Home health regulatory update Agency for Health Care

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Home health regulatory update Agency for Health Care Powered By Docstoc
           Anne Menard
         Home Care Unit
 Bureau of Long Term Care Services
           Currently Licensed
2,315 home health agencies
  County with largest #: Miami-Dade 799

371 nurse registries
           Palm Beach 86
2,240 homemaker companion services
           Miami-Dade 335
          Home Health Agencies
70% Certified for Medicare and/or Medicaid
  – 707 are not certified, but 160 pending

63% Accredited – 1,457 HHAs
  – 850 both state & fed’l (accredited deemed)
  – 607 state accredited only

   Criminal Background Screening 2010 Legislation

Legislation that changed the process:
• Replaces all Level 1 background screening with Level 2
• Requires Level 2 rescreening every 5 years
• All Level 2 screenings must be submitted electronically
• Changes the positions requiring screening
   – Employees Who:
      • Provide Personal Care or Services Directly to Clients
      • Have Access to Client Funds, Personal Property, or Living Area
      • Contractors Who Provide Personal Care or Personal Services
        Directly to Clients
 AHCA Background Screening Process Improvements
                    to Date
   Implemented Electronic Fingerprints Program
   Background Screening Data System Rewrite
    – Improved Automation and Speed of Results
    – Handle Electronic Fingerprints
    – Expand Accounts Based on New Florida Law for Provider and Contract
• Growth in Annual Screening from 63,000 to Over 200,000 Due to
  New Florida Law (8/1/2010 to date – 194,332)
• Handle Significant Increase in Workload with Existing Staff/
• Current Turn Around Time 0 – 5 Days
              Issues with Process
• Cannot track screenings until the result is
  received at the Agency
• Screenings submitted to incorrect ORI
• Missing or incorrect SSNs
• No provider information retained on screening:
  – Unable to notify providers if there is an issue or status
  – Inability to communicate with providers regarding
    rejected prints
 Federal Background Screening Grant
• Florida 1 of 12 states awarded a $3 Million
  Federal Grant from the Centers for Medicare
  and Medicaid Services to expand Background
  Screening of Long Term Care Staff

• 2 Year Project: October 2010 – September
 Goals for the Federal Background Screening
• Technology System Improvements (Phase I and II)
   – Provide State Criminal History Results to Providers
   – Automate Provider Screening Result Notifications
   – Eliminate Duplicative Screening
• Connection with Other Data Systems (Phase I)
   – Medicare Exclusion Registries/Medicaid Terminations
   – Health Practitioner Licensure Information (DOH)
• Rapback (Retained Prints) (Phase II)
   – Enable Notification of Arrests for Persons Screened
• Centralize Screening Functions (Phase I and II)
        Agency for Health Care Administration
         Background Screening Resources

Agency for Health Care Administration Web Site

Thank you for reporting unlicensed home care.

Reminder: Knowingly providing home health services in an unlicensed
  assisted living facility (ALF) or adult family care home (AFCH) --
  unless HHA or employee reports to the state within 72 hours after
  providing services – is grounds to deny, revoke & suspend a license
  & impose a fine. 400.474(1)(2)(c), F.S.

If there is no license posted, check at

Call the AHCA complaint # (888) 419-3456 to report
 When providing wound care to ALF residents
• A resident cannot remain in any ALF with stage 3 or 4
  pressure sores.

• If a resident is admitted with a stage 2 pressure sore, the
  ALF must have:
   – Limited Nursing Services (LNS) or Extended Congregate Care
       (ECC) license and provide the appropriate nursing care
   – The ALF must employ or contract with a nurse to provide the
   – The resident must contract with a home health agency for
       nursing care
   If there is no improvement in 30 days, the resident must be
            ALF residents care limitations
Prohibited Services
• Mechanical lifting equipment – such as Hoyer lifts
• Restraints - only ½ bed rails with physician order every 6 months
• Oral, nasopharyngeal, or tracheotomy suctioning - unless under care of hospice (but ECC can
    do tracheotomy suctioning)
•   Peg tubes (feeding tubes) – unless self maintained; except hospice patients where there is licensed staff
    to maintain

Restricted Services
• Residents cannot be bed bound – unless Extended Congregate Care license & then only up to
   14 days.
• 24 hour nursing services
     – Residents may not be admitted to any ALF if they need 24-hour nursing supervision
     – Residents who later need 24 hour nursing supervision may stay in an ALF if:
            •     ALF has an ECC and necessary licensed staff or
            •     ALF has LNS license hospice is providing necessary licensed staff
       Please report ALF concerns
• Resident rights – grievances go unanswered or
  rights were violated
• Residents neglect
  – not receiving their medication
  – not getting enough food
  – hygiene neglect, wet clothing,
  – no staff present
         Please report ALF concerns
• Building Safety. Obvious and urgent safety hazards related to
  the building such as:
   – Unstable construction
   – Fire alarms/building systems
   – Building safety devices (locking mechanisms)
• Concerns should be made to local building officials

• Obvious and urgent safety hazards unrelated to the building
  may be reported to AHCA.
      Reporting AHCA Complaints
• AHCA Contact (888) 419-3456
• Online report Health Care Facility Complaint
  Form at:
• Provide detailed information such as
  patient/resident names, dates, times of events
  and where the event occurred
 Reporting abuse, neglect & exploitation
• Florida law 415.1034, F.S., requires that any person who
  “knows, or has reasonable cause to suspect, that a
  vulnerable adult has been or is being abused, neglected, or
  exploited shall immediately report such knowledge or
  suspicion to the central abuse hotline.”
• There is a similar law for children.

