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AHCA Home Health Regulatory Update

Anne MenardHome Care Unit

Bureau of Health Facility RegulationAgency for Health Care Administration

July 24, 2012

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Licensed as of July 13, 2012

2,272 home health agenciesMost: Miami-Dade 743

Broward 251 Palm Beach 195

416 nurse registriesBroward 97 Palm Beach 95

2,174 homemaker companion services

Miami-Dade 315 Broward 216

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2,272 Home Health Agencies

• 71% Certified for Medicare and/or Medicaid– 1,070 Medicare only – 68 Medicaid only– 472 Medicare & Medicaid

• 661 (29%) are not certified, but 154 pending of the 507 not seeking certification, only about 90 do not provide any nursing

AHCA for HHAs

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Secretary

Division of Health Quality Assurance

Bureau of Health Facility Regulation

Home Care Unit

Bureau of Central Services

Background Screening Unit

Financial Analysis Unit

Bureau of FieldOperations

8 Field Offices(surveys)

OASIS Help Desk (850) 412-4501

Complaint Call Center1-888-419-3456

Division of Medicaid

Bureau of Medicaid Services

(policy)

Bureau of Medicaid Contract Management

(provider enrollment)

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Background Screening Update

From the definitions in Chapter 435, Employment Screening:

435.02(2), F.S. “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.

(3) “Employer” means any person or entity required by law to conduct screening of employees pursuant to this chapter.

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At the AHCA Background Screening Web Site Now

Your agency can:• Track screenings from the time the screening request is

initiated until a determination is made.• Find results already available (reduces duplicative screening).• Get a “status” report and a “completed screening listing”

report of screenings requested (eliminates the need to search for each screening result individually).

• Maintain an employee roster by entering hire and separation dates for each employee. Get a notification to the employer if the eligibility status of an employee changes.

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At the AHCA Background Screening Web Site now

• See the “Instructions for Initiating and Accessing Screening Results” at the site.

• Make sure your agency has completed the on-line form for access to the site through the Web Portal & the Single Sign-On process.

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2012 Florida Legislature - Law Changes Background Screening

HB 943 (Chapter 2012-73, Laws of Florida) effective April 7, 2012

1. Screening from other state agenciesAHCA may accept proof of Level 2 screening conducted within the previous 5 years from the Department of Elder Affairs. DOEA can accept AHCA’s.

Proof of screening received from other state agencies must use the equivalent screening standards as AHCA.

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2012 Law Changes - Background Screening from Other State Agencies

AHCA may accept proof of Level 2 from:• the Department of Health for CNAs only• the Department of Children and Families (all but day care,

foster care & adoption)• the Agency for Persons with Disabilities • the Department of Elder Affairs.

The individual must not have had a break in service from a position that requires screening for more than 90 days. (408.809(2), Florida Statutes).

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2012 Law Changes - Background Screening

408.809(2)(b), F.S.”…. the agency may accept as satisfying the requirements of this section proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the agency…provided that:…(b) The person subject to screening has not had a break in service from a position that requires level 2 screening been unemployed for more than 90 days;”

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Background Screening 90 day break in service - how to determine:• Ask the applicant

• Check with prior employer to verify dates of employment

• See Provider/Facility Types Subject to Screening at the Background Screening web page – determine if level 2 required

• Once employee rosters are submitted to web, AHCA site will calculate the 90 day break in service for persons screened through AHCA.

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2012 Law Changes Background Screening

2. Provides a staggered rescreening schedule for AHCA regulated providers over a 3-year period (2013-2015):  

– Individuals for whom the last screening was conducted on or before December 31, 2004, must be rescreened by July 31, 2013.

– Individuals last screened between January 1, 2005 and December 31, 2008, must be rescreened by July 31, 2014.

– Individuals last screened between January 1, 2009 and July 31, 2011, must be rescreened by July 31, 2015.

 

408.809(5), Florida Statutes

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2012 Law Changes – Background ScreeningStaggered Re-Screening - continued

Explanation: Changes in 2010 required all employees to have level 2 screening (fingerprints, FDLE & FBI) every 5 years beginning August 1, 2010.

• Many of the persons working at the time of the law change had level 1 screening & qualified and would be subject to the 5 year rescreening on July 31, 2015.

• The change in law now allows rescreening over a 3-year period to spread the cost and workload of screening.

