1. 1 State of Michigan Department of Community Health Bureau of Health Systems

2. 2 Welcome

3. 3 Presenters Roxanne Perry, Trainer Roxanne Perry, Trainer Division of Operations Jane Naasko, Licensing Officer Jane Naasko, Licensing Officer Nursing Home Monitoring Division Sophie Skoczen, Manager Sophie Skoczen, Manager Division of Operations

4. 4 STATE REQUIREMENTS Any employee who becomes aware of physical, mental, emotional abuse, mistreatment or harmful neglect has responsibility to report to administrator or nursing director. Any employee who becomes aware of physical, mental, emotional abuse, mistreatment or harmful neglect has responsibility to report to administrator or nursing director. Any person may report physical, mental, emotional abuse, mistreatment or harmful neglect to department. Any person may report physical, mental, emotional abuse, mistreatment or harmful neglect to department. If chain of command report is required within facility – ensure administrator or director of nursing are advised. If chain of command report is required within facility – ensure administrator or director of nursing are advised. State reporting requirements based on actual abuse State reporting requirements based on actual abuse “Immediately” means as soon as possible not more than 24 hours after incident; See also State complaint manual, section 5242 “Immediately” means as soon as possible not more than 24 hours after incident; See also State complaint manual, section 5242

5. 5 CMS “Clarification of Nursing Home Reporting Requirements Dated…” December 16, 2004

6. 6 Update of Reporting Requirements for Alleged Violations of: Mistreatment Mistreatment Neglect Neglect Abuse Abuse Injuries of unknown source Injuries of unknown source Misappropriation of resident property Misappropriation of resident property

7. 7 42 CFR 483.13 (c)(2)(3)(4) Resident Behavior and Facility Practices F 225 (2) The facility must ensure that all alleged violations (2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, involving mistreatment, neglect, or abuse, including injuries of unknown source, and including injuries of unknown source, and misappropriation of resident property are reported misappropriation of resident property are reported immediately to the administrator of the facility and immediately to the administrator of the facility and to other officials in accordance with state law to other officials in accordance with state law (emphasis added) through established procedures (emphasis added) through established procedures (including the State survey and certification agency). (including the State survey and certification agency).

8. 8 (3)The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. (4)The results of all investigations must be reported to the administrator or their designated representative and to other officials in accordance with State law (including to the State Survey and Certification Agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

9. 9 What is Reportable Willful injury, verbal, sexual, physical or mental abuse. Willful injury, verbal, sexual, physical or mental abuse. Involuntary seclusion or unreasonable confinement, intimidation or punishment. Involuntary seclusion or unreasonable confinement, intimidation or punishment. Mistreatment Mistreatment Injury of an unknown source. Injury of an unknown source. Neglect, the failure to provide goods or services. Neglect, the failure to provide goods or services. Misappropriation of a resident’s property of any value. Misappropriation of a resident’s property of any value. These are reportable at any severity.

10. 10 What is Reportable Immediate Jeopardy An incident that caused or is likely to cause serious injury, serious harm, impairment or death to a resident. Injury or incident involving a death or criminal activity under investigation by a state of local law enforcement agency. Injury or incident involving a death or criminal activity under investigation by a state of local law enforcement agency. Abuse with serious injury Abuse with serious injury Injuries of unknown origin that result in interference with physiologic functions that are an immediate threat to life or have a strong potential to become an immediate threat to life. Injuries of unknown origin that result in interference with physiologic functions that are an immediate threat to life or have a strong potential to become an immediate threat to life.

11. 11 What is Reportable Immediate Jeopardy cont’d Elopement of a resident missing for more than two hours (less where there is a strong potential to become an immediate threat to life, e.g., either because of inclement weather conditions or known hazards outside the facility.) Elopement of a resident missing for more than two hours (less where there is a strong potential to become an immediate threat to life, e.g., either because of inclement weather conditions or known hazards outside the facility.) Resident to resident physical altercation with serious injury. Resident to resident physical altercation with serious injury. Serious injury that is life threatening to a resident. Serious injury that is life threatening to a resident. Sexual assault. Sexual assault.

