Medicare State Operations Manual Provider Certification

Transcription

1 Medicare State Operatins Manual Prvider Certificatin Department f Health and Human Services (DHHS) HEALTH CARE FINANCING ADMINISTRATION (HCFA) Transmittal 14 Date: MARCH 2000 HEADER SECTION NUMBERS PAGES TO INSERT PAGES TO DELETE (Cnt.) (6 pp.) (4 pp.) NEW/REVISED MATERIAL--EFFECTIVE DATE: March 25, 2000 Sectin 4132, Nurse Aide Training and Cmpetency Evaluatin Prgrams and Cmpetency Evaluatin Prgrams, is revised t reflect statutry changes t 1819(f)(2) and 1919(f)(2) f the Scial Security Act (the Act), and t prvide interpretive guidance relative t thse changes. Public Law revised the Act t permit a waiver f nurse aide training prgram disapprval in certain nursing hmes if the State determines that the facility meets specified exceptin criteria. DISCLAIMER: The revisin date and transmittal number nly apply t the redlined material. All ther material was previusly published in the manual and is nly being reprinted.

2 HCFA- Pub PROGRAM ADMINISTRATION AND FISCAL MANAGEMENT ACTIVITIES WITH ACCREDITED ENTITIES DEEMED TO MEET PARTICIPATION REQUIREMENTS Sectin 1865 f the Act allws HCFA t find that if the accreditatin f the fllwing entities by any natinal accreditatin rganizatin prvides reasnable assurance that the CPs r Cnditins fr Cverage, r Requirements fr SNFs, are met fr these entities, then HCFA may deem these entities by virtue f their accreditatin as meeting the Medicare cnditins. The entities cvered by the law that can be deemed are hspitals, psychiatric hspitals, ASCs, RHCs, labratries, hspices, HHAs, SNFs, CORFs, and clinic rehabilitatin agencies r public health agency prviders f OPT (including speech pathlgy services) r ccupatinal therapy services. Sectin 353 f the Public Health Service Act als prvides the same recgnitin fr accreditatin rganizatins and State licensure prgrams f CLIA labratries. HCFA published a ntice in the Federal Register t ntify the public f any rganizatins whse accredited specified types f prviders r suppliers are deemed t meet Medicare r CLIA participatin requirements. Sample validatin r substantial allegatin surveys f entities accredited by accreditatin rganizatins apprved by HCFA are acceptable reimbursement activity. See 1018 fr thse facilities that may participate by virtue f their accreditatin by an apprved accrediting bdy HIGHER THAN NATIONAL STANDARDS Sectin 1863 f the Act permits, at the request f a State, higher requirements fr that State than the Federal Cnditins r Requirements if apprved under a State plan. If apprved by the Secretary, the Secretary will impse like requirements in entities within that State. When a State has higher standards (apprved by the Secretary) than thse impsed natinally, the csts f certificatin activities necessary t apply the higher requirements are paid by Federal trust fund and grant mnies NON-FACILITY-RELATED ACTIVITIES In additin t activities that are related t individual facilities, there are ther activities necessary t the prper functining f the survey and certificatin prgram. These activities include relatinships with ther prgrams and rganizatins which permit effective accmplishment f prgram gals as they relate t individual facilities SA PROMOTIONAL AND PUBLIC INFORMATIONAL ACTIVITIES Mst f the prmtinal and public infrmatinal activities are carried ut by HCFA, primarily thrugh CO and ROs and, t a lesser extent, by intermediaries. Hwever, 1819(g)(1)(B) and 1919(g)(1)(B) f the Act require each State t cnduct peridic educatinal prgrams fr the staff and residents (and their representatives) f SNFs and NFs in rder t present current regulatins, prcedures, and plicies. Persns having general questins abut Medicare/Medicaid are referred t the RO fr infrmatin. Certain prfessinal relatins activities n the part f the SA s persnnel are necessary and prper fr maintaining nging relatinships in the health prfessins. Participatin by SA emplyees as speakers, panelists, r cnsultants at meetings f prfessinal rganizatins (hspital assciatins, medical scieties) in the interest f furthering cmpliance with Medicare/Medicaid standards and bjectives wuld be prper activities fr survey and certificatin funding Medical Scieties.-- Cntacts by SA fficials with medical scieties are desirable t clarify the bjectives f survey and certificatin prgram and enlist the cperatin f the medical scieties in meeting thse bjectives that are certificatin-related.

