Florida Agency for Health Care Administration. Division of Health Quality Assurance. Health Care Facility/ Provider Regulation

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1 Florida Agency for Health Care Administration Division of Health Quality Assurance Health Care Facility/ Provider Regulation September 2014

2 Program Topics Licensing Public Information and Transparency Background Screening Clearinghouse Regulatory Action Coordination Assisted Living Regulation Unlicensed Activity Facility Actions

3 Division of Health Quality Assurance Responsibilities State Licensure of Health Care Facilities and Providers Federal Certification Emergency Support Functions for Health Care Facilities The Florida Center for Health Information and Policy Analysis Florida Health Information Exchange Infrastructure 3

4 Licensed Health Care Facilities and Providers Licensure of 30 Facility Provider Types Over 40,000 Individual Providers Application Processing Initial Licensure License Renewal Every Two Years Change of Ownership Applications Inspections for Licensure Initial and Renewal Licensure Consumer Complaints Regulatory Concerns / Monitor Visits 4

5 Licensed Health Care Facilities and Providers Managed Care Health Care Certificate of Authority Office of Financial Regulation Issues License Medicaid Managed Care Contract Enforcement Tracking Subscriber Assistance Panel Dispute Resolution Certificate of Need Hospitals Hospice Nursing Homes Intermediate Care Facilities for Developmentally Disabled Plans and Construction Reviews Hospitals Ambulatory Surgery Centers Nursing Homes Intermediate Care Facilities for Developmentally Disabled 5

6 Licensed Health Care Facilities and Providers Abortion Clinics Adult Day Care Centers Adult Family Care Homes Ambulatory Surgery Centers Assisted Living Facilities Birth Centers Clinical Laboratories Crisis Stabilization Units Health Care Service Pools Health Care Clinics Health Care Risk Managers Home Health Agencies Home Medical Equipment Providers Homemaker Companion Agencies Homes for Special Services Hospices Hospitals Intermediate Care Facilities for Developmentally Disabled Nurse Registries Nursing Homes Prescribed Pediatric Extended Care Centers Residential Treatment Facilities Short Term Residential Treatment Facilities Transitional Living Facilities 6

7 Division of Health Quality Assurance Bureau of Field Operations Regulatory Inspections Complaint Administration Complaint Triage Management HQA Call Center Contract Manager Florida Center for Health Information and Policy Analysis Bureau of Health Facility Regulation Licensure and Certification Home Care Hospital and Outpatient Services Clinic Laboratories Health Care Clinics Assisted Living Long Term Care Regulation of Commercial HMOs Managed Care Subscriber and Beneficiary Assistance Bureau of Central Services Online Licensure Reporting Background Screening Clearinghouse Document Management (Laserfiche) Emergency Response Management Financial Analysis Hospital Financials Versa Regulation for Licensing Enforcement Coordination for Medicaid Managed Care Bureau of Plans and Construction Florida Health Finder Website Risk Management (Adverse Incident Reports) Health Care Consumer Information Electronic Health Records Certificate of Need Medicaid Managed Care Transparency Physical Plant and Plan Review for Health Care Facilities Hospitals Nursing Homes Ambulatory Surgery Centers Intermediate Care Facilities for the Developmentally Disabled

8 Licensure Process Application Submitted Provider Demographic Information Ownership Controlling Interests, Disclosures Administration and Management As Applicable: Operations Insurance, Financial Ability to Operate, Bonding Location Certificate of Need, Plans and Construction, Zoning, Fire Safety Inspection, Food Service Inspection Qualifications Staffing, Background Screening Verify History or Outstanding Issues Background Screening Prior Operation Fees, Fines, Overpayments Outstanding 8

9 Licensure Process Authorize Inspection Provider Requests When Ready Inspection Scheduled (Initial Licensure Only) Inspection Conducted Determine Compliance Verify Application Staffing, Qualifications, Policies, Physical Plant, Equipment Determine Successful Completion or Violations Final Application Review License Decision Approve or Deny 9

10 Online License Renewal

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14 Document Management Document Management Software Workflow shift to scan at intake Storage final documents Redaction of confidential information User access Retrieval File organization Interface with translations tools Publication Florida health Finder Web DM (legal orders, inspection reports) determine demand

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16 Facility and Provider Locator 16

17 FloridaHealthFinder.gov Facility Profile: Hospital 17

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20 Legal Final Orders

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23 FloridaHealthFinder.gov Compare Performance, Quality and Pricing Information on Hospitals and Ambulatory Surgery Centers Find volume, charges, length of stay, infection, readmission, complication & mortality rates Data on 150 conditions and procedures; updated quarterly Separate pediatrics and seniors section; deliveries and newborns section 23

