CDC - Influenza Outbreak Management in Long-Term Care Facilities

Thursday January 5, 2012

Influenza can spread quickly and have serious consequences in long-term care facilities, putting residents - especially those with certain medical conditions at greater risk of developing complications like pneumonia and bronchitis. The flu also can make chronic health problems worse and may result in hospitalization and sometimes even death.

The January 6, 2012 Morbidity and Mortality Weekly Report includes a report that highlights the importance of having and following an influenza outbreak management strategy.

CDC has posted consolidated influenza outbreak management guidance for long-term care facilities at: www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm

Federal Requirements for the IDR Process

Wednesday January 4, 2012

Federal Requirements for the Independent Informal Dispute Resolution Process

New regulations have been added at 42 CFR, Sections 488.331 and 488.431 as required under section 6111 of the Patient Protection and Affordable Care Act of 2010 enacted on March 23, 2010. This memorandum provides interim advanced guidance regarding the Federal requirements for the Independent IDR Process for nursing homes.

The Centers for Medicare & Medicaid Services (CMS) is in the process of updating the SOM to reflect the new regulations found at 42 CFR Sections 488.331 and 488.431. An advance copy of the interim guidance is attached to the memorandum.

IDR S&C Letter Dec 2011

Medicare S&C Budget FY 2012

Wednesday January 4, 2012

CMS Issues New Guidance for 2012 Medicare S&C Budget

The Centers for Medicare and Medicaid services (CMS) issued a new S&C memorandum on December 9, 2011 related to the Survey and Certification Budget for Physical Year 2012. The memorandum states that CMS is exploring methods to increase the focus on certain high priority areas. To make possible such increased focus and to accommodate the budget constraints, they are examining ways to reduce surveyor time in areas of lower risk. Particular areas in which they seek to increase the focus include:

• Poorly Performing Nursing Homes
• Inappropriate Anti-Psychotic Use
• Avoidable Falls

  The effective date of this material is January 1, 2012.  

For more details see attached memorandum.

FY 2012 Medicare S&C Budget

Smoking Safety in Long Term Care

Wednesday January 4, 2012

Smoking Safety in Long Term Care

The Centers for Medicare and Medicaid Services (CMS) issued a Survey & Certification (S&C) Memorandum November 10, 2011 reminding both surveyors and facilities of the importance of smoking safety for residents who smoke. The S&C memo reviews some of the information contained in the Surveyor Guidance for F323 - Accidents & Supervision.

Smoking Safety in Long Term Care

Dining Practice Standards 2011

Wednesday January 4, 2012

Pioneer Network Announces New Dining Practices Standards 

The Pioneer Network announced that its Food and Dining Clinical Standards Task Force: A Rothschild Regulatory Task Force has finalized new Dining Practice Standards agreed to by twelve national clinical standard-setting associations. These nationally agreed upon new food and dining standards of practice support individualized care and self-directed living versus traditional diagnosis-focused treatment for people living in nursing home. The New Dining Practice Standards document reflects evidence-based research available to-date as well as current thinking.

The Pioneer Network stated that the importance of these new agreed upon clinical standards cannot be overstated as food and dining are an integral part of individualized care and self-directed living for people living in nursing homes.

Pioneer Network plans to submit the new Dining Practice Standards to CMS, FDA, CDC and the long-term care community at large.  It is anticipated that CMS will refer to these new agreed-upon standards of practice within long term care interpretive guidance where they fit as CMS usually refers to the current standards of practice set by the clinicians who work within the long term care field. It is the goal of the Task Force that surveyors, clinicians and interdisciplinary team members will put these new standards into practice in order to continue their efforts to improve quality of life for those living in nursing homes across the country.

New Dining Practice Standards 8-26-11

OSHA Press Release 2011

Wednesday January 4, 2012

OSHA to Focus on Nursing Home

The Occupational Safety and Health Administration will soon launch the National Emphasis Program on Nursing Homes and Residential Care Facilities. This is in response to what OSHA sees as higher than average incidents of occupational injuries and illnesses among health care support workers. Through this initiative, they will increase inspections of these facilities, focusing on back injuries from resident handling or lifting patients; exposure to bloodborne pathogens and other infectious diseases; workplace violence; and slips, trips and falls.

See OSHA Press Release 2011 for more details.  

OSHA Publishes New and Updated Materials on Worker Safety and Health

The Occupational Safety and Health Administration (OSHA) recently published new and updated educational brochures on a number of topics including workers' rights, employers' rights following an OSHA inspection, as well as how to protect workers from hazards in the construction, general and maritime industries. OSHA's Worker' Rights booklet describes the rights to which workers are legally entitled under the Occupational Safety and Health Act. The booklet, Employer Rights and Responsibilities Following an OSHA Inspection, reviews what happens after an inspection and is provided to employers during an OSHA inspection. The agency also recently published an updated Construction Industry Digest, and a new Small Entity Compliance Guide for Respiratory Protection Standard, Laboratory Safety Guidance, a series of new QuickCards and new publications to help protect construction, general industry and shipyard workers. Please call 1-800-321-OSHA or (202) 693-1999 to order copies or visit OSHA's Publications page: http://www.osha.gov/pls/publications/publication.AthruZ?pType=AthruZ)  to order online.

Outbreak of Contagious Disease or Condition Among Assisted Living Residents

Monday February 27, 2012

Once an outbreak has been identified, it is important the facility take the appropriate steps to contain it. State, local and county health departments offer guidance and regulations regarding responding to and reporting outbreaks.  This information is often received in advance of an outbreak and included in the infection prevention and control program. Plans for containing outbreaks usually include efforts to prevent further transmission of the infection while considering the need of all residents and staff.

We suggest that you review the Regulations in Assisted Living and Specialty Care Assisted Livings to ensure Regulatory Compliance. This information can be found in: Alabama Assisted Living Rules and Regulations 420-5-4-.05 Records and Reports andAlabama Specialty Care Assisted Living Rules and Regulations 420-5-20-.05 Records and Reports.

It is important that all infection prevention and control practice reflect current Centers for Disease Control guidelines.

Each facility should refer to their specificState:

• Rules and Regulations; and
• State and local health departments for reporting guidelines and recommendations.

Infection Control and the Norovirus

Monday February 27, 2012

Due to the recent reported cases of the Norovirus in nursing homes and assisted living facilities it is important that we remember what the facility's role and responsibility is regarding infection control.

Under the guidance for Surveyors in the State Operations Manual, F-441Infection Control, states; Recognizing and Containing Outbreaks An outbreak is typically one or more of the following:

• One case of an infection that is highly communicable;
• Trends that are 10% higher than the historical rate of infection for the facility that may reflect an outbreak or seasonal variation and therefore warrant further investigation; or
• Occurrence of three or more cases of the same infection over a specified length of time on the same unit or other defined areas. 

Once an outbreak has been identified, it is important the facility take the appropriate steps to contain it.  State health departments offer guidance and regulations regarding responding to and reporting outbreaks.  This information is often received in advance of an outbreak and included in the infection prevention and control program. Plans for containing outbreaks usually include efforts to prevent further transmission of the infection while considering the need of all residents and staff.

It is important that all infection prevention and control practice reflect current Centers for Disease Controlguidelines.

Component of an infection Prevention and Control Program

• Policies and procedures
• Infection Preventionist
• Surveillance( process and outcome)
•  Documentation
• Monitoring
• Data Analysis
• Communicable Disease Reporting
• Education
• Antibiotic Review

Facilities should review the complete guidance under CFR §483.65 Infection Control F441 for more details.

HHS Announces Intent to Delay ICD-10 Compliance Date

Tuesday February 21, 2012

As part of President Obama's commitment to reducing regulatory burden, Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10^th Edition diagnosis and procedure codes (ICD-10). 

The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 - a delay of two years from the compliance date initially specified in the 2008 proposed rule.  HHS will announce a new compliance date moving forward.

"ICD-10 codes are important to many positive improvements in our health care system," said HHS Secretary Kathleen Sebelius.  "We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead.  We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system."

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10.  Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

All HHS press releases, fact sheets and other press materials are available at: http://www.hhs.gov/news.

Norovirus Update

Tuesday February 21, 2012

Healthcare facilities, including nursing homes and hospitals, are the most commonly reported settings for norovirus outbreaks in the United States. The virus can be introduced into healthcare facilities by infected patients/residents--who may or may not be showing symptoms--or by staff, visitors, or contaminated food products. Outbreaks in these settings can be quite long-sometimes lasting months-and illness can be more severe, occasionally even fatal, in hospitalized or nursing home patients than for otherwise healthy persons.

Noroviruses are responsible for about half of all reported outbreaks of gastroenteritis (vomiting, diarrhea, and stomach cramping caused by inflammation of the stomach and intestines). While the vast majority of norovirus illnesses are not part of a recognized cluster, outbreaks provide important information on how the virus is spread and, therefore, how best to prevent infection.  Norovirus outbreaks occur throughout the year, but over 80% of them occur during November-April. In addition, norovirus outbreaks tend to increase periodically when new strains of the virus appear. The virus can be spread through food, water, by touching things that have the virus on them, as well as directly from person to person. There is no long-lasting immunity to norovirus; thus, outbreaks can affect people of all ages and in a variety of settings

Due to the recently reported outbreaks of the norovirus in Long Term Care and Assisted Living facilities we have attached several CDC norovirus related documents.

For more information we encourage you to visit the CDC web site at: http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm

Norovirus-Guideline for Healthcare Settings-2011

Norovirus Worksheet

Norovirus Poster

Norovirus Comm Framework

Norovirus Case Fact Sheet

NoroVirus-Management of Outbreaks in Healthcare Settings

Centers for Medicare and Medicaid Services is Considering Extending its Timeline for ICD-10 Code Conversion Compliance

Wednesday February 15, 2012

Healthcare providers could get some regulatory deadline relief soon. The acting head of the Centers for Medicare and Medicaid Services said today the agency is considering extending its timeline for ICD-10 code conversion compliance.

Under current ICD-10 rules, healthcare providers, payers, and others have until Oct. 1, 2013 to switch over their claims, billing, and other systems from current ICD-9 to ICD-10 codes for medical diagnosis and inpatient procedures. The transition from ICD-9 to ICD-10 involves expanding medical diagnosis codes from the current 14,000 to more than 67,000, and procedure codes from 13,000 to 85,000.

Marilyn Tavenner, the acting administrator of the Centers for Medicare and Medicaid Services, told a conference of the American Medical Association (AMA) that her agency could delay adoption of the ICD-10 system. Current law calls for physicians to adopt the new codes next year.

"I'm committing today to work with you to re-examine the pace at which we implement ICD-10," she said to loud applause. "I want to work together to ensure that we implement ICD-10 in a way that [meets its] goals while recognizing your concerns."

Critics - including the AMA - say switching to ICD-10 coding will require doctors' offices to deal with some 68,000 codes, more than five times the current 13,000. The change, according to the AMA, would cost medical practices anywhere between $83,290 and more than $2.7 million, depending on size.

Speaking to reporters after her prepared remarks, Tavenner said her office would formally announce its intention to craft new regulations "within the next few days."

LTC Provider University will provide updates when they become available.

CMS Allows Physician Assistants to Perform SNF Level of Care Certification and Recertifications

Monday February 13, 2012

On January 13, 2012 CMS published a pair of transmittals that revise Chapter 8, section 40.1 of the Medicare Benefit Policy Manual to add physician assistants to the list of practitioners that can perform the required initial certification and periodic recertifications of the need for skilled nursing facility (SNF) level of care. 

On January 13, 2012 CMS   issued Transmittal 153, entitled -"Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and Recertifications".  The transmittal provides guidance on the ability of physician assistants to perform level of care certifications and recertifications in skilled nursing facilities. The guidance implements Section 3108 of the Affordable Care Act.  According the guidance, a physician assistant may now perform the certification or recertification if the physician assistant collaborates with the physician but does not have a direct or indirect employment relationship with the facility.  

Please review the following two attachments for details.

Physician Assistants January 13, 2012

Physician Assistants Flyer

CMS Updates Information Related To Reporting Reasonable Suspicion of a Crime

Monday February 13, 2012

The Centers for Medicare and Medicaid Services (CMS) has recently issued an updated S&C memo on reporting the reasonable suspicion of a crime.

This memorandum informs SAs of the new section 1150B of the Act, which was established by section 6703(b)(3) of the Affordable Care Act and is entitled "Reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities." In order to promote timely application of the protections offered by section 1150B of the Act for LTC facility residents, CMS is explaining now the current obligations of LTC facilities to comply with the law as it is plainly written, without any delay that might be occasioned by waiting for any administrative rule-making process that might further clarify application of the law.

The updates appear in the Definitions and Questions and Answers sections.

In the definitions, the terms "agent" and "contractor" are further defined in Appendix One. These definitions will assist providers in determining who is included in "covered individuals."  

In the Q&A section of the memo, additional clarity is provided regarding the role of the facility in reporting the suspicion of a crime. It should be noted that this memo specifically states that a facility may report of a reasonable suspicion of a crime directly to the state survey agency and law enforcement on behalf of covered individuals. Additionally, the Q&A section provides clarity about the impact of this requirement on ICFs/MR.  

Please see the attached S&C letter for more detailed information.

Reporting Suspicion of Crime 20Jan2012 update

How to Protect Your Facility by Having Third Party Contracts in Place

Friday March 16, 2012

According to F500, if the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement, agreement or contract.  The arrangement, agreement, etc. pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility and the timeliness of the services. 

Therefore the facility is required to have contracts with all third party vendors that provide contract services.  Contracts should include at a minimum:

•  Clarification of services/scope of work
• Timeliness of the services
• Payment arrangements of the services/compensation
• Clarification of reporting/documentation requirements, if applicable
• Staff training requirements, screening, licensure, etc., if applicable
• Contract terms
• Period of agreement
• Termination of agreement

From the risk management perspective, the following terms should be included in the contract: 

• Independent Contractor provision - this agreement clarifies that the contractor is not a facility employee and therefore not subject to the facility's worker's compensation benefits or professional liability insurance coverage. 
• Hold Harmless/Indemnification provision - this agreement clarifies that one or both parties agree to not hold the other responsible for damages.  This agreement indemnifies one or both parties by agreeing to not hold the other responsible for any legal liability or looses as a result of a specified incident or action. 
• Insurance coverage by both parties - this clause states that each entity will carry their own general/professional liability insurance. This provision without a hold harmless/indemnification clause is only helpful if both the facility and the 3^rd party contractor are co-defendants. In other words, if the 3^rd party contractor is not a party to a claim against the facility, the 3^rd party contractor's liability insurance will not hold harmless or indemnify the facility.

In the event an incident/event occurs in which a vendor employee is involved and a claim arises, the outcome may depend upon the terms of the contract. 

The facility may want to consult with Corporate Counsel on the appropriate wording for contracts.

Gaps Continue to Exist in Nursing Home Emergency Preparedness and Response During Disasters

Wednesday April 25, 2012

Federal regulations require that Medicare and Medicaid certified nursing homes have written emergency plans and provide employees with emergency preparedness training. In a 2006 report about nursing homes that experienced hurricanes, the Office of Inspector General (OIG) found that emergency plans lacked many provisions recommended by experts. In response, CMS issued guidance checklists for emergency planning of health care facilities, long-term care (LTC) ombudsman programs, and State survey agencies (SA). The OIG conducted this study released April 2012 to assess emergency preparedness and response of nursing homes that experienced more recent disasters.

