PREPARING FOR A SURVEYlong-term care nursing facilities to dispute state and federal survey...

9/13/2017

WHAT YOU NEED TO K N O W ABOUT PREPARING FOR SURVEYS A N D RESPONDING TO A N ADVERSE SURVEY/LICENSURE ACTION

PHCA 2017 Convention September 26, 2017

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PREPARING FOR A SURVEY

OVERVIEW OF RECENT SURVEY AND

ENFORCEMENT ISSUES

Performance Aud i t of D O H Regulation and Oversight o f Nursing Facilities July 26, 2016

• Staff ing

• D ispos i t ion o f Complaints

• Inadequate Civ i l Money Penalties

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9/13/2017

OVERVIEW OF RECENT SURVEY AND ENFORCEMENT ISSUES

• D O H Civi l Penalty Assessment Guidel ine - 12/19/16: • Factors to be considered w h e n issuing c iv i l penalt ies:

• S ta tu to ry p rov i s ions a u t h o r i z i n g c i v i l pena l t ies u n d e r H C F A

• R e c o m m e n d a t i o n s c o n t a i n e d i n PA A u d i t o r General 's Per fo rmance A u d i t Repor t (July 2016)

• D O H ' s in teres t i n ef fect ive r e g u l a t i o n t o p r o m o t e t he h ighes t possib le q u a l i t y o f care a n d services fo r LTC res idents i n PA

• A n y faci l i ty w i t h a survey exit date on or after 1/1/2017 may be subject, w h e n warranted, to c iv i l penalt ies calculated o n a per v io la t ion per day basis pursuant to 35 P.S. § 448.817

OVERVIEW OF RECENT SURVEY AND

ENFORCEMENT ISSUES CON'T.

D O H Civ i l Pena l t y Assessment G u i d e l i n e • G u i d a n c e f r o m t h e Sec re ta ry o f H e a l t h preserves D O H ' s

" d i s c r e t i o n to t ake i n t o c o n s i d e r a t i o n o t h e r m i t i g a t i n g o r a g g r a v a t i n g c i r cums tances . " I f m i t i g a t i n g o r a g g r a v a t i n g c i r c u m s t a n c e s w a r r a n t d e v i a t i n g f r o m t h e Secretary 's g u i d a n c e , t h e D i v i s i o n o f N u r s i n g Care Fac i l i t i es w i l l b e ab le to p r o p o s e a n a l t e r n a t i v e c i v i l p e n a l t y w i t h a spec ia l c o m m i t t e e f o r m e d b y t h e Secretary .

OVERVIEW OF RECENT SURVEY AND ENFORCEMENT ISSUES CON'T.

I m m e d i a t e Jeopardy C i t a t i ons

• Issue o f D O H m a k i n g i m m e d i a t e j e o p a r d y (IJ) d e t e r m i n a t i o n s t h a t w e r e i n c o n s i s t e n t w i t h g u i d a n c e u n d e r A p p e n d i x Q d u r i n g t i m e p e r i o d o f a p p r o x i m a t e l y 11/15/2016 u n t i l 12/20/2016.

• Susan W i l l i a m s o n ( D i r e c t o r , D i v i s i o n o f N u r s i n g Care Fac i l i t ies ) i ssued c l a r i f y i n g i n f o r m a t i o n t o t h e f i e l d o f f i ces o n 12/20/2016 i n s t r u c t i n g f i e l d o f f i ces to f o l l o w A p p e n d i x Q w h e n m a k i n g IJ d e t e r m i n a t i o n s .

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9/13/2017

NEW LTC SURVEY PROCESS

New LTC Survey Process (Effective November 28, 2017)

• O n e u n i f i e d s u r v e y p r o c e s s t h a t w i l l u t i l i z e s t r e n g t h s

f r o m b o t h t h e T r a d i t i o n a l s u r v e y p r o c e s s a n d Q u a l i t y

I n d i c a t o r S u r v e y ( Q I S ) p r o c e s s

• G o a l o f b e i n g m o r e e f f e c t i v e a n d e f f i c i e n t

• F o c u s i s r e s i d e n t - c e n t e r e d

• N e w s u r v e y p r o c e s s p r o v i d e s s t r u c t u r e t o e n s u r e

c o n s i s t e n c y w h i l e a l l o w i n g s u r v e y o r s a u t o n o m y

• N e w s u r v e y p r o c e s s w i l l b e a n a u t o m a t e d p r o c e s s ( i . e . ,

c o m p u t e r s o f t w a r e - b a s e d ) .

