The Texas Department of Aging and Disability Services (DADS) issued a provider letter to Nursing Facilities and Hospitals Seeking Medicare Certification for a Skilled Nursing Care Unit to inform them about new policy documents issued by the Centers for Medicare and Medicaid Services (CMS) regarding workload prioritization on initial certification surveys.
Attached to the two-page letter is a two-page Q&A memo. Download the letter and attachment here for more information.
CMS published the final Calendar Year 2008 Medicare Home Health Prospective Payment System (PPS) rule on August 29, 2007. This final rule requires changes to Outcome and Assessment Information Set (OASIS-B1) data set, and DADS notified Medicare-certified Home Health Agencies of these changes. See the OASIS-B1 page for more information. You may download the provider letter here.
Mary Ousley, past chair of the American Health Care Association, which represents long term care providers, testified before a congressional committee last week about the long term care profession’s experience with the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87).
OBRA ‘87 is considered landmark legislation because it established many nursing home oversight rules in place today. Ousley said that in order to improve nursing facilities, providers, regulators, and consumers must cooperate in the process.
“What we have is a system that defines ‘success’ and quality in a regulatory context that is often measured by the level of fines levied and the violations tallied – not by the quality of care, or quality of life,” Ousley said. “The statute envisioned a resident-centered, outcome-oriented, consistent system of oversight. Unfortunately the system we have today bears little resemblance to that vision.”
In response to the growing concern over long term care quality, lawmakers introduced a bill called the Long Term Care Quality and Modernization Act of 2006. Ousley believes this measure will help improve quality of care and encourage cooperation.
Source: American Health Care Association
March 9
The Texas Health and Human Services Commission (HHSC) announced on behalf of the Texas Department of Aging and Disability Services (DADS) that it has adopted the repeal of §§7.301 - 7.311 and §§7.313 - 7.316 in Chapter 7. The repeal is intended to facilitate the consolidation of rules dealing with volunteer programs and donations to DADS by striking obsolete rules. For more information, see the relevant section in the March 9 Texas Register.
Additionally, HHSC will submit an amendment to the STAR+PLUS 1915(b) waiver, which will “phase in the capitation payments for inpatient behavioral health services made to Managed Care Organizations (MCOs) contracted with HHSC under the STAR+PLUS waiver program.” HHSC’s notice of intent to submit an amendment that appeared in the February 27 issue of the Texas Register misidentified the geographic areas to be affected. The correct areas and contact information for obtaining a copy of the proposed amendment can be found here.
March 16
HHSC adopted an amendment in compliance with the state legislature, intended to ensure that all Medicaid recipients in nursing homes are given information about end-of-life care. For more information, see the relevant section in the March 16 Texas Register.
In order to comply with the state legislature, HHSC submitted an amendment that will require DADS to “accept an accreditation survey of an assisted living facility…conducted by an accreditation commission instead of an initial or annual licensing survey of the facility conducted by DADS staff, under specified circumstances.” For more, see the relevant section of the March 16 Texas Register.
HHSC announced the adoption of an interim per diem reimbursement rate for small, state-operated Intermediate Care Facilities for Persons with Mental Retardation (ICF/MR), including facilities operated by DADS, effective September 1, 2006: $188.30.
Additionally, HHSC will hold a public hearing to receive public comment on proposed Medicaid payment rates on April 10, 2007, at 1 p.m. in the Lone Star Conference Room of the Health and Human Services Commission, Braker Center, Building H, located at 11209 Metric Blvd, Austin, Texas. See more details about the reimbursement rate and public hearing here.
Also see DADS Rules in Progress.
There have been several survey and certification letters posted on the Texas Department of Aging and Disability Services web site since January. Please click on the titles to download letters in PDF format.
Federal
- Multiple Providers — Medical Gas Storage and Usage Considerations (1/12/07)
- Publication of the Hospital CoPs: Requirements for H and P; Authentication of Verbal Orders; etc. (1/26/07)
- Electronic Signature Guidance in Inpatient Rehabilitation Facilities (IRFs) (1/26/07)
- Psychiatric Residential Treatment Facilities (PRTF) Clarification (2/16/07) (ZIP file)
State
In a new provider letter, the Texas Department of Aging and Disability Services (DADS) has asked assisted living facilities to complete a survey about their needs and preferences for future joint training courses.