For this study, the OIG analyzed national survey data to determine compliance with Federal regulations. They also conducted site visits to 24 selected nursing homes that experienced floods, hurricanes, and wildfires in 2007-2010. They interviewed nursing home administrators and staff, local emergency managers, and representatives from State LTC ombudsman programs and SAs. They also compared the emergency plans of each selected nursing home to the CMS checklist for health care facilities.

The OIG found that most nursing homes nationwide met Federal requirements for written emergency plans and preparedness training. However, they identified many of the same gaps in nursing home preparedness and response that were found in the 2006 report. Emergency plans lacked relevant information including only about half of the tasks on the CMS checklist. Nursing homes faced challenges with unreliable transportation contracts, lack of collaboration with local emergency management, and residents who developed health problems. LTC ombudsmen were often unable to support nursing home residents during disasters; most had no contact with residents until after the disasters. SAs reported making some efforts to assist nursing homes during disasters, mostly related to nursing home compliance issues and ad hoc needs.

The OIG made three recommendations to CMS and one recommendation to Administration on Aging (AoA). CMS agreed with their recommendations to revise Federal regulations to include specific requirements for emergency plans and training, update the State Operations Manual to provide detailed guidance for SAs on nursing home compliance with emergency plans and training, and promote use of the checklists. AoA also agreed with their recommendation to develop model policies and procedures for LTC ombudsmen to protect residents during and after disasters.

The top 10 disaster prone states, as ranked by historical statistics on disaster declarations are Texas, California, Oklahoma, New York, Florida, Louisiana, Alabama, Kentucky, Arkansas and Missouri.

Sources: Department HHS Office of Inspector General; CMS; Long Term Care Ombudsman

The National Long Term Care Ombudsman Resource Center link: http://www.ltcombudsman.org/issues/emergency-preparedness

Office of Inspector General April 2012 Report:

Nursing Home Emergency Preparedness and Response Report 2012

OIG Memo to CMS April 13, 2012:

OIG Emergency Memo April 13-2012

CMS Emergency Preparedness Checklist:

CMS Emergency Preparedness for Every Emergency checklist revised Sept 2009

Pain vs. Behaviors

Monday April 23, 2012

It has been recently noted after review of numerous medical records a common trend has been identified.  Residents with impaired cognition are exhibiting behaviors i.e. screaming out, resisting care, removing clothes etc.  The residents are being assessed for behavioral interventions and some resident are being placed on psychoactive medications while pain is the cause of the resident's behaviors. Residents were not consistently assessed for pain during the behavioral assessment phase to rule out pain.  Facilities may want to review current systems and processes to ensure there is an evaluation of the resident for pain with the onset and/or increase in behaviors.   This will also help in the prevention of unnecessary drugs.  See article below.

Management of Pain In Persons With Dementia  

Pain is a common medical condition in older persons; especially residents in long term care (LTC) settings. Pain is defined as a sensory and emotional experience associated with actual or potential tissue damage. Chronic persistent pain occurs in 24% of LTC residents while only 29% are free of all pain. Most, i.e., 74%, demented nursing home residents have some pain and the majorities, i.e., 70%, are untreated or under-treated.

Pain can have multiple origins; however, discomfort produced by musculoskeletal disease is the most common problem in the older person, e.g., arthritis 42%, bone fracture 12%. Untreated or under-treated pain can produce significant suffering as well as agitation and behavioral problems in persons with dementia. Regular administration of acetaminophen can reduce agitation in more than one-half of agitated, demented patients with pain.  

Assessment and management of pain is an important responsibility of any clinical management team. Dementia patients are less likely to receive analgesics despite the fact that they experience suffering equal to cognitively intact individuals.  

Source: Richard E. Powers, MD (2008) - Bureau of Geriatric Psychiatryhttp://www.alzbrain.org/

Employee Rights Notice Posting

Monday April 23, 2012

April 30, 2012 is the new deadline for nearly all nursing facilities and assisted living communities to display posters informing employees of their rights under the National Labor Relations Act (NLRA), according to the National Labor Relations Board.  The notice should be posted in a conspicuous place, where other notifications of workplace rights and employer rules and policies are posted. Employers also should publish a link to the notice on an internal or external websites if other personnel policies or workplace notices are posted there.                         

You may download and print the notice using the links below. You may also call 202-273-0064 and copies will be mailed to you free of charge.

IMPORTANT INFORMATION ABOUT POSTERS

The poster is required to be 11 x 17 inches, in color or black-and-white. When printing to full size, be sure to set your printer output to 11 x 17. Or you may print the two 8.5 x 11 pages and tape them together.

English Posters

English Employee Rights Poster 11 x 17  English Employee Rights Poster 8-5 x 11

Spanish Posters

Spanish Employee Rights Poster 11 x 17

Spanish Employee Rights Poster 8-5 x 11

National Plan to Address Alzheimer’s Disease

Wednesday April 11, 2012

On January 4, 2011, President Barack Obama signed into law the National Alzheimer's Project Act (NAPA), requiring the Secretary of the U.S. Department of Health and Human Services (HHS) to establish the National Alzheimer's Project. The law also establishes the Advisory Council on Alzheimer's Research, Care, and Services and requires the Secretary of HHS, in collaboration with the Advisory Council, to create and maintain a national plan to overcome Alzheimer's disease (AD).

Building on the preliminary work on this plan, on February 7, 2012, the Obama Administration announced a historic $156 million investment to tackle Alzheimer's disease.

The draft of the National Plan is being submitted to the Advisory Council for consideration and input. It was also be open for public comment through March 30, 2012.

To read the draft in its entirety click on the following link:

Draft National Alzheimer's Plan 2012

NCCAP National Examination

Monday April 9, 2012

The National Certification Council of Activity Professionals has implemented an examination that all NEW applicants must complete in order to apply for national certification at the ADC or ACC level(s) effective January 1, 2012. Please note that is will not affect those individuals already certified at any level with NCCAP prior to December 31, 2011.

The test consists of questions from the nine topic areas and the 163 competencies defined in the MEPAP curriculum. Completion of the Modular Education Program for Activity Professionals, 2^nd Edition will prepare the applicant for the exam. There will be 50 questions on the test and applicants will have one (1) hour to complete the test. Applicants must make a 70% to pass the exam. Comira and ACT testing centers will administer the examination and they are located throughout the United States and Canada.

For additional information regarding the new testing policy and procedure please contact the NCCAP office or visit their web site at www.nccap.org

Source: National Certification Council for Activity Professionals

Disparities/Minority Health: Lower flu vaccination rates for black nursing home residents a cause for concern

Monday April 9, 2012

The average flu vaccination rate among nursing home residents nationwide was 72 percent during the 2005-2006 flu season. This was well below the Healthy People 2010 goal of 90 percent. A new study found that black nursing home residents have lower flu vaccination rates than their white counterparts. It found that over three consecutive flu seasons (2006-07, 2007-08, and 2008-09), the odds of being vaccinated were 14-16 percent lower for blacks than for whites within the same facility.This difference persisted even after excluding residents who were either offered but declined vaccination, or were vaccinated outside the facility.

The Brown University researchers also found that nursing homes with high proportions of black residents had lower vaccination rates for both blacks and whites than did facilities with lower proportions of black residents. These facilities generally have a high proportion of Medicaid residents. Therefore, they have less revenue and fewer opportunities to cross-subsidize care with income from more profitable Medicare and private-pay patients.

The researchers suggest that low revenue, insufficient staffing, and poor-quality performance may all contribute to the lower vaccination rates in these facilities. They also point out that blacks are consistently more likely than whites to refuse flu vaccinations when offered. To completely eliminate racial differences in flu vaccination rates, educational programs that focus on elderly blacks and their families may be necessary, suggest the researchers. Their study was supported in part by the Agency for Healthcare Research and Quality (HS16094).

Source: Agency for Healthcare Research and Quality  http://www.ahrq.gov/research/apr12/0412RA23.htm

End of Life Care During the Last Days and Hours

Tuesday April 3, 2012

The Registered Nurses Association of Ontario (RNAO) and the guideline development panel have compiled a list of implementation strategies to assist health-care organizations or health care providers that are interested in implementing this guideline.  

According to the RNAO, this nursing best practice guideline is a comprehensive document, which provides resources necessary for the support of evidence-based nursing practice. The document must be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. This guideline should not be applied in a "cookbook" fashion, but rather as a tool to enhance decision-making in the provision of individualized care. In addition, the guideline provides an overview of appropriate structures and supports necessary for the provision of best possible care.  

The purpose of this best practice guideline is to provide evidence-based recommendations for Registered Nurses and Registered Practical Nurses on best nursing practices for end-of-life care during the last days and hours of life. The guideline does not replace consultation with palliative care specialists, who can support nurses to provide quality end-of-life care. The guideline is intended to be a resource to nurses who may not be experts in this practice area. It is acknowledged that individual competencies vary between nurses and across categories of nursing professionals. The inclusion of recommendations on clinical, education, organization and policy topics makes this guideline applicable to nurses in all domains and settings of practice  

Source: Agency for Healthcare Research and Quality

End of Life Care During the Last Days and Hours

Antipsychotic Drugs Might Raise Heart Attack Risk: Study

Monday April 2, 2012

WEDNESDAY, March 28 (HealthDay News) -- Antipsychotic drugs can raise the risk of heart attack in older patients with dementia, a new study suggests.

It's common to prescribe antipsychotics to older patients with dementia to control symptoms such as agitation, hallucinations and aggression. Previous studies have found that this use of the drugs may be linked to an increased risk of stroke and death from all causes.

But until now, the risk of heart attack associated with the use of antipsychotic drugs in older people with dementia had been "poorly examined," wrote study author Dr. Antoine Pariente, of Universite Bordeaux Segalen in France, and colleagues.

They looked at nearly 11,000 patients, aged 66 and older, in Quebec who were being treated with cholinesterase inhibitors for dementia and were also prescribed antipsychotics.

Within a year of starting treatment with the antipsychotics, 1.3 percent of the patients had a heart attack. Compared to those not taking antipsychotics, the risk of heart attack among those taking them was 2.19 times higher for the first 30 days, 1.62 times higher for the first 60 days, 1.36 times higher for the first 90 days, and 1.15 times higher for the first year.

"Our study results indicate that the use of [antipsychotic medications] is associated with a modest increase in the risk of [heart attack] among community-dwelling older patients with treated dementia," the researchers wrote. "The increased risk seems to be highest at the beginning of treatment and seems to decrease thereafter, with the first month of treatment accounting for the highest period of risk."

The study, which found an association between antipsychotic use and heart attack but did not prove cause-and-effect, appeared online March 26 in the Archives of Internal Medicine.

"Because [antipsychotic] use is frequent in patients with dementia ... the increased risk of [heart attack] may have a major public health effect, which highlights the need for communicating such risk and for close monitoring of patients during the first weeks of treatment," the authors concluded in a journal news release.

Further research is required to learn more about why the use of antipsychotic drugs in dementia patients may increase the risk of heart attack, Dr. Sudeep Gill and Dr. Dallas Seitz, of Queen's University in Kingston, Ontario, Canada, wrote in an accompanying editorial.

"Meanwhile, physicians should limit prescribing of antipsychotic drugs to patients with dementia and instead use other techniques when available, such as environmental and behavioral strategies, to keep these patients safe and engaged," they suggested.

While the study found an association between antipsychotic drugs and heart attack risk, it did not prove a cause-and-effect relationship.

SOURCE: JAMA/Archives journals, news release, March 26, 2012

OSHA - Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents

Wednesday May 30, 2012

The purpose of Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents is to provide general policies and procedures that apply when workplace violence is identified as a hazard while conducting an inspection under a national, regional or local emphasis program and when responding to incidents of workplace violence, especially when conducting inspections at worksites in industries with a high incidence of workplace violence.  

Workplace violence is recognized as an occupational hazard in some industries and environments which, like other safety issues, can be avoided or minimized if employers take appropriate precautions. At the same time, it continues to negatively impact the American workforce. Workplace violence has remained among the top four causes of death at work for over fifteen years, and it impacts thousands of workers and their families annually.  

Research has identified factors that may increase the risk of violence at worksites. Such factors include working with the public or volatile, unstable people. Working alone or in isolated areas may also contribute to the potential for violence. Handling money and valuables, providing services and care, and working where alcohol is served may also impact the likelihood of violence. Additionally, time of day and location of work, such as working late at night or in areas with high crime rates, are also risk factors that should be considered when addressing issues of workplace violence.

Click the link below for the complete report:

Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents

The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

Tuesday May 29, 2012

Source: Agency for healthcare Research and Quality (AHRQ)

Identifying Medications that Older Adults Should Avoid or Use with Caution

Friday May 25, 2012

For more than 20 years, the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults has been the leading source of information about the safety of prescribing drugs for older people. To help prevent medication side effects and other drug-related problems in older adults, the American Geriatrics Society (AGS) has updated and expanded this important resource. The expanded AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults identifies medications with risks that may be greater than their benefits for people 65 and older.

This summary is from the full report titled, AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. It is in the March 2012 issue of the Journal of the American Geriatrics Society (JAGS). The report is authored by the American Geriatrics Society    

Click Link Below for Summary: Beers Criteria - Updated 2012

Free Online Training for MDS 3.0 Section M: Skin Condition

Thursday May 10, 2012

Free Online Training for MDS 3.0 Section M: Skin Condition

This FREE video and handouts of the pressure ulcer assessment and coding training session for MDS 3.0 Section M: Skin Condition was delivered in Las Vegas on August 10, 2010.  It was posted online by the Centers for Medicare and Medicaid Services (CMS) on January 20, 2011.  This lecture was part of the CMS sponsored introduction to MDS 3.0.  If you still want access to the information it is posted on YouTube! The link is posted below with the slides/handouts.

You can view the slides/handouts, watch the video, and get free in-depth training on this important topic for resident assessment in long-term care.  The lecture is 1 hour and 42 minutes long and reviews all aspects of prevention, wound identification, staging, and coding, including sample coding challenges and wound quiz. 

You Tube link to video:

http://www.youtube.com/watch?v=7km6NHbVxHs 

Handouts/slides:

MDS 3.0 Training Slides 2 Section M

MDS 3.0 Section M Study Aid

MDS 3.0 Training Slides Section M

DEMENTIA – A PUBLIC HEALTH PRIORITY

Friday June 29, 2012

Dementia Incidences to Triple Says World Health Organization

 The World Health Organization has released data on the current state of dementia care worldwide and the prevalence of the disease, both currently and in the future. Among other findings, researchers predict the number of people with dementia worldwide to triple by 2050.

The World Health Organization compiled the results of a number of studies in a new report about the prevalence, effects, and implications of dementia. According to the report, in 2010 35.6 million people worldwide had dementia, a number expected to nearly double every 20 years. In 2010 the worldwide costs of dementia were estimated to be 604 billion US dollars, a number also expected to grow over the coming years. Despite the high social and financial costs, only eight countries have national programs to address dementia.

