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

Florida Agency for Health Care Administration

Division of Health Quality Assurance Health Care Facility/ Provider

Regulation

Program Topics

• Licensing

• Public Information and Transparency

• Background Screening Clearinghouse

• Regulatory Action Coordination

• Assisted Living Regulation

• Unlicensed Activity

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

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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

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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

• 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

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Licensed Health Care Facilities and 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

Division of Health Quality Assurance

Bureau of Health Facility Regulation

Bureau of Field Operations Bureau of Central Services

 Regulatory Inspections

 Complaint Administration

Complaint Triage Management HQA Call Center Contract Manager

 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

 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

 Physical Plant and Plan Review for Health

Care Facilities

 Hospitals  Nursing Homes

 Ambulatory Surgery Centers  Intermediate Care Facilities for

the Developmentally Disabled Florida Center for Health

Information and Policy Analysis  Florida Health Finder Website  Risk Management (Adverse

Incident Reports)  Health Care Consumer

Information

 Electronic Health Records

 Certificate of Need

 Medicaid Managed Care

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

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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

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

Facility and Provider Locator

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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

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Comparative Information

for Nursing Homes

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 – www.MyFloridaRx.com

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!!!!

Visits to FloridaHealthFinder.gov,

2008 – 2014

*

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• 2014 Projection – 3,100,000 visits

Year Number of Visits 2008 825,764 2009 1,351,713 2010 1,664,872 2011 1,820,047 2012 1,980,022 2013 2,578,443 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000 1,600,000 1,800,000 2,000,000 2,200,000 2,400,000 2,600,000 2008 2009 2010 2011 2012 2013

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

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

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

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 email notifications of employment status changes for all employees.

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 email notifications

– View status at each stage of the screening process, including Fingerprints Submitted, Fingerprints Received from FDLE,

Fingerprints Rejected, Fingerprints Rejected 2nd – NCO requested

– Employer email 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

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

Clearinghouse Statistics

As of July 31, 2014 the Clearinghouse has provided a cost savings to Agency providers and DOH licensees of $1,265,990.00.

Regulatory Collaboration

• Electronic access to Abuse Reports

• Long Term Care Ombudsman reports

• Attorney General involvement in Medicaid

cases

• Law enforcement interest in unlicensed

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Regulatory Complaints

• Consumers are better informed

– New sources of data

– Internet

– Publicly available data bases maintained by state and federal agencies pursuant to legislative

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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 Process

• Complaint Intake

• Call Center 1-888-419-3456, Option #1

• Online complaint http://ahca.myflorida.com/contact/index.shtml

• Written submissions – letter, email

• Mail 2727 Mahan Drive Mail Stop #49, Tallahassee, FL 32308

• 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

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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

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

What is an Assisted Living Facility?

429.02(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.

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 429.02 (16)

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.

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. 429.41(1)(k)].

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,

Admission Criteria

• Not require 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.

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

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.

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.

Classification of Deficiencies

Florida Statute 408.813 Florida Statute 429.19

• 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-$5000

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

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.

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

Specialty Licenses

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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

Specialty Licenses

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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.

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

Unlicensed Activity

• Awareness - Educate Partners

• Create Partnerships – Joint Initiatives

• Target Resources and Materials

• Raise Visibility

Unlicensed Activity

Under 429.08: 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. 775.082, s. 775.083, or s. 775.084. 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. 775.082, s. 775.083, or s. 775.084. Each day of continued operation is a separate offense.

Unlicensed Activity Investigations

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)

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

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.

Unlicensed Activity Investigations

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.

Unlicensed Activity Investigations

EXCEPTION: 429.04 (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.

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

Unlicensed Activity

• Verify if a provider is licensed as an Assisted

Living Facility or Adult Family Care Home

• www.floridahealthfinder.gov

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.

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.

Facility Actions

• Actions Affecting Operation

– License Revocation – Medicaid Termination – Payment Disruption – Emergency Actions • Process Steps • Partner Collaboration

• Managed Care Involvement

Contacting AHCA

www.ahca.myflorida.com

• Local HQA Field Offices

• Licensing Units

• Medicaid Contacts