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					Agency For Health Care Administration

Regulatory Update Training
September 2004 / January 2005


Presenters:
  Polly Weaver, Chief of Field Operations
  Molly McKinstry, Chief of Long Term Care Services
  Susan Acker, Ph.D., Director of Nursing Services
  Agency for Health Care Administration-Division of Health Quality Assurance



                      Agency for Health Care Administration
Hurricane Season 2004




    Agency for Health Care Administration
             Emergency Plans
• Check Current Plans to Ensure They Are Up-to-date
• Consider Lessons Learned From Recent Experience
• Check Vendors to Ensure They Will Honor
  Agreements – Supplies, Transportation, Receiving
  Facilities
• Consider Secondary Evacuation Plan/location If
  Initial Is Affected
• Ensure Appropriate Receiving Facility
• Prior to Evacuation, Reach Agreement on Supplies
  and Resources and Who Will Provide

                Agency for Health Care Administration
      Emergency Preparedness

• Test Emergency Generators
• Check Supply of Drinking Water; If Contractor Is
  Used Ensure Service Provider Is Able to Meet
  Needs
• Check Non-perishable Food Supplies; Assure
  Regulatory Minimums Are Met
• Review Loss of Power Plans


               Agency for Health Care Administration
                Evacuation
• Notify AHCA Of Evacuation
• Staffing and Other Basic Requirements to
  Meet Resident Needs Are Not Waived
• Ensure Resident Information Follows the
  Resident
• When Returning Residents to a Facility
  After Damage, Obtain AHCA Approval
  First

             Agency for Health Care Administration
            Emergency Resources

• First Contact: Local Emergency Management
  http://www.floridadisaster.org/County_EM/county_list.htm#
• Florida Emergency Information Line
      800-342-3557
• Emergency Support Function – 8
      850-410-1822
      800-320-0519 (request ESF-8)


                    Agency for Health Care Administration
        Regulatory Update

• Regulatory Changes
• AHCA Information Regarding Trends
• Regulatory Statistics




            Agency for Health Care Administration
       2004 Legislative Changes
• Inactive License for a Portion of Facility
   – Rule Must First be Established
   – Allows a Contiguous Portion of Nursing Home Beds to Become
     Inactive for 12 Months, Renewable Annually
   – Retains Ability for Entire Facility to be Inactive for up to 18 Months
   – Established Requirements for Request and Approval
• Staffing
   – CNA Increase to 2.9 Delayed from May 1, 2004 to July 1, 2005
• Certificate of Need
   – Allows Development of New Nursing Home Beds in Limited
     Circumstances; An Exception to the CON Moratorium
   – Rural Counties in Limited Circumstances
   – Counties Without a Nursing Home Where a Nursing Home Closed
     Since July 2001
       2004 Legislative Changes
Nursing Homes
• CNA In-service Hours
   – Requires In-Services Hours as a Condition of CNA Certification
     Rather Than Nursing Home Employment
   – Refers the In-Service Requirements of S. 464.203(7), F.S.
   – Remains 18 Hours Annually
• DON Signature on Care Plans
   – Allows Another RN to Sign Resident Care Plans for DON
   – RN Must Have Institutional Responsibilities in Writing
   – RN Cannot be a Temporary Staff Person
• Gold Seal
   – State and Federal Nursing Homes are Deemed Financially Stable and
     Not Required to Submit Financial Statements
       Nursing Home Gold Seal
• Thirteen Homes Received the Award in November,
  2004

• Performance Criteria Include:
      • Financial Soundness and Stability
      • High Quality of Care Ranking Among Other
        Nursing Homes in Their Region
      • Excellent Record With the State Long-term
        Care Ombudsman Program
      • No “Conditional” Licenses nor Nursing Home
        Watch List Appearances in the Past 30 Months
      • Evidence of Community Involvement
      • Stable Workforce

               Agency for Health Care Administration
           Gold Seal Awards
New Gold Seal Recipients:
• Baldomero Lopez Memorial Veterans’ Nursing
  Home, Land O Lakes
• Bay Village of Sarasota, Sarasota
• Life Care Center of Hilliard, Hilliard
• Mayflower Healthcare Center, Winter Park
• Miami Jewish Home & Hospital for the Aged,
  Miami
• Ponce Plaza Nursing and Rehabilitation, Miami
• Sunnyside Nursing Home, Sarasota
• Water’s Edge Extended Care, Palm City

               Agency for Health Care Administration
     Nursing Home Gold Seal

Renewing Gold Seal Recipients:
• Harbour’s Edge, Delray Beach
• John Knox Village Medical Center, Tampa
• The Pavilion for Health Care, Penney Farms
• River Garden Hebrew Home for the Aged,
  Jacksonville
• Village on the Green, Longwood