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2012 Law Changes Background Screening

3. Employer may hire a person prior to completion of a screening for training and orientation purposes. The individual may not have direct contact with any patient/client until successful completion of a screening. (435.06(2)(d), Florida Statutes).

Explanation: Previously, the law prohibited an employer from hiring an individual until the screening process was complete and the person was deemed “Eligible”.

If the final screening determination is “Not Eligible”, the employer must terminate the person or place the person in a position that is not required to undergo screening.

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2012 Law Changes Background Screening – Future Implementation

4. Creates the “Care Provider Background Screening Clearinghouse” Implementation is expected to begin in October 2012• Purpose: to provide a single data source for background

screening results of persons required to be screened by law for employment in a position that provides services to children & aged and/or disabled individuals.  (435.12, F.S.)

• To be entered into the Clearinghouse, the person screened must: – Undergo Level 2 screening & have fingerprints retained by

the FDLE and

– Have a photograph taken at time of fingerprinting 

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2012 Law Changes - Background Screening Care Background Screening Clearinghouse continued

• State agencies that may participate in the Clearinghouse:– Department of Children and Families – Department of Health– Agency for Health Care Administration– Department of Elder Affairs – Department of Juvenile Justice– Agency for Persons with Disabilities – Vocational Rehabilitation

• AHCA will be responsible for maintaining the Clearinghouse & will be working with the other agencies to become part of the Clearinghouse over time.

• The fee for retaining fingerprints is $24.00 for 5 years.  This fee is in addition to the screening fee & the Live Scan Service Provider processing fee & is required at the time of screening. 

Note: the retention of fingerprints eliminates the need for subsequent fingerprinting and state rescreening, providing future cost savings.

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Agency for Health Care Administration Background Screening Resources

AHCA Background Screening Web Site• http://www.ahca.myflorida.com/backgroundscreening

Contact: • bgscreen@ahca.myflorida.com• (850) 412-4503

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2012 Law Change for Nurse Registries

CS/CS/HB 787 – effective July 1, 2012400.506(18) “An administrator may manage only one nurse registry, except that an administrator may manage up to five registries if all five registries have identical controlling interests as defined in s. 408.803 and are located within one agency [AHCA] geographic service area or within an immediately contiguous county.”

Same as home health agency law

State law has authority over the state ;rule

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2012 Law Changes - Administrator continued

“Identical controlling interests” means the nurse registries share:

• the same legal entity (same Employer ID #) • have the same people or entities with the exact same % of

ownership – same for management company• have the same board of directors.

“Immediately contiguous county” means the borders of the counties touch each other. There needs to be a licensed nurse registry office in each of the counties that are contiguous.

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2012 Law ChangesChapter 408, Part II, Florida Statutes

CS/CS/HB 787 – effective July 1, 2012

1. 408.804(3), F.S. “Any person who knowingly alters, defaces, or falsifies a license certificate issued by the agency, or causes or procures any person to commit such an offense, commits a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083. Any licensee or provider who displays an altered, defaced, or falsified license certificate is subject to the penalties set forth in s. 408.815 and an administrative fine of $1,000 for each day of illegal display.”

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2012 Law Changes Chapter 408, Part II, Florida Statutes

2. 408.806(2)(d), F.S. Allows the Agency to send a courtesy notice, at least 90 days before the expiration of a license to inform the licensee of the upcoming expiration date. The courtesy notice will be provided by e-mail, postcard or letter but not by certified mail.

If the licensee does not receive a notice, the licensee is still legally obligated to timely file the renewal application with fee & is not excused from paying any late fee.

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2012 Law Changes Chapter 408, Part II, Florida Statutes

3. A late application fee* will be included in the omissions letter. It must be paid prior to issuing the license. 408.804(2)(e), F.S.

Fee is still $50 per day up to a max of $500 for HHA and NR

* For applications received less than 60 days prior to expiration but not past the expiration date.

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2012 Law Changes Chapter 408, Part II, Florida Statutes

4. 408.810(9), F.S. “A controlling interest shall notify the agency within 10 days after a court action to initiate bankruptcy, foreclosure, or eviction proceedings concerning the provider in which the controlling interest is a petitioner or defendant.”

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2012 Law Changes Chapter 408, Part II, Florida Statutes

5. Fine 408.813(3) - AHCA may impose a fine for a violation that is not designated as class I, II, III, or IV. Unless otherwise specified in law, the amount may not exceed $500 for each violation.