• Nurse registries, home health agencies & anyone should
  report any suspected or known abuse, neglect or
  exploitation of patients to the Department of Children and
  Families Abuse Hotline at 1-800-962-2873.
  Penalties for providing less than fair
market value services or staffing to ALFs
AHCA may deny, suspend or revoke the license
 & shall impose a fine of $5,000 for a HHA or
 NR (400.474(6)(b)(c), and 400.506(15)(a), F.S.)

Providing staff free to ALFs, Adult Day Care
  Centers & AFCHs (nurses, CNAs, home health
  aides, etc.) is a fine of $15,000 for HHAs.
  (400.518(4), F.S.)
          HHAs Contracting for Therapy
A. Contracting with another business to provide therapy to
   patients You refer the patients to the business & they send out
     therapists to the patient’s homes. The business you contract with would
     need to be:
1.   a home health agency that has therapists, or
2.   a certified rehabilitation agency, or
3.   a comprehensive outpatient rehabilitation facility (CORF), or
       [The state law exempts from home health agency licensing certified
                 rehabilitation agencies and CORFs (400.464(5)(m), FS)]
4.   a therapy practice that provides only one kind of therapy such as
             physical therapy.
       [An entity that provides a single health care professional discipline is not an
       organization for the purposes of home health agency licensing per 400.462
       (22), FS]

(from 13.3 of the Frequently Asked Questions, at - click on “home health agency”)
          HHAs Contracting for Therapy
 B. When you have therapists on your staff already & you need a
   temporary replacement -- for one that is on vacation, or while you fill
   that vacancy or when you have a seasonal shortage -- you can
   contract with a health care services pool for temporary staff.
    – The state law says that a health care services pool “provides temporary
       employment in health care facilities, residential facilities, and agencies …”
       (400.980 (1), F.S.).

     – “Temporary employment” means “employment whereby a pool hires its own
       employees or independent contractors and assigns them to health care facilities
       to support or supplement the facilities’ work force in special work situations
       such as employee absences, temporary skill shortages, seasonal workloads, and
       special assignments and projects” (59A-27.001 (1), Florida Administrative

(from 13.3 of the Frequently Asked Questions, at - click on “home
     health agency”)
             State rule writing
• Cannot write a rule without specific authority
  in state law to do so
• Ratification by the Legislature is required if a
  rule is likely to increase the regulatory costs
  more than $1 million in the aggregate within a
  5 year period from the date of
  implementation (120.541 (3), F.S. - 2010)
Home Health Agency Rules:
• Starting over with rule development
• Have submitted a draft for rule development to
  the Governor’s Office of Fiscal Accountability and
  Regulatory Reform
• Once receive approval to begin rule development
  - will post draft at web site & Fl Admin Weekly - -
  requesting comments
  - will hold rule development workshop
   Home health agency rule repeals
AHCA reviewed all programs for rules that could
  be repealed
HHA repeal notice published in the 6-24-11 Fla
  Admin Weekly & posted at AHCA web site.
Repeal should be effective in August for 2 rules:
1. 59A-8.0086 – Denial, Suspension, Revocation of
   License and Imposition of Fines - contents
   already in 408, Part II & 400, Part III, F.S.
     Home health agency rule repeals
2. 59A-8.0185 – Personnel policies
Joint Administrative Procedures Committee legal review found
    that AHCA no longer had legal authority for this rule

What requirements will be removed when this rule is repealed:
• Health statements from employees
• A plan for orientation of all health personnel
• Job descriptions
• A file for each employee - with name, address, next of kin for contact,
   evidence of qualifications, the results of background screening, dates of
   employment and separation, and evidence of training. Files are kept for 1
   year after separation.
Home health agency survey standards
• Will have revised survey standards at the time
  the rule repeal takes effect. (August 2011)
• Will remove the standards re 59A-8.0185
  Personnel Policies:
  H 202 communicable disease (health statement),
  H 201 re personnel policies
  H 204 personnel records
             Nurse Registry Rules
Will be submitting proposed rules -- based on 2010 rule
  workshop & comments received -- to the Governor’s
  Office of Fiscal Accountability and Regulatory Reform
  for approval in July.
Once approval is received, will put at web site & Florida
  Administrative Weekly, provide opportunity for
  comments & hold a public hearing.