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4 4117 PROGRAM ADMINISTRATION AND FISCAL MANAGEMENT Objectives may relate t a specific CP r Cnditin fr Cverage r t brader bjectives such as effective use f the different levels f care ffered thrugh hspitals, LTC facilities, HHAs, and ther medical facilities RELATIONS WITH OTHER PROGRAMS It is incumbent n each State t maintain effective liaisn with ther prgrams having activities similar t thse perfrmed fr the survey and certificatin prgram. The need fr establishing and maintaining relatinships is particularly bvius with reference t licensure prgrams. In additin t licensure, examples f ther prgrams with gals clsely related t thse f certificatin are hspital survey and cnstructin prgrams, health facilities planning prgrams, and mental health and chrnic ESRD prgrams. These prgrams, while nt bearing the same relatinship t survey and certificatin as des licensure, include activities that apprximate health insurance activities. Additinally, the SA shuld cnsider jint activities with mutually benefitting prgrams n an "ad hc" basis. This assumes that each State makes prtracted and frequent cntacts at an administrative level in the interest f the survey and certificatin prgram DEEMING AND WAIVER OF NURSE AIDE TRAINING AND COMPETENCY EVALUATION REQUIREMENTS OBRA 1987 prhibits skilled nursing facilities and nursing facilities frm using as nurse aides any individuals wh have nt successfully cmpleted a nurse aide training and cmpetency evaluatin prgram r cmpetency evaluatin prgram apprved by the State. OBRA 1987 and 1989 deemed sme individuals t meet this requirement and permitted States t waive this requirement fr thers. All individuals wh are deemed t meet the nurse aide training and cmpetency evaluatin prgram requirements, r fr whm the State waives the requirement t cmplete a cmpetency evaluatin prgram, must be included in the nurse aide registry described in A nurse aide is deemed t satisfy the requirement f cmpleting a nurse aide training and cmpetency evaluatin prgram if, befre July 1, 1989, he r she cmpleted a nurse aide training and cmpetency evaluatin prgram f at least 60 hurs and made up at least the difference between the number f hurs in the prgram he r she cmpleted and 75 hurs in supervised practical nurse aide training, r in regular in-service nurse aide educatin. A nurse aide is deemed t satisfy the requirement f cmpleting a nurse aide training and cmpetency evaluatin prgram if, befre July 1, 1989, the individual was fund cmpetent (whether r nt by the State) after cmpleting nurse aide training f at least 100 hurs duratin. The State may deem an individual t have cmpleted a nurse aide training and cmpetency evaluatin prgram if the individual cmpleted, befre July 1, 1989, a nurse aide training and cmpetency evaluatin prgram that it determines wuld have met the requirements fr apprval at the time it was ffered. The State may waive the requirement fr an individual t cmplete a cmpetency evaluatin prgram fr any individual wh can demnstrate t its satisfactin that he r she has served as a nurse aide at ne r mre facilities f the same emplyer in the State fr at least 24 cnsecutive mnths befre December 19, Any individual described abve may be emplyed as a nurse aide by a nursing hme if that individual is als cmpetent t perfrm nursing r nursing-related services NURSE AIDE TRAINING AND COMPETENCY EVALUATION PROGRAMS AND COMPETENCY EVALUATION PROGRAMS The Omnibus Budget Recnciliatin Act f 87 requires the State t specify thse nurse aide training and cmpetency evaluatin prgrams and cmpetency evaluatin prgrams it apprves. The State