12. 12 What is Reportable Incidents with Actual Harm Harm – A negative outcome that has compromised the resident’s ability to maintain or reach the highest practicable physical, mental, or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. (CMS definition.) Harm – A negative outcome that has compromised the resident’s ability to maintain or reach the highest practicable physical, mental, or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. (CMS definition.) Harm is physical or psychosocial injury or damage. (American Heritage Dictionary) Harm is physical or psychosocial injury or damage. (American Heritage Dictionary)

13. 13 What is Reportable Incidents with Actual Harm cont’d Resident is intimidated/threatened resulting in mental or psychosocial status change. Resident is intimidated/threatened resulting in mental or psychosocial status change. Resident is physically abused-spitting/slapping/sticking with sharp object/pushing/pinching. Resident is physically abused-spitting/slapping/sticking with sharp object/pushing/pinching. Falls resulting in fracture (e.g. handrails not secured); Falls resulting in fracture (e.g. handrails not secured); Inappropriate use of restraints resulting in injury. Inappropriate use of restraints resulting in injury. Inadequate staffing which negatively impacts on resident health and safety. Inadequate staffing which negatively impacts on resident health and safety. Failure to obtain appropriate care or medical intervention, i.e. failure to respond to a significant change in the resident’s condition. Failure to obtain appropriate care or medical intervention, i.e. failure to respond to a significant change in the resident’s condition.

14. 14 What is Reportable Incidents with Actual Harm cont’d Refusal to readmit a resident putting resident at risk. Refusal to readmit a resident putting resident at risk. Elopement of a resident (subsequently found) resulting in harm. Elopement of a resident (subsequently found) resulting in harm. Misappropriation of property Misappropriation of property

15. 15 BHS-OPS-362 FACILITY INCIDENT REPORT Includes: Resident diagnosis – victim, alleged abuser Resident diagnosis – victim, alleged abuser Injury, if any, and resident’s current status Injury, if any, and resident’s current status Summary of incident: What happened, when, how did it happen, who was involved Summary of incident: What happened, when, how did it happen, who was involved

16. 16 BHS-OPS-363 Facility Investigative Report: Includes: Conclusion Statement: Substantiated vs. Not Substantiated Conclusion Statement: Substantiated vs. Not Substantiated Copy of Incident/Accident Report Copy of Incident/Accident Report What? Where? Date? Time? What? Where? Date? Time? Physician and Family Notified? Physician and Family Notified? Identify Guardianship Identify Guardianship How did the Incident Affect Resident? How did the Incident Affect Resident? Mental Status of Victim/Resident? Mental Status of Victim/Resident? Event: Isolation vs. Pattern Event: Isolation vs. Pattern

17. 17Continued… Name of Hospital/Treatment Required Name of Hospital/Treatment Required Witness Information Witness Information Witness Written Statement Witness Written Statement Alleged Perpetrator Information Alleged Perpetrator Information Alleged Aggressor/Resident Information Alleged Aggressor/Resident Information Current Status of Resident: Nursing Home/Hospital? Current Status of Resident: Nursing Home/Hospital? X-ray Report, Physician’s Orders and Progress Notes, Nurse’s Notes, and Care Plan Addressing the Problem/Issue (send only the documents that are relevant) X-ray Report, Physician’s Orders and Progress Notes, Nurse’s Notes, and Care Plan Addressing the Problem/Issue (send only the documents that are relevant) What Corrective Action was taken or will be taken by the Facility? What Corrective Action was taken or will be taken by the Facility?

18. 18 BHS-OPS-363 Facility Investigation Report SPECIAL ATTENTION: Summary of Investigation  Conclusions  Evidence, documentation, statements  Action taken by facility  Care plan  Training  Personnel action  Revised policies and procedures  Monitoring  Installation of new equipment

19. 19 How to Report Alleged Abuse On line Submission of BHS-OPS-362 within 24 hours @www.michigan.gov/bhs; or On line Submission of BHS-OPS-362 within 24 hours @www.michigan.gov/bhs; orwww.michigan.gov/bhs A typed or legible handwritten report (facility incident report BHS-OPS 362 form) on alleged abuse must be submitted within 24 hours by mail or fax. (517)241- 0093; or A typed or legible handwritten report (facility incident report BHS-OPS 362 form) on alleged abuse must be submitted within 24 hours by mail or fax. (517)241- 0093; or CIU hotline @ 1-800-882-6006; requires a follow-up written report CIU hotline @ 1-800-882-6006; requires a follow-up written report An investigative report (investigation report An investigative report (investigation report (BHS-OPS 363 form), must be submitted within 5 days. (BHS-OPS 363 form), must be submitted within 5 days. Facility may use own forms but must contain the necessary information Facility may use own forms but must contain the necessary information

20. 20 Reminder 24-Hour Emergency Hotline for Nursing Home Monitoring 24-Hour Emergency Hotline for Nursing Home Monitoring1-877-278-8484 Enables your facility to inform us of emergencies in a timely manner, to report what steps have already been taken by your facility or others to respond to the event, and to enable us to assist your facility in any further steps which need to be immediately taken.

