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9/9/2014

1

Understanding Alternative Sanctions for Home Health Agencies with

Deficiencies

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B. Not Accredited

C. Accredited By Another Organization

9/9/2014

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CMS Alternative Sanctions for Home Health Agencies:

What’s at stake?

Nathan Constable

Senior Manager of Communications and Policy

Background

• November 8, 2012 CMS Final Rule

– Imposes alternative sanctions for HHAs that are found to have condition level deficiencies during state survey agency (SA) survey.

– Prior to ruling, only enforcement option CMS had was termination within 100 days.

– Sanctions allow agencies to come into compliance before being terminated

Purpose of the Sanctions

• Ensure HHAs remain in and sustain substantial compliance with Medicare Conditions of Participation (COPs) and state law.

• HHAs continue to provide care to patients and maintain highest practicable functional capacity.

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Reasons for SA Visit• Initial Certification

– Applies to HHAs not on an accreditation track.

• Recertification – Applies to HHAs that are not accredited with deemed status.

• Complaint or Immediate Jeopardy– Applies to all HHAs

• Validation Survey– Applies to a percentage of all HHAs– Only five percent of CHAP‐accredited HHAs have received validation surveys

Available Sanctions

• Civil Monetary Penalties

• Suspension of Payment for all New Admissions

– Includes readmissions

• Temporary Management of HHA

• Directed Plan of Correction

• Directed In‐Service Training

Factors Considered in Selection of Sanctions• Seriousness of deficiencies

• Poses immediate jeopardy

• Nature and duration of deficiencies

• Repeat deficiencies

• Failure to provide quality care

• Organizational and system‐wide problems

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Actions Taken: IJ Posed

• Termination if IJ is not removed within 23 days

• CMS may also impose immediate sanctions

Actions Taken: IJ Exists

• HHA provider agreement is immediately terminated

• One or more sanctions may be imposed as well.

Actions Taken: Condition Level Finding• 100 day termination track, or

• Alternative sanctions imposed instead of termination

– Termination will occur after six months of noncompliance

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Temporary Management

• Imposed when failure to comply with COPs is directly related to poor/lack of management impairing HHA from correcting deficiencies.

• HHA management must relinquish authority and control to temporary manager.

• Temporary manager oversees correction of deficiencies.

• Maximum period = six months

Suspension of Payment• Suspension of payment for all new Medicare admissions and readmissions.

• May be imposed alone or in addition to other sanctions.

• No reimbursements to HHA for period of sanction.• HHA is required to notify any new patient admission of the fact that Medicare payment would not be available because of sanction.

• HHA is precluded from charging the Medicare patient for those services unless it notifies the patient both orally and in writing that the patient understands that Medicare payment is not available.

Directed Plan of Correction

• Plan developed by state or Regional Office (RO).

• Requires HHA to take specific actions within specific time frames to achieve compliance.

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Directed In-Service Training

• Used when the state, CMS or temporary manager believe education is needed to correct deficiencies.

• All staff required to attend specific in‐service training program.

Civil Monetary Penalties

• May be imposes for number of days not in compliance OR for each instance of noncompliance.

• Cannot exceed $10,000 per day.

• Penalties range from $500‐$10,000.

Civil Monetary Penalties: Determining the Amount• CMS considers certain factors in its determination.

– Size of the agency and its resources

– Information on HHA’s operations and resources

– Evidence of self‐regulating quality assessment and performance improvement system.

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Civil Monetary Penalties:Adjustments to Penalties• CMS may increase or decrease the amount of the penalty if the level of noncompliance changes.

• CMS will increase penalty if:– HHA is unable or unwilling to correct deficiency.

– System‐wide failure in the provision of quality care

– Determination of immediate jeopardy with actual harm.

• CMS may decrease penalty if substantial and sustainable improvements have been made even though HHA is still not in compliance.

Civil Monetary Penalties:Range of Penalty Amounts• Upper Range

– $8,500 to $10,000 per day of non‐compliance for condition‐level deficiency that is immediate jeopardy.

