Survival Guide for Long-Term Care Providers Update Since SB 1202 Presentation by the Agency for Health Care Administration September/October 2002

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Survival Guide for Long-Term Care
ProvidersUpdate Since SB 1202Presentation by
the Agency for Health Care AdministrationSeptembe
r/October 2002
Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Updates Recent Activities

• SB 1202 Questions Answers Adverse Incidents
• Liability Claims and Insurance
• 2002 Legislative Changes
• Nursing Home Staffing
• Alzheimers Training
• Gold Seal Program

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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New Slides

• Blue Background
• Underlined Text
• Added to Presentation
• Not in Handout
• Post on AHCA Web Site

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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SB 1202 Emphasis on Adverse Incidents

• Asked Quality of Care Monitors
• Definition of Adverse Incidents
• Questions and Answers Published
• February 2002
• May 2002

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Definition

• Florida Statutes 400.147(5)
• (a) An event over which facility personnel could
  exercise control and which is associated in whole
  or in part with the facility's intervention,
  rather than the condition for which such
  intervention occurred, and which results in one
  of the following

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Definition

• Florida Statutes 400.147(5)(a) continued
• 1. Death
• 2. Brain or spinal damage
• 3. Permanent disfigurement
• 4. Fracture or dislocation of bones or joints
• 5. A limitation of neurological, physical, or
  sensory function
• 6. Any condition that required medical attention
  to which the resident has not given his or her
  informed consent, including failure to honor
  advanced directives or
• 7. Any condition that required the transfer of
  the resident, within or outside the facility, to
  a unit providing a more acute level of care due
  to the adverse incident, rather than the
  resident's condition prior to the adverse
  incident

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Definition

• Florida Statutes 400.147(5)
• (b) Abuse, neglect, or exploitation as defined in
  s.415.102
• (c) Abuse, neglect and harm as defined in s.
  39.01
• (d) Resident elopement or
• (e) An event that is reported to law enforcement.
• (Note Always defined as adverse incident
  regardless of facility control. See Chart 5
  Adverse Incident Reporting.)

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Definition

• Q What is the Agencys position on reporting
  skin tears, bruises or fractures of unknown
  origin, in terms of adverse incident reporting?
  Is the same interpretation applied in hospitals?
• A If it meets the definition of an adverse
  incident pursuant to section 400.147 for nursing
  homes or 400.423 for assisted living facilities
  it must be reported. There are some differences
  in the definitions of adverse incidents for
  hospitals versus nursing homes and assisted
  living facilities, but each entity is expected to
  operate in compliance with their respective
  regulations.

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident - Elopement

• Q - How is elopement defined for the purposes
  of adverse incident reporting?
• A - Elopement is when a resident leaves the
  facility without following facility policies and
  procedures for signing out.

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incidents Baker Act

• Q Baker Act referrals and risk management
  reporting requirements Does a facility have to
  report a call for law enforcement transportation
  as an adverse incident?

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incidents Baker Act

• A Events reported to law enforcement for
  investigation are considered adverse incidents
  pursuant to sections 400.147(5)(e), F.S.
• A call to law enforcement for something other
  than investigation, e.g. transportation only,
  would not alone meet the definition of an adverse
  incident.
• However, a Baker Act situation must be reviewed
  independently to determine if it meets one of the
  definitions of an adverse incident.

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Reporting

• Q If, prior to the required report date,
  facility staff determine that an incident does
  not meet the definition of an adverse incident as
  specified in statute, is a report to the Agency
  still required?

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Reporting

• A Only those incidents that meet the definition
  of an Adverse Incident must be reported to the
  Agency.
• If the facility is able to determine that the
  incident does not meet the definition, prior to
  the required report date, then a report is not
  required.
• However, if the facility has not yet determined
  if the incident meets the adverse incident
  definition the incident must be reported on the
  1-Day report.
• After the facility investigation is complete and
  if it is determined that the incident does not
  meet the definition of an adverse incident, then
  the facility staff may report on the 15-Day
  report that the incident was determined not to be
  an adverse incident.

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Report

• Q What should a facility provide in the adverse
  incident report?
• A - All the questions on the Adverse Incident
  Report forms should be answered. The description
  of the incident should include answers to basic
  questions like Who, What, Where, When, Why,
  allows AHCA reviewers to determine appropriate
  action.
•  

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Confidentiality

• Q Are a facilitys risk management and quality
  assurance records protected from public
  disclosure once they are sent to the Agency, such
  as with a plan of correction?
• A All documents received by the agency are
  considered public records unless there is a
  specific public record exemption in law. Only
  the adverse incident reports themselves are
  protected from public record. Any documents
  submitted with a plan of correction are not
  protected from public disclosure, however,
  resident unique identifying information remains
  protected and redacted from documents prior to
  the release of the records.

