AHCA Home Health Regulatory Update Anne Menard Home Care Unit Bureau of Health Facility Regulation Agency for Health Care Administration July 23,

Licensed as of July 10, ,217 home health agencies County with largest #: Miami-Dade 669 Broward 256 Palm Beach nurse registries Broward 110 Palm Beach 108 1,704* homemaker companion services Miami-Dade 191 Broward 179 * Decrease is due to 2012 law exempting businesses that only serve developmentally disabled clients under contract with the Agency for Persons with Disabilities. 2

2,217 Home Health Agencies 71% Certified for Medicare and/or Medicaid 1,016 Medicare only 62 Medicaid only 490 Medicare & Medicaid 649 not Medicare or Medicaid (29%) – 163 have applied for Medicare and/or Medicaid As of 7/10/2013 3

Home Health Agency Rules Florida Administrative Code, Chapter 59A-8 Chapter 59A-8 was updated with some new items added that were required in state law, some items removed for regulatory reduction, and some items revised. The rule revisions were effective July 11, Updated standards for surveyors will not be in use until August. Rules cannot repeat what is stated in the law. Thus, home health agencies must follow both laws & rules: Florida Statutes and Florida Administrative Code. 4

Home Health Agency Rules Many of the rules and laws are enforced through on-site surveys. State survey standards are verbatim quotes from rules and laws. Survey standards are in the State Regulation Set used by surveyors at - select “Home Health Agency” and select the “Laws, Rules and Surveys” tab. The revised State Regulation Set with the latest rule revisions will be at this site by August. Accrediting organizations must include state requirements when they survey your agency. 5

State Law Required AHCA to Write Additional Director of Nursing Rules Is every home health agency required to have a director of nursing? No “A home health agency that is not Medicare or Medicaid certified and does not provide skilled care or provides only physical, occupational, or speech therapy is not required to have a director of nursing.” (2)(c), Florida Statutes The state law (5),F.S., requires AHCA to write the rules for oversight by the director of nursing. There are three parts to this law: 1. Standards for oversight: , Florida Statutes “Rules establishing minimum standards.—The agency shall adopt, publish, and enforce rules ….which must provide reasonable and fair minimum standards relating to: … (5) Oversight by the director of nursing. The agency shall develop rules related to: (a) Standards that address oversight responsibilities by the director of nursing of skilled nursing and personal care services provided by the home health agency’s staff;” 6

New Director of Nursing Rule 59A (2)(d), FAC The new rule says: “The director of nursing shall establish a process to verify that skilled nursing and personal care services were provided.” 59A (2)(d), FAC The process is not specified in the rule & is left up to each home health agency to determine. Your agency should have already have some way of verifying that, for example, Nurse James went to the home of patient John Smith on Tuesday to provide nursing care. 7

New Director of Nursing Rules 2. A certified daily report upon request The state law requires: (5), F.S. states…. “The agency shall develop rules related to: (b) Requirements for a director of nursing to provide to the agency [AHCA], upon request, a certified daily report of the home health services provided by a specified direct employee or contracted staff member on behalf of the home health agency. The agency may request a certified daily report only for a period not to exceed 2 years prior to the date of the request;” 8

New Director of Nursing Rule 59A (2)(d), FAC The new rule says: When requested by an AHCA employee, the director of nursing shall provide a certified report that lists the home health services provided by a specified direct service staff person or contracted staff person for a specified time period. What is meant by “home health services”? The law states: ‘Home health services’ means health and medical services and medical supplies furnished by an organization to an individual in the individual’s home or place of residence ……: (a) Nursing care (b) Physical, occupational, respiratory, or speech therapy (c) Home health aide services (d) Dietetics and nutrition practice and nutrition counseling (e) Medical supplies, restricted to drugs and biologicals prescribed by a physician (14), F.S. 9

New definition in rule 59A-8.002(20), FAC “Nursing care” means treatment of the patient’s illness or injury by a registered nurse or a licensed practical nurse that is ordered as required in (2), F.S.* and included in the plan of care. * (2), Florida Statutes, refers to treatment orders by a physician, physician’s assistant or advanced registered nurse practitioner. (This state law applies to licensed agencies. Medicare & Medicaid agencies still are required to have orders by physicians per federal regulation 42 CFR (c).) 10