NEW LTC SURVEY PROCESS

Sample Selection

• S a m p l e s i z e i s d e t e r m i n e d b y t h e f a c i l i t y c e n s u s

• 7 0 % o f t h e t o t a l s a m p l e i s M D S p r e - s e l e c t e d r e s i d e n t s

a n d 3 0 % o f t h e t o t a l s a m p l e i s s e l e c t e d o n s i t e b y t h e

s u r v e y t e a m

• M a x i m u m s a m p l e s i z e i s 3 5 r e s i d e n t s

PREPARING FOR A SURVEY

• C M S re leased n e w l o n g - t e r m care s u r v e y f o r m s a n d u p d a t e d i nves t i ga t i ve p r o t o c o l s t o be u s e d f o r t h e n e w su rvey p rocess :

- Prov ides a l i s t o f i n f o r m a t i o n t h a t a m u s t p rov ide t o surveyors i m m e d i a t e l y u p o n entrance, w i t h i n

one h o u r a n d w i t h i n fou r hou rs o f ent rance, b y the e n d o f the f i r s t day o f survey a n d w i t h i n 24 hou rs o f ent rance.

ce Confe • E n t r a n f a c i l i t y i l i t y

e h o

• Faci l i - U t i l i z e d t o i d e n t i f y p e r t i n e n t car 1) n e w l y a d m i t t e d res idents i n t he last 30 days w h t he f ac i l i t y a n d 2) a l l o t h

gories fo r t i l l res id i

M a t r i e cate o are s n g i n

er res idents .

• C r i t i c a l E lemen t Pathways - Pa thwa cess t o '

ays p rov ide gu idance to survey d u r i n g the i nves t i ga t i on process t o de te rm ine comp l i ance w i t h t he LTC Requ i remen ts o f Pa r t i c i pa t i on . ( N O T E : LTC Survey Pathways ( to ta l o f 41) can be accessed v ia t he f o l l o w i n g CMS webs i te : h t t p s : / / w w w . C M S . g o v / M e d i c a r e / P r o v i d e r - E n r o l l m e n t - a n d -C e r t i f i c a t i o n / Gu idance fo rLawsAndRegu la t i ons / N u r s i n g - H o m e s . h t m l )

ors

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9/13/2017

CMS FINAL RULE REGARDING CHANGES TO SURVEY TEAM COMPOSITION & INVESTIGATION OF COMPLAINTS

• O n August 4, 2017, CMS publ ished a f ina l rule1 tha t clarifies the regulatory requirements for team compos i t ion for compla in t surveys and aligns the regulatory provisions for invest igat ion c compla ints w i t h the statutory requirements f ound i n sections 1819 and 1919 o f the Social Security Act .

^ M e d i c a r e P rog r ; R i l l i n g f o r Sk i l l ed

as ing P r o g r a m , S m p o s i t i o n , a n d C o r r e c t i o n IP I n f l u e n z a V a c c i n a t i o n I m m u n i z a t i o n R e p o r t i n g M e a s u r e i n t h e

2020 w h i c h c a n be accessed v i a t h e f o l l o w i n g l i n k : •aire gister. g o v / d o c u m e n t s /2017/08/04/2017-

c t i ve -paymen t -sys tem-and-conso l i da ted -

a m : P rospec t i ve P a y m e n t - S y s t e m a n d C o n s o l i d a t e d N u r s i n g Fac i l i t ies (SNF) f o r FY 2018, SNF Va lue-Rased

N F Q u a l i t y R e p o r t i n g P r o g r a m , Survey T e a m o f t h e P e r f o r m a n c e P e r i o d f o r t h e N H S N

n g c h Pu r

Co H C ESRD Q I P f o r PY h t t p s : / / w w 16256/medicare-p b i l l i n g - f o r - s k i l l e d

w.feder r o g r a m -- n u r s i n g

prospe [ - fac i l i t ies

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CMS FINAL RULE REVISION CON'T.