             Agency for Health Care Administration
      Report to the Legislature
      May 2004 – Status Report

Nursing Home and Assisted Living Facility: Adverse
 Incidents & Notices of Intent Filed

http://www.fdhc.state.fl.us/Publications/index.shtml

Also see Semi-Annual Report on Nursing Homes
  Report to the Legislature December 30, 2004

                 Agency for Health Care Administration
          Adverse Incidents Reported to AHCA
                       4000
                       3500
                       3000
                       2500
                       2000
                       1500
                       1000
                        500
                           0
                                      As s is ted Living Facilities      Nurs ing H om es

May 15, 2001 to May 14, 2002                     1468                         3145
May 15, 2002 to May 14, 2003                     1302                         3394
May 15, 2003 to May 14, 2004 *                   1996                         3175

                                 Agency for Health Care Administration
     Adverse Incident Analysis

For The One Year Period May 15, 2003 Through
  May 14, 2004, The Agency Received:

• 3,175 Nursing Home Adverse Incidents
• 1,996 Assisted Living Facility Adverse Incidents

• 19,378 Total Reports Submitted - 5,171 Were
  Determined To Be Adverse Incidents After Final
  Facility Staff Review

               Agency for Health Care Administration
     Adverse Incident Analysis

AHCA On Site Visits In Response To Adverse
  Incidents:
• 84 On-Site Visits To Nursing Homes
• 48 On-Site Visits To Assisted Living Facilities

Of These Surveys 3 Nursing Homes And 5 Assisted
  Living Facilities Were Cited For Class I and/or
  Class II Deficiencies

               Agency for Health Care Administration
             Adverse Incident Outcomes
                               1800
                               1600
                               1400
                               1200
                               1000
                                  800
                                  600
                                  400
                                  200
                                      0
                                                                                                                                  La w
                                               Tra ns f e r    F r a c tu r e   A b u s e /N e g le c t   E lo p e m e n t
                                                                                                                             Enf orc e me nt

M a y 1 5 , 2 0 0 1 to M a y 1 4 , 2 0 0 2       1 50 5           1 0 30                 8 79                  38 3               318
M a y 1 5 , 2 0 0 2 to M a y 1 4 , 2 0 0 3       1 56 8            948                 1 08 8                  35 7               238
M a y 1 5 , 2 0 0 3 to M a y 1 4 , 2 0 0 4       1 49 3            837                 1 06 3                  47 4               395


                                             Agency for Health Care Administration
                                       Nursing Home NOIs
                                             Nursing Home Notices of Intent July 2002 - June 2004

 110

 100

   90

   80

   70

   60

   50

   40

   30

   20

   10

    0
          7/02   8/02   9/02     10/02 11/02 12/02   1/03   2/03   3/03   4/03   5/03   6/03     7/03   8/03   9/03   10/03 11/03 12/03   1/04   2/04   3/04   4/04   5/04   6/04
Series1   56     74     46        60    82     80    106    96     83     74     103    72       75     56     75      71    49    57     56     64     50     54     50     33
                               *Based on NOI received by facility for month                    **This data may change due to later reporting by facilities


                                                        Agency for Health Care Administration
      Characteristics of Reported Litigation


                                 For-Profit         Non-Profit         Total    Multi-
                                                                                Facility
                                                                                Owner
   Licensed Nursing Homes           491                 179             670       527
   Lic NH Submitting NOI            410                 123             533       438
Total # of Lic NOI Submitted       2,289                454            2,743     2,449
      Total # of Lic Beds          60,937              21,464          82,401   65,021
 # Of NOI per 1000 Lic Beds        37.56               21.15           33.29     37.66
  Total # of Lic Complaints         509                  88             597       558
Complaints per 1000 Lic Beds        8.35                4.10            7.25     8.58




                               Agency for Health Care Administration
Notices of Intent Past 3-Years
      548 Nursing Homes Reporting NOIs
             May 2001 - May 2004


  # Nursing Homes                                     # NOI Reported

       100                                                   1
       224                                                2 to 4
       149                                                5 to 9
       75                                               10 or more




              Agency for Health Care Administration
Notices of Intent Past Year
     339 Nursing Homes Reporting NOIs
            May 2003 - May 2004


# Nursing Homes                                      # NOI Reported

     153                                                    1
     149                                                 2 to 4
     35                                                  5 to 9
      2                                                10 or more




             Agency for Health Care Administration
Nursing Home Complaints Filed in Clerk of Court
 Complaint Service Dates June 2002 - April 2004