DADS offers courses to assisted living providers “related to common deficiencies and violations” and other topics of interest. To participate in the survey, follow this link. You may view the course offerings here and download the provider letter here.
In a letter dated May 12, the Texas Department of Aging and Disability Services (DADS) asked providers to participate in an online survey for joint training courses. Based on the survey, DADS will assess the needs of nursing, assisted living, adult day care, and intermediate care facilities when developing joint training courses for long term care providers.
According to the letter, there is no fee to take the confidential survey, which will be accessible for the next 60 days, starting today. You may download the letter here.
The Texas Department of Aging and Disability Services has issued a letter informing Home and Community Support Services Agencies about what they can expect when their agency is surveyed. The letter outlines each stage of the process, including how to begin the informal review of deficiencies, and agency rights and responsibilities.
Download a PDF copy of the five-page letter.
A State or two in Region VI appear to be confused about what compliance date to assign when a facility clears on a revisit. Thus, CMS sent a recent Regional Survey And Certification Letter to all State Survey Agencies to clarify the issue. Click here to see the letter.
It is suspected that the letter was prompted by a conversation between CMS and the unamed State Survey agencies that went something like this:
“If you find deficiencies on an initial or annual visit, you are to send the facility the 2567 by the tenth business day after you exit the facility. Got it little buddy?”
“Got it Skipper. After the exit, I am to leave the facility and then to get the 2567 back to them within 65 days.”
“No! No! No! You are to get the 2567 back to them within 10 business days.”
“Okay. Okay. I’ve got it. I am to wait until 10 days before DPNA goes into effect to get them the 2567.”
“”
“Let’s go on to something else for the moment. If the facility clears on the first revisit, you are to assign the compliance date as the date the facility says it corrected if the facility provides documentation to verify continued compliance after correction was achieved. If the facility has no correction-monitoring data-but is in compliance-the correction date will be the last date on the plan of correction submitted by the facility. Understand?”
“?”
“If the facility clears on the second revisit and the facility has collected data showing correction and verifying continued compliance-the date proven by that data is to be the compliance date. If they have no data, the date of the revisit is the compliance date.”
“I think I get it! When we go back in
after the initial survey, if the facility clears-the compliance date is the date of our revisit. Right, Skipper?”
“”
(”What did I do to deserve this?”)
“Huh?”
If you have a bad survey, it is important that you:
* Thoroughly document what you actually did to correct-not just your plan,
* Collect monitoring data that will prove that the correction was effective. (e.g. collect data demonstrating that your staff is doing things correctly and demonstrating competency)
* Record the monitoring data in an understandable way so that you can prove to the re-survey team that compliance was achieved on your preferred date.
* Have this data handy for the revisit
If you live in the unamed State(s) that are not getting your 2567 to you in a timely manner and causing you to go into DPNA because of insufficent time to get things together:
* Begin your correction the second the surveyors exit.
* Consider writing letters to CMS documenting the violations of procedure
* Contact your attorney for assistence.
Until recently, the New Mexico Survey Agency allowed providers to file only the Informal Dispute Resolution request- without your rebuttal information- by the tenth day after receipt of the 2567. The agency then permitted additional time for filing the rebuttal information as long as it was received two weeks prior to a meeting of the Informal Review Committee meeting.
The above described practice, though contrary to the written policy, was allowed until now. Contacts at the DOH have now indicated that the practice has apparently reverted to the written policy which was promulgated on 11-25-03. This policy requires that you file, along with the initial request, all of your IDR rebuttal materials by the 10th day.
It should be noted that the policy does not define what it means by “filing a written request.” In the legal world, “filing” generally means placing in the mailbox or having postmarked on the due date. Thus, if you mail a document on the due date, it is considered filed timely. That’s the general practice.