New Director of Nursing Rule 59A (2)(d), FAC continued The new rule also says: “ A certified report shall be in the form of a written or typed document or computer printout and signed by the director of nursing. The report must be provided to the surveyor within two hours of the request, unless the time period requested is longer than one year, then the report must be provided within three hours of the request.” What do you already have in place at your agency that could be used to show that the specified staff person provided the service (home health aide, nursing care, physical therapy…etc.) on the requested days? Your existing scheduling documents or computer scheduling type programs that show the patient visits made by staff each day? Telephony reports for Medicaid visits? A log or other document staff turn in that shows the patients that were visited & the service (i.e. home health aide, nursing care, etc.)? 11

New Director of Nursing Rules 59A (2)(d), FAC continued When would a certified report be requested? Here are some examples: A surveyor may ask for such a report when there is concern that services were not provided by a staff person -- such as when investigating complaints of patient neglect, false billing or falsification of records. On a survey, 3 patient records have no notes to show that all the nursing visits were made more than 2 months ago as specified in each patient’s plan of care. The agency cannot provide any nurses notes when requested, but says the nurses did make the visits. 12

New Director of Nursing Rules continued 3. A quality assurance program The state law requires: (5), F.S. states….“The agency shall develop rules related to: (c) A quality assurance program for home health services provided by the home health agency.” The state rule: A quality assurance program was already in rule. New items have been added & are underlined below. 59A (2)(e), FAC “The director of nursing shall establish and conduct an ongoing quality assurance program. The program shall include at least quarterly, documentation of the review of the care and services of a sample of both active and closed clinical records by the director of nursing or his or her delegate. The director of nursing assumes overall responsibility for the quality assurance program. How many records should the agency review in its sample? Your home health agency decides how many. 13

New Director of Nursing Rules Quality Assurance Program continued 59A (2)(e) “The quality assurance program is to assure that: 1. The home health agency accepts patients whose home health service needs can be met by the home health agency; 2. Case assignment and management is appropriate, adequate, and consistent with the plan of care, medical regimen and patient needs. Plans of care are individualized based on the patient’s needs, strengths, limitations and goals.; 3. Nursing and other services provided to the patient are coordinated, appropriate, adequate, and consistent with plans of care. 4. All services and outcomes are completely and legibly documented, dated and signed in the clinical service record; 5. The home health agency’s policies and procedures are followed; 6. Confidentiality of patient data is maintained; and 7. Findings of the quality assurance program are used to improve services.” 14

New Director of Nursing Rules Quality Assurance Program continued Are all patient records required to be sampled for quality assurance? No. Quality assurance is required only for clinical records of patients receiving skilled services (nursing care, physical, occupational, respiratory and speech therapy, dietetics and nutrition practice and nutrition counseling, social work). The therapy-only home health agencies are not required to have a director of nursing in state law and thus, are not included. Patients that are only receiving home health aide services (including services provided by certified nursing assistants), homemaker, and companion services are not included. 15

Director of Nursing Rules Rule on biomedical waste has been updated Policies and procedures may now be developed by the administrator or alternate administrator, not just the direct of nursing. The revision clarifies that rule only apply to agencies that provide nursing and physical therapy The requirement to comply with specific Department of Health rules has been removed, referring instead to the Department’s web site. 59A (2)(b), FAC “ The director of nursing, the administrator, or alternate administrator shall establish policies and procedures on biomedical waste for home health agencies providing nursing and physical therapy services. The Department of Health website has information on biomedical waste handling and the requirements at

Home Health Agency Rules Updated Regulatory reduction changes 1.Removes the 1-year experience requirement for physical therapist, occupational therapists, and therapists assistants; 59A (6)(8) 2.Permits training of home health agency staff to be done at drop-off sites to save costs; 59A-8.003(8) 3.Chapter 59A-8 is shorter since items that are now in 408, Part II, F.S. and 59A-35 have been removed. 4. Rather than specify tasks that can be performed in the rules, the RN, LPN, PT, PTA, OT and OTA rules refer to the scope of practice authorized by the license issued for each of these professions. Here’s one: An LPN shall… “provide care to the patient, including the administration of medications within the scope of practice authorized by the license issued by the state of Florida for a licensed practical nurse.” 17

