Author Archives: Janet K. Feldkamp RN BSN LNHA CHC JD

Holidays Can Be A Time To Spot Changes In Elderly Family Members

Slight changes in behavior or personality can be subtle and not easily noticed if you interact with the person frequently.  However, many Americans will be visiting with elderly family members during the upcoming holidays and might not have seen their loved ones for several months.  Subtle changes can be more easily identified if it has been a period of time since the last interaction.  The holidays can be a good time to reassess as to whether your elderly family members may need some additional guidance or assistance due to physical or mental status issues.  Try to assess the circumstances and observe the person as they currently are and not as the invincible parent or relative that they have been all of their life.  It may be the time for family members to assist the senior with life changes or transitions in living environment or the addition of support mechanisms.

The following is a list of potential warning signs that your family member may need some medical assessment or assistance with activities of daily living:

  • Changes in basic personality
  • Inability to concentrate on and complete simple to moderate tasks including household chores or paying bills
  • Unsteadiness of gait or a history of recent falls
  • Loss of important items such as car keys or wallet
  • Dressing inappropriately for the season or wearing multiple layers of clothing
  • Difficulty in discussing recent and current events
  • Repetition of same information during short conversations
  • Neglect of their environment or their personal appearance
  • Unusual dents to vehicle or the garage

If signs or symptoms such as the above are noticed, assist your family member to seek out assessment and/or intervention to address the concerns.  Don’t ignore those signs and symptoms of confusion or personality change as they may be the warning signs of illnesses such as dementia or other acute or chronic illnesses.  Many community resources are available to assist family members and seniors and help the senior connect to those resources.  Enjoy the holiday season with family while assuring that your aging seniors remain safe and healthy.

CMS Releases the Civil Money Penalty Analytic Tool

The Centers for Medicare and Medicaid Services (“CMS”) recently released the civil money penalty (“CMP”) analytic tool used by CMS Regional Offices (“RO”) to review, approve or modify the proposed fines for nursing facilities (“NF”) and skilled nursing facilities (“SNF”)(collectively “NF”) (Link). Regulatory guidance CMS S&C 15-16-NH was released on December 19, 2014 and includes a description and the components of the analytic tool used by CMS since April, 2013 to determine the adequacy of the proposed CMPs for survey violations for NFs. The RO is required to review and either approve or modify the proposed CMPs issued by each State Agency based upon NF Medicare and Medicaid certification citations. Providers have often wondered about the actual calculation method being utilized by CMS and this analytic tool lays out the interpretation factors being used by CMS when applying the factors in the required by 42 CFR 488.404 for consideration when imposing a CMP on a facility as result of a single survey or for multiple surveys in a survey cycle.

CMPs and other enforcement remedies are required to be imposed based upon the scope and severity of the regulatory citations either for health deficiencies or life safety code deficiencies. CMS indicates that the analytic tool does not replace professional judgment but it to be used as a guideline in the CMP calculation process. The guidance states that the tool is “provide logic, structure, and defined factors for mandatory consideration in the determination of CMPs.” The analytic tool distinguishes between the use of Per Instance penalty use and a Per Day penalty use. A Per Instance penalty is a single defined fine amount between $1,000 and $10,000 for the survey cycle. The analytic tool indicates that a Per Day penalty is to be used unless the specific requirements are met for the Per Day penalty. A Per Instance penalty is often less costly to a provider than a Per Day penalty and is typically preferred by providers due to the certainty of the actual amount being imposed.

Per Instance penalties can only be applied if:
1. The facility is not a special focus facility;
2. Findings are no more than a G level (actual harm, isolated) or an F level (no actual harm, widespread with substandard care) and the facility has a good compliance history for the past 3 standard surveys; and
3. Findings of past noncompliance are not cited at a G level or an F level substandard care.

In addressing the discretion and professional judgment to be used by the RO personnel the guidance provides for a 35% increase or decrease in the CMP amount without CMS Central Office approval. If the RO proposes to increase or decrease the CMP amount by more than 35%, Central Office must provide approval of those changes. The stated purpose of the utilization of the analytic tool is to provide a more consistent application of enforcement remedies. The guidance also states that a Per Day CMP is to begin on the first day of noncompliance which may or may not be during the on-site survey. Also, the Per Day CMP is to start on the first day of identified noncompliance even if that date is prior to the survey. However, the CMP start date cannot be prior to the date of the last standard survey. This guidance reaffirms the imposition of CMPs that are applied retrospectively with a possibility that CMPs may be imposed as far back as 15 months. A retrospective CMP imposition can be in the hundreds of thousands of dollars for providers for an immediate jeopardy citation and can result in significant ramifications for providers.

A few of the factors that change the proposed amount of CMPs and are calculated with the tool include:
1. Scope and severity of the citations;
2. Number of citations;
3. Repeated citations;
4. Facility culpability; and
5. Facility financial condition.

The guidance provides some examples related to application of criteria for facility culpability based upon Departmental Appeals Board (“DAB”) cases. Those examples include repeated failure to follow or clarify doctor’s treatment orders; repeated failure to notify doctor of significant changes; repeated failure to supervise resident with a known history of elopement; staff failure to report physical, verbal or sexual abuse and egregious dignity issues.

