Quality of Care Issues: Prevention and Response · Quality of Care Issues: Prevention and Response...
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3/7/2012 1 Quality of Care Issues: Prevention and Response HCCA's 16th Annual Compliance Institute Monday, April 30, 2012 Ari J. Markenson, J.D., M.P.H. Benesch Friedlander Coplan & Aronoff LLP 50 Main Street, Suite 1000 White Plains, New York 10606 914.682.6822 [email protected] Robert A. Hussar, Esq., CHC Manatt, Phelps & Phillips, LLP 30 South Pearl Street, 12th Floor Albany, NY 12207 518.431.6730 [email protected] Quality of Care Issues • Generation of QC Issues/Enforcement • Surveys/Inspections • Residents/Families • Employees/Contractors • Data Mining
Transcript of Quality of Care Issues: Prevention and Response · Quality of Care Issues: Prevention and Response...
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Quality of Care Issues: Prevention and Response
HCCA's 16th Annual Compliance InstituteMonday, April 30, 2012
Ari J. Markenson, J.D., M.P.H.Benesch Friedlander Coplan & Aronoff LLP
50 Main Street, Suite 1000White Plains, New York 10606
Robert A. Hussar, Esq., CHCManatt, Phelps & Phillips, LLP
30 South Pearl Street, 12th FloorAlbany, NY 12207
Quality of Care Issues
• Generation of QC Issues/Enforcement• Surveys/Inspections• Residents/Families• Employees/Contractors• Data Mining
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Quality of Care Issues
• Surveys/Inspections• Annual and Complaint Surveys
• Statements of Deficiency/Citations• Top Deficiency Categories Nationally, By
Region• Survey teams have become more
aggressive with referrals of matters to other enforcement agencies
• Necessitates the rights links between clinical, QA, risk management and compliance team
Quality of Care Issues
• Residents/Families• Very vocal consumer base in continuing
care – dramatic change from historic patients and families
• Enormous consumer education - rights to file complaints with enforcement authorities
• Understanding complaints/incident reports important part of compliance function
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Quality of Care Issues
• Employees/Contractors• Behold the Whistleblower!• Significant uptick in whistleblower complaints
• Specifically care related in continuing care setting• Compliance professionals need to be connected
to HR, risk management and others to get in on the front lines of the percolating issues.
Quality of Care Issues
• Data Mining• Publically reported QA/QI data +• Publically reported staffing data +• Publically reported financial data =
• A very exciting and well researched Quality of Care compliant
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Common Survey / DOJ / OIG Findings
• Lack of assessments and evaluations of residents’ needs• Lack of care planning and nursing interventions; • Staffing at the nursing homes was not sufficient to provide
adequate nursing care • Resident abuse/ neglect / rights were not respected• Inadequate resident nutrition and hydration • Wound care was not provided at the nursing home • Residents often did not receive their medication as prescribed • Medical records were falsified and a "charting party" occurred
to fill in medical records so that it appeared that all medication had been properly given, regardless of whether the medication was actually given or not
• Submitted claims were not provided or were worthless
Standards
42 CFR Part 483 – Requirements For States and Long Term Care Facilities
§ 483.25 Quality of care.Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
“Based on the comprehensive assessment of a resident, the facility must ensure that—”
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Enforcement Tools
• False Claims Acts• Elder Justice Act• CMPLs / Exclusion• Corporate Integrity Agreements• State Actions• Private Rights of Action
Enforcement Tools
• False Claims Act(s)
• Worthless Services • False Certification TheoriesPremise
Care was so poor that it was equivalent of no performance at all
Services not provided or provided as claimedHistoryCurrent Status
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Enforcement Tools• Elder Justice Act of 2009 (S. 795)
Each covered individual shall report to the Secretary and 1 or more law enforcement entities .... any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility.
TIMING.—If the events that cause the suspicion—
(A) result in serious bodily injury, the individual shall report the suspicion immediately,but not later than 2 hours after forming the suspicion; and
(B) do not result in serious bodily injury, the individual shall report the suspicion notlater than 24 hours after forming the suspicion.
PENALTIES.—
• General - CMP of not more than $200,000; or excluded for up to 3 years
• Increased Harm -CMP of not more than $300,000 and excluded for up to 3 years
Enforcement Tools
• CMPLs
• Exclusion• Mandatory• Permissive
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Enforcement Tools
• Corporate Integrity Agreements
• Independent Monitor (for quality)• Medical Director Involvement• Quality Assurance Monitoring
Committee• CEO Certification
Enforcement Tools
• State Actions
• Survey and Certification
• Medicaid Audits and Investigations
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Enforcement Tools
• Private Rights of Action
• Federal – Resident Bill of Rights - OBRA ‘87
• State – various state laws
Quality of Care Issues - Prevention
•Prevention•Driven by –
•Compliance links,•Employees•Data; and•Processes
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Quality of Care Issues - Prevention
• Compliance Links to• Clinical
• Care planning• Quality
• Quality Assurance• Performance Improvement
• Staffing • Resident needs• Facility census
• Resource use/Purchasing• Inventory
Quality of Care Issues - Prevention
• Employees• Training, Retraining and Even More
Training• Clinical care• Compliance• Risk Management• Reporting Issues
• Involvement in solutions
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Quality of Care Issues - Prevention
• Data• Quality Data
• Track specific events and get to root causes• Pressure ulcers• Med errors• Resident falls
• Resident Safety/Incidents• Prevention of accidents and undesirable outcomes• Reporting of events when they happen
• Managing Corporate Integrity• Doing the right thing, all the time by following the leads provided in
useful data• Spike in percentage of med-errors, who, what, were and why?
Quality of Care Issues - Prevention
•Processes•Clinical – Care Planning/Care Oversight•HR and Patient – Reporting, Investigation
and Response•Auditing – Clinical, Risk Management, QA
and Compliance Integration
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OIG 2012 Work Plan
• Medicare Requirements for Quality of Care in Skilled Nursing FacilitiesWe will determine the extent to which SNFs:• developed plans of care based on
assessments of beneficiaries, • provided services to beneficiaries in
accordance with the plans of care; and• planned for beneficiaries’ discharges
OIG 2012 Work Plan
• Safety and Quality of Post-Acute Care for Medicare Beneficiaries (New)Review the quality of care and safety of beneficiaries transferred to postacute care:
Evaluate the transfer process
Identify rates of adverse events and preventable hospital readmissions from post-acute-care settings
Focus on SNFs, IRFs and long-term-care hospitals.
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OIG 2012 Work Plan
• Hospitalizations and Rehospitalizations of Nursing Home Residents
• Nursing Home Compliance Plans (New)
• Oversight of Poorly Performing Nursing Homes
• Hospice Marketing Practices and Financial Relationships with Nursing Facilities (New)
• Medicare’s Oversight of Home Health Agencies’ Patient Outcome and Assessment Data
Resource
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Resource
Resource
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Resource
Questions?