Survey T e a m C o m p o s i t i o n

• Regulatory prov is ion clarifies tha t on ly surveys conducted under sections 1819(g)(2) and 1919(s)(2) o f the Social Security Act ("Act ') are subject to the requirement at §488.314 tha t survey teams inc lude a registered nurse.

gulatory prov is ion also clarif ies that compla in t surveys d surveys related to on site moni to r ing , i nc lud ing revisit

surveys, are subject to the requirements o f 1819(g)(4) and

• Re an

1919(g)(4) o f the Ac t and §488.332 w h i c h allows for the use o f a specialized investigative team that may inc lude appropriate healthcare professionals bu t need no t inc lude a registered nurse.

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M I N I M U M DATA SET (MDS) FOCUSED SURVEYS • I n N o v e m b e r 2016, C M S issued a Su rvey & C e r t i f i c a t i o n Le t te r (Ref :

S & C : 1 7 - 0 6 - N H ) a d d r e s s i n g M i n i m u m D a t a Set ( M D S ) f o c u s e d surveys.

• T h e S&C Le t te r d iscussed O I G a n d s u b s e q u e n t C M S s u r v e y o r t e d da ta

s a i m e d at o n r e s i d e n t assess ing t h e accu racy o f n u r s i n g f a c i l i t y se l f - rep

assessments , as r e q u i r e d b y 42 C.F.R. § 483.20.

• I t c i t ed ev idence t h a t 4 7 % o f SNFs m i s r e p o r t e d assessment i n f o r m a t i o n i n 2012, c a u s i n g M e d i c a r e t o o v e r p a y t h e fac i l i t i es .

• C M S i n d i c a t e d t h e y p l a n t o c o n t i n u e t o c o n d u c t M D S f o c u s e d surveys t h r o u g h f i sca l year 2017.

• T h e Pennsy l van ia D e p a r t m t c o n d u c t i n g s u c h surveys, f o

e n t o f H e a l t h has r e c e n t l y b e g u n c u s i n g o n r e s i d e n t assessment a accuracy.

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M I N I M U M DATA SET (MDS)

FOCUSED SURVEYS

• A d v e r s e sur c a n i m p a c t

• A survey f i n d i n g a de f i c i ency s t e m m i n g f r o m res iden t assessment i naccu racy can resu l t i n c i v i l m o n e t a r y penal t ies .

vey o u t c o m e s w i t h respec t t o r e s i d e n t SNFs f i n a n c i a l l y a n d m a y r e q u i r e r e m e

assessment accuracy ;d ia l a c t i o n .

ccurate res iden t assess s i f i ca t ions , can resu l t i

• Wh. specifi whether a Med

men ts , w h i c h af fect M D S sco edica

res a n d RUG the fac i l i ty .

• Ina^ clas n M r p a y m e n t s t o

en a survey cites resident assessment inaccuracies w i th respect to cific residents, the facility wi l l l ikely have an obligation to determine

icare overpayment results f rom those in • I f a survey cites widespread assessment i

l ikely w i l l need to determine whether t h Medicare and/or Medicaid (

re ove

the facility most ave resulted in

cies rs h

naccura ose erro

overpayments.

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STEPS TO PREPARING FOR A SURVEY

• U n d e r s t a n d n e w LTC su rvey process

• Rev iew LTC F i n a l Ru le (e f fec t i ve 11/28/16) a n d rev i sed i n t e r p r e t a t i v e g u i d a n c e u n d e r A p p e n d i x PP o f t h e Sta te O p e r a t i o n s M a n u a l (e f fec t i ve 11/28/17)

• Ensu re p o l i c i e s / p r o c e d u r e s c o m p l y w i t h LTC F i n a l Ru le

• E d u c a t e / t r a i n f a c i l i t y s t a f f r e g a r d i n g p o l i c i e s / p r o c e d u r e s

• T r a i n s t a f f o n w h a t to e x p e c t d u r i n g a su rvey

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STEPS TO PREPARING FOR A SURVEY

• C o n d u c t M o c k Surveys

• Facil i ty staff vs. outside consul tant

• U t i l i za t ion o f new Entrance Conference Worksheet, Facil i ty Mat r i x and Cr i t ica l Element Pathways as tools to assess compl iance w i t h LTC Final Rule and iden t i f y any systems, procedures and /o r processes o f care tha t need improvement .