However, a contact at DOH has indicated that is not DOH’s interpretaion. It’s interpretation is that the IDR materials must be received by DOH in Santa Fe by the 10th day. If it is received after the 10th day, it will be considered untimely and will not be considered.
This is unfortunate because it means that facilities located outside Santa Fe will have to mail IDR rebuttal material earlier and will not have the advantage of the full ten days to prepare the material. In the alternative, they may have to fax the materials–although that may be a problem if the rebuttal information is voluminous. Further, the policy does not indicate if fax filings will be accepted.
Regardless, interpreting the policy in this manner does not treat all facility’s equally. Facilities located in or near Santa Fe are in a position to hand deliver the materials on the due date. Facilities located elsewhere will not have that advantage.
The only fair way to handle this is to require that IDR requests and rebuttal materials be put in the mail, or given to another carrier, on or before the 10th day. Handling it in this manner gives all facilities the full ten days to prepare the materials.
The contact at DOH also indicated that if an IDR is due on Sunday, but received on Monday, it will be considered untimely–even though none of the DOH employees are on premises to accept delivery on Saturday or Sunday.
Therefore, if your IDR is due on a weekend or holiday, DOH must receive the documentation on the day before the holiday or weekend. Again, this signficantly cuts down your time for preparation. If DOH is not going to have anyone available to accept deliveries on Saturday and Sunday, the due date should be moved to Monday.
Finally, ten days to put together the rebuttal materials is unrealistic in many cases. A sixty page 2567 addressing 15 or 20 patients is difficult to challenge in such a short period of time.
In the meantime, please note that the practice has changed. If you have an attorney or corporate nurse doing your IDR’s, it is important that the attorney or corporate nurse receive the 2567 the very day that you receive it.
UPDATE:
Apparently, DOH is reevaluating the above information. We were told that if an IDR rebuttal is due on a weekend, but received the following business day–it will be considered timely.
I have received some insights from a source from CMS in Dallas about how your inservices could be improved that may help you when you are dealing with survey issues.
The holding of an inservice in and of itself is not compelling evidence that you are fixing problems before (as part of Quality Assurance) or after (as part of a Plan of Correction). The folks at CMS want to know that an inservice has effectively taught staff how to carry out particular functions.
The folks at CMS are concerned that staff is merely going to an inservice to pick up paychecks and is not focused on learning. This is a reasonable concern. How many times have you written grocery lists during a particularly boring seminar you have attended for Continuing Education credit? Haven’t we all occasionally gone off to La La Land when we should have been listening?
It is important that you not only inservice, but that you perform “return demonstrations” or competency tests to ensure that your staff is “getting it” and not just sitting there like a bump on a log. It is equally important that you monitor staff for competency in the area for a reasonable time after the inservice to ensure that staff members remember, understand and accept the importance of the information or change in systems.
How is this important in the context of surveys and regulatory litigation?
If you are confronted with an issue of past noncompliance already fixed by your Quality Assurance Committee, the surveyors need proof that the “fix” really took and that the facility did come back into compliance.
Also, if you failed to clear on the second survey–and then you do clear on a third–CMS will fix the compliance date as the date of third revisit rather than as the date you alleged compliance. Thus, DPNA and CMP’s may be treated as if they run past your POC date. For instance, if you allege that you were in compliance pursuant to your POC on October 18 and the surveyors actually clear you during a third revisit on November 18, CMS will consider November 18 to be the date you came back into compliance. This, of course, is unfair. However, you may be able to negotiate with CMS if you have good evidence that you actually were in compliance on October 18.
Good evidence of compliance must include proof that the staff is actually doing things in accordance with what you taught them during the inservice. Thus, documentation of the results of “return demonstration” or other measures of competency will be crucial to convince CMS that CMP’s and DPNA should have ended on October 18 rather than November 18. Also, provide documentation showing that you monitored the “fix” for a reasonable period after, and that it was actually working.
Such evidence is important to convince CMS for purposes of negotiating a case. It is also important should you go to Hearing.
The bottom line is that just showing that you inserviced staff to correct and issue is not enough. Essentially, you must show that you led the horse to water–and he did, indeed, drink.
This is what the little bird said to me.