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.
Posted in Certification, CMS Transmittals, Long Term Care, Medicaid, Medicare, Nursing Facility, Nursing Home, Participation, Skilled Nursing Facility, Survey and Certification Letters
Tagged Centers for Medicare and Medicaid Services, Nursing Home, Skilled Nursing Facility
On October 30, 2013, the New York State Office of the Medicaid Inspector General (“OMIG”) issued a press release that New York recovered $211 million from the federal government out of an identified $496 million in Medicaid erroneous payments related to home care recipients who are dually eligible for both Medicare and Medicaid funds. On October 1, 2013, the New York State Department of Health’s Fiscal Group received the $211 million payment through the action of OMIG, which was the largest single monetary recovery in OMIG’s history.
These payments were recovered by New York State as part of a federal project, the Third-Party Liability Home Health Care Demonstration Project, which is reviewing home health care involving dual eligible recipients, and is being conducted in conjunction with the University of Massachusetts Medical School. Continue reading
Posted in DHHS, Health & Human Services, Health Care, Home Health, Long Term Care, Medicaid, Medicare, New York, Nursing Facility, Nursing Home, Participation, Participation, Payers, Reimbursement, Skilled Nursing Facility
Tagged Centers for Medicare and Medicaid Services, CMS, Home Health, Medicaid, Medicare, New York, Nursing Home, OMIG, Skilled Nursing Facility, SNF
The U.S. 6th Circuit Court recently upheld a DHHS Departmental Appeals Board decision that found a skilled nursing facility’s (“SNF”) deficiencies were at an “immediate jeopardy” level relating to a failure to notify a physician or family member of a significant change in a patient’s condition. See, Claiborne-Hughes Health Center v. Sebelius, 6th Cir. No 09-3239, 6/25/10.
The Claiborne-Hughes Health Center is a SNF in Franklin, TN. The decision was based upon surveyors findings that the facility failed to comply with 42 C.F.R. §483.10(b)(11). Section 483.10(b)(11) requires a facility to immediately consult with a resident’s physician and notify the resident’s family members or legal representation when there is a significant change in a resident’s physical, mental, or psychosocial status.
The failure to comply with the applicable regulation related to Claiborne-Hughes’ policy on recording patient fluid-intake. Surveys completed in August and September of 2006 revealed that the facility was not sufficiently monitoring patient fluid intake in accordance with its own policies.
A copy of the decision can be found at – http://caselaw.findlaw.com/us-6th-circuit/1529702.html
Posted in Civil Litigation, DAB Decisions, Health Care, Health Care Providers, Nursing Home, Participation, Post Acute Care, Tennessee
Tagged ALJ Decisions, Certification, CMS, Conditions of Participation, Departmental Appeals Board, Immediate Jeopardy, Medicaid, Medicare Enrollment, Nursing Home, Skilled Nursing Facility, SNF
On February 24, 2010, the Senate of the State of New York passed (S.3164/A.7729), The Family Health Care Decisions Act (the “FHCDA”). The New York Assembly passed the bill in January. This important piece of legislation allowing for surrogates to make health care decisions in certain circumstances has been in the works since 1993. NY Governor David A. Paterson applauded the passage of the FHCDA.
Consumers and health care providers have historically had to rely on a patchwork of common law decisions and the Health Care Proxy and Do-Not-Resuscitate laws to address personal health care decisions. New York common law (in a line of well know court decisions) provides that life-sustaining treatment cannot be withdrawn or withheld, unless clear and convincing evidence of the patient’s wishes can be produced. An advance directive could serve as that evidence but way too often patients have not completed one when they were competent.
The FHCDA now provides a framework for health care decisions to be made by surrogates. By doing so, it reduces the uncertainty and need for judicial determination in many situations in which current law did not provide a clear way for a health care decision to be made for an incompetent patient.
You can find a copy of (S.3164/A.7729), The Family Health Care Decisions Act at http://assembly.state.ny.us/leg/?default_fld=&bn=A07729%09%09&Summary=Y&Actions=Y&Votes=Y&Memo=Y&Text=Y
Posted in Acute Care, Advanced Directives, Clinics, Consumers, Continuing Care, Health Care Decisions, Home Health, Hospice, Hospital, New York, Nursing Home, Palliative Care, Physicians, Post Acute Care, Rehabilitation
Tagged Advanced Directives, Consumer, FHCDA, Health Care Decisions, Health Care Proxy, Home Health, Hospital, New York, Nursing Home, Patient, Physician, Surrogate Decisions