The report emphasizes that a variety of services, including caregiver support programs, residential care communities, and palliative care options, are needed to serve those with dementia. High-income countries are generally able to provide more options for citizens, but the report makes it clear that even high-income countries have room for improvement. For example, seven out of eight survey respondents from high-income countries report that their country provides support for residential care, but many of these countries do not provide sufficient care. Poland, for instance, only reported one community specifically designed for individuals with dementia.

Read the full report: Dementia: A Public Health Priority

Revised Guidance for Tag F492

Monday June 18, 2012

Current guidance in Appendix PP of the State Operations Manual for Tag F 492, 42 CFR §483.75(b) and (c) States that this tag should be cited only when the authority having jurisdiction has both made a determination of noncompliance and has taken a final adverse action as a result. There has been confusion as to whether this requirement may be cited when a facility simply does not meet a State regulation. This memorandum clarifies and revises the Centers for Medicare & Medicaid Services (CMS) guidance to Surveyors in Appendix PP of the SOM regarding citations under Tag F492.

June 1, 2012 CMS issued a revision and clarification to the Interpretive Guidance for F492. The effective date of this memo is immediately. These changes will be incorporated into the next revision of Appendix PP of the SOM. Please read the attached document for details.

Revised Guidance for F492

Disaster Planning Information

Tuesday June 5, 2012

All long term care providers and operators have an obligation to prepare for potential disasters. Each facility is unique with regard to the types of residents/clients served, geographical location, types of disasters to plan for and proximity to local assistance. Preparation, education, and practice are the keys to a well-managed event involving a catastrophic occurrence that comes with little or no warning.  

We have recently added numerous documents, forms, and guides to assist health care facilities in this planning process. These forms are located behind the "Risk Management Resource Center" door. We remind all facilities that any workable disaster plan must be tailored to the individual facility. It is advised that a committee be formed to develop and analyze all material for the manual, as well as provide regular reviews and updates.  The following documents posted are:

• Nursing Home Incident Command System (NHICS)
  • Guidebook
  • Incident Management Team
  • Position Crosswalk
  • Quick Guide to Job Responsibilities
  • Incident Briefing & Operational Log
  • Incident Objectives
  • Organization Assignment List
  • Incident Communications Plan
  • Staff Injury Plan
  • Organizational Chart
  • Incident Message Form
  • Facility System Status Report
  • Personnel Time Sheet
  • Volunteer Staff Registration
  • Master Emergency Admit Tracking Form
  • Master Resident Evacuation Tracking Form
  • Procurement Summary Report
  • Resource Accounting Record
  • Facility Resource Directory
  • Master Facility Casualty Fatality Report
  • Resident Evacuation Tracking Form
  • Incident Action Safety Analysis
  • Emergency Water Supply Planning Guide
  • National Criteria for Evacuation Decision - Making in Nursing Homes
  • Caring for Vulnerable Elders During A Disaster - Hurricane Summit

Listed below are links to also assist you in locating additional information that you may require:  

FEMA:

http://www.fema.gov/  

Homeland Security:

http://www.dhs.gov/files/prepresprecovery.shtm  

American Red Cross Preparedness Fast Facts: http://www.redcross.org/portal/site/en/menuitem.86f46a12f382290517a8f210b80f78a0/?vgnextoid=92d51a53f1c37110VgnVCM1000003481a10aRCRD  

Kentucky All Hazards Long Term Care Planning & Resource Manual: http://www.kahsa.com/Kentucky-All-Hazards-Long-Term-Care-Planning-%26-Resource-Manual-p-373.html  

California Association of Health Facilities - Disaster Preparedness Program: http://www.cahfdisasterprep.com/PreparednessTopics.aspx  

Florida Health Care Association - Emergency Preparedness Tools: http://www.fhca.org/facility_operations/emergency_preparedness_tools/ http://www.fhca.org/emerprep/index.php  

National Nurse Emergency Preparedness Initiative:

http://www.nnepi.org/index.htm  

Texas Health Care Association-Disaster Preparedness Tools: http://www.txhca.org/disasterpreparedness.htm

CMS Use of Insulin Pens

Friday June 1, 2012

The Centers for Medicare & Medicaid Services (CMS) has recently received reports of use of insulin pens for more than one patient, with at least one 2011 episode resulting in the need for post-exposure patient notification. These reports indicate that some healthcare personnel do not adhere to safe practices and may be unaware of the risks these unsafe practices pose to patients. Insulin pens are meant for use by a single patient only. Each patient/resident must have his/her own. Sharing of insulin pens is essentially the same as sharing needles or syringes, and must be cited, consistent with the applicable provider/supplier specific survey guidance, in the same manner as re-use of needles or syringes.

The Centers for Disease Control and Prevention (CDC) has also become increasingly aware of reports of improper use of insulin pens, which places individuals at risk of infection with pathogens including hepatitis viruses and human immunodeficiency virus (HIV). This notice serves as a reminder that insulin pens must never be used on more than one person.

Follow the link to visit the CDC page on Injection Safety:

http://www.cdc.gov/injectionsafety/clinical-reminders/insulin-pens.html

CDC Insulin Pen Poster:

Clinical Reminder for Use of Insulin pen

CMS Survey & Certification letter on Insulin pens:

Use of Insulin Pens May 18 2012

The Sorrow of Suicide – National Institute of Health

Wednesday July 11, 2012

Suicide is tragic. It cuts a life short, and it devastates the family, friends and loved ones left behind. Those who survive a suicide attempt might end up with severe disability or other injuries. The children of people who die by suicide are more likely to later die by suicide themselves. With such extreme consequences, why would anyone make the dire decision to choose death over life?

That's a question scientists have been struggling to answer for decades. "When you're in a suicidal state, you're kind of closing down your options. You see it as the only solution. You're not really able to entertain other ideas," says Dr. Jane Pearson, who heads a suicide research consortium at NIH. "What's the science behind that? What's happening in the brain that leads people to think so dysfunctionally?"

 Recognizing those at risk is essential. Suicide is the 10th leading cause of death nationwide, and it's the 3rd leading cause of death among adolescents. Nearly 37,000 Americans died by suicide in 2009, according to the U.S. Centers for Disease Control and Prevention. More than half of those deaths were from firearms.

People of all genders, ages and ethnicities are at risk for suicide. Women are more likely than men to attempt suicide, but men are more likely to die by suicide. That's because men often choose deadlier methods, such as firearms or suffocation.

"The highest risk groups are older men," says Pearson. "In fact, white men who are 85 and older have a rate of suicide that's 4 times the national average."

To read the entire NIH report in this attachment.

QAPI CMS Survey and Certification Letter – June 2012

Monday July 9, 2012

Memorandum Summary

• Quality Assurance and Performance Improvement (QAPI) Activities:  Section 6102(c) of the Affordable Care Act mandates the Centers for Medicare & Medicaid Services (CMS) to establish standards and provide technical assistance to nursing homes on the development of best practices relating to QAPI. The CMS put forth several initiatives to implement these provisions that include:
• Refinement of QAPI Tools and Resources:  Ongoing development of QAPI tools and resources that nursing homes may use to design and implement an effective QAPI program.
• Launch of a QAPI Demonstration:  Demonstration project in 17 nursing homes in 4 States to test tools and resources and provide technical assistance to nursing homes in QAPI implementation.
• Rollout of QAPI materials:  CMS will release materials later this calendar year that will support nursing homes in QAPI implementation.
• Draft of the QAPI Regulation:  CMS is in the process of drafting a new QAPI regulation.
• Launch of the Nursing Home Quality Improvement Questionnaire:  The CMS has launched a nursing home quality improvement questionnaire using an independent contractor. The data collection period is from June 25 through September 28, 2012.

Nursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotics Drugs

Tuesday July 24, 2012

This study used a random sample of records from a previous Office of Inspector General (OIG) study of elderly nursing facility residents with Medicare claims for atypical antipsychotic drugs between January and June 2007. They reviewed the records for evidence of compliance with Federal requirements for resident assessments and documentation of decision-making. They also reviewed the records for evidence of compliance with Federal requirements for care plan development and implementation.

Nearly all records reviewed (99 percent) failed to meet one or more Federal requirements for resident assessments and/or care plans. The resident assessment and care plan process involves four steps. One-third of records reviewed did not contain evidence of compliance with Federal requirements regarding resident assessments, the first step. Further, for 4 percent of records, nursing facility staff did not document consideration of the Resident Assessment Protocol for psychotropic drug use as required, the second step. Ninety-nine percent of records did not contain evidence of compliance with Federal requirements for care plan development, the third step. Finally, 18 percent of records reviewed did not contain evidence to indicate that planned interventions for antipsychotic drug use-the fourth step-actually occurred.

Please read the following attachments for more details and CMS response to the report.

OIG Report Care Plans for Residents Receiving Atypical Anitpsychotic Drugs

Interventions to Reduce Acute Care Transfers

Tuesday August 14, 2012

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change n resident condition.  The INTERACT program is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities.

The INTERACT goal is to improves care and reduce the frequency of potentially avoidable transfers to the acute hospital. Transfers to the hospital can be emotionally and physically difficult for residents, and result in numerous complications of hospitalization, and they are costly.

In the plans for health care reform, Medicare may financially reward facilities with lower hospitalization rates for certain conditions. By improving the identification, evaluation, and communication about changes in resident status, some, but not all acute care transfers can be avoided.

The attached pdf Transitions and Long-Term Care: Reducing Preventable Hospital Readmissions Among Nursing Facility Residents explains what INTERACT is and how to use the quality improvement tool.

Reducing Preventable Hospital Readmissions Among Nursing Facility Residents 

TheINTERACT web site; www.interact2.net is a free web site for facility use in decreasing acute care transfers. The web site contains information about INTERACT, INTERACT II Tools, Educational Resources, and Links to Other Resources.

Important Reminder About Medicare Secondary Payer Laws

Wednesday September 5, 2012

Please read the following reminder regarding the Medicare Secondary Payer Act. Medicare Secondary Payer Act Reminder

2012 CMS Nursing Home Action Plan

Wednesday September 5, 2012

1. Enhance Consumer Engagement.
2. Strengthen Survey Processes, Standards, and Enforcement.
3. Promote Quality Improvement.
4. Create Strategic Approaches through Partnerships.
5. Advancing Quality through Innovation and Demonstration. 

1. Improving the individual experience of care.
2. Improving the health of populations.
3. Reducing the per-capita cost of care of populations.

Partnership to Improve Dementia Care in Nursing Homes

Wednesday September 5, 2012

CMS is using several approaches to successfully implement this initiative. CMS is developing and conducting trainings for nursing home providers, surveyors, and consumers. We are conducting research, raising public awareness, using regulatory oversight, and public reporting to increase transparency.

Risk Management Certification Program - Register NOW!

Friday September 7, 2012

Registration is now open for the 2012 CQRMS Training Program.  If you would like more information about this program please contact Nancy Lee (contact information listed in the brochure).

Seating is limited, early registration is recommended.

Registration brochure: 2012 CQRMS web brochure

Hand Hygiene

Friday September 14, 2012

Hand Hygiene (HH) has always been a concern in long term care facilities and recently, in some states, there has been an increase in the number of citations being written related to HH. A recent article published in the Journal of Applied Gerontology, titled "Hand Hygiene Deficiency Citations in Nursing Homes" addresses this area of concern.

Click on the link below to take you to the article.

http://jag.sagepub.com/content/early/2012/08/01/0733464812449903.abstract

Transitioning to the ICD-10 - Hospitals

Friday September 14, 2012

The healthcare industry faces enormous pressure to transform the delivery system from acute centric care into more cost effective care across the preventative, chronic, acute, and long-term continuum. The marketplace is demanding that providers align, and that change is implemented aggressively. The current industry backdrop is an environment where the cost of drugs, supplies, technologies and staffing are increasing, competition from entrepeneurs who capture opportunities in attractive niches is intensified, and consumer interest in public scorecards on hospital and physician safety, quality, and satisfaction has risen. All the while reimbursement rates from third party payors (Medicare, Medicaid, and Commercial Health Plans) is trending downward.

To continue reading this article, click the link below:

Transition to ICD 10

Antipsychotic Alert

Tuesday September 18, 2012

Please see the two attachments regarding a recent lawsuit involving alleged off-labeled use of an antipsychotic and a press release from the U. S. Department of Justice in which a company maintained specialized sales force to market drug for off label purposes; Targeted elderly dementia patients in nursing homes.  

Alert-CMS Initiative for the Use of Antipsychotics subject of lawsuit
U.S.  Department of Justice Press Release

OIG - Nursing Facilities' Employment of Individuals With Criminal Convictions

Tuesday April 26, 2011

Our analysis of criminal history records maintained by the Federal Bureau of Investigation (FBI) revealed that 92 percent of nursing facilities employed at least one individual with at least one criminal conviction. Overall, 5 percent of nursing facility employees had at least one criminal conviction.

Federal regulation prohibits Medicare and Medicaid nursing facilities from employing individuals found guilty of abusing, neglecting, or mistreating residents by a court of law, or who have had a finding entered into the State nurse aide registry concerning abuse, neglect, or mistreatment of residents or misappropriation of their property. Interpretive guidelines from CMS for this regulation state that "[nursing] facilities must be thorough in their investigations of the past histories of individuals they are considering hiring." Despite this guidance, Federal law does not require that nursing facilities conduct FBI or statewide criminal background checks. Although FBI maintained criminal history records provide a comprehensive source of criminal histories, the records do not contain information on whether the victim of a crime was a nursing facility resident and therefore cannot be used by themselves to determine whether a conviction disqualifies an individual from nursing facility employment.

Most often, criminal convictions were for crimes against property (e.g., burglary, shoplifting, and writing bad checks) and occurred prior to employment. We also found that despite the lack of a Federal requirement for nursing facilities to conduct criminal background checks, most States required, and/or nursing facilities reported conducting, some type of background check.

In light of the National Background Check Program that the Patient Protection and Affordable Care Act created, we recommended that CMS develop background check procedures. In developing those procedures, CMS should (1) clearly define the employee classifications that are direct patient access employees and (2) work with participating States to develop a list of convictions that disqualify an individual from nursing facility employment under the Federal regulation and timeframes in which each conviction bars the individual from employment.

In its written comments on the report, CMS agreed with our recommendation. CMS stated that in its solicitation to States for the National Background Check Program, the definition of "direct patient access employee" is broad and outcome based, which in nursing facilities should include all staff. CMS stated that it will work with the States through the National Background Check Program to assist them in developing lists of convictions that disqualify individuals from employment, as well as defining whether any of those conviction types can be assumed to be mitigated because of the passage of time and which convictions should never be considered mitigated or rehabilitated.

Click here for the full report

OIG- Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents

Wednesday May 4, 2011

Report: OEI-07-08-00150

05-04-2011

For the period January 1 through June 30, 2007, we determined using medical record review that 51 percent of Medicare claims for atypical antipsychotic drugs were erroneous, amounting to $116 million.

A member of Congress requested that OIG evaluate the extent to which elderly nursing home residents receive atypical antipsychotic drugs and the associated cost to Medicare. Specifically, this member expressed concern with atypical antipsychotic drugs prescribed to elderly nursing home residents for off-label conditions (i.e., conditions other than schizophrenia and/or bipolar disorder) and/or in the presence of the condition specified in the Food and Drug Administration's (FDA) boxed warning (i.e., dementia). Medicare requires that drugs be prescribed for "medically accepted indications" for reimbursement. Further, CMS sets standards to ensure that nursing home residents' drug therapy regimens are free from unnecessary drugs.

