Kenneth Daily, LNHA Elder Care Systems Group Kenn@qissurvey OHCA District II February 2013

1. State Budget, Federal Initiatives, Survey Update & What’s Hot Kenneth Daily, LNHA Elder Care Systems Group Kenn@qissurvey.com OHCA District II February 2013

2. Social and Economic Trends Pressure Providers Value Culture Change Accountability SNFs Use of Technology Aging Population Quality and Transparency

3. Budget History • 2009 Strickland Budget $180 million • 2011 Kasich Budget $360 million • Resulting in the gap of SNF uncompensated care • 2010 - $11.55/day ($208 million/year) • 2012 - $24.35/day ($438 million/year)

4. So What’s Happened • Star rating has declined (more 1 star and fewer 5 star facilities) • Immediate jeopardies have increase from 22 to 41 in past year • G –level or greater deficiencies have increased from 181 to 212 • Family satisfaction declined from 87.9% (2010) to 85.6% (2012)

5. Kasich Budget Proposal • State Fiscal Year (SFY) 2014-2015 biennium. • State taxes are revised through income tax and sales tax rate reductions, increased levies on oil and gas production, and extension of the sales tax to currently untaxed services. • Implement the expansion of Medicaid eligibility • Department of Medicaid • Departments of Mental Health and Alcohol and Drug Addiction Services are combined.

6. LTC Provisions • SNFs in Stark and Mahoning Counties will be moved to Peer Group 2 • Custom wheelchairs will be removed from the SNF rate (unbundled). It carries a SNF rate reduction of 32 cents per case mix unit. • A new program will be developed to pay SNFs higher rates for certain patients who otherwise would

7. Additional Changes for Those Under 60 years old • State dollar savings from moving a planned 1,200 individuals out of SNFs will be used to pay for non-Medicaid supports in the community (e.g., housing vouchers).Patients discharged from psychiatric hospitals or units will have to go through a Level 2 PAS before being admitted to a SNF and will not qualify for a hospital exemption.

8. NF Reimbursement Subcommittee • Revisions to SNF quality points system • Advance directives and overhead paging will become SNF licensure requirements • Convert Medicaid SNF patients who are veterans to Veterans Administration benefits, • Bed hold reimbursement will move from January 1 to July 1. • The SNF bed tax will be keyed to the federal maximum percentage (currently, 6% of total patient revenue)

9. Other Regulatory Provisions • BENHA will be renamed Board of Executives of Long-Term Services and Supports • Moving to ODA with scope expanding • Joint agency review of certain SNF plans of correction • State may terminate a facility’s provider agreement if it is designated as a Special Focus Facility • No improvement within 12 months or • Does not graduate from the SFF list within 24 months. • Definitions of specialty care in SNFs will be established for the LTC Consumer Guide. • Increase PNA $5/month • Assisted living waiver rates increased by 3%

10. OHCA Proposal • Nursing Facility Reimbursement Subcommittee recommended adjustments for HB 153 reforms to stabilize, and significant additional disruptions to LTC. The budget contains all of these. • Increase the quality component facility rate by $2.00, thereby expanding the percentage of the total rate dedicated to quality. • OHCA proposes $30 million per year in funding for the quality bonus program. • Payments would be based on each facility's number of quality points (above 5) and number of Medicaid days. This approach is the same as proposed in the 2012 MBR.

11. Capital Proposal • Capital component of the rate modified to create incentives for smaller homes, renovations, and bed forfeiture in over-capacity areas. • OHCA proposes a pool to fund Medicaid capital rate enhancements for facilities that document completing: a) a renovation; or b) construction of a smaller home. • The rate enhancements would be based on the added cost of the project over a specified threshold. Total payout would be capped at $15 million in year 1 and $20 million in year 2.

12. Electronic Health Record • Add Nursing Facilities among the providers that are qualified to receive Medicaid meaningful use payments for adopting electronic medical records (currently this is not an option under the federal program). • Meaningful Use Add-On of $1.00 per day to the current Medicaid rate for SNFs that meet appropriate standards for meaningful use of electronic health records in the SNF setting.