Home Health Agency Rules Updated Regulatory reduction changes 5. Change of administrator or alternate : Removes requirement to submit a resume and affidavit of good moral character when there is a change in the administrator or alternate administrator. Still requires notification of new administrator (not alternates) and a statement that the person meets the requirements in law. 59A (1)(b) “If an agency changes administrator the agency shall notify the AHCA Home Care Unit office in Tallahassee as required in subsection 59A (1), F.A.C. Notification shall consist of submission of the person’s name and a statement that the person meets the qualifications in Sections (1) and (1), F.S. Send the notification by , fax or mail …The administrator also must submit level 2 screening…or inform the Home Care Unit that level 2 screening was previously submitted.” 18

Home Health Agency Rules Updated Regulatory Reduction 6. Home health aides & certified nursing assistants Removes the requirement for certified nursing assistants to have training on specific items (59A (5)(i)). The rule used to say: (i) A home health agency shall ensure that a certified nursing assistant has competency in the home health core curriculum listed in subparagraphs 59A (5)(d)2. and 13. through 16., F.A.C. The requirement in the law is sufficient without the training that was specified in rule (3) “TRAINING.—A home health agency shall ensure that each certified nursing assistant employed by or under contract with the home health agency and each home health aide employed by or under contract with the home health agency is adequately trained to perform the tasks of a home health aide in the home setting.” 19

Home Health Agency Rules Updated Home health aides & certified nursing assistants (continued) It is up to the home health agency to determine if the CNA is “adequately trained to perform the tasks of a home health aide” or not as the law requires. Here are some possible ways --- Check references for any home health agency or individual patient Give the AHCA home health aide competency test. [Note – Medicare and Medicaid home health agencies have more competency evaluation requirements in federal survey standards from federal regulations 42 CFR and (b)(3) to (5)] Have an RN or LPN accompany the CNA on a home visit. The CNA may already have home health aide training… 20

Rules Updated Home Health Aides & Certified Nursing Assistants 59A (5)(l)3 adds the tasks associated with elimination that a home health aide and certified nursing assistant may do as requested by home health agencies. 3. b. Assisting with tasks associated with elimination: i. Toileting ii. Assisting with the use of the bedpan and urinal iii. Providing catheter care including changing the urinary catheter bag iv. Collecting specimens v. Emptying ostomy bags, or changing bags that do not adhere to the skin” 21

Rule Revisions Homemakers 59A (12)(a) Here are the paragraphs that are revised: (12)(a) The homemaker shall:… “2. Perform the functions generally undertaken by the customary homemaker, including such duties as preparation of meals, laundry, shopping, household chores, and care of children;” “8. If requested by the client or his responsible party, the homemaker may verbally remind the client that it is time to for the client to take his or her medicine.” 22

Rule Revisions Companions 59A (12)(b) Here are the paragraphs that are revised: (12)(b) The companion shall:…. “2. Accompany the client to doctor appointments, recreational outings, or shopping;” “8. If requested by the client or his responsible party, the companion may verbally remind the client that it is time for the client to take his or her medicine.” 23

Rule Revisions Clinical Records – 59A-8.022(6)(b) Rubber stamp signatures for physicians are no longer permitted. Advanced Directives 59A (2)(a) Use the April 2006 version of the “Health Care Advanced Directives – The Patient’s Right to Decide” rather than the 2004 for new patients. Still available at 24

Rule revisions 59A Comprehensive Emergency Management Plans Changes to the Comprehensive Emergency Management Plan (CEMP) form: The one-page “Information for Home Health Agency Patients” (Appendix B of the CEMP form) to the patient has one important sentence changed: “(1) If the patient has a caregiver*, the caregiver must accompany the patient and must remain with the patient at the special needs shelter.” *Caregivers can be relatives, household members, guardians, friends, neighbors and volunteers. The title “safety liaison” is used for the person in charge during an emergency as required in (1), F.S. The law on the cover page has been changed to use “State Surgeon General” instead of the Secretary of the Department of Health. HHAs do not have to re-do their CEMP Plans because of these changes, but please use the updated Information for HHA patients that may go to the special needs shelter. 25

