Agency for Health Care Administration

Secretary Rhonda Medows, M.D.

Division of Health Quality Assurance Liz Dudek

Division of Administrative Services Christy Gregg

Division of Medicaid Bob Sharpe

Payment of Fines Payment of Medicaid Overpayments

Health Facility Regulation Health Standards & Quality Field Operations Managed Health Care Plans and Construction Long Term Care Services

Medicaid Area Offices Health Systems Development Program Analysis Contract Management Pharmacy Services Research Medicaid Services

Inspector GeneralJudy Hefren,

Acting

Medicaid Program IntegrityFraud and Abuse

General CounselValda Clark-Christian

Legal Representation Imposition of Administrative

Sanctions Receivership

Agency for Health Care Administration

Division of Health Quality Assurance Liz Dudek

Bureau of Health Facility Regulation Jeff Gregg

Bureau of Field Operations Polly Weaver

Bureau of Long Term CareMolly McKinstry

Survey Field Offices Complaint Administration

Call Center Contract Manager 5-Day Abuse Reporting

Licensure and CertificationHome CareAcute CareLabsHealth Care Clinics

Certificate of Need Financial Analysis Background Screening

Bureau of Plans and Construction Skip Gregory

Plan Review for Health Care Facilities including Nursing Homes

Health Standards and Quality Susan Acker

Quality of Care Monitors Survey Integrity and Support Branch Informal Dispute Resolution MDS/OASIS Help Desk State Survey Training Coordination

Bureau of Managed Care Tom Warring

Regulation of Commercial HMOs Regulation of Medicaid HMOs – Quality

Control, Monitoring and Review

Deputy Rebecca Knapp

Licensure and Certification Nursing Homes and other LTC Facilities

Teaching Nursing Home Contract Management

Gold Seal Program Long Term Care Policy Issues Rule Development Receivership Nursing Home Watch List Guide to Nursing Homes (Joint with FO)

Long Term Care UnitCaraLee Starnes

Licensure of Assisted Living Programs Long Term Care Policy Issues

Facilities Data Analysis UnitJane Boerger

Assisted Living UnitAlberta Granger

Adverse Incidents and Liability Claims Nursing Home Staffing Reports and Bed

Vacancy

Agency for Health Care Administration

Research Program Analysis

Robert Butler

Medicaid Services Bob Maryanski

Reimbursement Policy Rate Setting Cost Report Processing & Audits Medicaid Lease Bonds Medicaid Budget Estimates

Medicaid Research Projects Medicaid Up or Out Contract

Management

Handbook Development Waiver Programs State Plan Program Development Medicaid Placement Issues PASSR Medicaid Nursing Home Bed

Reduction Efforts

Division of Medicaid Bob Sharpe

Contract Management Allan Strowd

Medicaid Provider Enrollment Contract Management for Fiscal Agent

Medicaid Claim Payment

Chief Operating OfficerSteve Grigas

Chief Financial OfficerKen Thurston

Health Systems Development

Steve Presnell

Pharmacy Services Pharmacy Prior Authorization Restocking Fees

Pharmacy ServicesGeorge Kitchens

Managed Care

Policy Development MediPass Disease Management

Medicaid Field Offices11 FO Managers

Field Offices Provider Claims Resolution,

Technical Assistance, andPolicy Training

Medicaid Beneficiary Support, Advocacy, and Assistance

Long Term Care Bed Growth

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

ALF beds

NH beds

Nursing Home Closures

Nursing Home Closures 2003 – Three Nursing Homes (459 Beds) 2002 – Twelve Nursing Homes (1,258 Beds) 2001 – Six Nursing Homes (605 Beds)

Based Upon Date Residents Were Discharged

Nursing Home Occupancy

80%

82%

84%

86%

88%

90%

92%

94%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

occ

up

ancy

rat

e

Nursing Home Medicaid Reimbursement Versus Total Cost

Nursing Home Medicaid Reimbursement Versus Total Cost

$22.50

$13.96 $14.06 $13.42 $12.98 $14.30 $14.67 $14.37 $15.17 $11.64 $12.43 $15.33

$-

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

$160.00

$180.00

199801 199807 199901 199907 200001 200007 200101 200107 200201 200207 200301 200307

Rate Sem ester

Per

Die

m

Average Total Cost Average Total Reimbursement Total Difference

Nursing Home Reimbursement Versus Patient Care Cost

$6.51 $6.75 $6.86 $7.29 $6.07 $7.09 $7.02 $6.91

$1.37 $1.57 $1.75 $1.51

$-

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

199801 199807 199901 199907 200001 200007 200101 200107 200201 200207 200301 200307

Rate Semester

Per

Die

m

Patient Care Average Reimbursement Patient Care Average Cost Patient Care Difference