13. Specialty Care • Develop an rate structure for nursing facilities that "specialize" in care for specific diagnoses or conditions. • OHCA proposes authorizing development of special rates for SNFs that agree to care for Medicaid patients who otherwise would be placed in hospitals for high intensity care or rehabilitation.

14. Other Proposals • SNF Bed Tax: OHCA proposes consideration of reducing the bed tax on SNFs. A tax reduction would be in keeping with the tax cutting theme of the Governor's budget. • Bundling: The Executive Budget "unbundles" custom wheelchairs and cuts the SNF rate. • Unbundling all the bundled services, with a corresponding SNF rate reduction. There is no reason to unbundle only wheelchairs and not the other items.

15. Sequestration Budget Control Act enacted Congress unable to vote on a Supercommittee deficit reduction proposal Fiscal cliff talks fail to achieve grand bargain to replace sequestration The American Taxpayer Relief Act delays sequestration Congress extends debt ceiling until May 19 Supercommittee fails to recommend a deficit reduction proposal Sequestration effective Jan 31, 2013 August 2, 2011 November 23, 2011 Jan 3, 2013 Dec 2012 December 23, 2011 March 1, 2013

16. Sequestration – As Good As it Gets???

17. Sequestration is One of Five Deficit Triggers in 2013 SEQUESTRATION FY13 CONTINUING RESOLUTION DEBT CEILING FY14 BUDGET DOC FIX

18. Mandatory Corporate Compliance §6401(7)(A) • As a condition of enrollment: ……. Shall have in operation a compliance and ethics program that has been reasonable designed, implemented and enforces so that it generally will be effective in preventing and detecting criminal, civil and administrative violations AND in promoting quality of care consistent with regulations developed by the Secretary, working jointly with HHS OIG.

19. Nursing Home Corporate Compliance • March 23, 2013, all skilled nursing facilities and nursing facilities must have an "operational compliance ethics program that is effective in preventing and detecting criminal, civil and administrative violations and in promoting quality of care.” • Designing, implementing and maintaining an effective compliance program has been a best practice since 2000

20. Compliance Components 1.      Compliance standards and procedures to be followed by the organization, its employees and other agents, capable of reducing the prospect of criminal, civil, and administrative violations. 2.      Specific, high-level personnel are assigned overall responsibility to oversee compliance with such standards and procedures and have sufficient resources and authority

21. Compliance Components 3. No individual may have substantial discretionary authority who have have a propensity to engage in criminal, civil and administrative violations 4. Effective communications of standards and procedures including training and written materials 5. Achieve compliance through monitoring and auditing systems designed to detect criminal, civil and administrative violations

22. Compliance Components 6. The compliance standards must be consistently enforced 7. Take steps to respond to the offense and to prevent further similar offenses. 8. The organization must periodically reassess its compliance program to identify modifications necessary to address changes within the organization and its facilities.

23. Quality AssurancePerformance Improvement S&C Memo 13-05-NH December 14, 2012

24. Description: What is QAPI? • QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. • PI is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems. PI identifies areas of opportunity and tests new approaches to fix underlying causes of persistent/systemic problems.

25. Quality Assurance and Performance Improvement (QAPI) • According to CMS, this initiative “significantly expands the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as sustain performance improvement” • QA: QUALITY ASSESSMENT • How are we doing compared to our industry? • PI: PROCESS IMPROVEMENT • Making it better • Think of it as “QAPI”

26. QAPI

27. Nursing Home QAPI Purpose Roll-Out • Phase I – September 2010 • Planning and development • Phase 2 – Fall 2011 • Testing and further development of QAPI tools and resources • Phase 3 • Initial rollout of foundational materials including Nursing Home Quality Improvement Questionnaire • Development of consumer and surveyor materials