Unclassified violations are:

a. Violating any term or condition of a license

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2012 Law Changes Chapter 408, Part II, Florida Statutes

Unclassified Violations Fine 408.813(3) continued:

b. Providing services beyond the scope of the license

c. Violating a moratorium imposed per 408.814, F.S

d. Violating any law in this part, authorizing statutes, or applicable rules.

Example: Not reporting change of administrator within 21 days (59A-35.110(1)(c), FAC)

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Homemaker Companion Services Exemption for APD providers

400.509(1), F.S. “An organization under contract with the Agency for Persons with Disabilities which provides companion services only for persons with a developmental disability, as defined in s. 393.063, is exempt from registration.”

• If also serving any other client population (such as elderly persons), not exempt

• Expect about 20% will no longer have to register

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2012 Law Change for Nurse Registries & Home Health Agencies

400.462(27), F.S. “‘Remuneration’ means any payment or other benefit made directly or indirectly, overtly or covertly, in cash or in kind. However, if the term is used in any provision of law relating to health care providers, the term does not apply to an item that has an individual value of up to $15, including, but not limited to, a plaque, a certificate, a trophy, or a novelty item that is intended solely for presentation or is customarily given away solely for promotional, recognition, or advertising purposes.”

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Medicare HHA UpdateChange of ownership

• If less than 36 months since initial Medicare enrollment or majority ownership change, the buyer has to enroll as a new (initial) HHA with CMS regional HH intermediary & be surveyed.

• Two of the exceptions:– HHA changing its existing business structure – from corporation,

partnership, or LLC – HHA parent company is undergoing an internal corporate restructuring

• See Medicare Program Integrity Manual, Chapter 15 http://www.cms.gov/manuals/downloads/pim83c15.pdf

• CMS letter S & C 12-14-HHA at http://ahca.myflorida.com/homecare at “Home Health Agency,” see Medicare/Medicaid tab. Check with the intermediary if questions.

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Proposed HHA Federal RegulationsCMS-1358-P - July 13, 2012

View at the CMS Home Health Agency Center www.cms.gov/Medicare/Medicare.html • New survey & enforcement requirements:

– Civil money penalties (fines) for deficiencies– An informal dispute resolution (IDR) process (similar to

nursing homes) when conditions of participation are not met

• 2013 Prospective Payment System rate updates• Modifications for therapy assessments documentation & face

to face encounter • Deadline for comments at CMS: Sept 4, 2012

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FLORIDA MEDICAID STATE PLAN HOME HEALTH SERVICES

During the 2012 legislative session, the Legislature mandated the Agency to: Reduce the daily limit of home health visits for non-pregnant

adults from 4 per day to 3 per day, effective August 1, 2012; Expand the home health agency monitoring pilot project in

Miami-Dade County on a statewide basis (or in counties determined to be cost-effective by the Agency); and

Expand the comprehensive care management pilot project for home health services statewide (or in counties determined to be cost-effective by the Agency) and to include private duty nursing and personal care services.

The current Home Health Coverage and Limitations Handbook, December 2011, is being updated to include these changes.

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HHA Quarterly Report 400.474(6)(f), F.S.

• Register for the updated quarterly reporting system prior to the next reporting period 10/1-15/12.

• Users will be able to change passwords online without having to contact AHCA staff.

• Web pages designed to be more user-friendly.

• Information coming by email to your HHA.

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Be Current on your Requirements for Personnel

• Some HHAs still require items that are no longer in rules or laws – or never were.

• Here’s a list I received from a social worker of items HHAs asked for:

What HHAs required Required in law or rule?

PPD TB test No

Chest X ray No

Physical exam No

Health statement free from communicable disease

No for HHA (Yes for Nurse Registry – 400.506(6)(a), FS)

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What HHAs required Required in law or rule?

HIV AIDS training biennially No, only a 1 time course per 381.0035, F.S. State survey standards only requires HH Aides, CNAs, homemakers & companions. Licensed professionals checked by DOH.

Level 2 background screening Yes

CPR No – only required of home health aide & C.N.A. in rule 59A-8.0095(5)(l)

Alzheimer’s Training Yes – one time only, 2 hours

Domestic Violence training No

HIPAA training No

OSHA update No

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State HHA Proposed Rule Revisions

Review & comment on proposed changes at http://ahca.myflorida.com/homecare - select “Home Health Agency”, also see “Laws, Rules and Survey”

Started review process …

Then will publish in Florida Administrative Weekly, offer rule hearing, before adoption.

