1. Healthcare Licensing & Surveys Ron Pearson, M.H.A., C.F.A.A.M.A. State Survey Agency Director Laura Hudspeth, MSc, RD, LD Chief, Healthcare Surveillance Branch Julia Van Dyke, RN Lead Health Surveyor May 2013

2. HLS Mission –Federal (85%): Serve as the agency for certification of healthcare facilities operating in Wyoming (Title XVIII, Social Security Act, Section 1864) HLS acts on behalf of the Secretary (HHS) as Federal Contractor applying and enforcing Federal standards CMS Survey and Certification program assures basic levels of quality and safety for Medicare and Medicaid beneficiaries –State (15%): Serve as the regulatory agency for licensure to operate within Wyoming (WY Statutes 35-2-901 thru 35-2-910) Protect health, safety and welfare of patients (residents) of licensed healthcare facilities Jurisdictional authority over fire safety and building codes for construction involving healthcare facilities

3. Organization

4. Branches Business Office –Manages daily operations of office including records, reports, equipment, supplies, vehicles, IT, budget, and HIPAA/FOIA requests –Performs licensing and administrative functions –Maintains HLS website and training records Health Care Surveillance –Schedules and conducts unannounced, on-site, objective, and outcome- based surveys –Investigates complaints from all sources including EMTALA violations –Reviews/validates incidents reported by providers –Oversees CNA/LTC Abuse Registry and CNA Training Program –Directs training program Life Safety & Construction –Reviews and approves healthcare construction plans and projects –Conducts Life Safety code surveys for licensure and certification

5. PROVIDER TYPE# IN WYOMINGLICENSED ONLYCERTIFIED ONLYLICENSED & CERTIFIEDDEEMED Adult Day Care Center 88 Assisted Living Facility 26 Ambulatory Surgical Center 20 4 Boarding Home 99 Critical Access Hospital 16 1 Community Mental Health Center 33 Comprehensive Outpatient Rehabilitation Facility 11 End Stage Renal Dialysis Center 99 Federally Qualified Health Center 13 Freestanding Diagnostic Treatment Center 11 Home Health Agency 4314291 Hospital 11 10 Hospice Facility 19118 Intermediate Care Facility for Mentally Retarded 11 Nursing Care Facility 38 Outpatient Physical Therapy/ Speech Pathology 11 Psychiatric Residential Treatment Facility 33 Psychiatric Hospital 22 Rehabilitation Facility 22 Rehabilitation Hospital 111 Rural Health Clinic 18 Total Providers 245613814613

6. Surveyors SurveyorCertification (SMQT)Experience (Yrs)Credentials Linda BrownHealth11RN, BS, CPHQ Janelle ConlinHealth12OTR/L Russ ForneyHealth, CLIA7PhD, MT Larry GoodmayHealth, Life Safety9MS Catherine HoffHealth< 1RN, BS Tony MaddenHealth6RN Kathryn MayHealth2RN Pat PrinceHealth19RN, BSN Lori ReussHealth8RD, LD Julia Van DykeHealth<1RN Average7.5 yrs Note: Currently recruiting to fill 2 vacant surveyor positions

7. Wyoming Performance Standards FFY 2013 (As of 05/02/13) NURSING HOMES 38 providers TIERREQUIREMENTCURRENT STATUS COMPLETED Tier 115.9 Mo Max Interval 12.9 Mo Avg 13.4 Mo Max Interval 11.7 Mo Avg 0 > 15.9 Mo Tier 2NH Oversight & Improvement Program2:4 staggered surveys done 1 SFF Tier 3NA Tier 4NA

8. Comparison of Frequently Cited LTC Health Tags FY2013 (to date) (Data Source: S&C PDQ/Run Date: 05/07/2013) WYOMING Top 5 REGION 8 Top 5 NATIONAL Top 5 Tag #Description% Surveys Cited (15 surveys) Tag # Description% Surveys Cited (279 surveys) Tag # Description% Surveys Cited (6,639 surveys) F441Facility Establishes Infection Control Prog 73.3%F441Facility Establishes Infection Control Program 49.5%F441Facility Establishes Infection Control Program 37.8% F309Provide Necess Care for Highest Prac Well Being 53.3%F323Facility Is Free of Accident Hazards 45.9%F371Store/Prepare/Distrib Food Under Sanitary Conditions 34.5% F371Store/Prepare/Distrib Food Under Sanitary Conditions 46.7%F371Store/Prepare/Distrib Food Under Sanitary Conditions 43.0%F323Facility is Free of Accident Hazards 29.9% F323Facility is Free of Accident Hazards 40.0%F309Provide Necess Care for Highest Prac Well Being 35.5%F309Provide Necess Care for Highest Prac Well Being 24.9% F279Develop Comprehensive Care Plans 33.3%F329Drug Regimen is Free From Unnecessary Drugs 31.9%F329Drug Regimen is Free From Unnecessary Drugs 22.5%