28. Nursing Facility Survey There has been a great deal of focus survey deficiencies by CMS, the press, Congress and consumers the past year More than 91% of all nursing facilities were cited for one or more deficiencies in 2010 Nearly 18% of nursing homes were cited for harm and/or immediate jeopardy Quality of care, resident assessment and quality of life are most common

29. Citations and Survey Time Nat’l QIS OH QIS Average Number of Citations/ Survey 7.2 5.7 Deficiency free 6.9% 9.6%

30. Scope and Severity A 1.2% B 2.7% C 3.0% D 65.3% E 19.9% F 4.8% G 2.4% H – L 0.55%

31. QIS – First Stage Preliminary investigations Quality of Care & Quality of Life Indicators CQIs are compared to national thresholds Identify Care Areas for Second Stage

32. QIS – Second Stage In-depth quality investigations Critical Element Pathways for investigations Assessment Care planning Reassessment Care areas are mapped to specific F tags (regulations)

33. Leading Deficiencies • Assessment F272 • Care Planning F279 • Professional Standards of Care F281 • Accident/ Hazards F323 • Quality of Care F309 • Unnecessary Medications F329 • Bowel/Bladder function F315 • Dignity F241 • Food Handling F371 • Pressure Sores F314 • Infection Control F441 • Environment F253 • Notify of change F 157 • Resident Abuse F223-26 • Staffing F353

34. S&C Memo 12-47-NH F 155 F155 discusses the resident’s rights to refuse treatment, formulate and advance directive, and refuse to participate in experimental research. Theprocess used to identify and update the resident’s preferences regarding care and treatment at a future A process by which the facility provides information to the resident or legal representative regarding: health status, treatment options, and expected outcomes; and Resident choices are implemented and re-evaluated (both routinely and when the resident’s condition changes significantly).

35. S&C Memo 12-48-NHF 309 Quality of Care • Promote the physical, mental and psychosocial well-being of residents approaching the end of life • Resident’s prognosis and the basis for it, and initiating discussions/considerations regarding advance care planning and resident choices • Periodically review resident care, services, and support that accommodate and honor the resident’s choices and rights, manage pain and other physical, mental, and psychosocial symptoms

36. ABCDE Mnemonic Ask the resident or his or her legal representative about (and screen for) pain and other symptoms related to the resident’s end of life status on admission and periodically thereafter; A: Assess regularly and systematically for symptoms (such as dyspnea, fatigue, declining function, anorexia/eating difficulties/weight loss, pain, loneliness, anxiety/apprehension, depression, constipation, and delirium) and their impact on the resident; B: Believe the resident’s report of pain and other symptoms; what precipitates pain(s) and symptoms; what makes the pains(s) and symptoms worse: and what relieves the pain(s) and symptoms;

37. ABCDE Mnemonic (cont’d) C: Choose symptom control options that are appropriate for and consistent with the resident’s or legal representative’s wishes; D: Deliver interventions in a timely, logical, and coordinated manner; E: Empower the resident and the resident’s legal representative to participate in defining the goals of treatment and planning the interventions to the extent possible; and evaluate the effectiveness of the chosen interventions.

38. S&C Memo 12-46-NHF322 • Feeding tube for nutrition and hydration only when the resident’s clinical condition requires and after efforts to maintain or improve have failed; • Assessment of the resident’s nutritional and clinical status; • Relevant functional and psychosocial factors (such as potential ability to maintain activities of daily living ADL); and • Prior interventions (nutrition therapy and medical intervention tried) and the resident’s response • Addressing malnutrition and dehydration; • Promoting wound healing; • Allowing the resident to gain strength and stabilize THE FACT IS... The tube feeding QCLI was removed in April 2012 since there were changes to the tube feeding section in MDS 3.0. The QCLI dictionary and the QCLI Results screen in ASE-Q indicate the QCLI has been removed. Once the tube feeding QCLI is activated, State Agencies will be notified with a QTSO Memo.