Providers should carefully review this recently issued S&C guidance to have a clear understanding of how the CMPs are calculated by CMS and what factors can affect the increase or decrease of those CMPs. Understanding the factors related to fines and sanctions imposed by CMS and the amount of discretion that is allowed in the imposition of fines are important in the operation of NFs on an ongoing basis.

Palliative Care Services Increasing Across the U.S.

Palliative care services are now more accessible to patients with serious and chronic illnesses in the United States. The Mayo Clinic defines palliative care as offering pain and symptom management and emotional and spiritual support when a patient faces a chronic, debilitating or life-threatening illness. Increasingly offered to patients of any age with a range of chronic illnesses such as cancer, multiple sclerosis and Parkinson’s disease, palliative care may be provided at the same time as curative medical regimens to help patients tolerate side effects of disease and treatment, and proceed with everyday life. According to a recent December 22, 2014 Wall Street Journal article, palliative care programs have increased three fold over the past decade. Many hospitals have specialized palliative care programs and 80% of hospitals with 250 beds or more provide such a program.

The provision of palliative care with or without curative treatment can lead increased patient and health care provider satisfaction, equal or better symptom control, less anxiety and depression, less caregiver distress, and potential cost savings. A patient’s quality of life can be enhanced with active and effective pain and symptom management. The need for aggressive pain and symptom management often lead patients to seek out a palliative care program to manage their symptoms during a chronic or terminal illness. Some patients also choose to utilize hospice care towards the end of their life journey after receiving services from a palliative care program. With the better availability of palliative care, those patients seeking pain relief and symptom control at any stage of their chronic or terminal illness care are able to find the services to address their needs including assisting the patient and the family to navigate the often complicated medical system.

Ohio: Sex Offender Screening Now Required for Long Term Care Facilities

The required date for screening for sex offenders in Ohio nursing homes, licensed residential care facilities and county homes (“Homes”) has now arrived. As of September 15, 2014, these Homes are required to screen for sex offenders including checking the online Ohio sex offender registry prior to admission. Also, if a registered sex offender is admitted, a care plan must be developed to protect other residents and provide a safe envrionment. The Homes must notify the residents and their sponsors of the sex offender’s admssion and provide a descrption of the safety plan. The Ohio Department is mandated by House Bill 483 to implement regulations regarding to these new requirements but as of this date the regulations have yet to be promgulated. Even without published regulations, Homes are required to comply with the new statute. Watch for updates on the sex offender screening requirements as the Ohio Department of Health issues regulations. The sex offender registry link is located at: http://icrimewatch.net/inden.php?AgencyID-55149

MyCare Ohio Transition Continues

Ohio’s transition to Medicaid managed care continues. The Ohio Department of Medicaid, the contracting agency with the 5 managed care companies now providing services to Ohio’s dual eligible population is [providing more information to Ohio providers during this transition period. Those dual eligible (eligible individuals for both Medicare and Medicaid) are being transitioned into these managed care private sector insurance programs. Some providers have been experiencing technical difficulties in submitting claims under the new managed care systems and providers are frustrated with slow payments. An updated released by the Ohio Department of Medicaid provides some statistics by region on the number of submitted claims and percentages of paid claims within 30 days of submission. The information provides a link to the Provider Payment Technical Assistance program to work with providers on a case-by-case basis to assist in resolution of issues and to resolve payment concerns. The Ohio Department of Medicaid issuance that includes the Provider Payment Technical Assistance link can be found at http://healthtransformation.ohio.gov/LinkClick.aspx?fileticket=V9a0WTwYchs%3d&tabid=105

New Ohio Sex Offender Requirements for Long Term Care Facilities

Nursing homes, residential care facilities and county homes (“Homes”) in Ohio will soon have additional requirements related to the admission of a registered sex offender. House Bill 483, the Mid-Biennium Budget Review bill was signed by Governor Kasich on June 16, 2014 with an effective date in September 15, 2014. Rules are required to be written by the Ohio Department of Health (“ODH”) in the future for further guidance. Requirements for the Homes include checking the Ohio sex offender registry before admission of a registered sex offender. Facilities can include questions about a registered sex offender status on their admission applications. The Homes must check the potential resident’s name in the required database to determine if the potential resident is an Ohio registered sex offender. If a registerd sex offender is admitted, a care plan must be devleoped to protect other residents and provide a safe environment free of abuse. Also, the Homes must notify residents and their sponsors of the sex offender’s admission and provide a description of the plan of care for safety. Sex offender registry link: http://www.icrimewatch.net/index.php?AgencyID=55149

Skilled Nursing PEPPER Reports Are Now Available Electronically

The second annual Skilled Nursing Facility (“SNF”) Program for Evaluating Patterns and Electronic Reports (“PEPPERs”) are now available to be retrieved via the secure portal at PEPPERresources.org. These reports are accessible to a limited number of high level management personnel within your organization. The Centers for Medicare and Medicaid Services (“CMS”) contracted with TMF Health Quality Institute (“TMF”) for the development, preparation and distribution of the PEPPERs to SNFs, as well as other health care provider types. Continue reading