9. Comparison of Frequently Cited LTC Health COMPLAINT Tags FY2013 (to date) (Data Source: S&C PDQ/Run Date: 05/07/2013) WYOMING Top 5 REGION 8 Top 5 NATIONAL Top 5 Tag #Description% Surveys Cited (25 surveys) Tag # Description% Surveys Cited (248 surveys) Tag # Description% Surveys Cited (21,532 surveys) F323Facility is Free of Accident Hazards 28.0%F323Facility is Free of Accident Hazards 12.1%F323Facility is Free of Accident Hazards 5.7% F241Dignity and Respect of Individuality 12.0%F309Provide Necess Care for Highest Prac Well Being 8.1%F309Provide Necess Care for Highest Prac Well Being 4.2% F441Facility Establishes Infection Control Prog 12.0%F441Facility Establishes Infection Control Prog 6.9%F157Inform of Accidents/Sig Changes/Transfer/Etc 2.6% F225Not Employ Persons Guilty of Abuse 12.0%F281Services Provided Meet Professional Standards 4.8%F225Not Employ Persons Guilty of Abuse 2.5% F425Pharmaceutical Svc – Accurate Procedures, RPH 12.0%F241Dignity and Respect of Individuality 4.0%F514Clinical Records Meet Professional Standards 2.1%

10. Comparison of Frequently Cited LTC Life Safety Code Tags FY2013 (to date) (Data Source: S&C PDQ/Run Date: 05/07/2013) WYOMING Top 5 REGION 8 Top 5 NATIONAL Top 5 Tag #Description% Surveys Cited (15 surveys) Tag # Description% Surveys Cited (279 surveys) Tag # Description% Surveys Cited (6,628 surveys) K147Electrical Wiring and Equipment 73.3%K062Sprinkler System Maintenance 48.4%K147Electrical Wiring and Equipment 31.1% K062Sprinkler System Maintenance 53.3%K147Electrical Wiring and Equipment 45.2%K062Sprinkler System Maintenance 30.4% K025Smoke Partition Construction 40.0%K038Exit Access37.6%K029Hazardous Areas – Separation 25.7% K050Fire Drills33.3%K018Corridor Doors36.6%K018Corridor Doors25.6% K052Testing of Fire Alarm 33.3%K029Hazardous Areas – Separation 34.4%K038Exit Access20.4%

11. Survey Citation Patterns Based on Last Current Uploaded Standard Health Surveys (Data Source: Casper 0311S / Run Date: 05/07/2013) # of Providers# of Providers Cited for SQC # of Providers Zero Health Deficiencies WY3811 Region6301542 U.S.15,6864311,505

12. Average Number of Deficiencies (Data Source: S&C PDQ / Run Date: 05/07/2013)

13. Complaints

14. Nursing Homes

15. Complaints Assisted Living Facilities

16. Informal Dispute Resolution (IDR) Informal opportunity to challenge facts and evidence surrounding disputed deficiencies Informal administrative process—not formal evidentiary hearing May dispute assigned scope and severity of citation if it has resulted in substandard quality of care or immediate jeopardy IDR frequency 6 (FFY 2011) 8 tags requested = 4 upheld, 2 modified 2 reversal 3 (FFY 2012) 3 tags requested = 1 upheld, 1 modified, 1 reversal 3 (FFY 2013 to date) 5 tags requested = 2 upheld, 2 modified, 1 reversal

17. How HLS Is Evaluated –Standard Surveys Comprehensive survey of all major requirements for quality –Complaint Investigations Investigation of complaint and provider’s compliance with CMS requirements –Comparative Surveys CMS conducts independent survey within 60 days of State survey to compare results –Observational Surveys (Federal Oversight Surveys) CMS team accompanies State survey team –State Performance Standards Review CMS assessment of State Survey Agency’s performance in targeted review areas –Frequency (6 standards) –Quality (8 standards) –Enforcement (3 standards)

18. State Performance Standards Review (FY 2012) FREQUENCYMet / Not Met Off Hours Surveys for Nursing HomesMet Frequency of Nursing Home SurveysMet Frequency of Non-Nursing Home Surveys – Tier 1Met Frequency of Non-Nursing Home Surveys – Tier 2Met Frequency of Non-Nursing Home Surveys – Tier 3Met Frequency of Data Entry of Standard Surveys (Non-Deemed Hosp/NH) NH – Met NDH - Not Met (3 CAHs – avg 71 days)

19. State Performance Standards Review (FY 2012) QUALITYMet / Not Met Documentation of Deficiencies on Form CMS-2567Met Conduct of NH Surveys IAW Federal Standards (FOSS)Met Documentation of Non-Compliance IAW Federal Standards (FOSS)Met Accuracy of Documentation During NH Comparative SurveysMet Prioritizing Complaints and IncidentsMet Timeliness of Complaint and Incident InvestigationsMet Quality of EMTALA InvestigationsMet Quality of Complaint/Incident Investigations for Nursing HomesMet

