According to Webster’s Dictionary, to work jointly with others or together especially in an intellectual endeavor is to collaborate. Recently, Florida Health Care Association had the opportunity to collaborate with the Centers for Medicare and Medicaid Services (CMS) Region IV Office and Agency for Health Care Administration (AHCA).
CMS Region IV Office representatives stated their four priorities which are to 1) improve CMS customer experience, 2) support state flexibility and local leadership, 3) support innovative approaches and 4) empower patients and clinicians. Linda Smith, CMS Associate Regional Administrator, and Kim Smoak, AHCA Bureau Chief of Field Operations, opened the meeting by communicating its purpose -for the three groups to collaborate to improve quality of care for the resident. It was stated that we all share the same goal of improving quality of care and outcomes.
The first topic focused on how the communication and decision-making authority process between the regional office and the survey agency works. The discussion was for FHCA to better understand the process that takes place during a survey. CMS advised that the decision making is evidence based from the documentation the survey team submits. It is important to understand everyone’s level of accountability. CMS is required to ensure residents are safe. The survey agency has the first level of decision making. When the surveyor team suspects an Immediate Jeopardy (IJ), they notify their Area Office which notifies the State Director and the Regional Office. Once the surveyor completes the 2567 with the evidence of the investigation, the survey will go through a Quality Assurance (QA) process, which may result in a change in the outcome. CMS has the final decision on enforcement, and it is based on State Agency input and the evidence provided. There are times the Region Office and State Agency disagree; it is then the CMS Region IV Associate Consortium Administrator reviews to make the decision.
The next topic discussed focused on the Informal Dispute Resolution, the Independent Informal Dispute Resolution (IIDR) processes and the roles of the State Agency and CMS Region IV office. CMS has the expectation that while the surveyors are at the facility, the facility can share information to aid in the investigation. Next, after the surveyors have exited, the facility can meet with the Area Office Supervisor with more information if needed. Once the 2567 goes through the QA process, the provider can file for Informal Dispute Resolution (IDR) in the 10-day timeframe. IDR is not to dispute the way the survey was completed, but it is a face-to-face time to dispute a citation. Personality differences, survey technique, etc. are to be reported to the Area Office. The State has 60 days to complete IDR once they have received everything. If attorneys are involved and they reschedule for their schedule, the clock stops for the state. If the IDR panel modifies the finding, the enforcement findings are rescinded or changed. The State Agency is required to contact everyone involved with the deficiency. They contact the facility, the resident and/or family who were affected by the deficiency. The facility will not lose the Civil Money Penalty (CMP) discount if they choose IIDR. The facility has 60 calendar days to pay the CMP to receive the 35% discount.
Many providers proceed with IDR to have the deficiency deleted. The results of the IDR could be no change in the deficiency, change in tag number, change in the examples of record or the scope and severity can increase or decrease. There are 2, 706 skilled nursing facilities in Region IV. In 2018, there were 158 requests for IDR and 18 requests for IIDR. The provider or their representative will not have an opportunity to speak at IIDR as the panel reviews the written documentation only. If the facility has an attorney involved, CMS has protocols for responses, and every response is reviewed by CMS attorney.
The third topic addressed the process for obtaining authoritative clarifications when ambiguities in the regulations exist. The CMS Central Office develops and approves policy, and the policy is written based on professional standards at the time the regulation was written. CMS Central Office is responsible for giving guidance when requested. Policy is not changed quickly as there are many legal layers and approvals needed.
To conclude the meeting, attendees were given information to take back to their groups. FHCA was reminded that AHCA must inspect 50% of 10% of the facilities for staffing. They will be focusing on the facilities with lower staff on weekends and days without RN coverage. The facility list was made using staffing data from the Payroll Based Journal (PBJ).
Another example CMS shared was issues on resurvey for IJ on abuse. Facilities are including staff education on identifying abuse as part of the Plan of Correction. The facilities use the online education systems for training. When the surveyors talk to staff about the education, they do not have the knowledge from the training and can’t pass training post-tests. In one instance, staff admitted to playing on the phone and not watching the online training.
Contract transportation was another area of IJs. CMS Region IV Office representatives stated it is the responsibility of the facility to ensure the transport vehicle has the proper straps, lifts, etc. for safe transporting before allowing the resident to leave the facility with the contracted transportation. This is an in-depth topic, so the groups agreed there will need to be additional meetings on this topic.
CPR is another area in which facilities in this region are receiving IJs. CMS’ expectation is that the resident’s wishes are to be honored at all times. The facility must have a system to know the resident’s wishes, and staff should be educated about the process. It was suggested that facilities have code blue drills so staff can practice prior to an actual event.
The meeting closed with CMS complimenting FHCA about our partnership with both the federal and state survey agencies on emergency preparedness. This collaboration has been a proven success.