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incident Confidentiality

• Adverse Incident Reports (1-Day and 15-Day) are
  Exempt from Public Disclosure
• The 5-Day Report of the Status of an Abuse,
  Neglect or Exploitation Not Specifically Exempt
  from Public Disclosure
• Accept the 15-Day Report by the 5th Day to Meet
  Federal 5-Day Requirement

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incidents

• Role of Risk Management Process
• Identification of Incidents
• Affect Compliance with Regulations
• Role of Quality-of-Care Monitor
• Risk Management Program
• Adverse Incident Identification
• Role in the Survey Process
• Regulatory Compliance Related to Occurrences
• Current Non-Compliance Except Egregious

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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AHCA Annual Adverse Incident Report

• 13,772 Adverse Incident reports processed
• 4,613 determined by facilities to be adverse
  incidents
• 3,145 Nursing homes
• 1,468 Assisted living facilities

Assisted Living Facilities 97 inspections
completed 23 inspections with deficiencies (24)
Nursing Homes 445 inspections completed 72
inspections with deficiencies (16)
Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Adverse Incidents Outcomes

• Nursing Homes
• 1,505 Event Required Transfer
• 1,030 Fracture or Dislocation
• 879 Abuse (Ch 415)
• 383 Elopement
• 318 Event Reported to
• Law Enforcement
• 27 Death
• 21 No Consent
• 13 Functional Limitation
• 3 Brain or Spinal Damage
• 2 Disfigurement

Assisted Living Facilities 926 Event
Required Transfer 510 Fracture or
Dislocation 261 Event Reported to Law
Enforcement 214 Elopement 133 Abuse (Ch
415) 40 Death 11 No Consent
1 Disfigurement
Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Practitioner Review

• Medical Quality Assurance Investigates
  Practitioners for Violations of Practice Acts
• Review All Adverse Incident Reports
• Practitioners Being Investigated Receive a Copy
  of the Adverse Incident Report
• Other Staff Names are Removed

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Staff Disciplinary Actions

• Referred for Investigation
• 567 Total Referred Out of 13,772 Reports
• 410 Certified Nursing Assistants
• 149 Licensed Nurses
• 3 Nursing Home Administrators
• 3 Pharmacists
• 2 Physical Therapist
• Average 5 of Referred Result in Prosecution
• 361 Investigations Completed
• 50 Found Probable Cause
• 95 Dismissed
• Ten Emergency Actions Against Practitioners

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Liability Claims Reported to AHCA

• 1,123 Liability Claims Reported
• - 1,050 Nursing Homes
• - 73 Assisted Living Facilities
• 33 Claims are for incident dates or residency
  dates since May 2001
• 1090 (97) of liability claims reported for
  incidents or residency dates prior to May 2001,
  and extend as far back as 1990

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Nursing Home Liability Claims Received by Month
Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Top Reasons for Claims Reported

• Assisted Living
• 13 Other
• 13 Fracture
• 12 Death
• 10 Transfer Involved
• 4 Abuse

• Nursing Homes
• 260 Other
• 159 Death
• 133 Fracture
• 89 Abuse
• 75 Transfer Involved

• Other for Nursing Homes Pressure Sores, Illness
  (Pneumonia, UTI), Falls, Weight Loss
  (non-terminal residents), Restraints, Unnecessary
  Medications

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Liability Insurance Requirement

• Insurance required for Nursing Homes and ALFs
• Recent changes for nursing homes now require
  General and Professional Liability Insurance
• No Minimum coverage Amounts are Required
• No Licenses have been Denied or Revoked to Date
  for Failure to have Insurance since January 1,
  2002
• The Risk Retention Group is working on a product
  to be available in September primarily ALFs
• 6 million advance to the Risk Retention Group
  for capitalization of the fund

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Nursing Home Bed Occupancy
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2002 Legislative Changes AHCA Semi-annual Report

• First report due December 30, 2002
• Data reported on a monthly basis
• Number of Notices of Intent to Litigate received
• Number of complaints filed with the Clerk of the
  Court
• Incident dates (or residency dates)
• Regulatory history including
• Deficiencies cited Nursing Home Guide
  information
• Nursing Home Watch List
• Federal CMS Quality Information Project

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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2002 Legislative Changes

• Continuing Care Retirement Community (CCRC)
  residents are not considered new admissions for
  the purposes of the moratorium on new admissions
  required for insufficient staffing - SB 1246
  amends 651.118 (13)
• (CCRC must meet staffing ratios)
• Medicaid Lease Bonds for Leased Nursing Homes
• - Exempts certain municipal bond leases from
  the lease bond requirement
• - Allows payment to a Medicaid overpayment fund
  in lieu of posting the Lease Bond
• Increase in Medicaid reimbursement to assist with
  cost of liability insurance

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Staffing Information

• Since January 1, 2002
• 138 facilities cited for one of the following
  staffing citations
• 109 citations for failure to meet the minimum
  staffing standards in the statute (N063)
• 11 Class IV, balance Class III
• Look at multiple periods
• 49 citations for failure to have sufficient staff
  to meet resident needs (F353)
• 14 citations for failure to self-impose a
  moratorium if staffing ratio is not met for 2
  consecutive days (N069) mandatory Class II
  deficiency
• Note Averages reported generally meet the
  required levels

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Report Staffing InformationNursing Homes