We also found that 14 percent of the 2.1 million elderly (i.e., age 65 and older) nursing home residents had at least 1 claim for these drugs. We determined using medical record review that 83 percent of Medicare claims for atypical antipsychotic drugs for elderly nursing home residents were associated with off-label conditions and that 88 percent were associated with the condition specified in the FDA boxed warning. We further determined through medical record review that 22 percent of the atypical antipsychotic drugs associated with the claims were not administered in compliance with CMS standards regarding unnecessary drugs in nursing homes, amounting to $63 million. Nursing homes' failure to comply with these standards may affect their participation in Medicare. However, nursing homes' noncompliance with these standards does not cause Medicare payments for these drugs to be erroneous.

To ensure that Medicare correctly pays for atypical antipsychotic drugs and that elderly nursing home residents are free from unnecessary drugs, we recommend that CMS (1) facilitate access to information necessary to ensure accurate coverage and reimbursement determinations, (2) assess whether survey and certification processes offer adequate safeguards against unnecessary antipsychotic drug use in nursing homes, (3) explore alternative methods beyond survey and certification processes to promote compliance with Federal standards regarding unnecessary drug use in nursing homes, and (4) take appropriate action regarding the claims associated with erroneous payments identified in our sample.

In its written comments on the report, CMS shared our concern and that of Congress over whether atypical antipsychotics and other drugs are being appropriately prescribed for elderly nursing home residents. CMS concurred with the second, third, and fourth recommendations; however, CMS did not concur with the first recommendation and expressed several general concerns with the report.

CMS did not concur with the first recommendation, stating that diagnosis information is not a required data element of pharmacy billing transactions nor is it generally included on prescriptions. OIG recognizes that the industry has not developed a standardized way of collecting diagnosis information for prescription drugs. However, without access to diagnosis information, CMS cannot determine the indications for which drugs were used. For this reason, CMS is unable, absent a medical review, to determine whether claims meet payment requirements.

Although CMS concurred with the second recommendation, we further recommend that CMS use its authority through the survey and certification processes to hold nursing homes accountable when unnecessary drug use is detected.

Although CMS concurred with the third recommendation, it did not believe some of the examples of alternative methods to promote compliance provided in the report to be practicable. We suggest that CMS either use its existing authority or seek new statutory authority to prevent payment and hold nursing homes responsible for submitting claims for drugs that are not administered according to CMS's standards regarding unnecessary drug use in nursing homes.

Click Here for Full Report

OIG- Billing Practices in Skilled Nursing Facilities

Thursday June 23, 2011

A summary and suggestions regarding the Office of Inspector General's Report on billing practices in Skilled Nursing Facilities

In December, 2010, the OIG issued a report on Medicare Part A services provided in the SNF setting. This summary addresses the findings along with suggestions. 

In the recent past the OIG has found a number of issues with SNF billing for Part A services. One such report analyzing claims from 2006-2008, found that 26% of claims submitted were not supported by the medical records resulting in over $500 million in potential overpayments. Along with these findings, the Medicare Payment Advisory Commission indicated that SNFs may be improperly billing for therapy in order to obtain additional Medicare payments.

Summary

• SNFs were increasingly billing for higher paying RUGs, even though the beneficiary characteristics remained almost the same.
• For-profit SNFs were more likely to bill higher paying RUGs than nonprofit and government SNFs.
• Some  SNFs had questionable billing in 2008, frequently billing for higher RUGs and having longer length of stays (LOS) than other SNFs.

OIG Conclusions

These findings raised concerns about the potentially inappropriate use of higher paying RUGs, especially the Ultra High category and deduced that the payment system offered incentives to place beneficiaries into these categories when that level of care was not needed. The report acknowledged that a new payment system was being introduced but felt that more needed to questionable billing practices.

Recommendations

If you are not sure if you are up to date with the Medicare guidelines and documentation standards or whether your SNF would pass a RAC Audit or other OIG or CMS review, then consider looking for related regulations, guidelines, MDS analysis on LTC Provider University's website.

Click here for a copy of the Full Report

Reporting Reasonable Suspicion of a Crime in a Long-Term: Section 1150B of the Social Security Act

Friday June 17, 2011

Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility. Reports must be submitted to at least one law enforcement agency of jurisdiction and the state survey agency (in fulfillment of the statutory directive to report to the Secretary).

This memorandum discusses applicability of this provision to the following Medicare and Medicaid participating long-term care provider types that are collectively referred to as "facilities" or "LTC facilities" in this memorandum:

• Nursing facilities (NFs),
• Skilled nursing facilities (SNFs),
• Hospices that provide services in LTC facilities, and
• Intermediate Care Facilities for the Mentally Retarded (ICFs/MR).

Click here for the report:

June 17, 2011 Reporting Reasonable Suspicion of a Crime

CMS Memorandum

Friday July 1, 2011

July 1, 2011 Changes to MDS 3.0 Assessment Modification & Formatting Policies & Nursing Home Compare website.

The purpose of this CMS memorandum is to describe changes that the Centers for Medicare & Medicaid Services (CMS) has made to the MDS 3.0 assessment modification and formatting policies, as well as changes to the Nursing Home Compare website as a result of MDS 3.0 implementation.

Click here for full report

The Centers for Medicare and Medicaid Services has announced it will cut Medicare payments...

Monday August 29, 2011

The Centers for Medicare and Medicaid Services has announced it will cut Medicare payments to skilled nursing facilities by $3.9 billion next year to recover overpayments it made to companies that inflated their costs. CMS says its newly recalibrated classification system, known as "Resource Utilization Groups Version 4," or RUG-IV, will eliminate skilled nursing facilities' ability to bill for a higher level of care than they actually provide to patients. According to a July 29 statement ...

http://money.msn.com/retirement/article.aspx?post=a6d41859-804e-49f4-9568-e4cf43be63b3

New Quality Indicator Survey (QIS) Documents

Thursday August 11, 2011

Click on the link below to download the QIS documents:

QIS Brochure April 2011

QIS Checklist Final July 2011

QIS Implementation Map April 2011

QIS Memo Checklist Changes July 2011

Same Sex Partners and Medicaid Liens, Transfers of Assets, and Estate Recovery – June

Monday August 8, 2011

The purpose of this letter is  to ensure that States are informed of the existing options and flexibilities regarding the application of Medicaid liens, transfer of assets, and estate recovery. Specifically, this letter is intended to advise States of existing choices and options regarding spousal and domestic partner protections related to liens, transfer of assets, and estate recovery.

Same Sex Partners MCD Liens Transfers Estate Rec 06 11

Government Report: Report Examines High Cost of Medicare Hospice in Nursing Homes

Friday August 5, 2011

Potential Risk Factors Regarding Mechanical Lifts & Slings

Wednesday August 3, 2011

Arbitration News

Tuesday August 2, 2011

Overhaul of Nursing Home Compare website is complete

Tuesday August 2, 2011

The redesign of the federal Nursing Home Compare website, which lets consumers file complaints more easily and compare facilities based on quality measures, is complete.

www.medicare.gov/nhcompare/

Wilson v. State Farm: One Small Victory for Primary Payers in the MSP Arena

Tuesday August 2, 2011

Government Report: Report Examines High Cost of Medicare Hospice in Nursing Homes

Tuesday August 2, 2011

Rehab facilities see reimbursement increase tied to quality measures

Tuesday August 2, 2011

Inpatient rehab facilities will see a 2.2% payment rate increase under the IRF Prospective Payment System in fiscal year 2012. The system will also establish a new quality reporting system authorized by the Affordable Care Act.

Provider shares take a hit on news of CMS reimbursement

Tuesday August 2, 2011

Nursing Home Hospitalization Influenced by Payer Status -from thirdage.com

Wednesday October 19, 2011

Article from Thirdage.com- by Caitlin Bronson

http://www.thirdage.com/news/nursing-home-hospitalization-influenced-by-payer-status_10-04-2011

A nursing home often decides whether or not to send an ill resident to the hospital or treat them on-site depending on their insurance status, a new study from the University of Rochester Medical Center found. As reported by ScienceDaily, residents enrolled in Medicaid are 27 percent more likely to be taken to the hospital than residents with private insurance.

And that often mean higher health care costs and poorer outcomes, said lead author Shubing Cai of Brown University.

"Nursing homes, in many instances, have discretion in whether to keep a patient in the facility and expend additional resources, or transfer the resident to the hospital," Cai said. "While we know that nursing homes tend to provide similar quality of care to all residents, hospitalization decisions are often different from the decisions involved in the provision of daily care and have a significant impact on the long-term health of residents."

According to the same publication, hospitalization of elderly patients is often linked with poor outcomes leading to further physical and psychological decline. Patients are more vulnerable to infections while in the hospital, experience a disruption in care and have been show to decline more quickly in functional status and become more confused.

The study authors recommend aligning incentives with Medicare and Medicaid, so that nursing homes are paid based on quality measures, including hospitalization rates.

ScienceDaily noted that Medicaid often reimburses nursing homes at a lower rate for treatment than does private pay insurance, and often below the necessary cost to provide onsite intensive care. That means nursing homes have a strong financial incentive to send ill residents on Medicaid to the hospital, where they know the cost will be taken care of by Medicare.

OIG Report February 2013 - SNF's Often Fail To Meet Care Planning and Discharge Planning Requirements

Monday April 1, 2013

The Office of the Inspector General (OIG) released a report February 2013 (OEI-02-09-00201) stating they found, "For 37 percent of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans. For 31 percent of stays, SNFs did not meet discharge planning requirements. Medicare paid approximately $5.1 billion for stays in which SNFs did not meet these quality-of-care requirements. Additionally, reviewers found examples of poor quality care related to wound care, medication management, and therapy. These findings raise concerns about what Medicare is paying for. They also demonstrate that SNF oversight needs to be strengthened to ensure that SNFs perform appropriate care planning and discharge planning."

The OIG made the following recommendations; "We recommend that the Centers for Medicare & Medicaid Services (CMS): (1) strengthen the regulations on care planning and discharge planning, (2) provide guidance to SNFs to improve care planning and discharge planning, (3) increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and to hold these SNFs accountable, (4) link payments to meeting quality-of-care requirements, and (5) follow up on the SNFs that failed to meet care planning and discharge planning requirements or that provided poor quality care. CMS concurred with all five of our recommendations."

You may read the entire OIG Report by clicking on the link below.

Alabama Supreme Court Rules in Arbitration Case

Monday April 1, 2013

The Alabama Supreme Court decided on a nursing home arbitration case on 3/22/2013 that has restricted somewhat the enforceability of our arbitration agreements, SSC Montgomery Cedar Crest Operating Company v. Linda Bolding, as attorney in fact and next friend of Norton Means. The decision specifically indicates that in the case of an incompetent resident, arbitration agreements will be enforced only if the person who signs the agreement has been appointed by the resident as durable power of attorney (DPOA) or has some other valid legal authority to act on the resident's behalf other than simply being the next of kin or being appointed as the sponsor.

What appears to be missing from the decision is whether the resident was competent when the arbitration agreement was signed. Unless a resident has been adjudicated to be incompetent by a probate judge, having a diagnosis of dementia or Alzheimer's diagnosis may not necessarily mean a resident is considered incompetent. If unsure whether the resident may or may not be competent to sign, we would suggest that you have the resident sign along with the power of attorney(POA) or the signature of someone with valid legal authority to act on the resident's behalf such as a guardian, conservator, or health care proxy.

It available, you may wish to review a copy of one of the three cognitive tests that was or has been given to the resident shortly before or after the resident signed the arbitration agreement. Although not officially guaranteed, the score could give you a clue as to whether the resident has or had the capacity to consent and sign the arbitration agreement on their own behalf.

• With a SLUMS score of 20-21 or less consistently, the resident probably should not consent or make their own decisions unilaterally. With a score of ≤21, it would be helpful to have the legally authorized representative sign too.

• With a BIMS score of 10 or less consistently, the resident probably should not consent or make their own decisions unilaterally. With a score of ≤10, it would be helpful to have the legally authorized representative sign too.

• If the mini mental status score was less than 15, we presumed that they probably could not consent or make their own decisions unilaterally. With a MMSE score of ≤15, it would be helpful to have the authorized representative sign and consent too.

In conclusion, the Alabama Supreme Court decision does seem to indicate that an arbitration agreement is enforceable against the resident and the resident's estate if it is signed by:

1.    A competent resident;

2.    By a family member on behalf of a competent resident; or

3.    By an attorney in fact under a durable power of attorney.

The decision does seem to say that an arbitration agreement is not enforceable if it is signed by:

1.    An incompetent resident; or

2.    A family member of an incompetent resident that has not been        

       appointed as the holder of the DPOA or appointed as another

       authorized legal representative on behalf of the resident.

If you would like a copy of the decision or to discuss this case further, please contact Lavonya below:

Lavonya K. Chapman, Esq., RN.|Director of Claims/Litigation
Arthur J. Gallagher Risk Management Services, Inc.

2200 Woodcrest Place, Suite 250

Birmingham, Alabama 35209
lavonya_chapman@ajg.com

(:205.414.2649 (direct) | 7:205.414.2632 (fax)

(:205.542.2771 (mobile)

Mandatory Corporate Compliance is Here: Are you Ready?

Tuesday April 2, 2013

Mandatory Corporate Compliance is Here:
Are you Ready?

Approved for 1 hour NAB credit
April 16, 2013
12:00 - 1:00 Eastern
Register Today: $79

Under the Sections 6102 and 6401 of the Affordable Care Act (ACA), Medicare and Medicaid certified nursing homes are required to have in place a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations and in promoting quality care. To date, however, the Centers for Medicare & Medicaid Services (CMS) has yet to promulgate regulations governing the statutory requirement. Regardless, facilities must have a plan in place effective March 23, 2013. Is your facility ready?

This webinar will:

• Review the essential structure and elements of an effective nursing home corporate compliance program based on existing guidance and the provisions of the ACA;

• Offer practical information to create a meaningful corporate compliance program. Provide understanding regarding how CMS guidance necessary to implement the ACA's compliance mandate is likely to impact providers.

 To register for this seminar go to www.care2learn.com

Potential Liability and Regulatory Impact

Monday April 22, 2013

Amgen, Inc., a California-based biotechnology company, has agreed to pay the United States $24.9 million to settle allegations that it violated the False Claims Act for marketing Aranesp to treat anemia in nursing home residents.  Aranesp may be indicated in residents who have anemia associated with conditions such as renal failure, dialysis or chemotherapy but not necessarily anemia from other causes.  The government alleged that Amgen distributed materials to consultant pharmacists and nursing home staff encouraging the use of Aranesp for patients who did not have anemia associated with chronic renal failure. 

Please see the attached release from the U. S. Department of Justice for additional details.

