Association of Home & Hospice Care: Alternative Penalties Webinar PowerPoint - 2014

Alternative Sanctions:

Minimizing the Impact on Your

Agency

Ken Burgess, JD

Matt Fisher, JD

David Broyles, JD

These materials have been prepared by Poyner Spruill LLP for informational purposes

only and are not legal advice. This information is not intended to create, and receipt of it

does not constitute, a lawyer-client relationship.

Why Are We Here Again

• AHHC of NC Webinars This Fall (Judy Adams)

One covered the alternative sanctions

Goal: not to repeat that

But, to come at them from a different angle

• Today’s Goals:

1. Establish a baseline of knowledge about alternative sanctions

1. What are the 5 alternative sanctions / mechanics of each

2. Some discussion of the Informal Dispute Resolution and Appeals

Processes

3. Share with you the 20+ year skilled nursing experience with them

4. Share a practical, proactive method of minimizing the impact of them

2

What Is An Alternative Sanction

• Alternative to termination of Medicare provider agreement

• Recent CMS presenter:

“Before, we could only terminate you; now we have these”

Implication: “this is a good thing”

Wrong: very few HHAs were ever terminated

CMS can still terminate an HHA and must for any noncompliance

lasting 6 months

These sanctions are not in lieu of termination, but in addition

Goal: bring about sustained compliance with COPs / eliminate

cyclical compliance

• Compliant only during / after surveys (complaint or recertification)

• CMS verbage: “the yo-yo syndrome”

3

When Can Alternative Sanctions Be Used?

• For any condition-level deficiency that:

Poses immediate jeopardy

Or substantially limits the HHA’s ability to furnish adequate care

• In the “professional judgment” of the surveyor

• Reference: CMS chart that guides surveyors on when to make a

deficiency “condition-level” but regs also permit use of “professional

judgment of surveyor

Or HHA has repeat deficiency:

• Condition-level deficiency that is substantially the same as or similar to

a condition-level OR standard-level deficiency on the most recent

standard survey or any intervening survey since the last standard one

CMS also says repeat standard deficiencies permit surveyor the

discretion to raise them to the level of a condition-level

4

First, An Example

• Ms. Smith = recent stroke patient but developed right hip

decubitus from immobility and incontinence during hospital

stay.

• Home health nursing is ordered for:

Decubitus care

Med teaching

Teaching related to skin care/integrity

And safety

Physical therapy ordered for mobility, strength training and to help

patient progress to a walker.

• Therapy is provided via a contractor to the HHA

5

The Survey

• From record reviews; interviews and home visit

observation, surveyor finds the following:

Patient has a new (second) decubitus on sacrum

Daughter, who has health issues, is primary caregiver and cannot

transfer patient or position her off of her back

Sacral decubitus is often wet with urine (and not getting pressure

relief from turning/repositioning)

MD was notified of the new decubitus but no interim order/verbal

order obtained indicating type of dressing change needed for

sacral decubitus to protect from incontinence

Nurse is using same dressing change on sacral and hip areas, but

there’s no order to do so—or any other order re that area

6

The Survey (continued)

• Nursing notes indicate drainage and foul odor

No medication changes sought/ordered re this

No recorded temperatures (do we have infection/sepsis?)

No contact with MD re the odor and drainage

• Therapy visits provided do not match the frequency

ordered

Therapy clinical notes don’t explain this disparity

Or whether various transfer techniques/options have been

explored in light of daughter’s inability to transfer patient

• No record of communication between nursing and therapy

re this patient or daughter’s inability to transfer/turn patient

7


• No documentation that HH aide services were offered

despite OASIS documentation supporting need for

maximum assistance

• Result: Citations at:

G156 –Acceptance of patients; Plan of Care; Medical Supervision

G159-Plan of care is comprehensive/accurate/up to date

G164-Notification to MD of significant changes in patient condition

G165—Drugs/treatments administered as ordered

Likely cross reference to tags governing: skilled nursing services;

therapy services; clinical records; comprehensive assessments;

and administration (for oversight/communication, etc.)

8


• This is a condition-level deficiency because:

It adversely affects patient’s safety or health

• Probably an immediate jeopardy because it caused or is likely to cause

serious harm to patient (immediate jeopardy)

And because it substantially limits HHA’s ability to provide

adequate care

• Now, let’s discuss the alternative sanctions CMS could

use

• Then the appeals processes

• Then, how we minimize the potential impact

9

SURVEY AND SANCTION

MECHANICSBY MATT FISHER

10

Overview of New Alternative Penalties

Regulations

• Where is it?

