HOME HEALTH REGULATORY UPDATE

Anne MenardHome Care Unit

Bureau of Long Term Care Services

Currently Licensed 2,315 home health agencies

County with largest #: Miami-Dade 799

371 nurse registries Palm Beach 86

2,240 homemaker companion servicesMiami-Dade 335

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

STATE LAW UPDATE

FOR ALL HOME HEALTH AGENCIES & NURSE REGISTRIES

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

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

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

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

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)

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

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

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

careIf there is no improvement in 30 days, the resident must be discharged.

ALF residents care limitationsProhibited 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

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

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.

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

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.

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.)

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”)

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”)

STATE RULE UPDATE HOME HEALTH AGENCIES

AND

NURSE REGISTRIES

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)

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

Home health agency rule repeals AHCA reviewed all programs for rules that could

be repealedHHA 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:1. 59A-8.0086 – Denial, Suspension, Revocation of

License and Imposition of Fines - contents already in 408, Part II & 400, Part III, F.S.

Home health agency rule repeals 2. 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.

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 policiesH 204 personnel records

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.)

Medicare & Medicaid Home Health Agency Surveys

CMS Revisions For surveyors from state agencies &

accrediting organizations

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

• 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

23From CMS Basic Home Health Agency training for surveyors

• 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

31From CMS Basic Home Health Agency training for surveyors

Conditions & Level 1 Standards484.10 Patient Rights - G107, G109484.12 Compliance with Fed/State/Local Laws -

G121484.14 Organization/Services/Administration -

G123, G133, G143, G144484.18 Acceptance of Patients, Plan of Care,

Medical Supervision - G157, G158, G159, G164, G165, G166

From CMS Basic Home Health Agency training for surveyors 12

Conditions & Level 1 Standards (cont.)484.30 Nursing: G170, G172, G173, G174, G175,

G176, G177484.32 Therapies: G186, G187, G188484.36 Home Health Aide: G224, G229484.48 Clinical Records: G236484.55 Comprehensive Assessment of Patients:

G331, G332, G334, G335, G336, G337, G338, G340

From CMS Basic Home Health Agency training for surveyors 13

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

Standard Survey EndsHHA 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 14

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 15

484.10 Patient Rights

43Basic Home Health Agency

Level 1

G107, G109Consider citing the condition when:• The HHA is out of compliance with G107 and

G109 and one additional tag within that condition. (G100-G116)

Standard SurveyPartial Extended Survey

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

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”

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)

If you don’t agree with the surveyor1. 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

AHCA web siteshttp://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

Contact information – HHA & NRAnne Menard – Unit SupervisorAnne.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