michigan department of licensing and regulatory affairs (lara)
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Michigan Department of Licensing and Regulatory Affairs (LARA). Bureau of Health Systems Mike Pemble, Director September 13, 2011 For Joint Provider Surveyor Training. Health Systems. License, certify and/or regulate facilities: 442 Nursing Homes 174 Hospitals - PowerPoint PPT PresentationTRANSCRIPT
MichiganMichigan Department ofDepartment of Licensing Licensing and Regulatory Affairs (LARA)and Regulatory Affairs (LARA)
Bureau of Health SystemsBureau of Health SystemsMike Pemble, DirectorMike Pemble, DirectorSeptember 13, 2011September 13, 2011
ForFor
Joint Provider Surveyor TrainingJoint Provider Surveyor Training
Health SystemsHealth Systems License, certify and/or regulate facilities:License, certify and/or regulate facilities:
442 Nursing Homes 442 Nursing Homes 174 Hospitals 174 Hospitals 10 Psychiatric Hospitals / 50 Licensed Psychiatric Programs10 Psychiatric Hospitals / 50 Licensed Psychiatric Programs 9 Organ Transplant Facilities9 Organ Transplant Facilities 581 Home Health Agencies 581 Home Health Agencies 111 Hospice Programs and 22 Hospice Residences 111 Hospice Programs and 22 Hospice Residences 196 End Stage Renal Disease (Dialysis)196 End Stage Renal Disease (Dialysis) 153 Rural Health Clinics 153 Rural Health Clinics 70 Freestanding Surgical Outpatient Facilities (26 licensed only)70 Freestanding Surgical Outpatient Facilities (26 licensed only) 54 Ambulatory Surgical Centers54 Ambulatory Surgical Centers 19 Comprehensive Outpatient Rehabilitation Facilities and 11 19 Comprehensive Outpatient Rehabilitation Facilities and 11
Portable X-Ray FacilitiesPortable X-Ray Facilities 209 Rehabilitation Facilities (formerly Outpatient Physical Therapy) 209 Rehabilitation Facilities (formerly Outpatient Physical Therapy) 7,397 Clinical and Physician Office Labs7,397 Clinical and Physician Office Labs 10,038 Radiological Facilities10,038 Radiological Facilities
BHS Staffing
2010 Early Retirement Incentives
75 Vacancies since 10-1-10 (33%)
Filled 58 Positions
17 Remain Vacant
Approximately 1 Year HCS Independence
Potential Worker Concessions FY12
Health SystemsHealth Systems
Key Accomplishments:Key Accomplishments:
Eliminated long standing Eliminated long standing nursing home complaintnursing home complaint backlog (continuous challenge to maintain)backlog (continuous challenge to maintain)
Innovative nurse recruitment techniques assist in filling Innovative nurse recruitment techniques assist in filling health care surveyor vacancies (10 currently)health care surveyor vacancies (10 currently)
Improved coordination and efficiencies in the survey Improved coordination and efficiencies in the survey process (e.g. combined revisits)process (e.g. combined revisits)
Improved Timing of Survey Report Issuance Improved Timing of Survey Report Issuance Biannual Joint Provider-Surveyor Training Attendance Biannual Joint Provider-Surveyor Training Attendance
at All Time High (835 today) at All Time High (835 today) Improved communication with provider communityImproved communication with provider community
CMS Region V – ChicagoCMS Region V – ChicagoTotal All Provider TypesTotal All Provider Types
Ohio – 12,993Ohio – 12,993 Nursing homes: 955Nursing homes: 955Illinois – 12,219Illinois – 12,219 Nursing homes: 788Nursing homes: 788Michigan – 9,450Michigan – 9,450 Nursing homes: 428Nursing homes: 428Indiana – 7,218Indiana – 7,218 Nursing homes: 503Nursing homes: 503Minnesota – 4,676Minnesota – 4,676 Nursing homes: 386Nursing homes: 386Wisconsin – 4,509Wisconsin – 4,509 Nursing homes: 390Nursing homes: 390
Source: OSCARSource: OSCAR
Total Number of Surveys Conducted - All Providers (Standard, Complaints, Revisits, LSC)
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
FY 2007
FY2008
FY 2009
FY 2010
FY 2007 9083 6515 2800 3022 8577 2929
FY2008 9437 6736 3065 3204 9109 3021
FY 2009 8979 6854 3395 3091 8882 3194
FY 2010 7673 6301 4044 2976 7930 2563
IL IN MI MN OH WI
Source: CASPER 11/29/2010
Michigan is the only state in Region V that shows an increase in the number of surveys conducted in FY 2010.