Chapter 10 of the State Operations Manual

• What does it do?

Provide for a means to enforce the Rules applicable to all CMS

Participating Home Health Providers

• Why do you as providers care?

11

Survey Process

• How often are Standard Surveys?

No later than 3 years from last standard survey

May be performed within 2 months of a change in ownership or

administration

Must be performed within 2 months of a significant number of

complaints"

• Extended Surveys or Partial Extended Surveys for

situations where a deficiency was noted

See§ 10006.3 & 10007.1

12

Survey Process

• Post Survey Revisits required in any situation where there

are deficiencies noted.

But can be simply a letter or a phone call for minor deficiencies

See§ 10006.6

• Surveys to be conducted by survey teams of varying sizes

including at least one RN with home health survey

experience

See§10004.1 & 10004.2

• Surveys are unannounced

With penalties for anyone who gives advance notice to a provider

of a planned survey

See§ 10008.1 & 10008.4

13

Deemed Status

• Home Health Agencies ("HHAs") can acquire certification

for participation in Medicare via a State Agency survey or

via deemed status through a CMS-approved Accrediting

Organization (“AOs")

• Deemed status HHAs will be under the jurisdiction of their

AOs for survey purposes

Unless a Condition-Level deficiency is found in a survey, in which

case the deemed status provider reverts back to the oversight of

the State Agency

See§10008.1 & 10008.4

14

Branch Offices

• In some cases, deficiencies cited for Branch Offices may

be imputed to the Parent Offices and vice versa

• A Branch Office is defined as being:

…part of the HHA and is located sufficiently close to share

administration, supervision, and services in a manner that renders

it unnecessary for the branch independently to meet the conditions

of participation as an HHA.

• When a deficiency is found at one, the deficiency, and any

associated penalties, shall apply to both the parent and

the branch

See§10010.4

15

Available Sanctions

• In addition to Terminating the Provider Agreement, the

following penalties are available:

Civil money penalties ("CMPs")

Suspension of payment for all new admissions;

Temporary management of the HHA;

Directed plan of correction; and

Directed in-service training

See§10010.5

16

Factors Considered in Imposing Sanctions

• Whether there is Immediate Jeopardy;

• The frequency and duration of the non-compliance;

• Repeat deficiencies at either a parent or branch location;

• Extent that deficiencies are directly related to failure to

provide quality care;

• Extent to which the HHA is part of a larger organization

with systemic problems; and

• Indications of system-wide failure to provide quality care

See § 10010.6

17

Immediate Jeopardy Deficiencies

• Termination of the Provider Agreement is required if the

Immediate Jeopardy is not removed within 23 days

However, additional penalties – such as a Civil Monetary Penalty –

can be imposed in addition to terminating the Provider Agreement

See§100112& 10012

• The stated goal of this rule is for action to be swift in

enforcement for Immediate Jeopardy deficiencies

• The clock is ticking from the moment you receive

notification.

18

Condition-Level Non-IJ Deficiencies

• CMS has a choice:

Terminate the Provider Agreement within 100 days if still non-

compliant

-or-

Impose one of the Alternative Sanctions, such as a CMP

• If Alternative Sanctions are imposed, and there is no

substantial compliance with respect to the Condition-Level

deficiencies by the end of 6 Months, the Provider

Agreement is automatically terminated

See§10013

19

Civil Monetary Penalties

• CMPs can be imposed regardless of whether Immediate

Jeopardy exists

• Penalties are imposed for either:

Per Day Penalties: The number of days that the provider is not in

substantial compliance with one or more of the Conditions of

Participation '"CoPs”

- or -

Per Instance Penalties: For each instance that the provider is not

in substantial compliance

• The total amount of the CMP cannot exceed $10,000 for

each day of non-compliance

See§10017.1

20

CMPs : Choice of Penalties

• The key here is the definition of "per instance“

A single event of non-compliance identified and corrected during a

survey for which the statute authorizes CMS to impose a sanction.

• Thus, while there may be a single event which leads to

non-compliance ...

