Charting the Course of Post-Acute and Long-Term Care Medicine Mid-Atlantic Medical Directors Association November 10, 2018

Office of Health Care Quality Rachelle Pierre-Mathieu, MD, MPP Update: Office of Health Care Quality Rachelle Pierre-Mathieu, MD, MPP Medical Director November 10, 2018

Disclosures I have no financial or ethical disclosures in preparation or delivery of this presentation.

Learning Objectives Review the role of OHCQ and present updates in monitoring, licensing, and certification of care facilities  Identify strategies for medical directors to implement to prevent deficiencies in clinical care.  

OHCQ Functions Issue licenses, authorizing the operation of a business in Maryland Recommend certifications to CMS, authorizing participation in the Medicare and Medicaid programs Conduct surveys to determine compliance with State and federal regulations, which set minimum standards for the delivery of care Educate providers, consumers, and other stakeholders

Trust the provider, but verify compliance with the regs What is OHCQ’s role? Trust the provider, but verify compliance with the regs

OHCQ Oversees 42 Provider Types Ambulatory Care Long Term Care Assisted Living Laboratories Developmental Disabilities Hospital Birthing Centers Comprehensive Outpatient Rehab Facilities Cosmetic Surgery Centers Freestanding Ambulatory Surgery Centers Freestanding Dialysis Centers Health Care Staff Agencies Home Health Agencies Hospices Hospice Houses Major Medical Equipment Providers Nurse Referral Agencies Outpatient Physical Therapy Centers Portable X-ray Providers Residential Service Agencies Surgical Abortion Facilities Intermediate Care Facilities Forensic Residential Services Nursing Homes Adult Medical Day Care Assisted Living Facilities Cholesterol Testing Sites Employer Testing Labs Federal Waived Labs Forensic Labs Health Awareness Test Sites Hospital Labs Independent Reference Labs Physician Office Labs Point-of-Care Labs Public Health Testing Tissue Banks DD Respite Services Group Homes Habilitation Services Individual and Family Support Services Intensive Treatment Programs Community Mental Health Centers Correctional Health Care Facilities Federally Qualified Health Centers Freestanding Medical Facilities HMOs Hospitals Limited Private Inpatient Facilities Patient Safety Programs Residential Treatment Centers Transplant Centers

Number of OHCQ Licensees as of July 1, 2016, 2017, and 2018 Number of Licensees July 1, 2016 July 1, 2017 July 1, 2018 15,236 15,390 16,678

Quality, Safety, and Oversight Group Memorandums Survey and Certification (S & C) is now Quality, Safety, and Oversight (QSO)

QSO 18-08-NH An Initiative to Address Facility Initiated Discharges that Violate Federal Regulations Discharges which violate Federal regulations continue to be one of the most frequent complaints made to Ombudsman Programs. CMS initiative: CMS is examining State survey agency’s intake and triage of discharge complaints, developing examples of inappropriate and appropriate discharges, identifying best practices, developing training, and evaluating enforcement options. Civil Money Penalty (CMP) Reinvestment Projects Assistance: CMS is encouraging States to pursue CMP-funded projects that may help prevent facility initiated discharges that violate federal regulations.

QSO 18-15-NH Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long-Term Care Setting CMS and CDC are collaborating on the development of a free on-line training course in infection prevention and control for nursing home staff in the long-term care setting.

QSO 18-18-NH Final Revised Policies Regarding the Immediate Imposition of Federal Remedies When the current survey identifies immediate jeopardy that does not result in serious injury, harm, impairment or death, the CMS Regional Offices may determine the most appropriate remedy. Clarified that Past Noncompliance deficiencies are not included in the criteria for Immediate Imposition of Remedies. For Special Focus Facilities, S/S level “F” citations under tags F812, F813, or F814 are excluded from immediate imposition of remedies.

SB 108 - Regulation of Health Care Programs, Medical Laboratories, Tissue Banks, and Health Care Facilities - Revisions Permitted the Department to issue non-expiring licenses and eliminate licensure fees for all provider types, allowing providers to reinvest in their business and enhance the quality of services. Allowed OHCQ to focus on licensure, certification, and survey activities, thereby strengthening the oversight of providers. Initial licensure applications are processed faster, providing greater access and choice for consumers.

Benefit to Small Business This law particularly benefits the 2,600 small businesses overseen by OHCQ by decreasing start-up costs, speeding initial licensure, issuing a non-expiring license, and eliminating licensure and relicensure fees.

SB 386 - Maryland Nursing Home Resident Protection Act of 2018 OHCQ shall annually receive 10 new full–time merit positions related to the survey, licensure, discipline, or regulation of related institutions, including assisted living programs, to protect vulnerable residents served by the related institutions, which positions will be received by the Office of Health Care Quality for each fiscal year beginning in fiscal year 2020. By fiscal year 2024, OHCQ will have 50 new positions.