– $10,000 per day if immediate jeopardy results in actual harm;

– $10,000 per day if there is immediate jeopardy that results in potential for harm

– $8,500 per day for an isolated incident of noncompliance that violates HHA policies and procedures

Civil Monetary Penalties:Range of Penalty Amounts

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Civil Monetary Penalties:Range of Penalty Amounts• Middle Range

– $1,500 to $8,500 per day for repeat and/or condition‐level deficiency that does not constitute immediate jeopardy.

– Directly related to poor quality patient care outcomes.



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Civil Monetary Penalties:Range of Penalty Amounts• Lower Range

– $500 to $4,000 per day for repeat and/or condition‐level deficiency that does not constitute immediate jeopardy

– Related to the structure or process‐oriented conditions instead of patient care outcomes.


Civil Monetary Penalties:Procedures• Appeals

– Prior to CMS collecting a civil money penalty (CMP)

– HHA may request a hearing with the Administrative Law Judge (ALJ) on the determination of noncompliance that caused penalty.

– Once a hearing is requested, CMS cannot collect CMP until a final agency decision

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Civil Monetary Penalties:Procedures• Waiving Right to Hearing

– HHA may waive the right to a hearing, in writing, within 60 days of notice of CMP.

– If HHA waives right to appear hearing within 60 calendar days of notice, CMS will reduce CMP by 35 percent.

Civil Monetary Penalties:Duration of Per-Day Penalty• Per‐day penalty begins to accrue on the last day of the survey where noncompliance was found.

• Continues to accrue until HHA achieves substantial compliance or the date of termination, whichever occurs first.

• Cannot extend beyond six months. HHA will be terminated if it cannot achieve compliance within six months.

Alternative Sanctions:Informal Dispute Resolution (IDR)

• HHAs have the opportunity to dispute a condition‐level survey finding that warrants a sanction.

• Initiation of the IDR process or failure of CMS or the State, as appropriate, to complete an IDR will not postpone or otherwise delay the effective date of any enforcement action.

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Alternative Sanctions and Accreditation

• Oversight of HHAs that are accredited with deemed status is under the jurisdiction of the Accrediting Organization (AO) and not the SA.

– Exception: Validation Surveys

• AO do not impose sanctions

Alternative Sanctions and Accreditation

• Validation surveys only occur when:

– SA conduct validation survey of accredited providers with authorization from RO.

• Only five percent of CHAP‐accredited HHAs have received validation surveys.

– In response to a “substantial allegation” or immediate jeopardy complaint.

• These surveys focus on the COPs related to the allegations.

Takeaways

• CMS can enforce five different types of sanctions, individually or in combination.

• Sanctions are imposed after a SA survey find noncompliance with COPs

• Accredited agencies with deemed status are not subject to SA surveys, with rare exceptions.

• Accreditation with deemed status greatly reduces the likelihood of HHA receiving sanctions

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The Importance of Accreditation

Dawn Murr‐Davidson RN, BSN

Regional Director of Professional Services

Risk Reduction Through Accreditation• Culture of internal examination

• Culture of Readiness

• Framework for ongoing process improvement

• Validation through site visit

• Decreased risk for SA site visit and sanctions

Types of SA Visits for Accredited Agencies• Validation Visit

– Applies to a percentage of all HHAs

– Only five percent of CHAP accredited HHAs have received a validation survey

– This percentage would be similar for all AOs

• Complaint or Immediate Jeopardy

– Applies to all HHAs

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Validation Visits

• CHAP conducted 989 deemed home health site visits in 2013

• CMS conducted roughly 50 validation site visits on CHAP in 2013 (5% of all deemed home health site visits)

• Using these figures, an agency who chooses an Accreditation Organization for their deemed status has a 5% chance of being surveyed by CMS as part of a validation visit

Complaint or IJ Visits• Ultimately states may chose to do the high risk to patient safety visits, but in general complaints about deemed agencies are referred to their respective AO for investigation

• If a complaint is severe in nature and is possibly an IJ, the state may go into the organization directly

• When the state conducts a site visit, a deemed agency may be subject to sanctions.– This is still unclear because a review of prior required actions from the AO visit would need to occur.

Decreasing the Risk for IJ and Complaint SA Visits• Look at internal complaint and monitoring process (QAPI)

• Consider accreditation if not already accredited by an AO

– State defers many complaint visits to the AO

– Complaint may be reported directly to the AO

– If an SA visit occurs, the gate is open to other issues that may arise during the visit.