24 Comparative Information for Hospitals 24

25 Comparative Information for Hospitals 25

26 Comparative Information for Hospitals 26

27 Comparative Information for Nursing Homes 27

28 Other Comparison Tools Health Plans quality performance and member satisfaction survey results Physicians volume for total hip and total knee replacements, heart bypass surgery, angioplasty, and spinal fusion (hospital data - based on Operating Physician ID and Principal Procedure) Hospice Providers family satisfaction scores Prescription Drug Prices 28

29 Uses of Data Explanations of why this data is important Facility/Physician experience Identify potentially preventable events Efficiency of care Quality of care Assists providers in quality improvement Provides consumer empowerment Assists consumers in making well informed health care decisions TALK TO YOUR HEALTH CARE PROVIDER!!!! 29

30 Visits to FloridaHealthFinder.gov, * 2,600,000 2,400,000 2,200,000 2,000,000 1,800,000 1,600,000 1,400,000 1,200,000 1,000, , , , , Projection 3,100,000 visits Year Number of Visits , ,351, ,664, ,820, ,980, ,578,443 30

31 Criminal Background Checks Care Provider Background Screening Clearinghouse State and Federal Collaboration Federal Pilot Federal Authority Child Protection Act Eliminates Duplication Continual Feedback Rap Back Automation Efficiencies Online Application Interface with Other Data Systems Multi-Agency Access to a Single Host System

32 Care Provider Background Screening Clearinghouse The Clearinghouse currently hosts regulatory criminal background screening results Agency for Health Care Administration Department of Health Department of Education Division of Vocational Rehabilitation Medicaid Managed Care Health Plans Remaining specified agencies to be implemented Department of Children and Families Agency for Persons with Disabilities Department of Elder Affairs Department of Juvenile Justice

33 Employer Screening Process Regulated employers create an online account to the Clearinghouse As employees are considered, names and demographics are entered for query Check against existing screenings first or attach to a pending request If no results, screening is initiated Florida screening results are provided Eligible or Ineligible is provided based upon screening type 33

34 Employee/Contractor Roster Initial employment /contract status and any changes in status must be reported within 10 business days. Employee/contractor must be added to employee/contractor roster to receive arrest and criminal registration notifications. If an employer becomes aware that an employee/contractor has been arrested for a disqualifying offense, the employer must remove the employee/contractor from contact with any vulnerable person that places the employee in a role that requires background screening. Even though the requirement is only for employees/contractors with a Clearinghouse screening, it is highly recommended that ALL employees/contractors are added to the employee roster. By doing so the provider will receive notifications of employment status changes for all employees. 34

35 Employer Benefits of the Clearinghouse During the initiation process, employers will connected with approved Livescan service providers, so that you may enter applicant information, as well as schedule and pay for appointments through one system. By initiating the screening through the Clearinghouse website employers: Be able to track a screening through the entire screening process and receive notifications View status at each stage of the screening process, including Fingerprints Submitted, Fingerprints Received from FDLE, Fingerprints Rejected, Fingerprints Rejected 2 nd NCO requested Employer notification for each status change, reducing the time needed to search the system for updates Screenings in process and screening results will be displayed on employers page, reducing the need to search the entire database 35

36 Benefits of the Clearinghouse Applicants fingerprints retained for 5 years State retention available at this time Federal retention expected in 2015 Retention of fingerprints enables notification of an arrest when the Agency by Florida Department of Law Enforcement Law requires rescreen of federal check for a 90 day break in employment If employee is in Clearinghouse, only federal rescreening is required (currently $16.50) Provides a photo of the applicant taken at the time of screening 36

37 Clearinghouse Statistics AHCA Clearinghouse AHCA Total DOH Clearinghouse DOH Total 0 As of July 31, 2014 the Clearinghouse has provided a cost savings to Agency providers and DOH licensees of $1,265,

38 Regulatory Collaboration Electronic access to Abuse Reports Long Term Care Ombudsman reports Attorney General involvement in Medicaid cases Law enforcement interest in unlicensed activity

39 Regulatory Complaints Consumers are better informed New sources of data Internet Publicly available data bases maintained by state and federal agencies pursuant to legislative mandates 39

40 Regulatory Complaints Jurisdiction based on regulatory authority Complaints that are not confirmed/substantiated an important part of the regulatory process When a complaint is not investigated No regulatory authority to address the complaint Complaint allegations have previously been investigated Complaint is referred to an accrediting organization 40