There can be more than one instance of non-compliance identified

and more than one civil money penalty imposed during a survey

• Cannot impose both a "per instance" and a "per day“

penalty simultaneously for a single deficiency ...

… but both can be used in the same survey cycle

See§10017.1

21

CMPs : Factors Impacting Amount of

Penalty

• Factors considered in determining amount of penalty

include:

The size of the agency and its resources;

Accurate and credible resources such cost reports and

claims information, that provide information on the

operations and the resources of the HHA; and

Evidence that the provider has a built-in, self-regulating

Quality Assessment and Performance Improvement

("QUAPI") system

See§ 10017.2

22

CMPs : Amount of Penalty: Immediate

Jeopardy Deficiencies

• Immediate Jeopardy Deficiency: Penalties in the upper

range of the $10,000 per day limit

The penalty in this range will continue until compliance can be

determined.

A revisit will follow only after the provider submits a "credible

allegation of compliance" in the form of documented execution of a

Plan of Correction

If on revisit, the IJ has abated, but a Condition-Level deficiency still

exists, the penalty amount may be reduced prospectively

See§10018. 1

23

CMPs : Per-Day Penalties : Immediate

Jeopardy Deficiencies

• High-End Per-Day Penalty Ranges:

Penalty of $10,000 per day for a deficiency or deficiencies that is

determined to be immediate jeopardy and that results in actual

harm;

Penalty of $10,000 per day for a deficiency or deficiencies that is

determined to be immediate jeopardy and that result in a potential

for harm; and

Penalty of $8,500 per day for an isolated incident of non-

compliance that is in violation of established HHA policies and

procedures

See§ 10018.1

24

CMPs: Per-Day Penalties: ConditionLevel

Non-IJ or Repeat Penalties

• Middle Per-Day Penalty Ranges:

Penalties imposed for a repeat and/or Condition-Level deficiency

that does not constitute immediate jeopardy, but is directly

related to poor quality patient care outcomes will be in the

range of $1,500 to $8,500 per day of non-compliance.

• Lower Per-Day Penalty Ranges:

Penalties imposed for a repeat and/or Condition-Level deficiency

that does not constitute immediate jeopardy and that is related

predominately to structure or process-oriented conditions

rather than directly related to patient care outcomes will be in

the range of $500 to $4,000 per day of non-compliance

See§ 10018.2 & 10018.3

25

CMPs : Per-Instance Penalties

• Can be multiple instances of non-compliance during a

survey leading to multiple penalties.

• Individually, these penalties can range from $500 to

$10,000 per instance, without exceeding the limit of

$10,000 for each day of non-compliance

See§ 10018.4

• There are charts which lay out some of the suggested

Penalties in § 10019

26

Other Sanction Types

• While CMPs are the often the most discussed, the other

types of penalties can be just as concerning:

Suspension of payment for all new admissions;

Temporary management of the HHA;

Directed plan of correction; and

Directed in-service training

See§10010.5

27

Suspension of Payment for New

Admissions

• Suspension of payment for new admissions of Medicare

patients may be imposed anytime an HHA is found to be

out of substantial compliance with Condition, IJ, or not

Notice of 2 calendar days before the effective date in immediate

jeopardy situations

Notice of 15 calendar days before the effective date in non-

immediate jeopardy situations.

• This would have no impact on patients who have been

receiving care from the HHA before the effective date of

this sanction

See§10016.2 & §10016.3

28


Admissions• Suspension of Payment can last a grand total of 6

months, ending when either:

CMS terminates the Provider Agreement

- or -

When substantial compliance with the CoPs is achieved

• There is no recoupment for services provided to Medicare

patients admitted during the time the suspension was in

place

See§10016.4

29


Admissions

• Thus, any new referrals and admissions while under this

sanction are taken at the risk of no payment until the

sanction is lifted

• Furthermore, the provider is precluded from charging a

Medicare patient for such services unless it could show

that, before initiating the care, it had notified the patient

or representative both orally and in writing in a

language that the patient or representative can

understand that Medicare payment is not available

See§10016.3

30

Temporary Management of the HHA

• In situations where the failure to comply with the CoPs is

deemed to be directly related to poor management or lack

of management such that it is likely to impair the HHA’s

ability to correct deficiencies, CMS may choose to impose

temporary management of the HHA

• Temporary Management may be imposed anytime an

HHA is found to be out of substantial compliance with

Condition, IJ, or not


jeopardy situations



See§ 10015.1 & 10015.2

31

Temporary Management

• Temporary Management can last a grand total of 6

months, ending when either:

CMS terminates the Provider Agreement

- or -

When substantial compliance with the CoPs is achieved

See§ 10015.2 & 10015.4

• The Temporary Manager will be selected by the State

Agency

• Failure of the existing management to relinquish control of

the HHA to the Temporary Manager will result in

Immediate Termination of the Provider Agreement

See§ 10015.5

32

Temporary Management

• The provider must pay the Temporary Manager’s salary at

the prevailing rate

See§ 10015.5

• Temporary Manager has full operational and executive

authority over the staff and HHA

This includes, hiring, firing, policies, and all other aspects of

operations

See§ 10015.3

33

Directed Plan of Correction

• A Directed Plan of Correction may be imposed when the

HHA has either:

deficiencies that warrant directing the HHA to take a specific

action(s)

- or -

when the HHA fails to submit an acceptable plan of correction

for condition level deficiencies

See§10023.3

• Notice


jeopardy situations



See§10023.6

34

Directed Plan of Correction

• The actions outlined in a Directed Plan of Correction are

not optional or subject to interpretation

Each of the outlined actions are an imperative mandate which

must be fulfilled

• The costs associated are to be born entirely by the

provider and can prove to be quite expensive

35

Directed In-Service Training

• Directed in-service training is a remedy that may be used

when the State Agency, CMS, or the temporary manager

believe that education is likely to correct the deficiencies

and help the HHA achieve substantial compliance.

• The provider bears all costs of the directed in-service

training

The trainers are mandated to the provider by CMS or the State

Agency

See§10024.1 – 10024.5

• For Home Health providers, there is likely to be added

expense considering that the staff is not tied to a single

bricks and mortar facility

36

Notice of Penalty

• Upon receiving a Notice of Penalty, the clock starts ticking

on appeal rights.

A request for Informal Dispute Resolution ("lDR”) must be made in

writing within the 10 days provided for submitting a Plan of

Correction

See§10009.3

A formal notice of appeal must be made in writing within 60 Days

from receipt of the notice of imposition of a penalty

See§ 10021.1

• Which brings us to an overview of the IDR and Appeal

process by David Broyles…

37

REFUTING DETERMINATIONS:

INFORMAL DISPUTE

RESOLUTION & APPEALS

BY DAVID BROYLES

38

YOU RECEIVED THE CMS-2567 FORM…WHAT

COMES NEXT??

• Informal Appeal Procedure

Informal Dispute Resolution (IDR)

See§ 10009 & 42 CFR 488.745

• Appealing Noncompliance

Noncompliance Leading To CMP

See§ 10020.3 & 42 CFR § 4108.40

Waiver of Hearing By HHA

See§ 10020.4

• Settlement of CMPs

See§ 10021.4

39

INFORMAL DISPUTE RESOLUTION (IDR)

What is IDR & when is it available?

• IDR offers an HHA the opportunity to informally dispute one or more

condition-level deficiencies cited by the State or CMS Regional Office

(RO).

See§ 10009.1 & 10009.2

• IDR will occur with the agency that conducted the survey.

• The IDR process, as established by the State or CMS RO, must be in

writing and available for review.

Elements for IDR adopted by CMS designed to clarify and expedite the

process.

• 3 elements.

• States are free to incorporate elements into their own procedures.

See§ 10009.1

40


Elements Adopted By CMS In Notice To HHA

• Notice indicating the process is an informal administrative process and not a

formal evidentiary hearing.

• Notice that the HHA may be accompanied by counsel and if the HHA so

chooses, must indicate in its request so CMS may also have counsel

present.

• Notice that CMS will verbally advise HHA of decision on the informal dispute,

followed by a written confirmation.

See§ 10009.1

41


Notification of IDR Availability To HHA

• HHA will be notified of the availability of IDR in transmittal letter sent with the

CMS-2567.

• Transmittal letter contents:

– Inform the HHA of the opportunity for IDR and requirements for submitting

request by the HHA.

– What the request by HHA should include.

» Deadline for written request by HHA – within same 10 calendar day POC

submission period.

» Contact information to request IDR.

» State’s procedure for the IDR.