 40
 35
 30

 25
 20
 15
 10
  5
  0       Jun-   Jul-   Aug-   Sep -   Oct -   No v-    Dec-   Jan-   F eb-   M ar-   Ap r-   M ay-   Jun-   Jul-   A ug -   Sep-   Oct -   No v-   Dec-   Jan-   F eb-   M ar-   A p r-
           02    02      02     02     02       02       02     03     03      03      03      03      03    03      03       03    03       03      03     04     04      04      04


         Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr-
          02 02 02 02 02 02 02 03 03 03 03 03 03 03 03 03 03 03 03 04 04 04 04
 Total    17     23     30     30      24      26        31    35     40      26      36      39      28     32     13       25     25      11      23     17     15      16      14

                                                       Agency for Health Care Administration
Nursing Home Complaints Filed in Clerk of Court
        By AHCA Receipt Date June 2002 - April 2004


90
80
70
60
50
40
30
20
10
 0       Jun-   Jul-   Aug-   Sep -   Oct -   Nov-   Dec-   Jan-   Feb-   M ar-   A pr-   M ay-   Jun-   Jul-   Aug-   Sep -   Oct -   No v-   Dec-   Jan-   Feb-   M ar-   Ap r-
         02     02     02      02     02      02      02    03      03     03      03      03     03     03     03      03     03       03     03     04      04     04      04


        Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr-
         02 02 02 02 02 02 02 03 03 03 03 03 03 03 03 03 03 03 03 04 04 04 04
Total    8      7       9     13      10      15     87     37     26     38      20      31      25     16     26     16      21      14      10     82     21     14      25

                                                     Agency for Health Care Administration
   Number of Nursing Homes on
        The Watch List
            Calendar Quarter                               Number of Facilities
April 1, 2001 – June 30, 2001                                     79
July 1, 2001 – September 30, 2001                                 90
October 1, 2001 – December 31, 2001                               89
January 1, 2002 – March 31, 2002                                  82
April 1, 2002 – June 30, 2002                                     87
July 1, 2002 – September 30, 2002                                 71
October 1, 2002 – December 31, 2002                               50
January 1, 2003 - March 31, 2003                                  52
April 1, 2003 - June 30, 2003                                     51
July 1, 2003 - September 30, 2003                                 46
October 1, 2003 - December 31, 2003                               44
January 1, 2004 – March 31, 2004                                  39




                       Agency for Health Care Administration
                                                       Nursing Home
                                Nursing Home Deficiencies
                                                 Type of Deficiencies by Year

                         9000

                         8000

                         7000
Number of Deficiencies




                         6000

                         5000
                                                                                                     Sc/Sv B through F Defs

                         4000                                                                        Sc/Sv G and higher Defs


                         3000

                         2000

                         1000

                           0
                                1999   2000        2001          2002          2003   Jan-Jun 2004
                                                          Year



                                              Agency for Health Care Administration
Nursing Home Deficiencies for Failure to Have
   Sufficient Staff to Meet Resident Needs


                      Citations for F353

   150
   100                                                 Citations for
    50                                                 F353
     0
         2000 2001 2002 2003 2004
                             thru
                             June


               Agency for Health Care Administration
        All Nursing Home Staffing
               Deficiencies

                                                                      2004
                             2000             2001 2002      2003   (June)
Citations for F353            120              110   78        64       28
N063                           11               28 166         83       36
N063 & F353                     0                6   15         7        2
N069                            0                2   16         4       10




                     Agency for Health Care Administration
     Grant Proposal Requests
Use of Civil Money Penalty (CMP) Funds

• CMPs Returned to Florida Based Upon
  Medicaid Participation of Sanctioned Nursing
  Homes
• Deposited in State Quality of Long Term Care
  Improvement Trust Fund
• Authorization to Spend $500,000 Annually
• Expenditures Must be Consistent with State
  and Federal Requirements

             Agency for Health Care Administration
          Federal Guidance

• Federal Regulations 42 CFR 488.442(g) and
  Section 7534B of the State Operations
  Manual Direct

• Use of CMPs for Protection of Health or
  Property of Residents of Facilities That the
  State or the Centers for Medicare and
  Medicaid Services (CMS) Finds Deficient

              Agency for Health Care Administration
            Federal Guidelines
• Prevention of Deficient Practice Through Educational
  Means by Development of Videos, Pamphlets, or
  Other Publications Providing Best Practices
• Development of Public Service Announcements on
  Issues Directly Related to Identified Deficient Areas
• Employment of Consultants to Provide Expert
  Training to Deficient Facilities
• Issuing Grants to Facilities for Projects Such As the
  Eden Alternative
• Other Projects That Directly Benefits Facility
  Residents

                 Agency for Health Care Administration
        Federal Limitations

• A Loan to a Facility Having Financial Difficulty
  Meeting Payroll or Paying Vendors is an
  Inappropriate Use of the Funds