Complaint Response TimeComplaint Response Time
Average Number of Days from Receipt of Average Number of Days from Receipt of Complaint to Surveyor OnsiteComplaint to Surveyor Onsite
Non IJ High Priority Complaints:Non IJ High Priority Complaints:
2007 – 102.5 days2007 – 102.5 days
2008 – 105.7 days2008 – 105.7 days
2009 – 84.5 days2009 – 84.5 days
2010 – 23.4 days2010 – 23.4 days
2011 to date – 15.9 days2011 to date – 15.9 days
IL - 788 IN - 503 MI - 428 MN - 386 OH - 955 WI - 390
FY 2007 770 422 335 389 870 358
FY 2008 789 483 409 392 880 398
FY 2009 773 532 463 390 891 373
FY 2010 757 521 461 390 895 330
Total Number of Surveys Conducted Long Term Care – Standard Health Surveys
Source: CASPER 1/3/2011
The number of LTC standard surveys in FY 2010 has decreased in four of six states in Region V. However, Michigan standard surveys held steady for the year. The number of completed standard surveys in Michigan for FY10 is 38% higher than FY07.
1092
274
1139 1031 1104
5135
1260
3646
1285
5644
1257
5063
1295
4443
0
1000
2000
3000
4000
5000
6000
FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010
Complaints vs. FRI's Intake History - Michigan
Source: ACTS 11/17/2010
Source: CASPER 11/29/2010
Michigan is the only state in Region V that shows an increase in the number of complaint surveys conducted in FY 2010.
Total Number of Surveys Conducted, Long Term Care - Complaint Health Surveys
0
500
1000
1500
2000
2500
3000
FY 2007
FY 2008
FY 2009
FY 2010
FY 2007 2846 1584 555 411 2226 896
FY 2008 2742 1450 616 503 2452 858
FY 2009 2826 1443 721 516 2052 913
FY 2010 2430 1434 1503 511 2058 798
IL IN MI MN OH WI
Root Cause Analysis of IncidentsRoot Cause Analysis of Incidents
““Why” (vs. How) did this incident occur?Why” (vs. How) did this incident occur?Are any other residents at risk for similar Are any other residents at risk for similar occurrences?occurrences?What can be done differently so this What can be done differently so this doesn’t happen again to any resident?doesn’t happen again to any resident?Implement new plan.Implement new plan.Monitor Closely to Determine Monitor Closely to Determine Effectiveness.Effectiveness.Modify as Needed.Modify as Needed.
Total Number of Surveys Conducted Long Term Care – Revisit Health Surveys
Source: CASPER 1/03/2011
MI has increased the numbers of revisits by 52% since 2007. No other state in Region V shows this type of increase.
0
200
400
600
800
1000
1200
1400
1600
1800
FY 2007
FY 2008
FY 2009
FY 2010
FY 2007 1570 1044 637 445 1373 597
FY 2008 1630 1131 777 455 1514 618
FY 2009 1730 1040 867 467 1520 692
FY 2010 1506 1052 968 458 1428 575
IL IN MI MN OH WI
Issuance of 2567 ReportsIssuance of 2567 Reports
Time period evaluated – 5/30/11 thru 9/9/11 (15 wks)Time period evaluated – 5/30/11 thru 9/9/11 (15 wks)
Target is to issue all reports within 10 business daysTarget is to issue all reports within 10 business days
BHS issued 604 reports in this time frameBHS issued 604 reports in this time frame
84% of all reports were issued within 10 days84% of all reports were issued within 10 days
Average for all reports was 8 daysAverage for all reports was 8 days
Reports that went beyond 10 days averaged 17 daysReports that went beyond 10 days averaged 17 days
Initiatives and GoalsInitiatives and Goals
Consistency Work GroupConsistency Work Group Electronic Plan of CorrectionElectronic Plan of Correction Posting of Survey Reports Posting of Survey Reports Hot Weather Issues: Baseline Physical Hot Weather Issues: Baseline Physical
Plant SurveysPlant Surveys Continued Improvement for Report TimelinessContinued Improvement for Report Timeliness Elder Justice Act: Reporting of CrimesElder Justice Act: Reporting of Crimes Independent IDR / PPACAIndependent IDR / PPACA Continued Collaborative Provider RelationsContinued Collaborative Provider Relations
Reporting of Events to BHSReporting of Events to BHS
Nursing Home Sprinkler StatusNursing Home Sprinkler Status
Federal deadline: August 13, 2013Federal deadline: August 13, 2013
Number of certified MI NH’s: 428Number of certified MI NH’s: 428
NH’s fully sprinklered: 325 (76%)NH’s fully sprinklered: 325 (76%)
NH’s NOT fully sprinklered: 103 (24%)NH’s NOT fully sprinklered: 103 (24%)
148 letters sent 8/10/11; 77 responses148 letters sent 8/10/11; 77 responses
Keynote AddressKeynote Address
Dr. Chuck Gokoo, MD, CMO, CWS, Dr. Chuck Gokoo, MD, CMO, CWS, FACCWSFACCWS
““A Clinical Guide to the F314 Tag”A Clinical Guide to the F314 Tag”