Out of the Penalty Box

Wednesday April 24, 2013

Care2Learn has recently posted a White Paper addressing the issue of avoiding unnecessary rehospitalizations. The paper states that roughly 40% of Medicare beneficiaries leaving the hospital are discharged to a post-acute setting, where the risk for rehospitalization begins, and the role of the skilled and assisted living facility and home health agency becomes critical in prevention. Effective October 2012, The Affordable Care Act instituted the Hospital Readmission Program, requiring the Centers for Medicare and Medicaid to reduce payments to hospitals with excessive 30-day readmissions. Read Out of the Penalty Box to learn about what you can do to implement evidence-based care processes and effective training, while partnering across the healthcare continuum to deliver better patient care and reduce unnecessary costs to your organization as well as CMS. Explore CMS' new payment and service delivery models of care that leverage both penalties and incentives for all healthcare providers.

For more information click on the attachment below or visit their web site at www.care2learn.com

Medicare Audit Improvement Act of 2013 (H.R. 1250)

Wednesday April 24, 2013

Medicare Audit Improvement Act of 2013 (H.R. 1250)
Legislation has been introduced that would make much-needed improvements to the Recovery Audit Contractor (RAC) program and other Medicare audit programs. Representatives Sam Graves (R-MO) and Adam Schiff (D-CA) introduced the Medicare Audit Improvement Act of 2013 (H.R. 1250), which, among other measures, would:

• Establish a consolidated limit for medical record requests
• Improve auditor performance by implementing financial penalties and by requiring medical necessity audits to focus on widespread payment errors
• Improve recovery auditor transparency
• Assure due process appeals for claims reopenings
• Allow accurate payment for rebilled claims
• Require physician review for Medicare denials

In a separate move, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on March 13, 2013, that would allow hospitals to be paid full Part B (outpatient) payment for inpatient claims denied during a RAC audit, when the care is found to be appropriate at the outpatient level, if the claim is one year old or less. This time limitation is particularly problematic to hospitals considering RACs audit claims for services provided during the previous three years. The Medicare Audit Improvement Act of 2013 (see above) would fix this Part B underpayment policy.

Revised Advanced Directives - F Tag 155

Monday March 18, 2013

The Centers for Medicare and Medicaid Services have made additional revisions to Surveyor Guidance at F Tag 155 in Appendix PP of the State Operations Manual.The attached document below includes the Memorandum, F155, and the Surveyor Training slides which include Interpretive Guidance and Investigative Protocol.

Revised F155 attached below.

Revised Advanced Directives - F Tag 155

F322-Gastric Tubes Revised

Tuesday March 12, 2013

The Centers For Medicare & Medicaid Services have revised F322 - Naso Gastric Tubes. The memo date March 8, 2013 stated that since the release of S&C 12-46-NH, CMS conducted further review of the interpretive guidelines for F tag 322 in Appendix PP of the SOM. Based on the additional internal and external stakeholder feedback the guidance and related training materials have been revised to provide additional clarification when determining compliance.

The memo, revised F322, and training material are attached below.

 F322 Naso-Gastric Tubes Revised

MEDICARE’S “OBSERVATION STATUS” FORCES SENIORS TO PAY THOUSANDS EXTRA FOR REHAB THAT ARE NOT REIMBURSED

Tuesday March 19, 2013

Recently at St. Peter's Hospital in Albany, U.S. Senator Charles E. Schumer joined Capital Region senior citizens and hospital executives to push his plan to change the Medicare law, so that elderly patients are not charged unfairly for receiving needed nursing home care after being hospitalized. Schumer noted that "observation" stay cases in hospitals, when the elderly individual is not technically an inpatient, have been on the rise in recent years, costing America's seniors thousands of dollars in medical bills. Currently, Medicare will only cover post-acute care in a skilled nursing home facility if a beneficiary has three consecutive days of hospitalization as an inpatient. Under Schumer's plan, the Improving Access to Medicare Coverage Act, "observation" stays will be counted toward the 3-day mandatory inpatient stay for Medicare to cover rehabilitation post-hospital visit.

 For example, Mr. Ike Cassuto recently broke his pelvis and spent four days at St. Peter's Hospital. In accordance with current law, St. Peter's listed him under "observation status" because no operation or procedure was performed. The consequence of this meant that Medicare will not pay for his 3-weeks in rehab that followed his hospital stay. Schumer emphasized it is the flawed Medicare law which is costing Capital Region seniors thousands of dollars.

 "In recent years, there's been a huge uptick in elderly patients under 'observation status' at Capital Region hospitals - and it's leaving seniors high and dry and hospitals no better off. A flawed Medicare law is to blame, and I have a plan to change that, so hundreds of thousands of seniors, like Mr. Cassuto, are not hit with huge rehabilitation bills after a lengthy hospital visit. This new Improving Access to Medicare Coverage Act  would allow senior citizens to count time spent under this 'observation status' towards Medicare-covered rehabilitation. If you are holed up in a hospital bed for days on end, it shouldn't matter what your billing status is, and this plan will save Capital Region seniors thousands."

 Schumer was joined by James K. Reed, President & CEO of St. Peter's Heath Partners; Mr.& Mrs. Ike Cassuto; James Barba, CEO of Albany Medical Center; Gail Myers of Statewide Senior Action and representatives from AARP. Schumer highlighted Mr. Cassuto's recent case, and explained that this is one example of hundreds of thousands. The number of observation cases has been on the rise in recent years, a consequence of policies meant to reduce Medicare expenditures. According to the Albany Times Union, St. Peter's Hospital, serving the Albany community since 1930, has reported that observation cases have nearly doubled in the past three years, with 2,560 cases in 2009 and 5,000 in 2012. This can lead to massive bills - in the tens of thousands of dollars - that senior citizens must pay for rehabilitation and nursing home care post-hospital visit.

 Schumer vowed to fight for the bipartisan Improving Access to Medicare Coverage Act  to address the flawed Medicare law. Currently, Medicare will only cover post-acute care in a skilled nursing facility if a patient has three consecutive days of hospitalization as an inpatient, not counting the day of discharge. Because of the uptick in observation cases, patients are enduring lengthier hospital stays in observation status and may unknowingly be treated under outpatient observation status for the entirety of their hospital visit. Under Schumer's legislation, observation stays will be counted toward the 3-day mandatory inpatient stay for Medicare coverage of skilled nursing facility services after a hospital visit. The Improving Access to Medicare Coverage Act of 2013 would amend title XVIII of the Social Security Act. Without being involved in billing technicalities between the hospitals and Medicare, Schumer's plan would ensure that patients 65 and older are eligible for coverage for their rehabilitation services, as long as they are in the hospital for three days.

"Observation stays" are specific, clinically appropriate services that treat and assess a patient in a hospital while a decision is being made as to whether patients will require further treatment as hospital inpatients, or if they are able to be discharged from the hospital. Hospitals, like St. Peter's, are following a flawed Medicare law in their treatment of many patients above 65 years old. In fact, Schumer noted, that hospitals are reimbursed less from Medicare for the treatment of patients under "observation" status than those that are inpatient. Hospitals also devote a significant amount of time and money to assuring that patients are properly classified as inpatients or outpatients.

Isadore "Ike" Cassuto's case is among the hundreds of thousands of elderly Americans who have been placed under "observation" status during a hospital stay, and who now face medical bills that Medicare refuses to cover for rehabilitation services. Mr. Cassuto came to St. Peter's Hospital after breaking his pelvis and was a patient for four days, but the hospital had him under observation without admitting him as an inpatient. Mr. Cassuto then underwent three weeks of rehabilitation, which was not covered under his Medicare plan, leaving him with $6,000 in medical bills.

"We thank Senator Schumer for his leadership on legislation that will promote fairness for Medicare patients who need rehabilitation following a hospitalization. Because of the uptick in the number of Medicare observation status billing codes throughout our state, NY StateWide Senior Action Council has developed a Patients' Rights Toolkit, available at  1-800-333-4374.  We encourage Medicare patients to ask about their status so that they can make informed decisions regarding their discharge plan, and uphold their rights to care through the appeals process when needed. Patients should not be forced to pay out of pocket for otherwise covered Medicare services due to institutional billing issues," said Gail Myers of the NY StateWide Senior Action Council.

SCHUMER: MEDICARE'S 'OBSERVATION STATUS' FORCES SENIORS TO PAY THOUSANDS EXTRA FOR REHAB THAT ARE NOT REIMBURSED - SENIORS ARE LEFT HIGH & DRY, UNABLE TO PAY HUGE BILLS POST-HOSPITAL STAY

Schumer's New Plan Would Change Three-Day Requirement & Allow Time Spent In 'Observation' To Count Toward Medicare-Covered Rehabilitation - Saving Seniors Huge Costs

Schumer Highlighted That 'Observation' Stay Cases Are Skyrocketing In Hospitals Across the Capital Region And Country, As Hospitals Comply With Flawed Medicare Law

Schumer Will Join Ike Cassuto Who Was Put Under 'Observation Status' At the Hospital- For Days-After Breaking His Pelvis, Meaning Medicare Won't Cover Nursing Home Recovery Care, Which Can Cost Thousands

The Importance of Marmet v Brown to Nursing Home Malpractice and Wrongful Death cases

Tuesday March 19, 2013

The U.S. Supreme Court case of Marmet Health Care Center v. Brown, decided on Feb 21, 2012, shows the advantage of a properly written and signed arbitration agreement in order to keep claims out of court where jurors decide and instead allow an arbitrator to decide the outcome.

Before Marmet, several states completely prohibited nursing homes from compelling residents to give up their right to a jury trial and declared all arbitration agreement in nursing home admission contracts to be unconscionable.

After Marmet Health Care Center v. Brown, nursing home owners and operators can have confidence that properly drafted and executed arbitration agreements will keep inevitable claims away from jurors.

Litigating claims in court can lead to unexpectedly high awards. Arbitration of claims is generally seen as offering significantly less potential for runaway jury awards by eliminating the emotions that fuel them. More predictable losses should result in lower overall claim payments, safeguarding funds that are better spent caring for residents. For these reasons, many long-term-care facilities have sought to use arbitration agreements when contracting with their residents upon admission. Plaintiffs often seek grounds to avoid the enforcement of arbitration agreements, in order obtain for themselves the potential of a much larger jury award.

The U.S. Supreme Court noted that in Marmet, arbitration agreements signed predispute, were enforceable and not void as a matter of public policy.  That Court went on to say "Congress did intend for the federal arbitration act (FAA) to take precedent over state law.

Properly drafted and executed arbitration agreements between facilities and their residents are generally enforceable. The impact that arbitration has on dispute resolution is so important that we expect to see it used routinely. Of course, care must be taken to avoid unenforceability, as is the case with any contract.

The most significant of these are a lack of mental capacity to consent, fraudulent inducement to sign, duress and unconscionability. Long term care facilities who choose not to utilized arbitration agreements will be well-advised to reconsider.

Arbitration agreements will go a long way toward reducing inappropriate and huge jury awards, allowing for better provision of care for nursing home residents.

For information on the provisions needed in arbitration agreements to increase the likelihood of being enforced or how the train your facility in getting them signed by the appropriate person(s), please contact:

Lavonya K. Chapman, Esq., RN.|Director of Claims/Litigation
Arthur J. Gallagher Risk Management Services, Inc.

2200 Woodcrest Place, Suite 250

Birmingham, Alabama 35209
lavonya_chapman@ajg.com

OSHA to Continue Aggressive Enforcement in 2013

Wednesday March 20, 2013

Occupational safety and health concerns are not limited to the construction and general industries anymore. Over the past four years, OSHA has become increasingly aggressive in its enforcement practices in every employment sector, rejecting collaborative efforts with employers, such as partnerships, to enhance workplace safety in favor of enforcement with higher citation classifications and enhanced penalties. With the reelection of President Obama and the understanding that Dr. David Michaels, Assistant Secretary of Labor, will remain the head of the OSHA for another four years, employers across the board can expect the agency to continue its aggressive enforcement tactics in 2013 and beyond.

To read more about OSHA enforcement, click on the link below.

Court Lowers “Burden” of Proof for OSHA Citations

Thursday March 21, 2013

The U.S. Court of Appeals for the 10th Circuit rendered an opinion that not only altered the agency's burden of proof for OSHA citations but effectively reduced that burden to little more than a semantic impediment. The Court declared that OSHA, or the Secretary of Labor need not establish the elements of the long established four-part Atlantic Battery test to prove a violation but instead must only prove that a "reasonably prudent employer" would have anticipated the hazard at issue and done more to prevent it. Further, the Court found this burden met where the Secretary had simply asserted that the employer at issue failed to act as a reasonably prudent employer without offering any evidence regarding whether a reasonably prudent employer in the same industry would have even recognized the hazard and, if so, what protective measures, if any, would have been taken.

In effect, the employer's liability is viewed in a vacuum with no reference to some recognized norms of safety recognition in the employer's industry. According to the Court, the Secretary only need to allege and prove that the specific employer's actions were "imprudent" and the violation will stand. 

For more details please read the following attachment:

Medical Record Documentation

Thursday March 21, 2013

The patient/resident medical record is the best evidence in a medical malpractice lawsuit. It is the medical record documentation, not the physician recall of details, which can most effectively defend a physician against a malpractice claim.

Why?

Liberty Mutual Study - Cost of Late Accident Reporting

Friday March 22, 2013

The prompt reporting of claims is one of the easiest ways to lower your total cost of risk; the sooner we learn about the claim the quicker we can engage in medical and disability management.  The results of this study emphasize the importance of reporting claims as soon as possible.

Below is a link to view the Liberty Mutual Study.

CMS Issues Final Rule on the Requirements for for Long-Term Care Facilities; Notice of Facility Closure

Tuesday March 26, 2013

On March 19, CMS issued in the Federal Register, a final rule that outlines steps that long-term care facilities need to take if they decide to cease business operations.



In the case of a facility closure, any individual who is the administrator of the facility must provide written notification of the closure and the plan for the relocation of residents at least 60 days prior to the impending closure or, if the Secretary terminates the facility's participation in Medicare or Medicaid, not later than the date the Secretary determines appropriate, according to the rule.



It also identifies penalties for non-compliance and clarifies the responsibility of the administrator of the facility to ensure that no new residents are admitted after written notice is submitted and that the notice of closure must include a plan for transfer and adequate relocation to another facility.

See the attachment below for details for: Medicare and Medicaid Programs; Requirements for Long Term Care (LTC) Facilities; Notice of Facility Closure



Megace: Potential Liability and Regulatory Impact

Sunday March 31, 2013

Megace: Potential Liability and Regulatory Impact

Par Pharmaceutical Co., has agreed to pay $45 million to settle allegations it improperly labeled and marketed its prescription drug Megace ES to elderly patients, the U.S. Department of Justice said.

Among other things, the company was accused of criminally misbranding Megace, which was approved by the FDA to treat weight loss tied to AIDS, as a treatment for non-AIDS-related geriatric wasting.

Despite being aware of harmful side effects, Par also targeted sales to nursing home residents with weight loss, and launched a sales force specifically for this market, according to the Justice Department.

A representative from the company didn't immediately respond to a request for comment. On behalf of Par, Chief Executive Paul V. Campanelli pleaded guilty to criminal misdemeanor charges in a New Jersey federal court on Tuesday, the Justice Department said. The company was fined $18 million and ordered to pay $4.5 million in criminal forfeiture, and agreed to pay $22.5 million to resolve its civil liability. "Today's resolution emphasizes the importance of the U.S. government's coordinated efforts to combat health care fraud," said Stuart F. Delery, of the Justice Department's civil division. "We expect companies to make honest, lawful claims about the drugs they sell."