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6 03-00 PROGRAM ADMINISTRATION AND FISCAL MANAGEMENT shuld fllw the requirements detailed in thrugh when reviewing and apprving prgrams, and when withdrawing apprval frm prgrams. The State may ffer its wn nurse aide training and cmpetency evaluatin prgram and/r cmpetency evaluatin prgram as lng as the prgram meets these requirements Apprval f Nurse Aide Training and Cmpetency Evaluatin Prgrams and Cmpetency Evaluatin Prgrams.-- If the State des nt ffer a nurse aide training and cmpetency evaluatin prgram r cmpetency evaluatin prgram, the State shuld review and apprve r disapprve all nurse aide training and cmpetency evaluatin prgrams, upn request. The State shuld apprve nurse aide training and cmpetency evaluatin prgrams and cmpetency evaluatin prgrams ffered by any entity as lng as the requirements fr apprval are met. A. Requirements fr Prgram Apprval.--Befre apprving a nurse aide training and cmpetency evaluatin prgram r cmpetency evaluatin prgram, the State shuld: Fr nurse aide training and cmpetency evaluatin prgrams, determine whether the requirements f are met; Fr cmpetency evaluatin prgrams, determine whether the requirements f are met; and In all reviews ther than the initial review, visit the entity prviding the prgram. B. Time Frames fr Review.--Within 90 days f a request t review a prgram r receipt f additinal infrmatin frm a requester, the State must: Advise the requestr whether the prgram has been apprved; r Request additinal infrmatin. The State may nt grant apprval f a prgram fr mre than 2 years. The State shuld require prgrams t ntify the State when there are substantive changes t the prgram within the 2-year perid, and the State shuld review prgrams t which substantive changes are made. C. Prhibitin f Prgram Apprval.--Unless prgram disapprval is waived in accrdance with subsectin E belw, the State must nt apprve a nurse aide training and cmpetency evaluatin prgram r nurse aide cmpetency evaluatin prgram ffered by r in a nursing hme if, in the 2 years prir t the State s review, that facility: In the case f a skilled nursing facility, has perated under a waiver under 1819(b)(4)(C)(ii)(II)f the Act; In the case f a nursing facility, has perated under a waiver under 1919(b)(4)(C)(ii) f the Act that as granted n the basis f a demnstratin that the nursing facility is unable t prvide nursing care required under 1919(b)(4)(C)(i) f the Act fr a perid in excess f 48 hurs a week; Has been subject t an extended (r partial extended) survey under 1819(g)(2)(B)(i) r 1919(g)(2)(B)(i) f the Act; Has been assessed a civil mney penalty described in 1819(h)(2)(B)(ii) r 1919(h)(2)(A)(ii) f the Act f nt less than $5,000. This requirement applies t civil mney penalties fr

7 Federal citatins nly after the facility has had an pprtunity t a hearing as specified in 1128A f the Act and the penalty is determined due and payable; r Rev

8 (Cnt.) PROGRAM ADMINISTRATION AND FISCAL MANAGEMENT Has been subject t a remedy described in 1819(h)(2)(B)(i) r (iii), 1819(h)(4), 1919(h)(1)(B)(i), r 1919(h)(2)(A)(i), r (iii), r (iv) f the Act. D. Withdrawal f Prgram Apprval.--Unless the State waives prgram disapprval in accrdance with subsectin E belw, the State must withdraw apprval frm: Any nurse aide training and cmpetency evaluatin prgram r cmpetency evaluatin prgram described in subsectin C, and Any nurse aide training and cmpetency evaluatin prgram r cmpetency evaluatin prgram if the entity ffering the prgram refuses t permit unannunced State visits. (Als, any facility that refuses t permit unannunced State visits is subject t having its prvider agreement terminated, and being excluded frm the prgram by the Office f the Inspectr General.) The State may withdraw apprval f a nurse aide training and cmpetency evaluatin prgram r cmpetency evaluatin prgram if the State determines that any f the requirements described in and are nt met by the prgram. The State may als withdraw apprval frm any prgram that des nt meet any requirements the State may have in excess f the minimum Federal requirements, r that therwise fails t meet State standards. When withdrawing apprval frm a nurse aide training and cmpetency evaluatin prgram r a cmpetency evaluatin prgram, the State shuld: Ntify the prgram in writing, indicating the reasn(s) fr withdrawal f apprval; and In the case f a nurse aide training and cmpetency evaluatin prgram, permit students wh have already started the prgram t finish it. E. Waiver f Prgram Prhibitin A State may waive the disapprval f prgrams ffered in (but nt by), certain nursing hmes if the State des all f the fllwing: a. Determines that there is n ther such prgram ffered within a reasnable distance f the facility. Generally, reasnable distance is cnsidered as any distance that culd be traveled within apprximately 1 hur frm the facility, factring in the typical mde f transprtatin fr staff in the area. Exceptins t what generally is cnsidered t be reasnable distance wuld be at the discretin f the State; b. Assures, thrugh an versight effrt that an adequate envirnment exists fr perating the prgram in the facility. States are encuraged t accmplish this versight effrt in cnsultatin with, fr example, a lcal schl f nursing. An adequate envirnment is cnsidered t exist if the facility has n deficiencies that cnstitute substandard quality f care at the time f its request fr a disapprval waiver. An versight effrt is cnsidered t exist if the State has a prcess in place t assure that the facility has n deteriratin in care that results in substandard quality f care during the waiver perid, and that the facility therwise cntinues t meet the waiver criteria during the waiver perid; and c. Prvides ntice f such determinatin and assurances t the State lng term care mbudsman. States are encuraged t als publish such a ntice fr residents and ptential residents. 2. Duratin f Waiver.--A waiver may nt exceed 2 years, but must be withdrawn earlier if the facility is subsequently fund t n lnger meet the waiver criteria. If 2-year disapprval perids verlap, any nn-waived disapprval in the earlier perid will cntrl waiver