• Address any compl iance issues.

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Responding to an Adverse Survey/Licensure Action

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APPEAL OPTIONS

• IDR • State IIDR • Federal IIDR • DOH Appeal • CMS Appeal • DAB Appeal • Federal Court

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INFORMAL DISPUTE RESOLUTION (" IDR")

• Gene ra l l y - T h e Federa l C e r t i f i c a t i o n Survey Process p r o v i d e s a n i n f o r m a l p rocess to d i s p u t e su rvey f i n d i n g s w i t h t h e Sta te su rvey agencies. 42 C.F.R. §488.331.

• P u r p o s e - To cha l l enge o n e o r m o r e de f i c i enc i es o n t h e CMS-2567 t h a t t h e f a c i l i t y be l ieves was c i t e d i n e r ro r .

• T i m e l i n e - M u s t s u b m i t I D R w i t h i n t h e same 10-ca lendar day p e r i o d t h e f a c i l i t y has f o r s u b m i t t i n g a n accep tab le P l a n o f C o r r e c t i o n .

• O t h e r - Fa i lu re t o c o m p l e t e t h e I D R t i m e l y w i l l n o t de lay t h e e f fec t i ve da te o f a n y e n f o r c e m e n t a c t i o n aga ins t t h e fac i l i t y .

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IDR PROCESS

• F a c i l i t i e s m a y n o t u s e t h e I D R p r o c e s s t o c h a l l e n g e :

• Scope a n d sever i t y (un less s u b s t a n d a r d q u a l i t y o f care o r i m m e d i a t e j e o p a r d y )

• Remedy ( i es ) i m p o s e d b y t h e e n f o r c i n g agency

• Fa i lu re o f t h e su rvey t e a m t o c o m p l y w i t h a r e q u i r e m e n t o f t h e su rvey process

• A l l e g e d i n c o n s i s t e n c y o f t h e su rvey t e a m i n c i t i n g o n e o r m o r e de f i c i enc ies a m o n g fac i l i t i es ; o r t h e

• A l l e g e d i n a d e q u a c y o r i n a c c u r a c y o f t h e I D R process

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IDR PROCESS

• D o c u m e n t a t i o n t o s u p p o r t I D R

• I D R s u b m i t t e d t o D e p a r t m e n t o f H e a l t h f o r r e v i e w

• D e c i s i o n o f D O H f i n a l - n o a p p e a l o f f i n a l d e c i s i o n

• I f I D R resu l t s i n e l i m i n a t i o n o f o n e o r m o r e de f i c ienc ies , t h e f o l l o w i n g app l i es :

• Fac i l i t y w i l l rece ive a "c lean" ( n e w ) CMS-2567

• A n y e n f o r c e m e n t a c t i o n i m p o s e d so le ly as a r esu l t o f o n e o r m o r e de f i c i enc ies w i l l b e resc inded .

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STATE INDEPENDENT INFORMAL DISPUTE RESOLUTION ("STATE IIDR")

P e n n s y l v a n i a ' s L o n g - t e r m C a r e N u r s i n g F a c i l i t y

I n d e p e n d e n t D i s p u t e R e s o l u t i o n A c t ( E f f e c t i v e

4 / 2 0 / 2 0 1 2 )

• Es tab l i shes a n i n d e p e n d e n t i n f o r m a l r e v i e w process f o r l o n g - t e r m care n u r s i n g fac i l i t i es t o d i s p u t e s ta te a n d f e d e r a l su rvey de f i c i enc i es

• Q u a l i t y I n s i g h t s o f Pennsy l van ia c o n d u c t s t h e State I I D R process

• S ta te I I D R process c o n d u c t e d o n a fee - fo r - se rv i ce basis ( c u r r e n t l y $ 9 5 / h o u r )

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STATE I IDR C O N T ' D .