Nursing Home Reimbursement Versus Patient Care Cost

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

Report to the LegislatureMay 2003 – Status Report

www.fdhc.state.fl.us - Publications and Forms

Adverse Incidents Reported

Total Number of Adverse Incidents

0

1000

2000

3000

4000

ALF NH

Year 1

Year 2

Adverse Incidents by Type May 15, 2002 – May 14, 2003

Type Nursing Home

Assisted Living

Death 26 17

Brain/Spinal 2 0

Disfigurement 5 2

Fracture/Dislocation 948 332

Functional Limitation 9  

No Consent 34 6

Transfer 1568 815

Adult Abuse (A/N/E) 1088 122

Child Abuse 9  

Elopement 357 155

Law Enforcement 238 135

     

Adverse Incident Inspections May 15, 2002 - May 14, 2003

# of Completed Inspections

# With Deficiencies

#Serious Deficiencies

% With Deficiencies

  NH ALF NH ALF NH ALF NH ALF

GRAND TOTAL 47 35 11 11 3 1 24% 31%

Nursing Home Notices of Intent ReceivedUpdated Monthly http://www.fdhc.state.fl.us/MCHQ/Long_Term_Care/FDAU/Reports.shtml

Nursing Home NOIs* Received by Nursing Homes as Reported to AHCA**

0

50

100

150

200

250

*Notice of Intents (NOIs) **Late reporting by nursing homes may cause data to change.

# of Claims 113 224 144 94 116 58 48 64 68 63 56 74 46 60 82 80 108 96 83 75 102 74 75 54 70

9/01 10/01 11/01 12/01 1/02 2/02 3/02 4/02 5/02 6/02 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

Assisted Living Facility Notices of Intent Received Updated Monthly

http://www.fdhc.state.fl.us/MCHQ/Long_Term_Care/FDAU/Reports.shtml

0

2

4

6

8

10

12

14

16

18

20

*Notice of Intents (NOIs) **Late reporting by ALFs may cause data to change.

# Claims 8 19 5 9 6 5 5 5 4 6 1 5 2 0 6 6 8 1 2 2 6 2 6 3

9/01 10/01 11/01 12/01 1/02 2/02 3/02 4/02 5/02 6/02 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

Semi-Annual Report onNursing Homes

Liability Claim Information

– Notices of Intent to Litigate– Claims File with Clerk of Court

Survey Deficiencies Federal Quality Measures

Nursing Home NOIs Reported

  For-Profit

Non-Profit

Multi-Facility Owner

Total

Licensed Nursing Homes

 506 (76%)

 163 (24%)

 337 (50%)

 669

Nursing Homes reporting NOIs

 408 (81%)

 97 (19%)

 275 (55%)

 505

NOIs Per Nursing HomeBased Upon 505 Nursing Homes Reporting

# Nursing Homes # NOIs Reported

129 1

227 2 to 4

115 5 to 9

34 10 or more

Notices of Intent By Nursing Home Profit Status

0

50

100

150

200

250

J un-01

J ul-01

Aug-01

Sep-01

Oct-01

Nov-01

Dec-01

J an-02

Feb-02

Mar-02

Apr-02

May-02

J un-02

J ul-02

Aug-02

Sep-02

Oct-02

Nov-02

Dec-02

J an-03

Feb-03

Mar-03

Apr-03

Not For Profit

For Profit

Total Federal “F” Tags Cited by Quarter

Note: Number is subject to change based on the entry of surveys in the system and other actions that change deficiencies such as IDRs and legal actions.

1300 1350 1400 1450 1500 1550 1600 1650 1700 1750

Apr-Jun 2001

July-Sep 2001

Oct-Dec 2001

Jan-Mar 2002

Apr-Jun 2002

Jul-Sep 2002

Oct-Dec 2002

Jan-Mar 2003

Total Federal “K” TagsCited by Quarter

0 50 100 150 200 250 300 350 400 450

Apr-Jun 2001

July-Sep 2001

Oct-Dec 2001

Jan-Mar 2002

Apr-Jun 2002

Jul-Sep 2002

Oct-Dec 2002

Jan-Mar 2003

Most Serious Nursing Home Deficiencies

(Federal "F" and "K" Tags)

0 10 20 30 40 50 60 70 80 90 100

Apr-Jun 2001

July-Sep 2001

Oct-Dec 2001

Jan-Mar 2002

Apr-Jun 2002

Jul-Sep 2002

Oct-Dec 2002

Jan-Mar 2003

Other SeriousDeficienciesG Level

Number of Nursing Homes on the Watch List by Quarter

Calendar Quarter Number of Facilities

April 1, 2001 – June 30, 2001 83

July 1, 2001 – September 30, 2001

90

October 1, 2001 – December 31, 2001

91

January 1, 2002 – March 31, 2002 84

April 1, 2002 – June 30, 2002 92

July 1, 2002 – September 30, 2002

72

October 1, 2002 – December 31, 2002

55

January 1, 2003 - March 31, 2003 63

Recent Legislative Changes

Nursing Homes Staffing

– Allows one day at 97% of staffing requirements without citation if facility does not have a Conditional license