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HHA Proposed Rule Revisions Adds 2 items that the law requires AHCA to write rules on:

1. Oversight by the Director of Nursing per 400.497(5), F.S. The proposed rule additions in 59A-8.0095(2) require the HHA to:• Have a process to validate that services were provided • Provide a certified report, if requested by a surveyor, to verify services by

a specific staff person during a specified time period. • Add to the existing quality assurance program -- a quarterly sample of

clinical records (sample size you determine) to check that: – (1) only patients whose service needs can be met by the HHA are

accepted; and – (2) each HHA’s own policies & procedures are followed.

 

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HHA Proposed Rule Revisions

2. Use of a recent unannounced licensure survey for a change of ownership as required in 400.497(6), F.S. Uses surveys within 24 months to hold down the costs for HHAs. [59A-8.003(5)(c)]

Makes other personnel rule changes requested by HHAs:• Removes the 1-year experience requirement for physical &

occupational therapists & their assistants;

• Clarifies the tasks that a home health aide can do related to elimination.

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HHA Proposed Rule Revisions

• Removes the requirement for certified nursing assistants to have training on specific topics to meet 400.476(3), F.S.

• Adds that homemakers & companions can remind patients to take their medicine.

Removes rubber stamped signatures for physicians to prevent fraud.

Removes items that are now in Florida Statutes & 59A-35, FAC & updates the statutory references in the rules.

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Home Health Agencies & Physicians

Does the state law or federal regulations require each HHA to have a medical director? No

Federal regulations for Medicare & Medicaid HHAs require a group of professional personnel to advise on policies, participate in evaluation of the HHA’s programs, maintain liaison with other community agencies, assist with community information…. One has to be a physician. (42 CFR 484.16)

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Home Health Agencies & Physicians

400.474(6)(i)(j), F.S.

If you have a physician that you give remuneration to, this would be your medical director per state law.• Medical director – only 1 per HHA permitted

Must have written contract, at least 1 year termPayment must be at fair market value for an

hourly rateInvoices for medical director payment describe

the work performed, the dates on which that work was performed, & the duration of that work

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Physician OrdersMedicare & Medicaid HHAs - The treating or attending physician that ordered the service is to sign the order. (This is not necessarily the primary care physician.)

All Medicare & Medicaid services require a physician’s order. Medicaid allows ARNP, PA if physician also signs the order.

Licensed-only HHAs – Nursing or therapy services requires an order from a physician, ARNP, or PA.

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If you don’t agree with the surveyor1. 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

http://ahca.myflorida.com/MCHQ/areas

4. If still not resolved, contact Chief of Field Operations, Polly Weaver (850) 412-4301

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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– 1st check http://ahca.myflorida.com/homecare - select

Home Health Agency or Nurse Registry - See Frequently Asked Questions or State Regulation Set

– Then call the Home Care Unit (850) 412-4403

or, send an email to

HQAHOMEHEALTH@ahca.myflorida.com

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Contacting AHCA• When you have questions about Medicaid letters you

receive, prior authorization, other Medicaid policy:– Contact the Medicaid area office - see the web site for

phone # & email link http://ahca.myflorida.com/Medicaid • When you have questions about your Medicaid audit:

– Call the person that sent the letter at the telephone number in the letter. Ask to speak to that person’s supervisor too, if needed.

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If your email has changed since your last application

• Please let AHCA Home Care Unit know – send an email to HQAHOMEHEALTH@ahca.myflorida.com with your correct email address.

• Notices (such as the email on the 2012 law changes & reminders to renew your license) will get to your agency quicker if you keep your email current.

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www.FloridaHealthFinder.gov

To find agencies & facilities • See Locate , select Facilities and Providers, then 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 get Excel listings from your search

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Get the new AHCA Mobile Facility Locator Application

For information on facilities or agencies & driving directions…and looking up whether a facility is licensed

See main page of http://ahca.myflorida.com – click on “Available on the App Store”

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Contact Information

Anne Menard – Supervisor

Anne.Menard@ahca.myflorida.com

• Medicare & Medicaid HHA certification & branch approvals

Cynthia Thomas

(850) 412-4403

Jan Benesh – HHA & NR licensing manager

• Ed Barnes - Change of ownership, licensing - HHA/NR

• Lenora Lowry - HHA• Natarsha Humphries - HHA/NR • Susan Glass - HHA• Pat Guilford - NR

HQAHOMEHEALTH@ahca.myflorida.com