• T i m e l i n e - S t a t e I I D R m u s t b e s u b m i t t e d w i t h i n

t h e s a m e 1 0 c a l e n d a r d a y s t h a t f a c i l i t y h a s t o

s u b m i t t h e P O C

• T o r e q u e s t a S t a t e I I D R , t h e n u r s i n g f a c i l i t y m u s t

s u b m i t :

• W r i t t e n I I D R r e q u e s t t h a t i d e n t i f i e s t h e d e f i c i e n c i e s

d i s p u t e d a n d t h e r e a s o n s f o r t h e I I D R r e q u e s t

• S u p p o r t i n g d o c u m e n t a t i o n

• C o p y o f 2 5 6 7

• I n d i c a t e t y p e o f r e v i e w r e q u e s t e d : D e s k r e v i e w ,

t e l e p h o n e r e v i e w o r i n - p e r s o n r e v i e w

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STATE I IDR C O N T ' D .

Q I P r e v i e w s t h e I I D R / s u p p o r t i n g d o c u m e n t a t i o n a n d

s u b m i t s a w r i t t e n r e c o m m e n d a t i o n t o t h e f a c i l i t y , w i t h

a c o p y t o D O H , w i t h i n 4 5 d a y s o f r e c e i p t o f t h e I I D R

r e q u e s t .

I f Q I P s u s t a i n s t h e d e f i c i e n c y , t h e n Q I P ' s w r i t t e n

d e t e r m i n a t i o n s h a l l i n c l u d e t h e r a t i o n a l e f o r i t s

d e c i s i o n a n d p r o v i d e r e c o m m e n d e d a c t i o n t h a t t h e

f a c i l i t y c a n i m p l e m e n t t o a c h i e v e c o m p l i a n c e .

I f Q I P r e v e r s e s t h e d e f i c i e n c y a n d D O H d i s a g r e e s ,

D O H h a s a u t h o r i t y t o n u l l i f y Q I P ' s d e c i s i o n . 23

FEDERAL INDEPENDENT INFORMAL DISPUTE RESOLUTION ("FEDERAL IIDR") • Federa l I I D R a p p l i c a b l e i f :

• The Centers for Medicare and Medica id Services ("CMS") imposes c iv i l money penalt ies against the nu rs ing faci l i ty; and

• The penalt ies are subject to be ing collected and placed i n an escrow account pend ing a f ina l administ rat ive decision.

• C M S m a y co l l ec t a n d p lace i m p o s e d c i v i l m o n e y p e n a l t i e s i n a n e s c r o w

a c c o u n t o n w h i c h e v e r o f t h e f o l l o w i n g occu rs f i r s t :

• The date o n w h i c h the I IDR process is completed, or

• The date w h i c h is 90 calendar days after the date of the not ice of impos i t i on o f the civ i l money penal ty

NOTE: I f a faci l i ty ut i l izes the IDR or State I IDR process to challenge the survey f indings, the faci l i ty cannot also ut i l ize the Federal I IDR process for the same survey unless the IDR or State I IDR process (whichever is applicable) was completed pr io r to the impos i t i on of the civ i l money penalty.

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FEDERAL IIDR

• T i m e l i n e : • A r e q u e s t f o r a Federa l I I D R m u s t be s u b m i t t e d w i t h i n 10 ca lendar

days o f t h e r e c e i p t o f t h e le t te r f r o m C M S r e g a r d i n g t h e i m p o s i t i o n o f t h e c i v i l m o n e y pena l t i es .

• T h e Federa l I I D R sha l l be c o m p l e t e d w i t h i n 60 ca lendar days o f a f ac i l i t y ' s r eques t .