39. QIS Update • 2012 review of QIS revels: • Typically 4 surveyors onsite for 4 +days • 81.5% of resident are interviewable • 14 quality of care/life indicators are triggered for stage II compliance investigation (down from initial studies suggesting as many as 22) • Surveyor initiated issues at survey = 1.4 • Ave citations recommended by software is 7.5 but average citation is 7.2 • Ohio average under 6 deficiencies

40. Source of “Trigger” Responses QIS rates for: • Resident Observation 16.6% • Resident Interview 19.4% • Family Interview 19.6% • Staff Interview 18.6% • Census Clinical Record 15.2% • Admission Clinical Record 17.8 %.

41. Triggered Care Areas • Frequently Triggered (> 60% of surveys) • Accidents and Falls, Pressure Sores, Community Discharge , Pressure Ulcers, • Commonly triggered (30%-59% of surveys) • Dental status, personal property, ROM, activities, Abuse/Abuse Prohibition, Environment, ADLs, Death, Sufficient staffing, personal funds, choices dignity • Less Frequently Triggered (< 20% of surveys) • Incontinence, participating in care planning, food quality, pain, skin (non-pressure), privacy, restraints, notification of change, positioning and social services

42. Triggered Care Areas cont’d Lowest issues triggered or outliers (less than 10%) • Social Services • Positioning • Notification of change • Restraints

43. Citation Rates for NON-Mandatory Facility Tasks • Unnecessary Med Use 39% • Kitchen 36.2% • Infection Control 35.8% • Dining 25.5% • Med Storage 23.7% • Med. Admin 14.3% • Liability Notices 11% • Resident Council 7.5% • QA & A 6.7% Rates = # cited divided by # investigated (not total # of surveys)

44. Citation Rates for Mandatory Facility Tasks • Abuse Prohibition 23.9% • Adm, Transfer, Discharge 22.4% • Environment 69.0% • Personal Funds 24.6% • Sufficient Nursing Staff 9.4% Rates = # cited divided by # investigated (not total # of surveys)

45. Frequency of Citations • High frequency when investigated in stage II (>50%) • Positioning (F309) • Environmental conditions (F253) • Physical restraints (F221)

46. Frequency of Citations • Medium frequency (25%-49%) • ADLs (F312-13) • Pain (F309) • Catheter (F315) • Accidents and falls (F323) • Social services (F250) • Pressure sores (F314) • ROM (F312-13) • Dental (F411-12) • Food Quality (F365) • Nutrition (F325)

47. Frequency of Citations • Low frequency (< 15%) • Abuse (F223,24,25,26) • Notification of change (F157) • Hospitalization • Personal property (F223,24,25,26) • Sufficient staffing (F353,54) • Community discharge (F202,03,04) • Death

48. Offsite Preparation Facility Tour Entrance Conference Stage 1 Sample Selection (3 Samples: MDS based, Admission, Census) (Resident, Family, & Staff interviews, Resident Observations, Medical Record Reviews) Facility Level Investigations Exit Conference Stage II Critical Element Pathways Facility Level Investigations Identify non-compliance and care deficiencies Compliance Investigations QIS Process

49. Additional Activities Medicare beneficiaries of last six months sampled from MDS data for review of Liability Notice and Beneficiary Appeal Rights review Resident lists: PASRR (MI or MR) Ventilator Dialysis Unit, Peritoneal, Home Certified Medicare Hospice Comfort/ End of Life care One Resident will be chosen from each care area during stage II THE FACT IS... If a resident was discharged from the SNF to home, and had not exhausted his/her benefits, the resident should be reviewed. Any Medicare Part A resident, who is discharged from the SNF and has not exhausted their benefits, is eligible for review for the issuance of an appeal notice. This includes residents that have been discharged home.

50. QIS Beginning • Ask nursing assistants questions, such as • What care is provided by STNA’s? • How many residents are under your care today? • Who determines the assignment? • Is there enough time to complete your assignment? • What happens if you do not get your assignment completed? • How is QA handled at the facility? • What steps do you take when the fire alarm sounds? • What is RACE?