– Adds greater flexibility to sharing of staff in a retirement community – rules may be developed

– CNA increase to 2.9 delayed until May 1, 2004 Gold Seal – AHCA will modify financial criteria

– Accept reviewed financial statement– CCRCs may use DOI financial criteria if accredited

Recent Legislative Changes

Quality of Long Term Care Facility Improvement Trust Fund– Allows state portion of federal nursing home fines to be

deposited into fund– Modifies projects that may be funded

Payment of fines – All entities regulated by AHCA must pay or make

arrangements to pay monies due to AHCA prior to a change of ownership

Medicaid expansion of the long-term care diversion– Expand LTC Diversion Program to serve more recipients– Plan for reduction in the number of Medicaid nursing

home beds

Assistance with EatingFederal Regulation Federal Register Vol. 68, No. 187, Friday September 26, 2003

http://www.access.gpo.gov/nara/index.html

Modifies Code of Federal Regulations effective October 27, 2003 Authorizes use of “paid feeding assistants” if:

– The individual has successfully completed a State-approved training course and

– Use of such assistants is consistent with state law

Florida Law Section 400.23(3)(b), Florida Statutes authorizes the agency to

develop rules to allow properly trained staff to assist residents with eating; rule must specify:– Minimum training requirements– Resident physiological conditions or disorders that require

nursing personnel assistance Rule must be in place before implementation in Florida

Federal Requirements

Supervision– Must work under the supervision of an RN or LPN– Must call a supervisory nurse for help on the resident

call system in an emergency

Resident Criteria– Residents without complicated feeding problems,

including difficulty swallowing, recurrent lung aspirations and tube or parenteral/IV feedings

– Base selection upon charge nurse’s assessment and resident’s latest assessment and plan or care

Training Requirements– Minimum 8 hours

Quality Improvement Activities UpdateQuality Improvement Activities Update

Nursing Home Project– QIO is lead– MDS data utilized and publicly reported – Contact Florida Medical Quality Assurance

Linda Wilkes1-813-354-9111

Operation Spot Check– Attorney General’s Office has lead

MDS Data Verification Project (DAVE)– 28 On-site visits to date– Designed to audit MDS data– Facilities identified based on off-site record

reviews and random selections

Nursing Home Staffing Citations

2002 - 260 Citations (206 Facilities) 166 for N063 (Staffing Ratios)16 for N069 (Self-Imposed Moratorium)78 for F353 (Insufficient to Meet Needs)21 for N063 with F35357 for F353 without N063

2003 to date - 129 Citations (116 Facilities) 74 for N063 (Staffing Ratios)3 for N069 (Self-Imposed Moratorium)52 for F353 (Insufficient to Meet Needs)6 for N063 with F35346 for F353 without N063

Nursing Home Immediate Jeopardy by Region

7/1/02-6/30/03

1/ 2 3 4 5/ 6 7 8 9 / 10 11

Current IJ Surveys

5 3 4 3 4 6 5 2

Past IJ (F698)

      1   1 1  

Total 5 3 4 4 4 7 6 2

Top 10 Deficiencies Nursing Homes

F371 Food must be stored, prepared and distributed under sanitary conditions

F281 Services provided by the facility must meet professional standards

F279 Facility must develop comprehensive care plans for each resident

F514 Facility must maintain clinical records professionally and accurately

F241 Facility must treat residents with dignity and respect

Top 10 DeficienciesNursing Homes Continued

F432 Drugs must be stored in locked compartments at proper temperature

F253 Facility must provide adequate housekeeping and maintenance services

F309 Facility must provide necessary care for highest practicable well being

F280 Comprehensive care plan must be timely, accurate and periodically reviewed

F323 Facility must be kept free of accident hazards

Top 10 Complaint AllegationsNursing Homes

Allegation Total Confirmed Resident Care 890 108 Resident Rights 469 58 Medicine Prob/Errors/Formulary 326

63 Staffing 324

33 Resident/Patient Abuse/Neglect287 43

Top 10 Complaint AllegationsNursing Homes Continued

Allegation TotalConfirmed

Falls/Injury 222 26 Dietary 218 26 Pressure Sores 177

18 Physical Plant 168

28 Infection Control 167

19

Resources

AHCA Web Site: www.fdhc.state.fl.us

Long-Term Care Unit (850) 488-5861Facilities Data Analysis Unit (850) 922-6089

Field Operations (850) 414-9796Health Standards and Quality (850) 922-9138