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The CHAP Accreditation Process

Quality of Services

Structure and

Function

Resources

Long Term

Viability


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Poll: Of the eight areas identified for sanctions on the previous slide, does your organization have at least one QAPI metric in:

A. 1‐2 areas

B. 2‐4 areas

C. 4‐6 areas

D. all identified areas

• Organizational Support

• Information is Key

• Providing Tools

• Incentives

Resource: Performance Improvement, Stages, Steps & Tools

Diagnosing Recurring Performance Problems

Organizational Support

Are the systems conducive to good performance?

Does adherence to policies and procedures set the tone and drive expectations?

Action step: Provide a process for ongoing performance improvement using data to drive outcomes

Diagnosing Recurring Performance Problems

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Diagnosing Recurring Performance Problems• Tools

oDo staff have all the items they need to do their jobs?

o Are there links between performance & identified barriers?

Action step: Provide tools for success

Diagnosing Recurring Performance Problems• Information Expectations and Feedback

o Do people know what is expected of them?

o Do they know how well they are doing

measured against expectations?

o Is the feedback method(s) understandable

and practical to their job?

o Is the feedback tied to something over which they have control (their own performance?)

Action step: Provide necessary information

Diagnosing Recurring Performance Problems•Incentives

oIf they do it the right way does the job get easier (incentive) or harder ( disincentive) ?

o If they do it right does anything improve?

o If both the above true is there a “ balance” in favor of doing it right?

o If they do it wrong what are the consequences?

o Are incentives contingent on their performance?

Action step: Provide accountability & reliability metrics

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Monitoring Strategies

• Identify the issue clearly

• Set well defined target– 95% of employees will

have annual eval within one month of anniversary date

• Determine data source– Record review

– Home visits

• Establish frequency– Daily check

– Monthly audit

• Determine process for analysis– QI committee?

– Nursing council?

• Distribution of findings– BOD?

– Care team members?

• What’s next– What is the next cycle of

improvement?

Common Deficiencies

• 484.36/G202 ‐ Home Health Aide Services• HHII.5m/G224 – Development of the Home Health aide plan of care

• HHIII.1e5/G229 – Home Health Aide Supervision every 14 days

• HHII.5n/G225 – Home Health Aide follows the plan of care

• HHIII.1d/G211, G214, G217, G218

• Preventive strategies

Common Deficiencies

• 484.18/G156 ‐ Acceptance of Patients, Plan of Care, Medical Supervision • HHII.5a/G159 – Elements of the Plan of Care/485

• HHII.5b/G158 – Care provided follows the established plan of care

• HHII.5i/G164 – MD notification

• HHII.7b/G165 – MD orders

• HHII.5g/G166 – Verbal orders


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Cultivating Culture of Excellence

• Communicate

• Collaborate

• Coordinate

• Change Leadership

• Build accountability & reliability into your monitoring process(es)

• Reward & celebrate your success

Common Deficiencies and Strategies to Avoid Them

Frances B. Petrella, BSN, RN

Regional Director of Professional Services

Common Deficiencies

• 484.30/G168 – Skilled Nursing Services• HHII.2c/G170 – SN follows the established plan of care

• HHII.2c/G172 – SN regularly re‐evaluates the patient

• HHII.2c/G173 – SN initiates the plan of care and makes necessary revisions

• HHII.2c/G176 – SN progress notes, coordinates services, informs the MD and other personnel of changes in the patient's condition and needs.

• HHII.2c/G177 – SN counsels the patient/family


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Common Deficiencies• 484.14/G122 – Organization, Services and Administration

• HHI.3/G123 – Scope of Services• HHI.4/G133 – Administrator organizes and directs ongoing

functions• HHI.4d/G124 and G125 – Supervision is not delegated to

another organization; agency monitors/controls contracted services

• HHII.2b/G127 – At least one qualifying discipline is fully employed by the agency

• HHII.4c/G143 – Care is coordinated• HHII.4d/G144 – Care coordination is documented


General Strategies

• Audit, audit, audit

• Analyze and trend findings

• Act on the trends as issues are identified

• Engage your staff; share the information

• Provide education

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