See§ 10009.3

42


Purpose of IDR Availability

• HHA opportunity to informally dispute condition-level deficiencies.

• Condition-level deficiencies only – not available for standard-level

deficiencies cited.

• Dispute is limited to the deficiency cited, not aspects of the survey.

• Initiation of the IDR process (or failure to complete the process) will not

postpone or otherwise delay effective date of enforcement action.

See§ 10009.2

43


Procedure & Mandatory Elements of IDR

• Process in place to implement Federal (CMS) control and accountability for

reliable and accurate State agency determinations of HHA noncompliance.

• Mandatory Elements of IDR Process:

– IDR may not be used to delay formal imposition of sanctions or challenge any

other aspect of the survey process.

– HHA must be notified of IDR availability in transmittal letter with certain

information to the HHA.

– Failure to complete IDR timely will not delay the effective date of enforcement

action.

– When HHA is unsuccessful at IDR, must be notified of such in writing.

– Certain actions must take place when HHA is successful at IDR.

– HHA shall have the opportunity to request IDR for each survey citing condition-

level deficiencies.

44


Procedure & Mandatory Elements of IDR (cont’d)

• State agency has the option to involve outside persons or entities

qualified to participate in the IDR process.

– What is the purpose of this option?

– What impact will this have?

• If successful at IDR, the HHA has the option to request a clean (new)

copy of the CMS-2567.

– When will that be available?

– When will the reporting systems be updated reflecting HHA success?

See§ 10009.3

45

APPEAL OF NONCOMPLIANCE DETERMINATION

• Before any CMP can be collected, HHA is entitled to a hearing, so long as it

is properly requested.

– What is the procedure for requesting a hearing and where can it be found?

See§ 10020.3 & 42 C.F.R. § 4108.40

• Hearing requested with the Administrative Law Judge (ALJ) on the

determination and basis for the CMP.

– If a hearing is requested, when can the CMP be collected?

• HHA does have the opportunity for review by the Departmental Appeals

Board if the HHA is unsatisfied with the ALJ decision.

See§ 10020.3 & 1128A of Social Security Act

46

APPEAL OF NONCOMPLIANCE DETERMINATION

Waiver of Hearing By HHA

• HHA may waive the right to a hearing if done in writing within 60 days from

the date of the notice imposing the CMP.

• Why would an HHA waive its right to a hearing?

– If the HHA properly waives its right to a hearing, CMS will approve the waiver and

reduce the CMP by 35%.

• How long will the HHA have to pay if it waives its hearing?

– Payment of the reduced CMP must be made within 15 days of the HHA’s receipt

of CMS’s approval of the waiver and reduction of the CMP.

– Examples of the impact on when CMP payment is due.

See§ 10020.4

47

ONE MORE OPTION - SETTLEMENT OF CMPs

• CMS Regional Office (RO) has the authority to settle CMP cases at any time

prior to a final administrative decision related to the case.

• What potential opportunity is available here?

– Potential opportunity for the HHA to settle a CMP for an amount less than total if it

is unsuccessful at IDR.

• How much authority does the RO have to settle?

– A settlement should not be for a better term or amount than the 35% reduction

available to the HHA had it waived its right to a hearing.

See§ 10021.4

48

HOW TO APPROACH A DECISION TO REFUTE A

NONCOMPLIANCE DETERMINATION

Practical Implications & Experience – Appealing Noncompliance

• What to do when a transmittal letter and CMS-2567 are received.

• The IDR process and opportunity:

– Chance to do the “real work” and have a “mini trial” at this level.

– Coordinate documents and prepare the case between legal counsel and clinical

representatives.

– Preference for informal and efficient resolution by all parties.

• Formal appeals:

– Complexity of formal appeals.

– Success rates seen with formal appeals in similar situations.

– “Option of last resort” with formal appeals and hearings.

49

PRACTICAL CONSIDERATIONS

BASED UPON THE

EXPERIENCE OF SKILLED

NURSING FACILITIESBY KEN BURGESS

50

The Skilled Nursing Facility Experience

• First, why do we care about the SNF experience?