41 Complaint Process Complaint Intake Call Center , Option #1 Online complaint Written submissions letter, Mail 2727 Mahan Drive Mail Stop #49, Tallahassee, FL Other information available Allegations reviewed for appropriate handling Determine jurisdiction Refer to another regulatory agency AHCA jurisdiction Control number assigned, triaged and prioritized Consider other AHCA interest Medicaid, Medicaid Program Integrity 41

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44 Complaint Regulatory Handling Inspections are generally conducted - Timing determined by priority - Compliance determination - Past non-compliance consideration - Report issued citations if appropriate Complainant informed unless anonymous Correction required Sanctions if appropriate 44

45 Initiatives Streamlining Activities for Efficiency Central Intake Electronic Document Workflow Automation of Inspection Process Automation of Information Improves Provider and Public Access Turnaround Time for Decisions and Results Reduce Labor Necessary to Support Workload/Growth Collaboration with Partners to Reduce Program Waste / Inappropriate Utilization Health Care Fraud and Abuse Regulatory Reduction Meaningful Regulations Statutory and Rule Reduction Efforts

46 What is an Assisted Living Facility? (5), F.S. Any building or buildings, section or distinct part of a building, private home, boarding home, home for the aged, or other residential facility. Operated for profit or not. Provides housing, meals, and one or more personal services for a period exceeding 24 hours to one or more adults who are not relatives of the owner or administrator. 46

47 What is an Assisted Living Facility? Personal services means direct physical assistance with or supervision of the activities of daily living and the self-administration of medication and other similar services. Florida Statute (16) 47

48 Resident Rights Live in a safe and decent living environment, free from abuse and neglect. Be treated with consideration, respect and with due recognition of personal dignity, individuality, and the need for privacy. Retain and use his/her own clothes and other personal property. Unrestricted private communication including receiving and sending unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any time between the hours of 9 a.m. and 9 p.m. Participate in and benefit from community services and activities to achieve the highest possible level of independence, autonomy, and interaction with the community. 48

49 Resident Rights Manage his/her own financial affairs unless the resident (or the resident's legal representative) authorizes the administrator of the facility to provide safekeeping for funds. Share a room with spouse if both are residents of the facility. Reasonable opportunity to exercise and to go outdoors at regular and frequent intervals. Adequate and appropriate health care consistent with established and recognized standards. 45 days notice for relocations. (ALF) Be free from physical and chemical restraints other than those prescribed by the resident's physician. The use of physical restraints shall be limited to half-bedrails and only upon the written order of the resident's physician and the consent of the resident or the resident's legal representative. [S (1)(k)]. 49

50 Admission Criteria At least 18 years old, Free from communicable disease, Can perform activities of daily living (ADLs), independently, with supervision or with assistance, Be capable of taking medication, Not a danger to self or others, 50

51 Admission Criteria Not require 24-hour nursing supervision or 24- hour professional mental health treatment, Not be bedridden, Not have stage 3 or 4 pressure ulcers. Stage 2 pressure ulcers must be getting treatment and improving, and Not require tube feeding, blood gas monitoring, certain other nursing services. 51

52 Admission Criteria A resident in a standard license ALF may be bedridden for up to 7 days. In an ALF with an extended congregate care license (ECC), the resident may be bedridden up to 14 days. Terminally ill residents under the care of a licensed hospice program may remain in an assisted living facility under certain conditions 52

53 Staffing Administrator; Responsible for facility oversight. May or may not own the facility. Must complete 26 hour core training requirement and pass exam within 3 months of becoming the administrator. Must complete 12 hours of continuing education every two years. Resident Aid/Medication Technician/Certified Nursing Assistant (C.N.A.); Not nurses, assist with ADLs, provide assistance with self-administration of medication. Completes a 4-hour medication training class and 2-hour annual updates. 53

54 Staffing Resident Care Director or Coordinator or Director of Nursing (DON) Not required in an Assisted Living Facility. However, medications can only be ADMINISTERED by a nurse. Staffing levels are based on the number of residents in the building and are calculated by the week. 54

55 Classification of Deficiencies Florida Statute Florida Statute Class I - Imminent danger to the residents, appears likely death or serious physical harm will result. $5000-$10,000 Class II Conditions pose a direct threat to the health, safety or security of the clients. $1000- $

