Agency for Health Care Administration
Intermediate Care Facilities for
the Developmentally Disabled
Licensure and Certification Issues
Presenter:
Kimberly Smoak, MSH
Health Services and Facilities Consultant
Health Quality Assurance
The purpose is to strengthen
Federal oversight and monitoring
and to take aggressive steps
to protect individuals who reside
in ICFs.
The Federal ICF/DD
Look-Behind Process
The Federal ICF/DD
Look-Behind Process
Factors in Choosing Facilities
for Look-Behinds
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
Scheduling of Federal Surveys
Scheduling of Federal Surveys
•
Generally conducted within 30 days of
the State Agency (SA) Survey
Conducting the Survey
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
After the Survey
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.
Florida Statistics
Florida Statistics
Since 2001, when the Federal Look-Behind process
began, Florida has had 23 federal surveys
conducted.
•
2003: Four Look-behinds conducted
W 124: 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.
11 Focus Tags Based on
Look- Behind Results
11 Focus Tags Based on
Look- Behind Results
11 Focus Tags Based on
Look-Behind (Continued)
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.
For More Information
For More Information
To find out more about the Federal Look-Behind
Contract visit the following Web Page:
www.cms.hhs.gov/medicaid/icfmr/icfcont.asp
To find out more about the History of the ICF Program
visit the CMS ICF Home Page at
:
Top Ten Deficiencies
Year Span
7/1/03-6/30/04
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.
Top Ten Deficiencies Year Span
7/1/03-6/30/04
(Continued)
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.
Top Ten Deficiencies
Quarter Period
4/1/04-6/30/04
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.
Top Ten Deficiencies Quarter
Period
4/1/04-6/30/04
(Continued)
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.
