2. Agenda *Kinds of Surveys *Rural Health Clinic Locations *Budget Issues *Helpful Web Sites

3. Here is your survey. No big deal. Or is it?

4. This is the CMS-2567 Statement of Deficiency

5. How to be a recipient of a 2567 In order to receive a prestigious CMS-2567 suitable for framing, KDHE will need to conduct an on- site survey. Surveys are generally one of three types: In order to receive a prestigious CMS-2567 suitable for framing, KDHE will need to conduct an on- site survey. Surveys are generally one of three types: Re-Survey Re-Survey Complaint Complaint Validation Survey Validation Survey

6. Survey Progression …. Good advice would be to stay centered. Survey triggered by Re-survey, complaint or validation survey Immediate Jeopardy (IJ) and COP- 23 day termination notice from CMS CMS-2567 comes from CMS with Termination notice. Abating IJ Removes 23 notice Survey results in No deficiencies or Findings. Provider submits Plan of Correction POC One or more COP’s CMS-2567 comes from SA With Termination Notice. SA to Revisit in 45 days.

7. Don’t go LEFT ……. 23 Day Termination Time Frames Survey triggered by Re-survey, complaint or validation survey Immediate Jeopardy (IJ) and COP- 23 day termination notice from CMS Day 1 Survey complete Day 2 Notification Day 3 Info to RO Day 5 Public Notice Day 10 Other info to CMS Day 23 Termination ………………………….

8. Don’t go RIGHT either ……. 90 Day Termination Time Frames Survey triggered by Re-survey, complaint or validation survey ……………….………… One or more Conditions of Participation C.O.P. Day 1 Date of Survey Day 10 SA Send Letter Day 45 SA Revisits Day 55-65 Continued COP’s Day 70 Public Notice Day 90 Termination

9. Stay Centered ….. Survey triggered by Re-survey, complaint or validation survey ………………… Survey results in No deficiencies or Minimal Findings Or Standards. Provider submits Plan of Correction POC Generally no revisit. ……………….

10. Why complete the CMS-2567? The Statement of Deficiencies The Statement of Deficiencies Surveyors visit your facility, write any deficiencies on the Statement of Deficiencies form, and then provide it to you. Write your plans for corrections on the form and return it to KDHE. The Statement of Deficiencies: Is the basic document available to the public about your facility's deficiencies and what is being done to remedy them. Provides an opportunity for you to furnish documentation that requirements have been met. Provides an opportunity for you to furnish documentation that requirements have been met.

11. Lets talk about rural health clinics!

12. Rural Health Clinic (RHC) 42 CFR 491.2 …. Means a clinic that is located in a rural area designated as a shortage area, is not a rehabilitation agency or a facility primarily for the care and treatment of mental disease, and meets all other requirements of this subpart. CMS has advised KDHE that a RHC can operate one rural health clinic from separate suite numbers within the same building with the same street address.

13. For example, one or more RHC’s on the first floor of this building and/or …… RHC #2 17-8918 RHC #1 17-8918

14. … a RHC on the second floor could operate with a single Medicare Provider Numbers. RHC #3 17- 8918

15. 42 CFR 491.5 Location of Clinic If clinic or center services are furnished at permanent units in more than one location, each unit is independently considered for approval as a rural health clinic. Each RHC requires their own provider number if they are located in separate buildings.

16. The key to our (or CMS) determination about whether or not one number will suffice is this … As long as both RHCs are provider-based and located on the campus of the main provider, they could be considered as one location. The clinic would need to ensure the requirements located at 42 CFR 491.6(a) are met. Specifically, the clinic must be "constructed, arranged, and maintained to insure access to and safety of patients, and provides adequate space for the provisions of direct services."

17. Separate Buildings – Separate Numbers RHC 17-8524 RHC 17-8534

18. Budget Issues

19. Health Facility Survey staff October 1, 2008 October 1, 2008 11 FTE’s July 10, 2009 July 10, 2009 8 FTE’s

20. Federal Funds Since federal funding was only sufficient at the outset to support approximately 6.5 FTE’s, KDHE has opted to conduct more risk management surveys and not replace staff that have terminated in 2009. Our federal fiscal year ends September 30, 2009. Since federal funding was only sufficient at the outset to support approximately 6.5 FTE’s, KDHE has opted to conduct more risk management surveys and not replace staff that have terminated in 2009. Our federal fiscal year ends September 30, 2009.

21. One time special funds for ….. Kansas has applied for one time funding from CMS to assist in conducting surveyors for providers that have no accrediting body to turn to for certification surveys. This would include such entities as RHC, ESRD, OPPT, Swing Beds, etc. Kansas has applied for one time funding from CMS to assist in conducting surveyors for providers that have no accrediting body to turn to for certification surveys. This would include such entities as RHC, ESRD, OPPT, Swing Beds, etc.