Comprehensive Emergency Management Plan Updates Review your plan annually & update procedures Submit changes in telephone #s & names of staff who lead your agency’s emergency response (your “Safety Liaison” ) to the county emergency management office & to the county health department. – Home Health agencies licensed for multiple counties report changes to each county health department & each county emergency management office. – Must include phone #s where staff can be contacted outside of the HHA’s regular office hours. 26

Home Health Agency Quarterly Report 2013 law changes reduced the fine for failure to report within the required time frame to: $200 a day for each day late up to a maximum of $5,000 Some home health agencies no longer have to report. “ A home health agency is exempt from submission of the report and the imposition of the fine if it is not a Medicaid or Medicare provider or if it does not share a controlling interest with a licensee, as defined in s , which bills the Florida Medicaid program or the Medicare program.” (7), F.S. 27

Home Health Agency Quarterly Report As you know, Single Sign On is used to submit your quarterly report through the AHCA web portal. Single Sign on is not an organization account for your agency, it is an individual account. The User name and password that is created belongs to the individual and should not be shared. There are two systems that use Single Sign On now and soon there will be a third: Background Screening Home Health Quarterly Report On-Line Home Health Agency Licensure Providers access the AHCA Portal through Single Sign On to use one of the three systems or all three if a single user requests access to each system. Many HHAs have staff that have forgotten their password. There are instructions on the steps for getting a new password. When the staff person who had the password leaves, a new user agreement must be completed. Call the AHCA Home Care Unit if you need help, (850)

Background Screening Care Provider Background Screening Clearinghouse Provides a single data source for background screening results of persons required to be screened by law for employment in positions that provide services to children, the elderly, and disabled individuals. Allows the results of criminal history checks to be shared among specified agencies when a person has applied to volunteer, be employed, be licensed, or enter into a contract that requires a state and national fingerprint-based criminal history check. Seven total state agencies will participate in the Clearinghouse— 1.Department of Health (DOH) 2.Department of Children and Families (DCF) 3.Department of Juvenile Justice (DJJ) 4.Department of Elder Affairs (DOEA) 5.Agency for Persons with Disabilities, and (APD) 6.Vocational Rehabilitation (DOE-VR) To be entered into the Clearinghouse, a person screened must: Undergo Level 2 screening and have fingerprints retained by FDLE, and Have a photograph taken at the time of screening, and Sign a privacy policy 29

Current Clearinghouse functionality Initiating a Clearinghouse Screening: It is very important for all screenings to be initiated through the Clearinghouse website prior to sending an applicant for fingerprinting. Initiating the original screening online will provide the privacy policy required for the employee to be included in the Clearinghouse and will also supply a view of the Florida Public Rap Sheet. Also, initiating the screening allows the ability to track a screening through the process and updates when an employee’s status has been changed or updated. To register and begin initiating screenings please visit the website at Your agency can initiate a screening and have the employee schedule and pay their own LiveScan appointment. (This is not available for all LiveScan vendors. Please contact the vendor and ask.) Print the LiveScan Request form for the applicant, employee or contractor to take to the vendor. 30

Current Clearinghouse Functionality Privacy Policy: Applicants must sign a privacy policy in order for their screening to be entered into the Clearinghouse. The privacy policy is available during the ‘Initiate New Screening’ process on the website. Employers must retain a copy of the privacy policy in the employee’s personnel file. Initiating an Agency Review: If an individual has been screened by another specified agency (i.e. Dept. of Health) and entered into the Clearinghouse, an AHCA provider must request an agency review on the Clearinghouse website. This will allow AHCA to make an eligibility determination for employment purposes without the provider having to pay for a completely new screening. 31

Current Clearinghouse functionality continued Initiating a Resubmission: The retention of fingerprints (effective for screenings on or after January 1, 2013) provides a cost savings for applicants that are in the Clearinghouse but have had a lapse in employment greater than 90 days. If there has been a 90 day lapse in employment, these applicants would only require a new national criminal history check – a resubmission of the retained fingerprints. A new state criminal history search will also be conducted, at no additional charge. A resubmission can be requested and paid for directly through the Clearinghouse website. Arrest and Criminal Registration Notifications: The retention of fingerprints will allow the Florida Department of Law Enforcement (FDLE) to report any new arrest/registration information to the specified state agencies. At this time the Agency is receiving arrest/registration notifications from FDLE and manually updating the employee’s eligibility as necessary. Bulletin Messages: Important updates will be displayed on the Home Page of the Clearinghouse results website. Providers should regularly check the home page for notifications regarding system outages, new regulations, etc. 32