(Note - Health statements are in nurse registry law
  400.506(6)(a), F.S. & cannot be removed from rule.)
Medicare & Medicaid Home
 Health Agency Surveys
           CMS Revisions
 For surveyors from state agencies &
      accrediting organizations
 CMS has revised the survey process
• For Medicare & Medicaid HHAs recertification
• States & accrediting organizations follow CMS
• Process improvements:
  – Uses existing data for pre-survey preparation
  – Focuses on standards most directly related to the
    delivery of high-quality patient care
      2011 – HHA Survey Process
• Emphasizes information from HHA staff
  interviews, clinical records & home visits
• Minimizes non-clinical record review paper
• Provides guidance for surveyors on
  expanding the survey & issuing deficiencies
• More specific guidance on citing standard &
  condition-level deficiencies

             From CMS Basic Home Health Agency
                    training for surveyors
           Standard Survey
• Focus on standards most directly related
  to delivery of high-quality patient care
• Selected standards to be checked are
  called “Level 1 standards”
• Standards are from 9 of 15 Conditions of
  Participation -- including Nursing &

            From CMS Basic Home Health Agency
                   training for surveyors
         Conditions & Level 1 Standards
        484.10 Patient Rights - G107, G109
        484.12 Compliance with Fed/State/Local
               Laws - G121
        484.14 Organization/Services/Administration
               - G123, G133, G143, G144
        484.18 Acceptance of Patients, Plan of Care,
               Medical Supervision -
               G157, G158, G159, G164, G165, G166

From CMS Basic Home Health Agency
training for surveyors              12
 Conditions & Level 1 Standards (cont.)
484.30 Nursing: G170, G172, G173, G174,
       G175, G176, G177
484.32 Therapies: G186, G187, G188
484.36 Home Health Aide: G224, G229
484.48 Clinical Records: G236
484.55 Comprehensive Assessment of Patients:
       G331, G332, G334, G335, G336, G337,
       G338, G340

From CMS Basic Home Health Agency
training for surveyors              13
                Standard Survey
• Surveyors stay at standard survey unless deficient
  practice is identified in the Level 1 standard

• Per CMS, compliance with Level 1 standards is:
  – highly likely to affect care delivery and patient
    outcomes and

  – the HHA is highly likely to be in compliance with all of
    the Conditions of Participation
                      Standard Survey Ends
HHA Survey ends with standard survey if:
     – HHA complies with all Level 1 standards;
     – No deficiencies are identified after home visits,
       clinical record reviews & interviews with patients
       and staff and
     – No additional issues/concerns are identified
       needing investigation

From CMS Basic Home Health Agency
training for surveyors              14
  Survey continues … and becomes partial
• When expected outcomes are not met for one
  or more Level 1 standards
• Other issues are recognized by the surveyor
• Survey becomes a partial extended survey
     – Level 2 standards are reviewed
     – Other standards may be reviewed

From CMS Basic Home Health Agency
training for surveyors              15
          484.10 Patient Rights
Standard Survey
            Partial Extended Survey

   Level 1            Level 2                    Associated

                       G101, G108,
   G107, G109                                      484.12,
                       G111, G114
                                                484.14, 484.18

   Consider citing the condition when:
   • The HHA is out of compliance with G107 and G109 and
     one additional tag within that condition. (G100-G116)

                     Basic Home Health Agency                    43
             Extended Survey
     • Must be conducted when any
       condition level deficiency is found
     • All conditions are reviewed
     • Must be conducted for accrediting
       organization validation surveys that
       CMS selects for the states to do

38                  Basic Home Health Agency
              To find out more
- Select “Internet-only manuals”, then “State
  Operations Manual”
- See Appendix B – Home Health Agencies

There is also a link from the AHCA home health
  agency page – - click on
  “home health agency” – see “Federal Regulation
  Set used by Surveyors”
 Most frequent CoPs not met in 2010
• G 156 – Plan of Care (11 HHAs)
• G 122 – Organization, Services &
  Administration – (9 HHAs) not providing services
• G 100 – Patient Rights (8 HHAs)
• G 235 – Clinical Records (8 HHAs)
 If you don’t agree with the surveyor
1. Ask the surveyor to show you the survey
  standard, law or rule during the survey
2. Discuss with surveyor at Exit Interview
3. Contact the AHCA Field Office Manager
4. If still not resolved, contact: Chief of Field
  Operations, Polly Weaver (850) 412-4301
            AHCA web sites -- select “home
 health agency” or “nurse registry” – licensing,
 state & federal survey standards, emergency
 management plan & local plan review contacts, &
 answers to frequently asked questions - select “Find
 Facilities or Providers” (updated nightly) + also
 see Consumer Guides
    Contact information – HHA & NR
Anne Menard – Unit Supervisor             Jan Benesh – HHA & NR               licensing manager
                                          • Ed Barnes - Change of
•   Medicare & Medicaid certification -     ownership
    HHA                                   • Lenora Lowry – HHA & NR
     – Cynthia Ibrahim – HHAs I to Z,     • Natarsha Humphries – HHA &
        & branch approvals, change of
        ownership                           NR
     – Ceather Watkins – HHAs A to        • Susan Glass - HHA

(850) 412-4403

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