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

10/03/2017 Mi Midw dwes est Divisio Division of of 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 LT New New LT New LTC Sur LTC Sur Survey Process/P Survey Process/P ocess/Phase ocess/Phase ase II ase II II Im II Im Implem Implem ementation 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 1

10/03/2017 New New LT New New LT LTC Sur LTC Sur Survey Process: Survey Process: ocess: Appe ocess: Appe Appendix Appendix ix PP ix PP 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 Pha Phase II Phase II II Implemen II Implemen plementation: plementation: tion: Enforcemen tion: Enforcemen ement 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 New LT New LT LTC Sur LTC Sur Survey Process: Survey Process: ocess: Pro ocess: Pro Provider Traini Provider Traini ning ning ng ng • Provider training can be accessed through the Integrated Surveyor Training Website (ISTW) • Webpage: https://surveyortraining.c ms.hhs.gov/index.aspx 2

10/03/2017 New New New LT New LT LTC Sur LTC Sur Survey Process: Survey Process: ocess: Pro ocess: Pro Provider Traini Provider Traini ning ning ng ng Webpage: https://www.cms.gov/Medicare/Provider ‐ Enrollment ‐ and ‐ Certification/GuidanceforLawsAndRegulations/Nursing ‐ Homes.html Emer Emer Emergency Emergency ncy Pre ncy Pre Preparedne Preparedne ness Requir ness Requir iremen iremen ements 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 Emergency Emer Emergency Emer ncy Pre ncy Pre Preparedne Preparedne ness Requir ness Requir iremen iremen ements ements • All Hazards Approach • Specific to the location of the provider/supplier and considers the particular type of hazards most likely to occur in their areas http://www.cnn.com/2017/09/20/health/florida ‐ nursing ‐ home ‐ ninth ‐ death/index.html 3

10/03/2017 Emer Emer Emergency Emergency ncy Pre ncy Pre Preparedne Preparedne ness Requir ness Requir iremen iremen ements: Com ements: Com Complian Complian liance 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 Ci Civil Civil vil Money vil Money Money Pe Money Pe Penalty (CM Penalty (CM (CMP) Polic (CMP) Polic licie licie ies & Analytic ies & Analytic Analytic Tool Analytic Tool ool ool • 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 Quality ality and ality and and Certi and Certi Certific Certific icatio icatio ion Ov ion Ov Over Over ersigh ersigh sight Re sight Re Reports (Q Reports (Q (QCOR) (QCOR) R) 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 4