Employee Roster “Employee” means any person required by law to be screened pursuant to this chapter, including, but not limited to, persons who are contractors, licensees, or volunteers (2), F.S. According to section (2)(c), F.S., an employer of persons subject to screening by a specified agency must register with the Clearinghouse and maintain the employment status of all employees within the Clearinghouse. Initial employment status and any changes in status must be reported within 10 business days. Current employees screened since January 1, 2013, who have a photo, retained prints, and a signed privacy policy must be added to the employee roster immediately or their status will change to “Resubmission Required-90-day lapse in employment” and payment will be required for a resubmission. You must add an employee to your employee roster to receive arrest and criminal registration notifications. Please remember, per section (2)(b), F.S., if an employer becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the employee in a role that requires background screening. * We are aware and currently working on the glitch in the system that won’t allow for licensed employees to be added to the employee roster. Please add them as an “Employee/Staff Person” until this situation is resolved. 33

Benefits of the Clearinghouse Allows the results of criminal history checks to be shared among specified state agencies, thereby reducing duplicative screenings for individuals requiring screening across multiple state agencies. Applicants will now have their fingerprints retained for a period of 5 years. The retention of fingerprints enables a provider to be notified of an arrest of their employee as soon as the information is reported to the Agency by FDLE. The retention of fingerprints will also provide a cost savings for those employees that are in the Clearinghouse but have had a lapse in employment greater than 90 days. After a 90 day lapse in employment, these applicants would only be required to pay for a new national criminal history check (currently $16.50). Provides a photo of the applicant taken at the time of screening. –The provider can verify that the person who applied for the position is the same person that had their background screening done. 34

Clearinghouse Statistics From January 1, 2013 to June 30, 2013: – 421 individuals arrested AFTER they were screened (rap backs)  149 individuals went from Eligible to Not Eligible for offenses including:  Grand Theft  Battery and Assault  Sex Offenses  Exploitation of the Elderly 35

Agency for Health Care Administration Background Screening Resources Agency for Health Care Administration Web Site -- See the Background Screening Clearinghouse Instruction Guide at the home page. Questions/Comments/Issues 36

CMS Temporary Moratorium on New Medicare Home Health Agencies in 2 Counties Miami-Dade and Monroe counties Beginning July 30 Denies the enrollment of new Medicare home health agencies Federal Register announcement is coming – watch the Home Health Agency Center at the CMS web site for the announcement Agency-HHA-Center.html

If your has changed since your last application Please let AHCA Home Care Unit know – send an to with your correct address. So you can get s including blasts sent by AHCA 38

If you don’t agree with the surveyor 1. Ask the surveyor to show you the survey standard or law, rule 2. Discuss with surveyor at Exit Interview 3. Contact the AHCA Field Office Manager 4. If still not resolved, contact AHCA Chief of Field Operations, Polly Weaver (850)

Contacting AHCA When you have questions about your survey or any standard that was cited as not met - Call the Field Office Manager or Supervisor When you have questions about laws, rules, the application form or requirements –1 st check - click on “Home Health Agency” or “Nurse Registry” - See Frequently Asked Questionshttp://ahca.myflorida.com/homecare –Then call the Home Care Unit (850) or, send an to 40

See “Locate” “Facilities and Providers” “Search by Facility Type/Location” Now “Advanced Search” has “Service Area” Select county & get all licensed for that county – includes those that may not be located in county Updated nightly from licensing data Can now get Excel listings by county & statewide

Get the AHCA Smartphone Facility Locator Application For information on facilities or agencies & driving directions See select “Find Facilities or Providers” and see “Smartphone Apps” 42

Contact information – Home Health Agencies & Nurse Registries Anne Menard – Supervisor Home Care Unit – 6 programs Medicare & Medicaid HHA initial certification & branch approvals -C ynthia Thomas (850) Jan Benesh – HHA & NR licensing manager Ed Barnes - Change of ownership & licensing Lenora Lowry – HHA Pat Guilford – NR Natarsha Humphries – HHA & NR Susan Glass - HHA myflorida.com