• Funds Cannot Be Used to Bring a Facility Into
  Current Regulatory Compliance

• Projects Should Be Limited to Funding on Hand
  and Should Be Relatively Short-term Projects


                Agency for Health Care Administration
          Grant Proposals
• All Florida Nursing Homes May Apply
• Proposals Must be Innovative and:
  – Provide Well Conceived Vision/Plan with
    Detailed Explanation and Steps to Achieve
    Improvement
  – Propose Achievable Goals
  – Provide Education Plan for Residents/Staff
  – Provide Detailed Implementation Plan
  – Provide Budget of Expenditures

             Agency for Health Care Administration
          Grant Proposals
• All Florida Nursing Homes May Apply
• Proposals Must be Innovative and:
  – Provide Well Conceived Vision/Plan with
    Detailed Explanation and Steps to Achieve
    Improvement
  – Propose Achievable Goals
  – Provide Education Plan for Residents/Staff
  – Provide Budget of Expenditures

             Agency for Health Care Administration
            Grant Process

• Initial Request for Interest and Proposals,
  Nursing Home Letter December 22, 2004
• Applications Will be Provided for
  Completion
• Proposals Will be Reviewed Within
  Available Funding
• Presentation May be Requested

              Agency for Health Care Administration
        Grant Participation

• Recipients of Grants Will Enter Into a
  Contract With the Agency
• Contracts Will Generally Be One Year;
  No More Than Two Years
• Monitoring Will Be Developed Based
  Upon the Project
• Quarterly Reports
• Onsite Reviews
            Agency for Health Care Administration
   Grant Information
& Proposal Submission

Bureau of Long Term Care Services
       Barbara Dombrowski
     Phone: (850) 922-0048
E-mail: dombrowb@fdhc.state.fl.us



        Agency for Health Care Administration
Top 10 Nursing Home Deficiencies
Top Ten Nursing Home Cites
                                                           Count Rank Rank Rank Rank
  Tag    Description                                       2004* 2004 2003 2002 2001
         Food must be stored, prepared, and
  F371   distributed under sanitary conditions              142   1    1    1    1
         Services provided by the facility must
  F281   meet professional standards                        100   2    2    3    4
         Facility must treat residents with dignity
  F241   and respect                                         86   3    4    4    3
         Facility must maintain clinical records
  F514   professionally and accurately                       83   4    6    5    6

         Facility must provide adequate
  F253   housekeeping and maintenance services               74   5    5    10   22
         Facility must develop comprehensive
  F279   care plan for each resident                         68   6    3    2    2

* January-June, 2004
                         Agency for Health Care Administration
Top 10 Nursing Home Deficiencies
Top Ten Nursing Home Cites
                                                            Count Rank Rank Rank Rank
  Tag    Description                                        2004* 2004 2003 2002 2001
         Comprehensive care plan must be
         timely, accurate and periodically
  F280   reviewed                                                 63   7    10   11   16
         Services must be delivered by qualified
  F282   persons in accordance with care plan                     63   7    11   13   7
         Drugs must be stored in locked
  F432   compartments at proper temperature                       52   8    9    6    5
         Facility must provide a safe, functional,
  F465   sanitary, and comfortable environment                    48   9    15   14   12
         Menus must meet nutritional needs of
  F363   residents                                                46   10   22   23   33

* January-June, 2004
                          Agency for Health Care Administration
   Top 10 Nursing Home Complaint
            Allegations
Allegation                     Count 2004* Rank 2004 Rank 2003 Rank 2002 Rank 2001
Resident Care                     380          1         1         1         1
Resident/Patient Abuse/Neglect    187          2         5         5         4
Resident Rights                   179          3         2         3         3
Medicine Prob/Errors/Formulary    163          4         3         4         5
Staffing                          155          5         4         2         2
Lack of Assessment                137          6         8        27        27
Administrative                    120          7        14        14        13
Falls/Injury                      102          8         6         6         8
Pressure Sores                     99          9         9        10         7
Dietary                            94         10         7         8         6

* January-June, 2004


                         Agency for Health Care Administration
            AHCA Resources
          Long Term Care Unit (850) 488-5861
       Bureau of Long Term Care (850) 414-9707
       Bureau of Field Operations (850) 414-9796
    Health Standards and Quality Unit (850) 922-9138

           AHCA Website: www.fdhc.state.fl.us
                        New Format

   AHCA Facilities and Agencies Directory Website:
www.floridahealthstat.com/qs/owa/facilitylocator.facllocator
           Federal Link to Survey Guidance:
  www.cms.hhs.gov/medicaid/survey-cert/siqhome.asp
                Agency for Health Care Administration

				
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