( N o t e : T h e Federa l I I D R is d e e m e d c o m p l e t e d w h e n a f i n a l d e c i s i o n f r o m t h e I I D R process has b e e n m a d e , a w r i t t e n r e c o r d has b e e n genera ted a n d t h e State su rvey agency has sen t w r i t t e n n o t i c e o f t h i s d e c i s i o n t o t h e fac i l i t y . T h e I I D R process is also c o n s i d e r e d t o be c o m p l e t e d i f a f a c i l i t y does n o t t i m e l y r e q u e s t or chooses n o t t o p a r t i c i p a t e i n t h e I I D R process. )

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FEDERAL IIDR

• D u r i n g t h e F e d e r a l I I D R p r o c e s s , a f a c i l i t y m a y n o t

c h a l l e n g e o t h e r a s p e c t s o f t h e s u r v e y p r o c e s s , s u c h

a s :

• Scope o r sever i t y (un less s u b s t a n d a r d q u a l i t y o f care o r i m m e d i a t e j e o p a r d y )

• Remedy ( i es ) i m p o s e d

• A l l e g e d f a i l u r e o f t h e su rvey t e a m to c o m p l y w i t h a r e q u i r e m e n t o f t h e su rvey p rocess

• A l l e g e d i n c o n s i s t e n c y o f t h e su rvey t e a m i n c i t i n g de f i c i enc i es a m o n g o t h e r f ac i l i t i es ; o r t h e

• A l l e g e d i n a d e q u a c y o r i n a c c u r a c y o f t h e I D R o r I I D R process

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FEDERAL IIDR

• R e q u e s t f o r F e d e r a l I I D R m u s t i n c l u d e :

• C o p y o f C M S l e t t e r i n d i c a t i n g f a c i l i t y is e l i g i b l e f o r a n I I D R r e v i e w

• W r i t t e n I I D R reques t t h a t i d e n t i f i e s t h e d e f i c i e n c i e s d i s p u t e d a n d reasons f o r t h e I I D R r e q u e s t

• S u p p o r t i n g d o c u m e n t a t i o n

• N a m e s a n d c o n t a c t i n f o r m a t i o n f o r r es iden ts i n v o l v e d i n t h e de f i c i enc i es f o r w h i c h t h e f a c i l i t y seeks a n I I D R r e v i e w o r t h e a p p r o p r i a t e r e s i d e n t rep resen ta t i ve (s )

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FEDERAL IIDR

O p p o r t u n i t y for Res ident o r Resident 's Representa t ive t o c o m m e n t :

• O n c e a f a c i l i t y reques ts a Federa l I I D R , t h e State m u s t n o t i f y t h e i n v o l v e d r e s i d e n t o r r e s i d e n t rep resen ta t i ve , as w e l l as t h e State's l o n g - t e r m care o m b u d s m a n , t h a t t h e y have a n o p p o r t u n i t y t o s u b m i t w r i t t e n c o m m e n t

28

FEDERAL IIDR

• T h e n o t i c e t o t h e r e s i d e n t / r e s i d e n t ' s rep resen ta t i ve , a t a m i n i m u m , m u s t i n c l u d e : • A br ie f descr ipt ion o f the f indings o f noncompl iance for

w h i c h the faci l i ty is request ing the I IDR, a statement about the CMP imposed based on those f indings, and reference to the relevant survey date

• Contact i n fo rma t ion for the State survey agency, or the approved I IDR ent i t y or person regarding when, where and how poten t ia l commenters must submi t the i r comments

• A designated contact person to answer quest ions/concerns • For residents and /o r resident's representatives, contact

i n fo rma t ion for the State's long- term care ombudsman.

29

FEDERAL IIDR

• W r i t t e n Record re: Federal I I D R • The I I D R en t i t y or pe rson m u s t generate a w r i t t e n record

as soon as pract icab le b u t no later t h a n w i t h i n 10 calendar days o f c o m p l e t i n g its rev iew

• W r i t t e n record shal l inc lude: • L is t o f each de f i c i ency or su rvey f i n d i n g s t h a t was d i s p u t e d

• A s u m m a r y o f t h e I I D R r e c o m m e n d a t i o n fo r each de f i c i ency or f i n d i n g at issue a n d t h e j u s t i f i c a t i o n fo r t h a t resu l t

• D o c u m e n t s s u b m i t t e d b y t h e f a c i l i t y t o d i s p u t e a de f i c i ency

