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

2. 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

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

4. 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.  

5. 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

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

7. 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

8. 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

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

10. QSO 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.

11. QSO 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.

12. QSO 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.

13. SB 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.

14. 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.

15. 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.

16. FY 18 Data

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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.

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

25. Reasons for Nursing Home Informal Dispute Resolution Decisions in FY 18

26. Health Care Quality Account Grants

27. 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

28. 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

29. 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

30. 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

31. CASE

32. Rachelle Pierre-Mathieu, MD, MPP
THANK YOU!
Rachelle Pierre-Mathieu, MD, MPP