FY 18 Data

Nursing Homes Activities from FY 16 to FY 18 Unit of Measurement FY16 FY17 FY18 Number of licensed nursing homes 230 228 Initial surveys of new providers 1 Full surveys 199 217 186 Follow-up surveys 41 50 35 Complaints and facility self-reported incidents 2,486 3,342 3,621 Complaints and self-reported incidents, investigated 2,057 3,026 2,979 Quality of care allegations 2,670 1,749 1,345 Resident abuse allegations 1,254 941 1,058

Most Frequently Cited Federal Deficiencies in Nursing Homes in FY 18 Federal Tag Description of Tag Total Citations F 512 Nursing Services - Charge Nurse Daily Rounds 250 F 506 Nursing Services - Care 24 Hours per Day 152 F 684 Quality of Care 111 F 842 Resident Records - Identifiable Information 109 F 510 Nursing Services - Charge Nurse 106 F 656 Develop and Implement Comprehensive Care Plan 90 F 657 Care Plan Timing and Revision 89 F 514 Resident Records - Complete/Accurate/Accessible 79 F 309 Provide Care and Services for Highest Well Being 77 F 321 Hazardous Areas - Enclosure 75

Nursing Home Enforcement Activities from FY 16 to FY 18 Unit of Measurement FY16 FY17 FY18 Civil money penalties levied, State 16 20 Civil money penalties levied, federal 38 61 36 Denial of payment for new admissions 5 7 1

Number of Actual Harm and Immediate Jeopardy Nursing Home Deficiencies by Federal Tag in FY 17 Description of Tag G H I J K L F 152 Right of resident's representative to make decisions   2 1 F 155 Right to refuse, formulate advance directives 4 3 F 156 Assure that each resident is informed of their rights   F 157 Notify of changes (injury, decline, room) F 201 Reasons for transfer/discharge F 203 Notice requirements before resident transfer/discharge F 204 Preparation for safe/orderly transfer/discharge F 223 Free from abuse, involuntary seclusion 5 F 225 Investigate/report allegations of abuse, neglect  F 280 Right to participate in care planning  F 284 Discharge planning process F 309 Provide care and services for highest well being 6 F 314 Treatment and services for pressure sores F 323 Free of accidents, hazards, supervision, devices 9 F 328 Treatment and care for special needs F 329 Drug regimen is free from unnecessary drugs F 333 Residents are free of significant med errors 15 F 353 Sufficient nursing  staff F 371 Ensure proper sanitation and food handling practices  F 385 Resident's care supervised by physician F 441 Infection control, prevent spread, linens F 490 Effective administration/resident well-being F 500 Arrangement of outside resources to meet resident needs F 501 Responsibilities of medical director F 520 Quality assurance committee Tags at G or above – 87 36 28 13 10

Number of Actual Harm and Immediate Jeopardy Nursing Home Deficiencies by Federal Tag in FY 18 Description of Tag G H I J K L F 155 Right to refuse, formulate advance directives 2   F 578* F 223 Free from abuse, involuntary seclusion 1 F 660* Discharge planning process F 309 Provide care and services for highest well being 4 F 314 Treatment and services for pressure sores F 323 Free of accidents, hazards, supervision, devices F 689* 7 3 F 333 Residents are free of significant med errors F 550 Residents rights to exercise his/her rights F 600 Free from abuse and neglect F 604 Right to be free from physical restraints F 610 Investigate, prevent, correct alleged violation F 678 Cardiopulmonary resuscitation (CPR) F 684 Quality of care F 710 Resident’s care supervised by a physician Tags at G or above – 47 24 17 *Due to the new federal regulations implemented in November 2017, regulatory tags and groupings were revised

Federal Tags in Grouping # of Actual Harm and IJ Deficiencies Regulatory Groupings for Actual Harm and Immediate Jeopardy Deficiencies in LTC in FY 18 Regulatory Groupings Federal Tags in Grouping # of Actual Harm and IJ Deficiencies Resident Rights   F 151 – F 177 2 Resident Behavior and Facility Practices F 221 – F 226 3 Quality of Care F 309 – F 334 14 Resident Rights* F 550 – F 586 Freedom from Abuse, Neglect, and Exploitation* F 600 – F 610 6 Comprehensive Resident Center Care Plans* F 655 – F 661 1 Quality of Life* F 675 – F 680 Quality of Care* F 684 – F 700 Physician Services* F 710 – F 715 Total 47 *Due to the new Federal Regulations implemented in November 2017, regulatory tags and groupings were revised.

Nursing Homes - Informal Dispute Resolutions In FY 18, there were 96 federal tags that were disputed in 27 IDRs and 1 federal tag in 1 independent IDR. The IIDR resulted in no changes to the tags. The IIDR results were not included in the next two slides.

Outcomes of Nursing Home Informal Dispute Resolutions by Federal Tag in FY 18

Reasons for Nursing Home Informal Dispute Resolution Decisions in FY 18

Health Care Quality Account Grants

Health Care Quality Account Grants Funds collected from civil money penalties imposed by CMS or OHCQ to nursing homes and by OHCQ to assisted living programs Support activities that improve the quality of life of individuals who reside in NHs and ALPs Three non-lapsing special funds: Federal nursing home account State nursing home account State assisted living account

Grant Applications Applications are accepted throughout the year Grants are awarded on a rolling basis, contingent on funding Committee reviews the applications: OIG, OAG, and OHCQ (Executive Director, Chief Fiscal Officer, Deputy Director of Federal Programs, Deputy Director of State Programs, and Chief Nurse) CMS must approve the use of federal funds

Available Funds for HCQA Grants October 1, 2018 Account Balance Federal nursing home $7,565,723 State nursing home $100,205 State assisted living $40,788 Total $7,706,716

Medical Director Pearls Process of notifying concerns to the medical director Clarify facility expectations for health care practitioners Ex. physician visits, response to notification, documentation... Process of monitoring providers and intervening on inconsistent standards of care (including practicing medical director) Be available for difficult cases or medical reviews Assist and coordinate educational programs for all types of medical providers

CASE

Rachelle Pierre-Mathieu, MD, MPP THANK YOU! Rachelle Pierre-Mathieu, MD, MPP 410-402-8183 rachelle.pierre-mathieu@maryland.gov