HOME HEALTH REGULATORY UPDATE

1. HOME HEALTH REGULATORY UPDATE Anne Menard Home Care Unit Bureau of Long Term Care Services

2. 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

3. 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

4. STATE LAW UPDATE FOR ALL HOME HEALTH AGENCIES & NURSE REGISTRIES

5. Criminal Background Screening 2010 Legislation Legislation that changed the process: Replaces all Level 1 background screening with Level 2 screenings 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

6. 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 Employers 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/ Resources Current Turn Around Time 0 – 5 Days

7. 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 change Inability to communicate with providers regarding rejected prints

8. 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 2012

9. Goals for the Federal Background Screening Grant 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)

10. Agency for Health Care Administration Background Screening Resources Agency for Health Care Administration Web Site http://www.ahca.myflorida.com/backgroundscreening Questions/Comments/Issues bgscreen@ahca.myflorida.com

11. REPORT UNLICENSED ACTIVITY 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 www.FloridaHealthFinder.gov. Call the AHCA complaint # (888) 419-3456 to report

12. 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 care The resident must contract with a home health agency for nursing care If there is no improvement in 30 days, the resident must be discharged.

13. 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

14. 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

15. 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.

16. Reporting AHCA Complaints AHCA Contact (888) 419-3456 Online report Health Care Facility Complaint Form at: ahca.myflorida.com/Complaint Provide detailed information such as patient/resident names, dates, times of events and where the event occurred

17. 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.

18. 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.)

19. 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 www.ahca.myflorida.com/homecare - click on “home health agency”)

20. 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 Code).  (from 13.3 of the Frequently Asked Questions, at www.ahca.myflorida.com/homecare - click on “home health agency”)

21. STATE RULE UPDATE HOME HEALTH AGENCIES AND NURSE REGISTRIES

22. 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)

23. STATE RULE UPDATE 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

24. 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: 59A-8.0086 – Denial, Suspension, Revocation of License and Imposition of Fines - contents already in 408, Part II & 400, Part III, F.S.

25. Home health agency rule repeals 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.

26. 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

27. 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.)

28. Medicare & Medicaid Home Health Agency Surveys CMS Revisions For surveyors from state agencies & accrediting organizations

29. 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

30. Emphasizes information from HHA staff interviews, clinical records & home visits Minimizes non-clinical record review paper compliance Provides guidance for surveyors on expanding the survey & issuing deficiencies More specific guidance on citing standard & condition-level deficiencies 2011 – HHA Survey Process 23 From CMS Basic Home Health Agency training for surveyors The new process places heavy emphasis on data and information gathered through staff interviews, clinical records, and home visits – data sources that are focused on patient care. Paper compliance with sources other than the clinical record receives less emphasis. And, to increase consistency between surveyors and from State to State, guidance is included for expanding from a standard survey to a partial extended or extended survey and citing deficiencies. The new process places heavy emphasis on data and information gathered through staff interviews, clinical records, and home visits – data sources that are focused on patient care. Paper compliance with sources other than the clinical record receives less emphasis. And, to increase consistency between surveyors and from State to State, guidance is included for expanding from a standard survey to a partial extended or extended survey and citing deficiencies.

31. 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 & Therapy Standard Survey 31 From CMS Basic Home Health Agency training for surveyors Refer to Protocols: Using the Level 1 and Level 2 standards, The new standard survey focuses on those standards determined to be most directly related to the delivery of high-quality patient care. Also to focus on patient care, new processes were identified to gather information – processes that rely more on direct communication with providers and agency support personnel and less on paper materials that are not directly related to patient care. Refer to Protocols: Using the Level 1 and Level 2 standards, The new standard survey focuses on those standards determined to be most directly related to the delivery of high-quality patient care. Also to focus on patient care, new processes were identified to gather information – processes that rely more on direct communication with providers and agency support personnel and less on paper materials that are not directly related to patient care.

32. 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

33. 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

34. 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

35. 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 The surveyor can make a determination that the HHA is in compliance with all CoPs when, after a review of the Level 1 standards, and after completing the required clinical record reviews, home visits, and interviews with patients and HHA staff, he/she does not discover any findings which would support a deficiency citation. So….if you review the Level 1 standards, and complete the required clinical record reviews, home visits, and interviews with patients and HHA staff, and do not discover any findings which would support a deficiency citation, the survey is finished. The surveyor can make a determination that the HHA is in compliance with all CoPs when, after a review of the Level 1 standards, and after completing the required clinical record reviews, home visits, and interviews with patients and HHA staff, he/she does not discover any findings which would support a deficiency citation. So….if you review the Level 1 standards, and complete the required clinical record reviews, home visits, and interviews with patients and HHA staff, and do not discover any findings which would support a deficiency citation, the survey is finished.

36. Survey continues … and becomes partial extended 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

37. 484.10 Patient Rights 43 Basic Home Health Agency

38. 38 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 Basic Home Health Agency If have identified CoP out: Need to look at the agencies’ policies and procedures that produced the substandard care (CoP-level deficiencies).If have identified CoP out: Need to look at the agencies’ policies and procedures that produced the substandard care (CoP-level deficiencies).

39. To find out more www.cms.gov/manuals 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 – www.ahca.myflorida.com/homecare - click on “home health agency” – see “Federal Regulation Set used by Surveyors”

40. 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)

41. 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 http://ahca.myflorida.com/MCHQ/Areas 4. If still not resolved, contact: Chief of Field Operations, Polly Weaver (850) 412-4301

42. AHCA web sites http://ahca.myflorida.com/homecare -- select “home health agency” or “nurse registry” – licensing, state & federal survey standards, emergency management plan & local plan review contacts, & answers to frequently asked questions www.FloridaHealthFinder.com - select “Find Facilities or Providers” (updated nightly) + also see Consumer Guides

43. Contact information – HHA & NR Anne Menard – Unit Supervisor Anne.Menard@ahca.myflorida.com Medicare & Medicaid certification - HHA Cynthia Ibrahim – HHAs I to Z, & branch approvals, change of ownership Ceather Watkins – HHAs A to H (850) 412-4403 Jan Benesh – HHA & NR licensing manager Ed Barnes - Change of ownership Lenora Lowry – HHA & NR Natarsha Humphries – HHA & NR Susan Glass - HHA HQAHOMEHEALTH@ahca. myflorida.com