22. What do the federal regulations require that we absolutely must survey?

23. The priority with which we conduct surveys is categorized into TIER’s. TIER-I is the first and highest priority.

24. The Tiers are contained in the budget that is also referred to as … “THE MISSION and PRIORITY DOCUMENT”

25. Tier Structure Tier I Tier II Tier III Tier IV High (do first) High (do first) HHA, Hospital Val & complaints High Medium High Medium 10% ASC, 5% hospitals & 10% ESRDs, 5% Targ. Samples. Mid-Level Mid-Level Non AO initials, 4 & 7 year requirements Lowest Priority Lowest Priority Remaining initials and greater Freq

26. Helpful Websites

27. INTERPRETIVE GUIDELINES The Interpretive Guidelines and Survey Procedures for various providers or suppliers are located in the Appendices to the State Operations Manual (SOM). For example: Hospitals = Appendix A, Psychiatric Hospitals = Appendix AA, EMTALA= Appendix V, or Critical Access Hospitals = Appendix W. There are many other appendices. One way to obtain a specific Appendix is to go to the webpage for the Table of Contents page for the Appendices to the SOM. Once at that page ‘click’ on the Appendix you wish to access. The Table of Contents Page for the SOM is found at: The Interpretive Guidelines and Survey Procedures for various providers or suppliers are located in the Appendices to the State Operations Manual (SOM). For example: Hospitals = Appendix A, Psychiatric Hospitals = Appendix AA, EMTALA= Appendix V, or Critical Access Hospitals = Appendix W. There are many other appendices. One way to obtain a specific Appendix is to go to the webpage for the Table of Contents page for the Appendices to the SOM. Once at that page ‘click’ on the Appendix you wish to access. The Table of Contents Page for the SOM is found at: www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc. pdf www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc. pdf www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc. pdf www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc. pdf

28. SURVEY AND CERTIFICATION LETTERS CMS Survey and Certification (S&C) releases information related to survey and certification guidance for various providers and suppliers to its Regional Offices and the State Survey Agencies through communications called Survey and Certification Letters. The letters are released on an ongoing basis. Once a letter is released, it is posted on the CMS website. The letters are organized by Federal fiscal years. For example, the first letter released for fiscal year 2009 would be labeled “S&C 09-01”. The S&C letters can be obtained at: CMS Survey and Certification (S&C) releases information related to survey and certification guidance for various providers and suppliers to its Regional Offices and the State Survey Agencies through communications called Survey and Certification Letters. The letters are released on an ongoing basis. Once a letter is released, it is posted on the CMS website. The letters are organized by Federal fiscal years. For example, the first letter released for fiscal year 2009 would be labeled “S&C 09-01”. The S&C letters can be obtained at: www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp

29. CMS HOME PAGE www.cms.hhs.gov www.cms.hhs.gov www.cms.hhs.gov

30. CMS SURVEY AND CERTIFICATION HOME PAGE The page provides general information regarding the activities of CMS Survey and Certification. The Interpretive Guidelines and S&C letters may also be accessed from this page. The page provides general information regarding the activities of CMS Survey and Certification. The Interpretive Guidelines and S&C letters may also be accessed from this page. www.cms.hhs.gov/SurveyCertificationGenInfo www.cms.hhs.gov/SurveyCertificationGenInfo www.cms.hhs.gov/SurveyCertificationGenInfo

31. ELECTRONIC CFR (e-CFR) The e-CFR is an electronic version of the Code of Federal Regulations (CFR). The CFR is divided into “Titles”, with “Title 42 Public Health”, containing CMS regulations. The Federal Register within the Government Printing Office publishes the CFR of an annual basis. The e-CFR is updated on an ongoing basis. The web address for the e-CFR is: The e-CFR is an electronic version of the Code of Federal Regulations (CFR). The CFR is divided into “Titles”, with “Title 42 Public Health”, containing CMS regulations. The Federal Register within the Government Printing Office publishes the CFR of an annual basis. The e-CFR is updated on an ongoing basis. The web address for the e-CFR is: http://ecfr.gpoaccess.gov http://ecfr.gpoaccess.gov http://ecfr.gpoaccess.gov

32. SOCIAL SECURITY ACT The laws that apply Medicare, Medicaid and other CMS programs are located in the Social Security Act (referred to as “The Act” or “SSA”). The Act is divided up into “Titles”. Medicare is Title XVIII and Medicare is Title XIX. The web address to obtain the online SSA is: The laws that apply Medicare, Medicaid and other CMS programs are located in the Social Security Act (referred to as “The Act” or “SSA”). The Act is divided up into “Titles”. Medicare is Title XVIII and Medicare is Title XIX. The web address to obtain the online SSA is: http://www.ssa.gov/OP_Home/ssact/ssact- toc.htm http://www.ssa.gov/OP_Home/ssact/ssact- toc.htm http://www.ssa.gov/OP_Home/ssact/ssact- toc.htm http://www.ssa.gov/OP_Home/ssact/ssact- toc.htm

33. Who to call: Charles Moore, Director Medical Services Bureau of Child Care & Health Facilities 1000 SW Jackson, Suite 200 Topeka, KS 66612 e-mail: cmoore@kdhe.state.ks.us Charles Direct Line 785-296-0131 FAX:785-291-3419 cmoore@kdhe.state.ks.us

34. Web site for Critical Access Hospital (CAH) Federal Regulations and Guidelines Appendix W http://www.kdheks.gov/bcchf/index.html Click on Bureau of Health Facilities and then forms to get to the above. http://www.kdheks.gov/bcchf/index.html

35. Other contacts in our Bureau: Anita Hodge RN, State Survey Manager 296-0127 Lynn Searles, Risk Management Specialist 291-3552 Tamara Wilkerson, Licensure & Certification 296-1263 Coordinator Lois Wilkins, Sr. Admin Assist-Licensure 296-1258 Theresa Carter, Sr. Admin Assist-Certification 296-1249 (all are Area code 785)

37. QUESTIONS? QUESTIONS?