A n y c o m m e n t s s u b m i t t e d b y t h e State l o n g - t e r m care

o m b u d s m a n a n d / o r res iden ts or r es i den t representa t i ves

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FEDERAL IIDR

• Federal I IDR Recommendat ion and Final Decis ion e ip t o f t h e I I D R w r i t t e n r e c o r d , t h e State Survey A g e n c y

("SSA") w i l l r e v i e w t h e I I D R r e c o m m e n d a t i o n s a n d :

• I f SSA agrees w i t h I I D R r e c o m m e n d a t i o n s a n d n o changes w i l l be m a d e t o t h e d i s p u t e d su rvey f i n d i n g s , t h e SSA w i l l send w r i t t e n n o t i c e o f t h e f i n a l d e c i s i o n t o t h e f a c i l i t y w i t h i n 10 ca lendar days o f r e c e i v i n g t h e w r i t t e n r e c o r d f r o m t h e I I D R e n t i t y / p e r s o n

• U p o n rec

• I f SSA d is ees w i t h o n e or m o r e o f t h e r e c o m m e n d a t i o n s o f t h e I I D R e n t i t y / p e r s o n , t h e c o m p l e t e w r i t t e n r e c o r d w i l l be sen t t o t h e a p p l i c a b l e C M S R e g i o n a l O f f i c e f o r r e v i e w a n d f i n a l d e c i s i o n . SSA w i l l t h e n send w r i t t e n n o t i c e o f f i n a l d e c i s i o n t o t h e f a c i l i t y w i t h i n 10 ca lendar days o f r e c e i v i n g C M S ' f i n a l d e c i s i o n .

agr

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FEDERAL IIDR

• Federa l I I D R R e c o m m e n d a t i o n a n d F i n a l D e c i s i o n c o n t ' d .

• I f SSA agrees w i t h I IDR recommendat ion(s) or has received a f i na l decision f r o m the CMS Regional Off ice and changes w i l l need to be made to the disputed survey f indings, the SSA w i l l , w i t h i n 10 calendar days o f receiving the w r i t t en record:

• Change deficiency(ies) citation content f indings as recommended • Adjust scope and severity assessments i f warranted by CMS policy

Annotate deficiency(ies) citations as "deleted" or "amended" where appropriate Have a SSA manager/supervisor sign and date revised CMS-2567

• Prompt ly recommend to CMS that any enforcement action(s) imposed solely because of deleted or altered deficiency citations be reviewed, changed or rescinded as appropriate; and

• Provide wr i t ten notice of the f inal decision to the facility

32

OVERVIEW

F e d e r a l I IDR IDR S t a t e I IDR

Submitted wi th in calendar days that facility has to submit POC

Submitted wi th in calendar days that facility has to submit POC

Submitted wi th in 10 calendar days of the receipt of the CMS letter imposing CMP's No Fee

Can only dispute federal deficiencies

10 10

Fee-for-Service basis No Fee

Can only dispute federal deficiencies

Can dispute state and defi federal ciencies

NO NOTICE to and NO OPPORTUNITY for

NO NOTICE to and NO OPPORTUNITY for

NOTICE to and OPPORTUNITY for

comment by resident/resident's representative

comment by resident/resident's representative

comment by resident/resident's representative

Quality Insights of PA Independent entity wi th in D O H Reviews IDR reviews State IIDR but the D O H reviews IIDR, but

i f SSA disagrees, CMS is D O H is final decision-final decision-maker

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9/13/2017

DOH APPEAL

• P o s s i b l e S a n c t i o n s :

• C M P

• P r o v i s i o n a l L i cense

• A p p e a l o f A d v e r s e S t a t e O r d e r s

• F i le a p p e a l w i t h i n 30 days o f t h e da te o f m a i l i n g o f t h e O r d e r

• A p p e a l o f s a n c t i o n does n o t a c t as a n a u t o m a t i c supersedeas

• M u s t s p e c i f i c a l l y d e n y t h e a l l e g a t i o n s

34

DOH APPEAL CONT'D.

A p p e a l o f A d v e r s e S t a t e O r d e r s ( c o n t i n u e d )

• A p p e a l f i l e d w i t h H e a l t h Po l i c y B o a r d

• H e a r i n g O f f i c e r t o c o n d u c t h e a r i n g

• P r a c t i c a l c o n s i d e r a t i o n s

• Possible admissions?