9 4-30 Rev PROGRAM ADMINISTRATION AND FISCAL MANAGEMENT rights in the secnd until the tw perids n lnger verlap. Belw are examples describing the effect f a series f survey findings n a facility s ability t have a waiver. EXAMPLE: Year 1: A survey cnducted at Facility X identifies substandard quality f care. The finding f substandard quality f care results in nurse aide training and cmpetency evaluatin prgram disapprval fr 2 years. The facility requests and is granted a waiver after the State has cnfirmed that the facility has remved the substandard quality f care. The waiver may nt exceed 2 years. Year 2: The survey f Facility X identifies substandard quality f care. Based n this current finding f substandard quality f care, the facility lses its existing waiver. This nurse aide training and cmpetency evaluatin prgram disapprval, based n this survey, is effective fr 2 years. Additinally, the facility frfeits the waiver granted in year 1 due t its inability t cntinue t meet waiver criteria at E.1.b. (i.e., t be free f deficiencies which cnstitute substandard quality f care. Year 3: The survey f Facility X identifies deficiencies which d nt cnstitute substandard quality f care, but result in the impsitin f denial f payment fr new admissins. The impsitin f this remedy results in nurse aide training and cmpetency evaluatin prgram disapprval fr 2 years. The facility requests and is granted a waiver. The waiver may nt exceed 2 years. Hwever, since the facility is currently perating under a nurse aide training and cmpetency evaluatin prgram disapprval fr 2 years, based n its year 2 survey, the waiver resulting frm this current survey will nt apply until the remainder f the disapprval perid (which verlaps with part f the waiver perid) is satisfied. F. Cnflicts f Interest.--States are gverned by their respective cnflict f interest laws and are free t develp their wn plicies r rules abut what may r may nt cnstitute a cnflict f interest relative t nurse aide training and cmpetency evaluatin prgrams. This gives States the ability t define their prgrams s that they can meet their needs relative t nurse aide training and cmpetency evaluatin prgrams while meeting the intent f the law. Factrs States may cnsider in making cnflict f interest determinatins may include, but are nt limited t, the fllwing: Whether the training prgram being ffered is wned and perated independently f the wnership and peratin f the nursing hme that has lst its ability t train; Whether facility staff, wh are als emplyees f an apprved utside training prgram, shuld be permitted t train in the facility (as emplyees f the utside training prgram) if the facility lses its ability t train; and Any ther factrs the State believes t be relevant in making cnflict f interest determinatins Requirements fr Nurse Aide Training and Cmpetency Evaluatin Prgrams.-- A. Hurs f Training.--A nurse aide training and cmpetency evaluatin prgram must cnsist f a minimum f 75 clck hurs f training in rder t be apprved by the State. The State has the discretin t require additinal hurs f training.

10 Rev (Cnt.) PROGRAM ADMINISTRATION AND FISCAL MANAGEMENT B. Restrictins n Activities f Students in a Nurse Aide Training and Cmpetency Evaluatin Prgram.--The State shuld nt apprve a prgram unless it ensures that: Students d nt perfrm any services fr which they have nt trained and been fund prficient by the instructr; and Students prviding services t residents are under the general supervisin f a licensed nurse r an RN. C. Instructr Qualificatins.--The training f nurse aides must be perfrmed by r under the general supervisin f a registered prfessinal nurse wh pssesses a minimum f 2 years f nursing experience, at least 1 year f which must be in the prvisin f lng-term care facility services. Instructrs f nurse aides must have cmpleted a curse in teaching adults r have experience in teaching adults r supervising nurse aides. In a facility-based prgram, the training f nurse aides may be perfrmed under the general supervisin f the Directr f Nursing, wh is prhibited frm perfrming the actual training. Other individuals may supplement the instructr. Fllwing are examples f thse wh might be useful in a nurse aide training and cmpetency evaluatin prgram: RNs; Licensed practical/vcatinal nurses; Pharmacists; Dietitians; Scial wrkers; Sanitarians; Fire safety experts; Nursing hme administratrs;

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