56 Classification of Deficiencies Class III Indirectly or potentially threaten the health, safety or security of residents. The agency specifies a timeframe for correction and, if corrected, a fine MAY not be imposed. $500- $1000 Class IV Violations the agency determines do not threaten the health, safety and security of the residents. The agency specifies a timeframe for correction and, if corrected, a fine MAY not be imposed. $100-$200 56

57 Classification of Deficiencies Unclassified Deficiencies Violations not designated as Class I, II, III, or IV. $500 Examples: No Level II background screens for staff, being over licensed capacity. 57

58 Top 10 Deficiencies July 2013-June 2014 Resident Rights Staffing Standards Medication Assistance with Self-Administration Staff Training Admissions Health Assessment Resident Care Supervision Food Service Medication Records Medication Storage Background Screening 58

59 Specialty Licenses Extended Congregate Care Aging in place Promotes resident choice, independence and decision making Requires specific policy and procedures Requires additional training for supervisor and staff Requires service plans and documentation Quarterly monitoring visits by AHCA 59

60 Specialty Licenses Limited Nursing Services Requires nursing assessments and nursing notes/documentation for all residents receiving limited nursing services The facility must employ or contract with a nurse Monitoring visits every six months by AHCA. 60

61 Specialty Licenses Limited Mental Health Licensure is required for ALFs with more than two mental health residents Requires additional training for administrator and staff The facility must have a cooperative agreement with a mental health provider A community living support plan must be in place between the resident, facility and provider The facility must assist the resident in carrying out the activities in the support plan and observe and document resident behavior 61

62 Unlicensed Activity Awareness - Educate Partners Create Partnerships Joint Initiatives Target Resources and Materials Raise Visibility Quantify Resource Implications

63 Unlicensed Activity Under : Unlicensed facilities; referral of person for residency to unlicensed facility; penalties. (1)(a) This section applies to the unlicensed operation of an assisted living facility in addition to the requirements of part II of chapter 408. (b) Any person who owns, operates, or maintains an unlicensed assisted living facility commits a felony of the third degree, punishable as provided in s , s , or s Each day of continued operation is a separate offense. (c) Any person found guilty of violating paragraph (a) a second or subsequent time commits a felony of the second degree, punishable as provided under s , s , or s Each day of continued operation is a separate offense. 63

64 Unlicensed Activity Investigations Allegations reported to complaint administration unit staff: Research location for ownership and/or prior history Possible unlicensed ALF, coordinate with law enforcement, Department of Children and Families or other agencies Tour facility, interview residents, observe if any services are provided, review any records (contracts, lease agreements, medication records) 64

65 Unlicensed Activity Investigations Determine how many residents reside at the location Determine how many, if any, residents are receiving assistance with medication and/or activities of daily living and who is providing the assistance 65

66 Unlicensed Activity Investigations Determine if the operator/provider and/or staff live at the location. If unlicensed activity is substantiated, AHCA will serve a notice of unlicensed activity violation. 66

67 Unlicensed Activity Investigations If a provider is billing Medicaid or managed care programs for a resident in an unlicensed location, the case can be referred to the Attorney General s Medicaid Fraud Control Unit. If abuse/neglect is identified, the Department of Children and Families is contacted. 67

68 Unlicensed Activity Investigations EXCEPTION: (d), F.S. (d) Any person who provides housing, meals, and one or more personal services on a 24-hour basis in the person s own home to not more than two adults who do not receive optional state supplementation. The person who provides the housing, meals, and personal services must own or rent the home and reside therein. 68

69 Unlicensed Activity: Risk Factors/Concerns Not regulated/monitored by AHCA or other agencies Often correlates with financial exploitation/abuse and neglect Agency also finds licensed providers operating unlicensed locations 69

70 Unlicensed Activity Verify if a provider is licensed as an Assisted Living Facility or Adult Family Care Home 70

71 When and What to Report? Be observant when in facilities: Any restraints? How is resident hygiene? What is the physical condition of the building? Is there enough staff? Is there enough food? Is there equipment you may not expect to see Hoyer lifts, peg tubes, hospital beds. 71

72 When and What to Report? Is the facility license posted? Have any residents eloped for the facility? Is there concern about residents with pressure ulcers? Any concerns about resident safety and treatment of residents in a facility can and should be reported. The Complaint Administration Unit may also refer complaints to other agencies such as the Department of Children and Families, Department of Health and the Long Term Care Ombudsman. 72

73 Facility Actions Actions Affecting Operation License Revocation Medicaid Termination Payment Disruption Emergency Actions Process Steps Partner Collaboration Managed Care Involvement 73

74 Contacting AHCA Local HQA Field Offices Licensing Units Medicaid Contacts 74