Megace, a megestrol acetate drug, lacked adequate directions for use in the treatment of geriatric wasting unrelated to AIDS, a use that wasn't approved by the FDA, the Justice Department said. The civil allegations against the company were related to claims submitted to federal health-care programs for uses that weren't approved by the FDA. U.S. officials alleged that Par was aware that megestrol acetate carried potentially fatal risks for elderly patients, including a heightened potential for deep vein thrombosis and toxic reactions in patients with impaired kidney function.

Please see the attached release from the U. S. Department of Justice for additional details. 

We wanted you to be aware of the above information as you continue to review all medications in conjunction with your Pharmacist and physician and work with your physician on providing documentation in the event medications are used for off-labeled use. 

Physician Delegation of Tasks in Skilled Nursing Facilities and Nursing Facilities

Friday May 17, 2013

The Centers for Medicare & Medicaid Services (CMS) is publishing this article to provide clarification of Federal guidance regarding Section 3108 of the Affordable Care Act (ACA), related to physician delegation of certain tasks in SNFs and NFs to NPPs (NPPs are formerly "physician extenders") such as nurse practitioners (NPs), physician assistants (PAs), or clinical nurse specialists (CNSs).

This article addresses the authority of NPs, Pas, or CNSs to perform certain tasks such as conducting physician visits and writing orders, and to sign certifications and re-certifications.

Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs, Issued May 8, 2013

Wednesday May 8, 2013

This updated Special Advisory Bulletin describes the scope and effect of the legal prohibition on payment by Federal health care programs for items or services furnished (1) by an excluded person or (2) at the medical direction or on the prescription of an excluded person. For purposes of Office of Inspector General (OIG) exclusion, payment by a Federal health care program includes amounts based on a cost report, fee schedule, prospective payment system, capitated rate, or other payment methodology. It describes how exclusions can be violated and the administrative sanctions OIG can pursue against those who have violated an exclusion. The updated Bulletin provides guidance to the health care industry on the scope and frequency of screening employees and contractors to determine whether they are excluded persons.

Is It Time to Renew Your Medical Director Agreement?

Friday May 17, 2013

In an arbitration ruling in December 2011 in case of The Estate of Jane Doe versus ABC Health & Rehabilitation Center the terms specified in the Medical Director Agreement played a significant role in the Arbitration Panel ruling in favor of the defendant ABC Health and Rehab.  The Arbitration Panel members found there had been no showing that any act or omission by the nurses at ABC Health and Rehabilitation Center constituted a breach of the applicable standard of care or caused the medical problems culminating in the resident's death.   A significant factor in the favorable outcome of this case for the facility was the terms of the Medical Director Agreement.  The Medical Director Agreement stated that the Medical Director was an independent contractor; the roles of the medical director were clearly stated and did not include a responsibility to diagnose or treat patients.  Rather, the agreement clearly stipulated that any services the physician was to provide in that regard were to be in his independent role as an attending physician and the facility was not liable for the acts or omissions of the attending physician. 

Are the roles of your Medical Director in your Medical Director Agreement clearly defined and separate from any acts he/she may engage is as attending physician who has a responsibility to diagnose and treat patients?  If not you may wish to review your contract with your corporate counsel and decide if clarification is needed to this area or any other areas of the agreement.

A sample Medical Director Agreement for your review is available from the American Medical Director Association at the link below. We do not recommend any changes to your agreement without review and discussion with your corporate counsel. 

www.amda.com

Corporate Compliance and Ethics Program Requirement

Thursday May 30, 2013

The Patient Protection and Affordable Care Act (PPACA) required all Medicare/Medicaid Skilled Nursing Facilities to have an effective Compliance and Ethics Program in place by March 23, 2013.

The primary purpose of the Compliance and Ethics Program is to prevent, detect, and correct any fraud, abuse, or waste, to promote quality of care, and to have an operational Compliance and Ethics Program in place to meet applicable federal, state, and local laws and regulations. In order to avoid potential exposure nursing facility providers should take steps to implement the required Compliance and Ethics Program.

Robinson Adams - Arthur J. Gallagher has partnered with Associated Long Term Care Insurance Company, Johnston Barton Proctor & Rose and Care2Learn to assist you with the development of your Compliance and Ethics Program and training along with answering any questions you may have concerning this program.  

Information from Johnston Barton Proctor & Rose on how they can help you develop your Corporate Compliance Program:

              Long Term Care - Corporate Compliance Management

                              Johnston Barton Proctor & Rose

Our law firm, in partnership with Robinson Adams - Arthur J. Gallagher, has developed a Corporate Compliance Program Template (the "Template") to assist long term care facilities in meeting this requirement.

Our Template includes a corporate compliance program, employee manual, copies of the applicable statutes  and  regulations,  in-service  log  and  instructions,  corporate  compliance  hotline  information,  and corporate  compliance  log and instructions.  The charge for the Template is $500.00.  Our law firm is also available to assist you with customizing and implementing the Template for your facility at a discounted rate.

If your facility is interested in purchasing the Template or if our firm can provide your facility with any other assistance in meeting the compliance program requirements of PPACA,  please call Angie Cameron at (205) 458-9489.

                                     Care2Learn

You may also contact Stu DeVust at Care2Learn at 941-465-4578 to find out how you can enroll in the following Corporate Compliance Online Courses:

1. Corporate Compliance - What You Need to Know (USS-11600)  

2. Corporate Compliance - What You Need to Know for Assisted Living (USS-11600A)      

3. Corporate Compliance and the Deficit Reduction Act for Management (USS-11200)     

Please contact Russ Crouch at 205-414-1390, or our vendor partners, if you need additional information or assistance.

Advanced Copy: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309 - Quality of Care and F329 - Unnecessary Drugs

Thursday June 20, 2013

Guidance - This memo conveys clarification to Appendices P and PP related to nursing home residents with dementia and unnecessary drug use. • Training - Mandatory surveyor trainings are available online at  

http://surveyortraining.cms.hhs.gov

S&C 13-35

Release of Mandatory Surveyor Training Program on Care of Persons with Dementia and Unnecessary Antipsychotic Medication Use - Release of Third Video

Thursday June 20, 2013

S&C: 13-34-ALL Memo

Release of Training Materials:The Survey and Certification Group (SCG) is providing the third and final training program on the care of persons with dementia and unnecessary antipsychotic medication use. The first two programs were made available in January 2013; the third program will be released after May 31, 2013.

Program Content and Design:The third program is a video-streaming that discusses how to cite severity. The first program provides survey basics related to care of persons with dementia and unnecessary medications. The second program is an interactive self-study with video clips that walks through portions of an actual nursing home survey. • Target Audience: These three programs are mandatory for all State and Regional Office surveyors and optional for other interested personnel. Surveyors have until August 31, 2013 to view the final training. The deadline to view the first two programs was April 30, 2013. 

American Health Care Association Quality Improvement Toolkits and Webinars

Friday June 21, 2013

AHCA has available and free to all AHCA members the 4 Key Strategies to Retain New Hires and Reduce Employee Turnover (toolkit and webinar) and the Clinical Considerations of Antipsychotic Management (Toolkit and webinar): http://qualityinitiative.ahcancal.org. This resource uses a process framework, based on the Nursing Process, to identify care objectives and expectations. It identifies tools and resources to help providers successfully manage antipsychotic medication use at the resident and facility level. The guide focuses on 7 critical steps needed to ensure quality outcomes that are successful and continuous.

Members will need to log-in to access the toolkits, as it is a member-only benefit. If log-in information is needed, please contact your facility Administrator or State Association and they can give you the information you need.

OIG - Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings

Friday June 21, 2013

June 2013 OEI-07-11-00010

In 2011, Medicare paid between 18 and 30 percent more than other insurers for 20 high-volume and/or high-expenditure lab tests. Medicare could have saved $910 million, or 38 percent, on these lab tests if it had paid providers at the lowest established rate in each geographic area. State Medicaid programs and 83 percent of FEHB plans use the Medicare CLFS as a basis for establishing their own fee schedules and payment rates, although most pay less. However, unlike Medicare, FEHB programs incorporate factors such as competitor information, changes in technology used in performing lab tests, and provider requests in their payment rates. Some State Medicaid programs and FEHB plans required copayments for lab tests, which, in effect, lowered the costs of lab tests for the insurer.

The OIG recommend that the Centers for Medicare & Medicaid Services (CMS) seek legislation that would allow it to establish lower payment rates for lab tests and consider seeking legislation to institute copayments and deductibles for lab tests. In its comments, CMS stated that it is exploring whether it has authority under current statute to revise payments for lab tests consistent with OIG's recommendation and that a proposal to establish "deductibles and coinsurance" for lab tests is not included in the fiscal year 2014 President's Budget.

To read the complete report click on the pdf below.

Gallagher Monthly Minute - June 2013

Wednesday June 26, 2013

Tips to Control the Risk with Communication

Release of Medical Records of Deceased Residents

Friday July 12, 2013

In Alabama, one has the right to obtain a deceased resident's medical records from an Alabama health care provider if the requester is the personal representative (such as the executor or administrator) of the deceased resident's estate.

The new HIPAA privacy final rule passed 3/26/2013 with a compliance deadline of 9/23/2013. The new final HIPPA rule says that those family members, relatives, and others who had access to the health information of the deceased prior to death, but had not qualified as a "personal representative"(PR) of the decedent under HIPAA Privacy Rule 164.502(g)(4) the final Privacy Rule allows covered entities (facility) to disclose a decedent's protected health information(PHI) to family members and others who were involved in the care or payment for care of the descendent prior to death, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the covered entity. Whether to adhere to the new HIPAA final rule is now at the discretion of the facility and is not mandatory.

We do not plan to make any changes to our current procedure unless the facility/covered entity directs us to do so. As such, we will still require a written request for the deceased resident's medical records signed by the personal representative of the estate on a HIPAA compliant release form along with the accompanying legal authority from the Probate court naming the requester as the PR.

This recent HIPAA amendment is addressed under number 2 below and authorizes the covered entity to produce protected health information or medical records to individuals who are not the PR, so long as those individuals were involved in the decedent's care/payment, need the PHI for that purpose and the decedent did not express a preference (that was known to the covered entity) for his/her PHI to not be released to the individual now seeking it. It will be interesting to see how this new HIPAA amendment plays out. Under this new amendment, the covered entity has the discretion to produce the PHI or not; HIPAA does not require that the covered entity produce, but rather permits the disclosure.

Under HIPAA, the confidentiality of a resident's protected health information continues after the resident's death. In general, the covered entity is not required to disclose a decedent's PHI to anyone other than the decedent's personal representative. The covered entity must (1) verify the identity of the individual and (2) verify that the individual has the legal authority to access the decedent's PHI. Recent amendments to the HIPAA privacy rule limit the time period for which the covered entity must protect a decedent's PHI to 50 years after the person's death. See45 C.F.R. 164.502(f). HIPAA provides for disclosure of a decedent's PHI as follows:

(1)Disclosure of PHI to Personal Representative- upon verification of identity and legal authority, the personal representative must be treated as the individual for purposes of disclosure

See 45 C.F .R. 164.502(g)(1)Standard: Personal representatives.As specified in  this paragraph, a covered entity must, except as provided in paragraphs (g)(3) and (g)( 5) of this section, treat a personal representative as the individual for purposes of this subchapter.

See 45 C.F.R. 164.502(g)(4)Implementation specification: Deceased individuals.  If under applicable law an executor, administrator, or other person has authority to act on behalf of a deceased individual or of the individual's estate, a covered  entity must treat such person as a personal representative under this subchapter,  with respect to protected health information relevant to such personal representation.

(2) Disclosure of PHI to family member, other relative, or close personal friend of decedent - The covered entity is permitted, but not required to disclose PHI to theseindividuals so long as the individual was involved in the decedent's care or payment for healthcare prior to death and the PHI is relevant to the family member, other relative or close personal friend's involvement; the disclosure also must not be contrary to the decedent's prior expressed preference. [1]

See 45 C.F.R 164.510(b)Standard: Uses and disclosures for involvement in the  individual's care and notification purposes-

(1) Permitted uses and disclosures.  (i) A covered entity may, in accordance with paragraphs (b )(2), (b )(3), or (b )(5) of this section, disclose to a family member, other relative, or a close personal friend  of the individual, or any other person identified by the individual, the protected health information directly relevant to such person's involvment with the individual's health care or payment related to the individual's health care.

See 45 C.F.R. 164.510(b)(5)Uses and disclosures when the individual is  deceased.If the individual is deceased, a covered entity may disclose to a family  member, or other persons identified in paragraph (b) (1) of this section who were  involved in the individual's care or payment for health care prior to the  individual's death, protected health information of the individual that is relevant to such person's involvement, unless doing so is inconsistent with any prior  expressed preference of the individual that is known to the covered entity.

(3) Disclosure of PHI to law enforcement- if the covered entity has suspicion that death may have resulted from a criminal act, then disclosure is permitted.

See 45 C.F.R. 164.512 Uses and disclosures for which an authorization or  opportunity to agree or object is not required. A covered entity may use or  disclose protected health information without the written authorization of the  individual, as described in § 164.508, or the opportunity for the individual to  agree or object as described in§ 164.510, in the situations covered by this section, subject to the applicable requirements of this section. When the covered entity is  required by this section to inform the individual of, or when the individual may  agree to, a use or disclosure permitted by this section, the covered entity's  information and the individual's agreement may be given orally.

See 45 C.F.R. 164.512(f)(4)Permitted disclosure: Decedents. A covered entity  may disclose protected health information about an individual who has died to a  law enforcement official for the purpose of alerting law enforcement of the death  of the individual if the covered entity has a suspicion that such death may have  resulted from criminal conduct.

(4) Disclosure of PHI to Coroners and Medical Examiners

See 45 C.F.R. 164.512(g)Standard: Uses and disclosures about decedents-(1)  Coroners and medical examiners. A covered entity may disclose protected health  information to a coroner or medical examaniner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. A covered entity that also performs the duties of a coroner or medical examiner may use protected health information for the purposes described in this paragraph.

(5) Disclosure of PHI to Funeral Directors

See 45 C.F.R. 164.512(g)(2) Funeral directors. A covered entity may disclose  protected health information to funeral directors, consistent with applicable law,  as necessary to carry out their duties with respect to the decedent. If necessary for  funeral directors to carry out their duties, the covered entity may disclose the  protected health information prior to, and in reasonable anticipation of, the  individual's death.

(6) Disclosure of PHI for Research Purposes-The covered entity is permitted to disclose PHI for research subject to various criteria not set out fully herein

See45 C.F.R. 164.512(iii)Research on decedent's information. The covered  entity obtains from the researcher:

(A) Representation that the use or disclosure sought is solely for research on the  protected health information of decedents;

(B) Documentation, at the request of the covered entity, of the death of such  individuals; and

(C) Representation that the protected health infomation for which use or disclosure is sought is necessary for the research purposes.

Member may login to review new and revised related forms.

Lavonya K. Chapman, Esq., RN, Claims Compliance Director

Arthur J. Gallagher Risk Management Services, Inc.