• AHCA collects semi-annual reporting of staff
  ratios, turnover and stability
• Next report
• - Will be sent to all facilities in September,
  2002
• - Due October 20, 2002
• - Anticipate on-line submission of staffing
  reports and monthly bed vacancy by October, 2002
• Centers for Medicare and Medicaid Services (CMS)
  also posts staffing data on Nursing Home Compare
• - From the CMS 671 form (provider completes
  during annual survey)

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Nursing Home Information

• Know What Others See About Your Facility
• Reconcile Information IDR
• Online Federal and State
• Public File
• Public Information Office [phone]

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Alzheimers Disease Training

• Department of Elder Affairs Rule is finalized,
  mailed to nursing homes in May - 58A-4.001(2),
  F.A.C.
• http//elderaffairs.state.fl.us/doea/mark.html
• (see Nursing Home Alzheimers Training)
• Nursing Home Training Provider Certification and
  Curriculum Approval maintained by the Florida
  Policy Exchange Center on Aging at USF at
  www.fpeca.usf.edu
• Recent Questions and Answers from the Department
  of Elder Affairs Attached
• Teaching Nursing Home CD-ROM Alzheimers
  Training for LPNs Contact LTC Unit Richard
  Kelly

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Legal Activity

• Conditional Licenses
• Fines for Deficiencies
• Late Fines
• Fine for Failure to Report Monthly Bed Vacancy
• Adhere to Timeframes
• Informal Hearing
• 40 Facilities Eligible for a 6-month Survey Cycle

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Other Legislative Updates

• Medicaid Up or Out
• Monitor Facilities with Lowest NH Guide Scores
• Improve or Terminate from Medicaid
• Funding Cut
• Consumer Satisfaction Survey
• Resident Interviews and Family Questionnaire
• Tool Survey Questions in Rule 59A-4
• Unable to Secure Contractor
• Funding Cut
• AHCA Still Required to Conduct Survey
• Gold Seal and Nursing Home Guide

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Gold Seal Award Recipients

• River Garden Hebrew Home for the Aged,
  Jacksonville
• The Pavilion for Health Care, Penney Farms
• John Knox Village Medical Center, Tampa
• Florida Presbyterian Homes, Lakeland
• Memorial Manor, Pembroke Pines
• Menorah Manor, St. Petersburg
• Presentation made by
• Lt. Governor Brogan on
• July 24, 2002

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Gold Seal Criteria

• Facility Must Be Licensed For 30 Months
•  Quality of Care Standards
• Consider Past 30 Months
• Top 25 In Quality of Care Rank
• (LTC Unit Contact Richard Kelly)
• No Conditional Licenses
• No Class I or II Deficiencies
•  Free of Bankruptcy Proceedings For Past 30
  Months (Including Parent Company)

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Gold Seal Financial Criteria

• Meet a Combination of Financial Thresholds over
  Past Three Years
• Positive Current Ratio of At Least One
• current assets (due in 1 year) greater than
  current liabilities (cash equivalent within 1
  year)
• Positive Tangible Net Worth
• (total assets exceed total liabilities)
• Time Interest Earned Ratio of At Least 115
• (profit margin is at least 15 of the interest
  expense)

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Gold Seal Financial Criteria

• Note candidates must submit audited financial
  statements and a one-year set of pro-forma
  financial statements and meet two of three
  thresholds on the pro-forma and
• Two of three financial thresholds for two of the
  three most recent years (one of which must be the
  most recent year), or
• All three thresholds for the most recent year

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Gold Seal Criteria

• Staff Stability
• Turnover Rate of Not More Than 85
• A Stability Rate of At Least 50
• Evidence of Efforts To Maintain Stable Workforce
• Outstanding Ombudsman Complaint History
•  
• Evidence of Family And Community Involvement
•  
• Targeted In-Service Training Programs
• See Statute 400.235 and rule 59A-4 for Specific
  Requirements

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Gold Seal Process

• Applications received (minimum of five)
• Staff review for regulatory then financial
  criteria
• Ombudsman review
• Initial Panel review and site visit selection
• Site visits conducted
• Final Panel review, site visit reports, facility
  presentations, and decision regarding
  recommendation to Governor
• Final decision by Governor
• Gold Seal Awards presented

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Current Gold Seal Reviews

• Meeting July 26 in Tampa
• Four Facilities Recommended
• Governors Decision

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Gold Seal Benefits

• Facility Marketing
• Agencys NH Guide Web-site and in the Next
  Hard-copy Publication
• Public Inquiries Legislative
• Future Benefits
• Nursing Home Licenses
• Gold Seal Facility Best Practices
• Request an Extended Survey Cycle

Agency for Health Care AdministrationDivision of
Managed Care Health Quality
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Resources

• AHCA Web Site www.fdhc.state.fl.us
• AHCA Annual Report on Adverse Incidents
• Gold Seal Applications
• Licensure Applications and Forms
• Nursing Home Guide
• Nursing Home Watch Lists
• Florida Health Stats Locate Facilities/Providers
  
• Long-Term Care Unit [phone]

Agency for Health Care AdministrationDivision of
Managed Care Health Quality