Agency for Health Care Administration

Transcription

1 Agency for Health Care Administration Presenter: Intermediate Care Facilities for the Developmentally Disabled Licensure and Certification Issues Kimberly Smoak, MSH Health Services and Facilities Consultant Health Quality Assurance Long Term Care Unit 1

2 The Federal ICF/DD Look-Behind Process The purpose is to strengthen Federal oversight and monitoring and to take aggressive steps to protect individuals who reside in ICFs. 2

3 Factors in Choosing Facilities for Look-Behinds OSCAR Data Media or Public Concern Same Condition of Participation Cited in Consecutive Years State Survey Agency Citing Standards only Few or no Abuse Citations No Federal Oversight for 1-3 Years Facility has Locked Unit for Criminal Offenders 3

4 Scheduling of Federal Surveys Generally conducted within 30 days of the State Agency (SA) Survey 4

5 Conducting the Survey Surveys Are Conducted in Accordance with the Following Federal ICF Protocols: Appendix J - Guidance to Surveyors Appendix Q - Guidelines for determining Immediate Jeopardy Principles of Documentation Eight Survey Tasks are performed Sample Selection Includes 75% of Sample from the SA Survey 5

6 After the Survey Federal Contract Surveyors complete CMS 2567 and send to provider. Provider responds with appropriate Plan of Correction. The CMS Regional Office, Contract Staff, and SA Staff will participate in a conference call to share findings and discuss discrepancies between the SA survey and Federal survey. 6

7 Florida Statistics Since 2001, when the Federal Look-Behind process began, Florida has had 23 federal surveys conducted. 2003: Four Look-behinds conducted 2004: Three Look-behinds conducted 7

8 W 124: 11 Focus Tags Based on Look- Behind Results Inform client, parent, guardian of clients medical, developmental, and behavioral status. W 125: Clients allowed and encouraged to exercise their rights as citizens of the United States. W 148: Notify parents, guardians of changes in condition. W 149: Develop, and implement policy and procedures that prohibit mistreatment, abuse and neglect. W153: All allegations of abuse, neglect, mistreatment and injuries of unknown origin are reported immediately to the administrator. W 154: Allegations are thoroughly investigated. 8

9 11 Focus Tags Based on Look-Behind (Continued) W 156: Results of investigations are reported to the administrator, and State officials within 5 working days. W 262: Specially constituted committee reviews, monitors, approves programs to manage inappropriate behavior. W 263: Written informed consent to implement behavior programs. W 264: The specially constituted committee makes suggestions to facility about their practices and facility addresses the suggestions. W 371: Clients are taught to administer their own medications. 9

10 For More Information To find out more about the Federal Look-Behind Contract visit the following Web Page: To find out more about the History of the ICF Program visit the CMS ICF Home Page at: 10

11 Top Ten Deficiencies Year Span 7/1/03-6/30/04 1. W 249: As soon as the IDT formulated clients IPP it must be implemented. 2. W 242: Include for clients that lack them training in personal skills. 3. W 369: Medications administered without error. 4. W 137: Clients right to retain and use personal possessions. 5. W 154: Thoroughly investigate all alleged violations of abuse, neglect and mistreatment. 11

12 Top Ten Deficiencies Year Span 7/1/03-6/30/04 (Continued) 6. W 130: Ensure privacy during treatment. 7. W 331: Provide clients with nursing services in accordance with their needs. 8. W 125: Clients allowed and encouraged to exercise their rights as citizens of the United States. 9. W 189: Facility must provide each employee with initial and continuing training. 10. W 460:Each client must receive a nourishing well balanced diet. 12

13 Top Ten Deficiencies Quarter Period 4/1/04-6/30/04 1. W 249: As soon as the IDT formulated clients IPP it must be implemented. 2. W 189: Facility must provide each employee with initial and continuing training. 3. W 137: Clients right to retain and use personal possessions 4. W 242: Include for clients who lack them training in personal skills. 5. K052: Health Care Occupancies are provided with a fire alarm system. 13

14 Top Ten Deficiencies Quarter Period 4/1/04-6/30/04 (Continued) 6. W 252: Data must be documented in measurable terms. 7. W 196: Standard for Active Treatment Services. 8. W 122: Condition of Client Protections 9. W251: Programs implemented by all staff who work with the client. 10. W 331:Provide clients with nursing services in accordance with their needs. 14

15 Life Safety Issues Appendix I provides Federal Survey Procedures and Guidelines for all Life Safety surveys, initial and recertification. Appendix I can be found at: Additional questions related to Life Safety surveys can be directed to the Office of Plans and Construction at (850) or your local Field Office Manager 15

16 ICF/DD Rule Update Currently - Being Reviewed Internally. Next Step - Rule Making Public Hearing which will be posted in the Florida Administrative Weekly. 16

17 Brief Overview of Rule Contents Licensure Requirements, Procedures, and Fees Classification of Deficiencies Admission Policies Personnel Standards Training and Habilitation Requirements Administration of Medication by Unlicensed Staff Fire Protection, Physical Plant Codes, and Construction Disaster Preparedness 17

18 Helpful Web Sites The Agency s web site, provides access to the following information by selecting Health Facilities and Providers: ICF/DD Licensure Application ICF/DD Statute Chapter 400 Part XI Code of Federal Regulations (CFR) 42 Part 483 Subpart I Local Field Office Contact Information 18

19 Contact Information Additional Questions Regarding ICF/DD Licensure and Certification Issues can be directed to the Long Term Care Unit at (850)