CMS Update - AHFSA

CMS Update - AHFSA

C1 LTC- Working Session Facility Reported Incidents & Complaints K a r e n Tr i t z , D i r e c t o r, D i v i s i o n o f Nursing Homes Gregg Brandush, Deputy Associate R e g i o n a l A d m i n i s t r a t o r, M i d w e s t D i v i s i o n o f S u r v e y a n d C e r t i fi c a t i o n Tu e s d a y, S e p t e m b e r 2 5 , 2 0 1 10:00 AM 11:15 AM John Day Ballroom Disclaimer

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. LTC Complaints, SETI Follow-up and FRIs Topics

SETI working session follow up Overview of LTC complaints What is a complaint? What needs to be investigated How to handle old complaints Complainant notification requirements Facility Reported Incidents 3 The Questions We Worked On:

1) What is a complaint 2) What needs to be investigated 3) How to triage complaints 4) How to deal with a frequent complainant 5) Best Practices for handling complaint workloads 4 The Dialogue: 1) What is a complaint Allegation of abuse, neglect, misappropriation or any potential noncompliance of state or federal requirements including injuries of unknown origin.

Any allegation of non-compliance/not facility reported incidents Clarify what needs to be reported Slide represents discussion content and is not CMS policy The Dialogue: 2) What needs to be investigated DO NOT INVESTIGATE: Allegations of events occurring X number or more of years ago; allegations of incidents relative to recent recertification survey if not in compliance or in in full compliance; do not investigate facility reported incidents Assess the seriousness of the complaint to determine if it needs to be investigated Dont investigate complaints older than the last recertification survey Slide represents discussion content and is not CMS

policy 6 The Dialogue: 3) Triage Assign lower triage levels to facility reported incidents Treat EMTALA complaints like all other hospital complaints Allow flexibility to gather additional information for facility reported incidents Clarify the difference between a complaint and an incident Improve Q6 audits by having cross-regional assessments to get a consistent definition of what constitutes an IJ Allow a case management approach to lower triage levels rather than an investigation Slide represents discussion content and is not CMS

policy 7 The Dialogue: 4) How to deal with a frequent complainant Use of cease and desist letters Single point of contact Involvement of legal counsel Communicate issue with Regional Office

Update open complaints with additional information rather than opening new complaints Slide represents discussion content and is not CMS policy 8 The Dialogue: 5) Best Practices for Handling Complaint Workloads Assign the surveyor based on the difficulty of the complaintassign the best surveyors to the challenging cases Minimize travel for surveyors when possible Offer incentives for additional assignments and off hour surveys Assign complaints to surveyors who prefer to work independently Develop a pre-survey plan

Prioritize complaints that have the highest probability of harm Complete multiple complaints at the same facility at the same time Pull multiple complaints at the same facility to the next recertification survey Slide represents discussion content and is not CMS policy 9 Areas of Clarification: 1) What is a Complaint? What needs to be investigated? When is an administrative review adequate? When No Action Necessary is appropriate? 10

Areas of Clarification: When would an investigation NOT be required? Generally, an alleged event occurring more than 12 months prior to the intake date would not require an investigation. Where there is sufficient evidence the facility does not have continuing non-compliance and the events occurred before the last standard survey. 11 Areas of Clarification: When is an administrative review adequate? An onsite investigation is not necessary when: Review of documentation reveals no evidence of non-compliance or

any non-compliance would not likely have caused physical or psychosocial discomfort The basis for this assessment is documented Findings should be confirmed at the next onsite survey 12 Areas of Clarification: When No Action Necessary is appropriate? SA or RO determines with certainty that no further investigation, analysis or action is necessary Events that occurred more than 12 months in the past unless the SA determines an investigation should be conducted

13 Areas of Clarification: 2)What needs to be communicated to a complainant: Section 5080.1 of Chapter 5 of the State Operations Manual Acknowledgement Regulatory authority to investigate Summary of how the investigation was done Dates of the investigation How a decision is made What the decision was Summary of the findings Follow up to be taken and referral information

14 15 What to Report? What is a Facility-Reported Incidents F608 Any reasonable suspicion of a crime against a resident Follows definition of a crime. F609 All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property Follows regulatory definitions and Appendix PP (F540,F602, F609)

16 Clarifying What Does Not Have to Be Reported Mental/Verbal - General outbursts, non-serious arguments Sexual Non-sexual physical contact, sexual contact where there is capacity to consent. Physical-Light physical contact between residents that does not result in injury, mental anguish or pain. Neglect Process structure failures did not lead to serious resident outcomes Injuries of Unknown Origin non-suspicious Disclaimer: This is not the whole draft policy. Handout has additional detail. 17

Development of FRI Reporting form Template under development Review state websites for accuracy and completeness Key, specific information on facility actions, whereabouts of resident, etc. 18 Group Discussion Feedback Handout Review what did we miss/what should we change? 19

20 State Intake and Triage Key Facts about FRIs Survey of States (23 States) -Tracking of FRIs Some FRIs are not tracked/controlled Paper based system Spreadsheet (e.g., Excel) Other State database (e.g., Access) State Web-based application (Providers enter the FRI online) ACTS 0

2 4 6 8 10 12 14 21 State Intake Requirements Need to have good, clear FRI reporting Need to have enough information to make a good decision

(minimum fields) System needs to know how many are coming in and what happened to them 22 Triage Illustration Date / Time Action 2/26 2/28

3/4 Patient reported sexual assault by an aide State received 24 Hour Initial Report from the provider alleging sexual assault by an aide. State received a 5-Working Day Report from provider -facility still investigating & allegation referred to law enforcement. Report made by a LTC ombudsman to the Complaint Intake Unit and recorded in ACTS as Immediate Jeopardy State survey started 3/18 3/21 3/24

State survey notes that IJ started 2/26 removed on 3/24. The survey was completed and the allegation was substantiated. The aide was eventually convicted of rape. 23 Considerations Public perception - 23 day follow-up on the state incident may not have gone out on rape if not called in through complaint. When came in as a complaint triaged as IJ- 2 days Not cited as past non-compliance or a lower level of current non-compliance Prolongs Immediate Jeopardy risk to residents and ultimately fine to provider (per day) 24

Current policy model Scheduled or next onsite Non IJ Medium Non-IJ - Low 10 day Non-IJ HIgh 2 day

Immediate Jeopardy 25 Do we need more? F a c i l i t y

A c t i o n Inadequate Response Request additional information review at next onsite. Onsite Investigation X

day Onsite Investigation Timing? Minimal or incomplete Request additional in resident status, information, review at protection, next onsite. investigation, correction. Onsite Investigation

X day Onsite Investigation Timing? Clear/thorough resident protection, investigation, and correction Next Onsite Visit ??

Onsite Investigation Timing X day Incident, but not Harm Harm to Resident Serious Harm or Death to Resident or Credible Threat Harm to Residents 26

Other policies 1. Role for closed, no action needed Administrative Action? 2. Role for investigation from other agency (APS, law enforcement) 3. When they can wait for 5-day? 4. Multiple low level threats case management approach 5. Past Non-compliance- encouraging prompt complete action. 27 Discussion Small group discussion Different model

Other policies 28 Questions and Comments

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