20. State Performance Standards Review (FY 2012) ENFORCEMENTMet / Not Met Timeliness of Mandatory DPNA Notification for Nursing HomesMet Processing of Termination Cases for Non-NH Providers/SuppliersMet Special Focus Facilities for Nursing HomesMet

21. Federal Oversight Surveys (FOSS) (2011 - 2012) SURVEY TEAM CONCERN IDENTIFICATION SAMPLE SELECTION GENERAL INVESTIGATION KIT/FOOD SVC INVESTIGATION MEDICATIONS INVESTIGATION DEFICIENCY DETERMINATION NH Survey (Amie Holt)Betty, Pat 555555 NH Survey (Sage View) Linda, Kathy, Karla 555454 Complaint Inv. (Cheyenne HC) Tony 555N/R 5 NH Survey (Thermopolis) Linda, Lori, Larry, Kathy 555535 NH Survey (Pioneer) Pat, Betty, Kathy, Larry 555555 NH Survey (Life Care Chey) Pat, Lori, Linda 555555 5 = Extremely Effective 4 = Very Effective 3 = Satisfactory 2 = Less Than Satisfactory 1 = Much Less Than Satisfactory

22. Federal Oversight Surveys (FOSS) (2013) SURVEY TEAM CONCERN IDENTIFICATION SAMPLE SELECTION GENERAL INVESTIGATION KIT/FOOD SVC INVESTIGATION MEDICATIONS INVESTIGATION DEFICIENCY DETERMINATION NH Survey (Westview) Pat, Linda, Russ, Larry, Rae Anne 555555 NH Survey (Life Care Chey) Linda, Pat, Lori 555555 5 = Extremely Effective 4 = Very Effective 3 = Satisfactory 2 = Less Than Satisfactory 1 = Much Less Than Satisfactory

23. Civil Monetary Penalties Background CMS sets health, safety and quality requirements that facilities must meet in order to participate in Medicare and Medicaid programs CMS routinely inspects nursing homes to ensure compliance with requirements for participation Congress has authorized CMS to impose enforcement remedies to achieve facility compliance with requirements Remedies are designed to minimize time between identification of violations and final imposition of remedies –May range from directing specific actions and timeframes needed to correct a deficiency under a directed plan of correction to those that provide facilities with financial incentives to return to and maintain compliance –Considerations: »Scope & Severity of deficiency (ies) »Relationship of one deficiency to other deficiencies »Facility’s prior history of noncompliance »Likelihood that remedy(ies) will achieve correction and continued compliance

24. Civil Monetary Penalties (Cont’d) Selecting Enforcement Remedies –Severity of remedy should increase with severity of deficiency –Immediate Jeopardy, J, K, and L: Facilities are terminated within 23 days or temporary management is imposed. CMPs from $3,050 to $10,000 per day or $1,000 to $10,000 per instance of noncompliance may also be imposed –Noncompliance that is actual harm (G, H, and I) require one or a combination of remedies: »Temporary management »Denial of Payment for New Admissions (DPNA) »Per day CMP of $50 to $3,000; or »Per instance CMP of $1,000 to $10,000 per instance of noncompliance –Additional remedies may be imposed for noncompliance that is actual harm »Depends on severity of deficiency and facility’s compliance history »Combination of state monitoring, DPNA, and a CMP may be imposed

25. Other Issues Electronic incident reporting Involuntary discharges from LTC facilities Non-payment Safety issue (perceived danger to staff or residents) Resident may appeal decision to State Office of Administrative Hearings WDH Director makes final decision Currently working with AG, DUPRE & CMS to clarify policy guidance

26. Reporting Alleged Abuse Put processes in place to ensure either the providers, complainants, or HLS staff are notifying DFS or law enforcement of allegations of abuse/neglect/financial exploitation –DFS presentation at HLS In-Service Training –Met with DFS (APS) Representative –Health Surveys Review policies, ask for abuse log/file, staff interviews Adherence to written policies (screen, in-service, how allegations investigated) All allegations must be investigated and resident protected Reported to law enforcement or DFS and additional agencies (HLS, BON, Ombudsman) –Incident Reporting Same requirements

27. Rules for Assisted Living Facilities Jan 2013: ALF Working Group formed Reps from ALFs, associations, Medicaid, HLS 23 issues/topics introduced for evaluation Feb 2013: Subgroups formed to work issues Management (Laura Hudspeth) Care (Sharon Skiver) Life Safety (Todd Wyatt) Staffing (Julia Van Dyke) Jun 2013: Subgroups recommend Rules changes Jul – Sep 2013: Promulgate changes to Rules

28. Questions ?