HHA alternative sanctions closely match the HHA sanctions

As do the mechanisms for use; notice periods; periods of duration

And the IDRs and the appeals

SNFs have a 20 plus year experience with these things

Our August meeting with DHSR Interim Director of DHSR Acute

Care Section (covering HHAs):

• “We will follow the SNF experience in enforcement”

So, you need to know what that experience has been

51

The SNF Experience With Sanctions

• CMPs are the most popular sanction

$$ in the bank

The feeling that providers feel it first in the wallet

And they can run daily until compliance achieved so they keep the

pressure on

• At $10,000/day for 30 days, total CMP = $300,000.00

For SNFs, in CMS Region IV, the CMPs have steadily increased:

• In terms of frequency of use as an alternative sanction

• In terms of per day value (the range selected from)

• In terms of duration

• So in terms of total dollars

52


• Suspension of admissions has been on the rise

Choice: stop admitting patients while it’s in effect

Or admit patients and hope you return to compliance fast

Often used in combination with CMPs – double financial impact

Generally, CMP is used for more routine deficiencies rather than a

suspension of admissions

• But CMS can impose suspension of admissions any time it can impose

any sanction

• They use it with serious issues/repeats/patterns of related deficiencies

53


• Directed Plans of Correction

Historically, rarely used…

• What if it doesn’t work?

• What if it makes things worse—whose liability?

Recently, DPOC use on the rise

• CMS dictates elements of your plan of correction & deadlines

– Missing them means additional sanctions and CMPs per day

• So, in the same time period you are developing your own POC; and

implementing it; and calling for a survey revisit to end the

noncompliance, you are wrangling to implement very expansive

DPOCs from CMS

• Recent SNF case: 14 separate steps in DPOC, including onsite in-

service training of every MD who worked with any patient

• These are time-consuming and can get very expensive

54


• Directed inservice training

Again, historically rarely used

Of late, on the increase

CMS can dictate:

• Who must be trained

• On what

• By when

• Covering specific topics

• Who you can use for training (CMS approved trainer)

• Required post-testing

• Require evidence of completion/testing/effectiveness

55

Minimizing the Impact of Sanctions

• It’s all about Plans of Correction (POCs)

• For virtually every cited deficiency, you must prepare POC

DHSR letter tells you this, and the due date, and required elements

In a POC, you must:

1. Address how corrective action will be accomplished for patients

affected by deficient practice;

2. Address how HHA will identify other patients having potential to

be affected by deficient practice;

3. Address how HHA will identify the underlying process/systems

that need improvement and what procedures/systemic changes

will be made to prevent recurrence; and

4. How HHA will monitor changes to ensure they work and last

56

Using POCs Proactively to Reduce

Sanction Impact

• When you have any self-discovered deficient practice, go

into full-post survey mode, as if you’d been cited, and

implement the full 4-point POC—and DOCUMENT IT

• Why?

CMS says return to compliance requires full POC implementation

ALJ’s who hear these appeals say the same thing—no return to

compliance until full POC has been implemented

Our SNF experience, using this approach, has resulted in:

• Minimizing the number of days of noncompliance (fewer CMP days)

• Avoiding suspension of admissions/directed POCs/in-service training

• In many cases: no citation at all because we found/fixed it !!!!!

57

Using POCs Proactively

• Other reasons are contained in your HHA alternative

sanction regulations:

Factors considered in imposing CMPs:

• Frequency/duration of noncompliance

– So, goal is to shorten duration and prevent recurrence

• Repeat deficiencies

• Getting a per day CMP versus a per instance

– “Per instance” means found and fixed during survey

– If corrected before time of survey, then there’s no basis under regulations

for an ongoing, prospective CMP

– SOM 10020.6: “the per day CMP would begin to accrue on the last day of

the survey that identified the noncompliance and would continue to accrue

until the HHA achieves substantial compliance” or is terminated”

58

Using POCs Proactively

Factors impacting amount of CMP: evidence the HHA has a built-

in, self-regulating QAPI system

• The 4 required POC elements are, in essence, also core components

of any good QAPI program

Definition of “repeat deficiency”—condition-level deficiency that is

same or substantially the same as one cited on prior standard

survey or any intervening survey since your most recent standard

survey (i.e., complaint surveys)

• So, implementing a full-scale POC before a survey, and hopefully

avoiding a citation, means that issue cannot later become the basis for

a “repeat deficiency” and thus a sanction

59

Applying The Approach — Our Earlier

Example: Step 1

• Step 1: What corrective action for Mr. Smith:

Full assessment of Mr. Smith re complications from second,

infected decubitus (vitals; temps; indicia of infection)