• Probabi l i ty o f success

35

CMS APPEAL

• P o s s i b l e S a n c t i o n s

• C M P

• D e n i a l o f P a y m e n t f o r N e w A d m i s s i o n s o r A l l I n d i v i d u a l s

• Loss o f N A T C E P

• T e r m i n a t i o n

36

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9/13/2017

CMS APPEAL

T h e f a c i l i t y m u s t a p p e a l w i t h i n 6 0 days o f r e c e i p t o f n o t i c e o f i m p o s i t i o n o f r e m e d i e s f r o m CMS. P r o c e d u r a l e l e m e n t s o f t h e a p p e a l p rocess are as f o l l o w s :

1. N o t i c e o f A p p e a l a n d reques t f o r h e a r i n g

2. P r e - h e a r i n g P r o c e d u r a l O r d e r

a. Case read iness r e p o r t

b. D o c u m e n t a n d w i t n e s s exchange

c. M u s t i d e n t i f y e v i d e n c e i n exchange

37

CMS APPEAL

Appea l Process cont'd.

3. Schedul ing o f hear ing a. CMS Mot ions to Dismiss b. T i m i n g

4. Hear ing before Admin is t ra t ive Law Judge ("ALJ") a. preparat ion - c l in ica l documenta t ion b. physical evidence c. witnesses, ident i f i ca t ion o f expert witnesses d. oral and wr i t ten summat ion e. use o f hearsay f. burden o f p roo f

38

CMS APPEAL

A p p e a l Process con t ' d .

5. D e c i s i o n o f A L J

6. D A B A p p e a l

7. S p e c i f i c i t y o f A p p e a l . I n o r d e r to p reserve f a c t u a l issues, appea ls s h o u l d b e spec i f i c , i n c l u d i n g w h i c h su rvey a n d T a g n u m b e r s are b e i n g con tes ted . T h e spec i f i c g r o u n d s f o r t h e d i s p u t e s h o u l d be i n c l u d e d a n d e x p l a n a t i o n s o f w h y t h e c o n c l u s i o n s are i n c o r r e c t . T h e focus s h o u l d be o n t h e a l leged d e f i c i e n t p r a c t i c e i n c o m p a r i s o n t o t h e r e g u l a t o r y r e q u i r e m e n t . Issues o f t i m i n g , dates, c h r o n o l o g i c a l o r d e r s h o u l d b e n o t e d .

39

13

9/13/2017

CMS APPEAL

W h a t is Sub jec t t o A p p e a l

1. O n l y a c t u a l r e m e d i e s - n o t de f i c i enc i es a l one

2. Sever i t y a n d scope i f r e l a t e d to IJ, S u b s t a n d a r d Q u a l i t y o f Care, Loss o f n u r s e a i de t r a i n i n g

3. C a n n o t a p p e a l p r o p o s e d o r w i t h d r a w n r e m e d i e s

40

CMS APPEAL

A p p e a l Cons ide ra t i ons

1. N a t u r e o f p r o p o s e d r e m e d y

a. I m m e d i a t e Jeopardy

b. Res iden t d e a t h , abuse, se r ious i n j u r y

c. S e c o n d consecu t i ve S/S "G"

d. S e c o n d rev i s i t w i t h a n y d e f i c i e n c i e s ( i n c l u d i n g n e w de f i c i enc ies ) a n d 6 m o n t h m a n d a t o r y t e r m i n a t i o n da te is a p p r o a c h i n g

e. T e r m i n a t i o n p r o p o s e d .

41

CMS APPEAL

A p p e a l Cons ide ra t i ons con t ' d .

2. W a i v e r o f a p p e a l i n exchange f o r 35% d i s c o u n t o n C i v i l M o n e t a r y Pena l t y

3. C a n y o u w i n o n m e r i t s ?

4. Cos t

42

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K i m b e r L. La tsha , Esq.

Tanya Dan ie l s Har r i s , Esq.

L A J M l ' DAVIS & MCKENNA

717-620-2424 k l a t s h a @ l d y l a w . c o m

t h a r r i s @ l d y l a w . c o m

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15