21. 21 3a)The application of S & C -06-01-CMS Document 3a)The application of S & C -06-01-CMS Document titled: “Nursing Homes: Citations of Past Non- titled: “Nursing Homes: Citations of Past Non- Compliance – Revised Guidance”. Compliance – Revised Guidance”. 3b)The application of Department Memorandum, dated September 13, 2006, titled: “Citations of Past Non-Compliance. Past Non-Compliance Presentation Objectives

22. 22 To cite past non-compliance, all three (3) of the following criteria must apply: To cite past non-compliance, all three (3) of the following criteria must apply: 1)The facility must have been out of the compliance 1)The facility must have been out of the compliance with a regulatory requirement at the time the incident occurred. 2)The non-compliance must have occurred after the exit date of the last standard survey and before the current survey. Past Non-Compliance

23. 23 3)There must be specific evidence that the facility corrected the non-compliance, at the time of the incident, and is in substantial compliance at the current survey. current survey. Past compliance evidence must show that the facility identified the (alleged) deficiency, developed and implemented corrective action following the incident and a period of compliance must be evident. Past Non-Compliance ( continued)

24. 24 Plan of Correction Requirements Resident Centered deficiencies In-depth analysis how deficiency occurred. In-depth analysis how deficiency occurred. How facility identified resident affected and residents having potential to be affected by same deficient practice How facility identified resident affected and residents having potential to be affected by same deficient practice Measures or systemic changes made to ensure that deficient practice will not occur. Measures or systemic changes made to ensure that deficient practice will not occur. How facility will monitor its corrective actions to ensure deficient practice is corrected and will not reoccur. How facility will monitor its corrective actions to ensure deficient practice is corrected and will not reoccur.

25. 25 Facility Past Non-Compliance Form (Sample) Facility Past Noncompliance Form Facility Past Noncompliance Form Date of Report: Administrator Name: Date of Report: Administrator Name: Facility name: Facility name: Address: Address: Phone #: Phone #: Resident Name: Date of Birth: Resident Name: Date of Birth: Room #: Room #: Diagnosis: Diagnosis: Date of event: Date of event: Was the resident injured? Was the resident injured? If yes –Describe injury: If yes –Describe injury: Description of deficient practice: (Why and how did it happen?) Description of deficient practice: (Why and how did it happen?)

26. 26 Facility Past Non-Compliance Form cont’d Plan of Correction:  In-depth analysis how the deficiency occurred  How facility identified resident affected and residents having potential to be affected by the same deficient practice  Corrective action taken for resident affected  Measures or systemic changes made to ensure that deficient practice will not occur and affect others

27. 27 Facility Past Non-Compliance Form cont’d  How facility monitors its corrective actions to ensure deficient practice is corrected and will not recur.  Name of person responsible for ensuring compliance with plan of correction. Date of completion of plan of correction. Attach documents for evidence of compliance. Name (printed) and Signature of person completing form

28. 28 Documentation of Past Non-Compliance 1.Past Noncompliance that is not Immediate Jeopardy and for which a quality assurance program has corrected the noncompliance, will not be cited if the facility brings this to the attention of the surveyor. The facility must provide the evidence to the surveyor who will contact his/her manager to review the information and make a determination if the evidence meets the criteria for past noncompliance. 2.Past noncompliance identified as immediate jeopardy is entered on CMS 2567 under the specific deficiency tag, scope and severity with supporting documentation. Note: The generic citation F698 has been discontinued. 3.The CMS 2567 should include the appropriate F-tag, date of deficiency, the date of past noncompliance, the evidence of past noncompliance and implementation of a plan of correction so that the civil money penalty amount can be determined.

29. 29 Past Non-Compliance cont’d  IDR 1. Will be allowed for past noncompliance cites. 1. Will be allowed for past noncompliance cites. i.e.: To contest whether a deficiency occurred. i.e.: To contest whether a deficiency occurred. 2. May IDR whether a past noncompliance citation is a deficiency. deficiency. 3. May not IDR whether a deficiency (cite) is past noncompliance.

30. 30 Enforcement For Past Non-Compliance Enforcement Action on Immediate Jeopardy Past Noncompliance 1. Civil money penalty is required for immediate jeopardy. A per instance CMP may be imposed. jeopardy. A per instance CMP may be imposed. 2. Past noncompliance does not apply to State Nursing Home Rules and the Public Health Code. A State of Michigan-tag (M-tag) may be cited and a State civil penalty order issued.

31. 31 RESOURCES BUREAU OF HEALTH SYSTEMS Michigan Operations Manual http://www.michigan.gov/bhs State Operations Manual (CMS) Appendix P http://cms.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdf Appendix PP http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidel ines_ltcf.pdf