Consult with and obtain order from MD for treatment of second

decubitus

• Include proper dressing; medications; issues around incontinence

Discuss with therapy approaches to resolve inability of daughter to

assist with turning/repositioning

• Repair documentation going forward of nurse/therapy communication

Arrange for HH aide services to assist with repositioning

Determine why therapy not provided as scheduled and either

modify schedule or provide therapy as scheduled

60

Applying The Approach: Step 2

• Step 2—Identifying other patients at possible risk from

deficient practice:

This is an internal audit step and process. Example:

Audit charts and in-home care of all current patients with limited

mobility to look for:

• Schedules for repositioning and plans to implement that schedule;

• Assessment of ability of primary caregiver to assist;

• Need for aide services

• Therapy consults

Audit charts of patients with therapy orders to ensure frequency of

care matches prescribed/scheduled therapy and, where

appropriate, that transfer techniques/options have been discussed

with therapy and primary caregiver

61

Applying The Approach: Step 2

Audit charts of all patients with pressure ulcers to look for:

• Ongoing assessment of status and change of condition

• Communication with MD for new/modified orders/new interventions

• Recordation of assessments and vitals / infection symptoms

Ask are there other issues, besides those specifically cited here,

we need to be examining to determine if we have systemic issues

• Here, we are identifying other patients who might be at

risk from any and all elements of our deficiencies

So, you must tailor that “audit” or inquiry to the facts in play

62

Applying the Approach: Step 3

• Step 3: Process / system/ other changes we’ll implement

to prevent recurrence (aka “the Fix”):

Retrain applicable nursing staff re:

• Recognizing and assessing all changes in condition

– Including causes (daughter’s condition here led to immobility and problems)

• Reporting all changes in condition to MD

• Obtaining orders related to new/changed conditions

• Reflecting same on assessment/plan of care documents

• Coordinating with other disciplines where appropriate (therapy)

• Infection control procedures (re the sacral wound treatment)

• Responding to signs of infection / determining cause / follow up

• Documentation of interactions with patient, caregiver and MD

– Including caregiver interactions showing limits in ability to assist patient

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Revise assessment tools to prompt consideration of the above

elements

Revise communication tools for:

• Reporting change in condition

• Prompting staff onsite to report to supervisor / MD change in condition

– Including follow up with MD for failure to respond with changed orders

• Therapy / nursing interactions and documentation of same

– Including therapy self-audit of patients being followed by therapy

Revise HHA policies and procedures on:

• [select those topics where you feel the Ps and Ps were the problem,

not the implementation of those by staff and list here]

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• Step 4: How the HHA will monitor these “fixes” to ensure

they work and deficient practice doesn’t recur:

Example: Director of nursing or designee will:

• Audit 10% of charts weekly for 6 months on issues identified above

– And/or conduct targeted random in-home visits to observe compliance

• Thereafter, DON/designee will audit 5% of HHA charts quarterly

• Results will be shared with QAPI Committee

– Further evidence of issues will be addressed with appropriate further

revisions to policies/procedures; staff training and/or communication tools

• This step is all about how do we know our “fix” worked and

is being maintained

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For Each of the Four Steps

• Include date by which each step/task is to be completed in

your self-directed POC process

• Then ensure they really are

• Document all of this carefully and hang on to it

We recommend spoon feeding surveyors

• Notebook divided into 4 parts, one for each step

– Tabbed

– Organized

• Our friends at the survey agency, as least for SNFs, tell us

they’ve really seen improvements since we began

teaching this in NC several years ago

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Finally . . .

• Is there anything new about this?

Not about Plans of Correction

But, yes, about using them to minimize the potential harm and

costs to you of this brand new set of sanctions and

survey/enforcement expectations

Before now, POCs helped you avoid termination from Medicare

They still do but they can also help you avoid sanctions

Or at least minimize their impact

And the approach is consistent with your QAPI obligations

And will be right in line with your risk management goals

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Questions?

David [email protected]

919.783.2923

Ken [email protected]

919.783.2917

Matt [email protected]

919.783.2924

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mailto:[email protected]



Association of Home & Hospice Care: Alternative Penalties Webinar PowerPoint - 2014

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Transcript of Association of Home & Hospice Care: Alternative Penalties Webinar PowerPoint - 2014