Christopher Burmeister Deputy Director Division of Health Improvement July 9, 2018 1190 S. St. Francis Drive Santa Fe, NM 87505 Phone: 505-827-2613 Fax:


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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Healt lth F Facili ilities Lic icensing a g and nd Oversi sight

Christopher Burmeister Deputy Director Division of Health Improvement July 9, 2018

1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Division of Health Improvement

  • Licensing and Certification
  • Long Term Care Facilities
  • Non Long Term Care Facilities
  • Deemed vs Non-Deemed
  • Enforcement: CMS vs State
  • Complaints and statewide investigations
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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Providers and Staff

  • 75 Nursing Homes
  • 266 Licensed ALF
  • 52 ICF/IID facilities
  • 4 non-deemed Hospitals
  • 64 non-deemed Home Health

Agencies

  • 57 ESRD
  • 35 Hospice
  • 11 Rural Health Clinics
  • 14 Ambulatory Surgical Centers
  • 15 Outpatient PT/ST
  • 4 Portable X-ray
  • Long Term Care: 17/27
  • ALF team 4
  • Non-LTC: 7/12
  • Life Safety Code: 6
  • Survey Processing: 3/5
  • Complaints: 4
  • Review/Enforcement: 3/4
  • MDS/OASIS Coordinator: 1
  • Nurse Aide Registry: 1
  • Clerks: 4/6
  • Management: 6/10
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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Long Term Care

  • F279 (41) Comprehensive care plan
  • F514 (34) Resident records are accurate
  • F280 (32) Right to participate in care planning
  • F371 (32) Sanitary food/storage/prep/service
  • F241 (31) Dignity and Respect of Individual
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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Immediate Jeopardy 2017

  • F 323 (7) Accidents and Supervision
  • F 441 (2) Infection control
  • (new F tags start 1/18)
  • Other citations: inappropriate discharge, physical

restraint, abuse/neglect, physician order, catheter care, insufficient staffing, no RN on duty

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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

ALF citations

  • Custodial drug permits/medications
  • Nutrition/resident rights
  • Staff qualification/staff training
  • Resident evaluations/Individual care plans
  • Admission and discharge
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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Complaints

  • Statewide intake in Santa Fe
  • From June

une 2 2017- May 2 201 018, we have reviewed and triaged 15, 5,06 061 reports and taken 1,295 295 hotline calls.

  • We have assigned 19

195 of those for an onsite investigation.

  • The maximum timeframes related to a federal onsite investigation of

complaints/incidents are as follows:

  • 2 day (Immediate Jeopardy)
  • 10 day (Non-Immediate Jeopardy High)
  • 45 day (Non-Immediate Jeopardy Medium)
  • Next onsite (Non- Immediate Jeopardy Low)
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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

CMS 2567 LTC Turn Around Time

20 2016 20 2017 20 2018 (Jan-Apr pril) l)

40% of surveys went out in 10 days 89% of surveys went out in 10 days 85% of surveys went out in 10 days

This Photo by Unknown Author is licensed under CC BY

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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

CMS 2567 NLTC Turn Around Time

201 016 201 017 201 018(Jan-Apr pril) l)

No Data Available 74% of surveys went out on time 92% of surveys went out on time

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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Best Practices- LTC

  • New Long Term Care Survey Process (LTCSP)
  • More time spent on investigations
  • Citing of different regulations, no threshold
  • LTC Surveyor Training
  • Kitchen/Dining
  • PASSR
  • State Epidemiology, infection control
  • Pressure Ulcers
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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

CMP Fund Project

CMP collected 201 012 $0 201 013 $534,194.29 201 014 $139,101.35 201 015 $195,963.72 201 016 $311,119.78 2017 17 $498,016.81 201 018 $1,242,275.90 Applic icat atio ion Y Year 2016 2017 2018 Number o

  • f Appli

lications r received 4 4 Numb mber o

  • f App

pplications a s appr pproved b by pa panel 1 3 Number o

  • f Applic

icat atio ions d denie ied b d by panel 1 Numb mber o

  • f App

pplications a s appr pproved b by CMS 3 Number o

  • f Applic

icat atio ions d denie ied b d by CMS

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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

OUR FUTURE

  • Community Relations- NMHCA, NMAHHC, ICF

Task Force & Dementia Partnership

  • Collaboration
  • Transparency
  • Relationship Building with CMS
  • Regulation interpretation
  • Report/Budget
  • Guidance
  • Continuing Focused Education
  • Surveyors
  • Managers
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1190 S. St. Francis Drive • Santa Fe, NM 87505 • Phone: 505-827-2613 • Fax: 505-827-2530 • nmhealth.org

Thank You

Contact: Christopher Burmeister 2040 Pacheco St 2nd Floor Santa Fe NM 87505 505-476-9074 Christopher.Burmeis@state.nm.us