2200 Woodcrest Place, Suite 250

Birmingham, AL  35209

lavonya_chapman@ajg.com

(205) 414-2649 (direct)

(205) 414-2632 (fax)

(205) 542-2771 (mobile)

To visit the LTC Provider University website go to   www.ltcpu.com

 [1]Attached is an excerpt from the Federal Register which discusses this new amendment to the HIPAA Rule. It is helpful and explains in some detail the rationale, concerns, etc. behind extending permissible disclosures of PHI to family members, other relatives and close friends of the decedent who would not qualify as a personal representative and otherwise would not have access to the decedent's PHI.

Partnering with you on Risk Control

Tuesday August 6, 2013

LEGIONNAIRES' DISEASE CAN AFFECT

RETIREMENT COMMUNITIES

There have been recent newspaper articles in the United States reporting outbreaks of Legionnaires' disease in retirement communities.  Legionnaires' disease is not contagious but is contracted when people breathe in tiny droplets of contaminated water from sources such as showers, water fountains, whirlpool tubs, etc.   The Centers for Disease Control and Prevention have many resources available on this topic for you to review relating to symptoms, causes, prevention and surveillance.  For additional information, please reference CDC.gov.  http://www.cdc.gov/legionella/about/

New Alabama Law Permits Employees to Have Guns in Vehicles on Employee Property

Tuesday August 6, 2013

Section 40-12-143 of the Alabama Code, made by Senate Bill 286, permits employees to have guns in their vehicles on their Employer's property. It may be a good time for facilities to evaluate their current work place safety policies.  Our partner, Johnston Barton Proctor & Rose, developed a detailed summary of this new amendment that went into effect on August 1, 2013.  We have included the summary below. For additional information on Section 40-12-143 of the Alabama Code you can contact Angie C. Cameron or Sarah C. Blutter at Johnston Barton Proctor & Rose LLP.  

OSHA's Revised Hazard Communication Standard - Globally Harmonized System Webcast

Thursday August 8, 2013

The Arthur J Gallagher Loss Control Practice Group developed a webcast providing an overview of OSHA's Globally Harmonized System mandatory regulation that provides insight on how to be compliant with this regulation. You can view this webcast by clicking on the following link:

http://ajg.adobeconnect.com/p4l83ypg2l4/

Risk Management Strategies Webcast Special Edition Series:

CMS Finalizes Contract Requirements Between Long Term Care Facility and Hospice Service

Monday August 12, 2013

Contract Requirements between Long Term Care Facilities and Hospice Service Providers

On June 27, 2013 CMS released the final ruling on contract requirements between long term care providers and Hospice Services.  This regulation will be effective on August 26, 2013.   Because there are similar services provided by both long term care facilities and hospice providers it is possible for residents to receive the same services or conflicting services from both companies.  The rationale behind the final ruling from CMS is to help ensure safe and quality care for residents by requiring a written agreement between the long term care facility and the hospice provider outlining the services that will be provided by both entities. 

When hospice services are provided in long term care facilities then each facility is responsible for ensuring that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of these services.  The long term care facility must meet the requirements of the contract between the hospice provider and the long term care facility and this contract must be signed by an authorized representative of the hospice service provider and the long term care facility before hospice care can be provided to residents at the facility. The written agreement must address issues such as:

• The services hospice will provide
• The hospice's responsibilities for determining the appropriate hospice plan of care
• The services the long term care facility will continue to provide, based on each resident's plan of care
• A communication process including how the communication will be documented between the long term care facility and the hospice service, to ensure that the needs of the resident are addressed and met 24 hours per day
• A provision that the long term care facility will immediately notify the hospice service about the following:  1) a significant change in the resident's physical, mental, social or emotional status; 2) clinical complications that suggest a need to alter the plan of care; 3) a need to transfer the resident from the long term care facility for any condition; and 4) the resident's death
• A provision stating that the hospice service assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided
• An agreement that it is the long term care facility's responsibility to furnish 24 hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs
• A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling; social work; providing medical supplies, durable medical equipment, and drugs; and all other services that are necessary for the care of the resident's terminal illness and related conditions
• A provision that when the long term care facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the long term care personnel may administer the therapies whether permitted by State law
• A provision stating that the long term care facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physician abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the facility becomes aware of the alleged violation
• A delineation of the responsibilities of the hospice and the facility to provide bereavement services to the long term facility staff

The final ruling also states that the long term care facility must designate a member of the facility's interdisciplinary team to be responsible for working with hospice representatives. This team member must have a clinical background. 

In addition to the CMS requirements in the agreement between the long term care facility and the hospice provider that are outlined above, from a risk management perspective, you should also consider adding the following additional provisions to the contract between your facility and the hospice provider:

• Independent Contractor provision - this agreement clarifies that the contractor is not a facility employee and therefore not subject to the facility's worker's compensation benefits or professional liability insurance coverage

• Hold Harmless provision - this agreement clarifies that one or both parties agree to not hold the other responsible for damages.  This agreement indemnifies one or both parties by agreeing to not hold the other responsible for any legal liability or losses as a result of a specified incident or action
• Insurance coverage by both parties - this clause states that each entity will carry their own general/professional liability insurance.  This provision without a hold harmless/indemnification clause is only helpful if both the facility and third party contractor are co-defendants.   In other words, if the third party contractor is not a party to a claim against the facility, the third party contractor's liability insurance will not hold harmless or indemnify the facility

The facility may want to consult with its Corporate Counsel before finalizing the language in the contract between the facility and the hospice provider, or with any other third party. 

To read the complete final rule, the Federal Register is attached.  

CMS Manual System Transmittal 86

Friday August 16, 2013

CMS Manual System Transmittal 86

Revisions to State Operations Manual (SOM) Chapter 5

EFFECTIVE DATE: July 19, 2013

IMPLEMENTATION DATE: July 19, 2013  

Complying with Medicare Signature Requirements

Friday August 16, 2013

Complying with Medicare Signature Requirements

The attached fact sheet describes common Comprehensive Error Rate Testing (CERT) Program errors related to signature requirements and provides information on the documentation needed to support a claim submitted to Medicare for medical services.

Click on the pdf below to read the entire document from DHHS.

Complimentary Seminar! Healthcare Forum

Friday September 13, 2013

Safety Seminar

Healthcare Forum

Friday October 4, 9am -3pm

Arthur J. Gallagher                                                                                  

Robinson Adams Insurance

2200 Woodcrest Place, Suite 250

Birmingham, AL 35209

  Click here to register!

Arthur J. Gallagher, in partnership with Liberty Mutual Insurance, is offering a complimentary Healthcare seminar to help recognize and reduce risk in the healthcare industry. The training covers a variety of safety and health topics specific to exposures faced by healthcare workers.

As a result of this training, participants will be able to:

• Evaluate slips and falls and implement prevention strategies
• Modify internal patient handling policies to include industry best practices
• Develop methods to track and measure safety performance
• Address the challenges and impact associated with an aging workforce
• Determine the impact of shiftwork on employees

This seminar is designed for Arthur J. Gallagher Risk Management Services and their clients who want to help reduce risk within their operation.  Complimentary continental breakfast and lunch will be provided.  Please register early as seats are limited.

If you have any questions email us at  Risk Control Learning or contact our Training Specialists at 877-588-2016. 

Accident Investigation - October

Wednesday October 2, 2013

A thorough accident investigation procedure is an important part of any safety program. It is essential that an employer understand what caused an accident to happen and what can be done to prevent a recurrence. This article provides you with information on when to begin the accident investigation and the steps that should be followed during the investigation process.  

Click on the link to view the article: 

Risk Management Safety Insight

Monday October 21, 2013

ROGUE SUPERVISOR: FEDERAL COURT REJECTS OSHA'S ATTEMPT TO CREATE STRICT EMPLOYER LIABILITY.

It is well recognized that employer knowledge is required for OSHA to establish a violation. Under most circumstances, this element can be satisfied when a supervisor, manager or foreman, who are agents of the employer, witnesses an employee exposed to a hazard, but does nothing about it.  But what happens when the supervisor, manager, or foreman is the individual violating OSHA's regulations?  

The article below examines a recent Federal Court of Appeal's decision rejecting OSHA's interpretation, and how that decision may affect OSHA's ability to prove a violation in the first place as well as the employer's ability to prove unavoidable supervisor misconduct affirmative defense.  

Fire Safety

Monday December 2, 2013

A Minute for Safety, by Arthur J. Gallagher & Co.

You are responsible for fire prevention and the safety of your coworkers in the event of a fire.  The best way to prevent workplace fires is to be aware of and on the lookout for potential fire hazards.  Employees should be trained about fire hazards and about what to do in the event of a fire.  This article will review the steps to take to reduce the risks from fire occurring in the workplace and what to do if one should occur:                                                                                                  

Handling Funds Following the Death of a Medicaid Resident

Thursday November 21, 2013

Alabama Medicaid Agency - Medicaid Alert

TO: Nursing Home Providers

The purpose of this alert is to clarify the procedures associated with handling funds following the death of a Medicaid-eligible nursing home resident. The Medicaid Administrative Codes 560-X-10-.14(3)(f) and 560-X-22-.25(5)(e) and the Social Security Administration Guide for Representative Payees require that nursing homes,upon the death of a resident, release any funds being held at the facility in the resident's name to the administrator of the deceased resident's estate. In the event that there is not a person who has been appointed to act as the administrator of the estate, the funds should be sent to the Alabama State Treasurer's Office, Unclaimed Property Division.  In an effort to ensure that all Alabama nursing home facilities are in compliance with the rules and regulations pertaining to the handling of the funds of deceased residents, the following instructions are provided in the pdf below.

MLN Matters Number - MM8458

Thursday December 12, 2013

In the regulations at42 CFR 409.32(c), the level of care criteria for SNF coverage specifies that the "… restoration potential of a patient is not the deciding factor in determining whether skilled services are needed." In addition, on January 24, 2013, the Court approved the settlement concerning the Jimmo v. Sebeliuscase which has eventually resulted in new guidelines for skilled care and skilled therapy.

The Centers for Medicare & Medicaid Services has now revised the Medicare Benefit Policy Manual, Publication #: 100-02, Chapter 8, § 20.1.2-Determination of Coverage, to clarify that skilled care and skilled therapy may be covered even for conditions that will not improve.

In the past many thought that Medicare coverage of skilled nursing care or therapy required documentation that a resident or Medicare beneficiary must have the potential for improvement from the nursing care or therapy.  The manual revisions, now clarifies that skilled care may be needed to maintain a current condition or prevent or slow a resident/patient's deterioration. The manual also includes specific examples of documenting skilled care.

Until theMedicare Benefit Policy Manualis updated, see the attachedMLN Matters Number: MM8458 or Related CR Transmittal #: R175BP. Effective Date: January 7, 2014,for guidance.

Please click on the MLN Matters article below:

Cardiopulmonary Resuscitation (CPR) in Nursing Homes

Monday December 16, 2013

Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR- certified staff must be available at all times.  

Please click on the article below to read the Memorandum regarding CPR in Nursing Homes:  

Key Cares

Thursday December 26, 2013

This Key Cares article focuses on winter fire prevention, and highlights methods to prevent the most common causes of home and workplace fires. This article also features information about obesity and body mass index. Please click on the link below to access the article.

http://campaign.r20.constantcontact.com/render?ca=5ce4b51f-21eb-4b00-8a64-4758b3916472&c=bed96d40-4cec-11e3-bcea-d4ae5292bb50&ch=bf3fa920-4cec-11e3-bd14-d4ae5292bb50

Active Shooter

Tuesday January 7, 2014

Active Shooter Preparedness - The potential for a shooting incident by an active shooter exists, unfortunately, in every workplace place throughout the United States. This article will help you and your staff create an emergency action plan to respond to an active shooter situation.    

This Arbitration Signature(s) Decision Tree

Tuesday January 28, 2014

This Arbitration Signature Flowchart will guide you and your staff on the signature options for your facility's arbitration agreement.     

Using eHealth Data Solutions CareWatch to Enhance Your QAPI Activities (Free Webinar):

Monday February 3, 2014

The Long Term Care Community is waiting for CMS to release the final Quality Assurance and Performance Improvement (QAPI) regulations, but your team should be preparing today to build a systematic, comprehensive, data driven approach to care. This free webinar will provide an overview of the eHealth Data Solutions CareWatch features that can enhance your QAPI activities and will discuss real life examples of the way CareWatch data can be used in the Plan-Do-Study-Act Cycle and your performance improvement projects (PIPs). See the link below on how to register for this free webinar presented by eHealth Data Solutions:     

https://www2.gotomeeting.com/register/602492442

ICD-10 in 2014

Thursday February 6, 2014

With less than one year to go until the October 1, 2014, ICD-10 compliance date, now is the time to assess your progress. CMS continues to work with health care organizations to develop and distribute a variety of resources to help you with your ICD-10 planning and preparation.

No matter where you are in your transition, there are ICD-10 resources available to you. Check the  provider resources page on the CMS website frequently for news and information to help you prepare, and visit your professional organization's website for resources tailored specifically to your needs. These resources can help you:

• Plan your journey - Look at the codes you use, prepare a budget, and build a team
• Train your team - Many options and resources are available
• Engage your partners - Talk to your software vendors, clearinghouses, and billing services
• Test your systems and processes - Test within your practice and with your partners

2014 is the year of ICD-10. The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. With everyone in health care working toward a successful transition, now is the time to make sure you are ready too.

Keep Up to Date on ICD-10

Visit the CMS  ICD-10 website for the latest news and resources to help you prepare for the October 1, 2014, compliance date. Sign up for  CMS ICD-10 Industry Email Updates and  follow us on Twitter.

CMS Revised Emergency Preparedness Checklist

Friday February 28, 2014

The Centers for Medicare & Medicaid Services (CMS) is alerting healthcare facilities that they have revised current emergency preparedness checklist information for health care facility planning. These updates provide more detailed guidance about patient/resident tracking, supplies and collaboration.

CMS has updated the S&C Emergency Preparedness Checklist - Recommended Tool for Effective Health Care Facility Planning. This updated checklist can be found at their S&C Emergency Preparedness Websitehttp://www.cms.hhs.gov/SurveyCertEmergPrep/.

CMS has stated that updates and new documents will be posted to the website as they become available.

The S&C letter is attached below.

AUDIT HOLIDAY

Tuesday February 18, 2014

CMS- February 18, 2014 - CMS is in the procurement process for the next round of Recovery Audit Program contracts. It is important that CMS transition down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other processes by the end date of the current contracts. In addition, a pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program. Several years ago, CMS made substantial changes to improve the Medicare Recovery Audit program. CMS will continue to review and refine the process as necessary. For example, CMS is reviewing the Additional Documentation Request (ADR) limits, timeframes for review and communications between Recovery Auditors and providers. CMS has proven it is committed to constantly improving the program and listening to feedback from providers and other stakeholders. Providers should note the important dates below:

• February 21 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR)

• February 28 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration

• June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment

CMS will continue to update this Website with more information on the procurement and awards as information is available. Providers should contact RAC@cms.hhs.gov for additional questions.

ADVERSE EVENTS IN SKILLED NURSING FACILITIES: NATIONAL INCIDENCE AMONG MEDICARE BENEFICIARIES

Saturday February 1, 2014

From 2008-2012, the OIG conducted a series of studies about hospital adverse events, defined as harm resulting from medical care. This work included a Congressionally mandated study to determine a national incidence rate for adverse events in hospitals. As part of this work, they developed methods to identify adverse events, determine the extent to which events are preventable, and measure the cost of events to the Medicare program. This study continues that work by evaluating post-acute care provided in skilled nursing facilities (SNF). SNF post-acute care is intended to help beneficiaries improve health and functioning following a hospitalization and is second only to hospital care among inpatient costs to Medicare. Although various health care stakeholders have in recent years paid substantial attention to patient safety in hospitals, less is known about resident safety in SNFs.

Because many of the events identified were preventable, our study confirms the need and opportunity for SNFs to significantly reduce the incidence of resident harm events. Therefore, the OIG recommends that the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) raise awareness of nursing home safety and seek to reduce resident harm through methods used to promote hospital safety efforts. This would include collaborating to create and promote a list of potential nursing home events-including events we found that are not commonly associated with SNF care-to help nursing home staff better recognize harm. CMS should also instruct State agency surveyors to review nursing home practices for identifying and reducing adverse events. AHRQ and CMS concurred with our recommendations.

To read the complete OIG report, click on the attachment below.

Congress Vote To Delay ICD-10

Wednesday March 26, 2014

UPDATE: On Thursday, March 27, 2014, the US House of Representatives passed a bill that would delay the implementation of ICD-10-CM/PCS to October 1, 2015.  Bill, H.R. 4302, Protecting Access to Medicare, mainly adjusts the Sustainable Growth Rate (SGR) for Medicare payments.  The SGR outlines how much physicians get paid for their services.  However, the bill includes a seven line section (Section 212) which delays the implementation of ICD-10-CM/PCS to October 1, 2015. 

Action on H.R. 4302 now moves to the Senate for a vote.  Senators are expected to vote on the bill in the coming days.   

The bill,  which would amend the Social Security Act to extend Medicare Payments to physicians and change other provisions of the Medicare and Medicaid programs and adjust the Sustainable Growth Rate (SGR), also includes a section that would delay ICD-10 to October 1, 2015. 

Senate Passes Bill that Delays ICD-10-CM/PCS Implementation

Monday March 31, 2014

On Monday, March 31, 2014, the Senate passed H.R. 4302, Protecting Access to Medicare Act of 2014, which included a section delaying the implementation of ICD-10-CM/PCS by at least one year.  The bill will now go before President Obama, who is expected to sign the bill into law.  

The bill, H.R. 4302 states that the Department of Health and Human Services (HHS) cannot adopt the ICD-10 code set as the mandatory standard until at least October 1, 2015.  ICD-10 was originally set to be implemented on October 1, 2014.  

Office of Inspector General (OIG) - Outlook 2014

Monday May 19, 2014

In this video senior executives from OIG will discuss the emerging trends in combating fraud, waste, and abuse in Federal Health Care Programs and upcoming projects in the newly released OIG Work Plan. OIG is a sister agency to the Centers for Medicare and Medicaid Services within the Health and Human Services Department. This podcast goes over how data is mined to direct audit resources and conduct investigations such as RAC Audits. 

View the Video from the Office of Inspector General

Federal Register - Long term care-hospice contracts

Tuesday May 20, 2014

In the attached documents you will find the issues that must be addressed in contracts between Long Term Care Facilities and Hospice Service Providers and the contract provisions that should be considered for inclusion from a risk management perspective.      

View Contract Requirements between Long Term Care Facilities and Hospice Service Providers

View Federal Register - Long term care-hospice contracts

How to Protect Your Facility by Having Third Party Contracts in Place

Monday June 2, 2014

Every contract has risks that must be reviewed from the perspective of protecting your entity and assets. This document is designed to provide you with guidelines and tools to help you manage those risks and to consider the regulatory and liability implications from contracted services.

To learn more about Third Party Contracts click on the icon below.

Third Party Contracts

Adult Portable Bed Handles Recalled by Bed Handles Inc.

Tuesday June 3, 2014

Adult Portable Bed Handles Recalled by Bed Handles Inc. Due to Entrapment and Strangulation Hazards; Three Deaths Reported

Description

WASHINGTON, D.C. - The U.S. Consumer Product Safety Commission (CPSC) and Bed Handles Inc., of Blue Springs, Mo., are announcing the voluntary recall of about 113,000 adult portable bed handles. When attached to an adult's bed without the use of safety retention straps, the handle can shift out of place creating a dangerous gap between the bed handle and the side of the mattress. This poses a serious risk of entrapment, strangulation and
death.

Three women died after becoming entrapped between the mattress and the bed handles. They include an elderly woman, age unknown, who died in an Edina, Minn. assisted living facility; a 41-year-old disabled woman who died in a Renton, Wash. adult family home; and an 81-year-old woman who died in a Vancouver, Wash. managed care facility.

The recall involves adult portable bed handles sold by Bed Handles Inc. from 1994 through 2007 that do not have safety retention straps to secure the bed handle to the bed frame to keep the bed handle from shifting out of place and creating a dangerous gap. Recalled models include the Original Bedside Assistant® (BA10W), the Travel Handles™ (BA11W) which is sold as a set of two bed handles, and the Adjustable Bedside Assistant® (AJ1).

For more information, including contact information and a photo of the Bed Handles click on the attachment below.

 Third Party Contracts

Cyber and Privacy Liability Insurance

Thursday June 12, 2014

Cyber and Privacy Liability Insurance provides coverage when data is breached within your business. Traditional insurance policies such as property and general liability generally have gaps which may not cover losses from a data breach at your organization. This article will introduce you to cyber and privacy liability insurance and examples of coverage that it may provide.

Download the  Cyber and Privacy Liability Insurance Article

Adverse Events In Skilled Nursing Facilities

Wednesday July 23, 2014

The Office of the Inspector General recently released their findings of a study they conducted from 2009-2011. In this study they found an estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. They attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011.

Because many of the events that were identified were preventable, their study confirms the need and opportunity for SNFs to significantly reduce the incidence of resident harm events.
Therefore, the OIG recommended that the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) raise awareness of nursing home safety and seek to reduce resident harm through methods used to promote hospital safety efforts. This would include collaborating to create and promote a list of potential nursing home events-including events that were found that are not commonly associated with SNF care-to help nursing home staff better recognize harm. The OIG stated that CMS should also instruct State agency surveyors to review nursing home practices for identifying and reducing
adverse events. AHRQ and CMS concurred with our recommendations.

QAPI Quick Start Kit

Tuesday July 29, 2014

Recently CMS proposed new rules combining F-250 Quality Assurance (QA) with additional ACA provisions of Performance Improvement (PI). In response, The Compliance Store developed the QAPI Quick Start Tool Kit. The link below contains all of the resources that you will need and outlines each step to help you get your QAPI Program up and running quickly. Staff improvements through QAPI equals decreased turnover, which leads to better quality of care.

Read More

CNA Webcast: Admissions and Transfers – Challenges Facing Aging Services Facilities

Friday August 1, 2014

CNA will be broadcasting a Webcast on Thursday August 7, 2014 at 12:00 Central Time on the admissions and transfer challenges facing aging services facilities. Facilities work with residents and their families on numerous sensitive issues that arise in this healthcare delivery setting. Appropriate identification of those residents who may be safely admitted and those who should be transferred poses a significant challenge. This webcast will address the admission and transfer issue, as well as resident behavior and health issues, and resident assessment tools. To register for this webcast please view this attachment.

Billing Errors & Omissions Liability Program

Friday August 8, 2014

Healthcare is one of the most regulated industries in the U.S. and healthcare providers are extremely vulnerable to allegations of improper billing by both governmental payers and private commercial payers. The Gallagher Billings E&O Program provides important protection to healthcare providers against such allegations. 

Read more about the Gallagher Billings E&O Program

Handling Funds Following the Death of a Medicaid Eligible Resident

Wednesday August 20, 2014

ALERT Nursing Home Providers

Regarding

Handling Funds Following the Death of a Medicaid - Eligible Resident

The purpose of this alert is to clarify the procedures associated with handling  funds following
the death of a Medicaid-eligible nursing home resident. 42 CFR § 483.10(c)(6), the Medicaid Administrative Code 560-X-10.-14(3)(f) and 560-X-22-.25(5)(e) and the Social Security Administration Guide for Representative Payees require that nursing homes, upon the death of a resident, release any funds being held at the facility in the resident's name to the individual or probate jurisdiction designated to administer the deceased resident's estate.

Attached to this alert is a newly developed Administrator of Estate Designation Form which will provide a resident the opportunity to designate who should receive the remaining personal funds. Upon the death of the resident, the completed form in the patient's record will allow a nursing home facility to turn over any remaining funds to the designated Administrator of the Estate.

See attached document for complete ALERT and Administrator of Estate Designation Form.

Webinar: Understanding Sepsis: Recognizing the Risk

Wednesday September 24, 2014

ASHRM Continuing Education Credits Available!

 AHA Solutions' Signature Learning Series

Friday, September 26

1. 1:30 p.m. - 2:30 p.m. Eastern
2. 12:30 p.m. - 1:30 p.m. Central
3. 11:30 a.m. - 12:30 p.m. Mountain
4. 10:30 a.m. - 11:30 a.m. Pacific

SPEAKERS:

1. Jim O'Brien,  M.D., MSc
2. Chairman, Board of Directors, Sepsis Alliance
3. Vice President, Quality and Patient Safety, Ohio Health Riverside Methodist Hospital
4. Pamela Popp, MA, JD
5.  Executive Vice President & Chief Risk Officer
6.  Western Litigation, Inc.
7. Tara Crockett, RN, BN, CHSE, Alumnus CCRN
8. Director Clinical Delivery
9.  Medical Simulation Corp

REGISTER NOW!

Sepsis can arise from any underlying infection, affecting anyone at any time. The symptoms can be easily missed, allowing the disease process to move quickly through the body, resulting in disability, loss of limbs or death.

Hospitals must move quickly and effectively to address this complex condition. This webinar illustrates the risks of  misdiagnosis, the challenges of treatment, and provides practical solutions that providers can undertake to increase early recognition, response and recovery.

Discover the key elements of successful sepsis performance improvement initiatives that improve patient outcomes, lower mortality and reduce health care cost.

You Will Learn:

1. The implications of sepsis to the health care industry
2.  The key challenges to sepsis identification and management
3. About a case study illustrating the difference between early intervention and later intervention
4.  Recommended next Action Steps for a 'SuspectSepsis' initiative

Click here to check out other live and online WLI events!

What should we know about Ebola?

Friday October 10, 2014

EBOLA(This information was obtained from the CDC website: www.cdc.gov)

Ebola, previously known as Ebola hemorrhagic fever, is a rare and deadly disease caused by infection with one of the Ebola virus strains. Ebola can cause disease in humans and nonhuman primates (monkeys, gorillas, and chimpanzees).

Ebola is caused by infection with a virus of the family Filoviridae, genus Ebolavirus.

A severe, often fatal disease, Ebola can be spread in several ways to others: through direct contact (through broken skin or mucous membranes) with a sick person's blood or body fluids or objects that have been contaminated with infected body fluids. Ebola symptoms usually begin after an incubation period ranging from 2 days to 21 days.

Symptoms of Ebola include:

• Fever (greater than 38.6°C or 101.5°F)
• Severe headache
• Muscle pain
• Weakness
• Diarrhea
• Vomiting
• Abdominal (stomach) pain
• Unexplained hemorrhage (bleeding or bruising)

Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the average is 8 to 10 days.

Recovery from Ebola depends on good supportive clinical care and the patient's immune response. People who recover from Ebola infection develop antibodies that last for at least 10 years.

Transmission

When an infection does occur in humans, the virus can be spread in several ways to others. Ebola is spread through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with

• blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola

• objects (like needles and syringes) that have been contaminated with the virus
• infected animals
• Ebola is not spread through the air or by water, or in general, by food. However, in Africa, Ebola may be spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats. There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (for example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread Ebola virus.

Healthcare providers caring for Ebola patients and the family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with infected blood or body fluids of sick patients.

During outbreaks of Ebola, the disease can spread quickly within healthcare settings (such as a clinic or hospital). Exposure to Ebola can occur in healthcare settings where hospital staff are not wearing appropriate protective equipment, including masks, gowns, and gloves and eye protection.

Once someone recovers from Ebola, they can no longer spread the virus. However, Ebola virus has been found in semen for up to 3 months. People who recover from Ebola are advised to abstain from sex or use condoms for 3 months.

Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospital

Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or suspected Ebola virus disease.

How do I protect myself against Ebola?

If you must travel to an area affected by the 2014 Ebola outbreak, protect yourself by doing the following:

• Wash hands frequently or use an alcohol-based hand sanitizer.
• Avoid contact with blood and body fluids of any person, particularly someone who is sick.
• Do not handle items that may have come in contact with an infected person's blood or body fluids.
• Do not touch the body of someone who has died from Ebola.
• Do not touch bats and nonhuman primates or their blood and fluids and do not touch or eat raw meat prepared from these animals.
• Avoid hospitals in West Africa where Ebola patients are being treated. The U.S. Embassy or consulate is often able to provide advice on medical facilities.
• Seek medical care immediately if you develop fever (temperature of 101.5°F/ 38.6°C) and any of the other following symptoms: headache, muscle pain, diarrhea, vomiting, stomach pain, or unexplained bruising or bleeding.
  • Limit your contact with other people until and when you go to the doctor. Do not travel anywhere else besides a healthcare facility.

For general information about Ebola, please use the links below:

• About Ebola(http://www.cdc.gov/vhf/ebola/about.html)
• Signs and Symptoms(http://www.cdc.gov/vhf/ebola/symptoms/index.html)
• Transmission(http://www.cdc.gov/vhf/ebola/transmission/index.html)
• Risk of Exposure(http://www.cdc.gov/vhf/ebola/exposure/index.html)
• Prevention(http://www.cdc.gov/vhf/ebola/prevention/index.html)
• Training (http://www.cdc.gov/vhf/ebola/hcp/safety-training-course)
• Educationalposter (http://www.cdc.gov/vhf/ebola/pdf/what-need-to-know-ebola.pdf)

 This information was obtained from the CDC website.

Your Medical Record is worth 10 times more to hackers than your credit card

Wednesday November 12, 2014

You medical record is worth 10 times more to hackers than your credit. The attachment below contains an article from the New York Daily News that provides information on how cyber criminals are breaking into healthcare computer networks to steal the personal information of patients.

Click here to read more.

Running Annual Background Checks on Employees

Monday December 1, 2014

Recently, the Gallagher Risk Management Services Claims Department has seen an increase in allegations relating to a facility's negligent hiring, training, and supervision of its employees.  Claims relating to the hiring, training, and supervision of employees are often tied to incidents where an employee of a facility has been accused of abuse / neglect of a resident and terminated.  While there is no requirement to perform intermittent background checks, running a background check once a year for every employee could potentially reduce the likelihood that a facility may be susceptible to a claim of negligent hiring, training, and supervision.  Bullet Screening Services provides comprehensive employment screening services.  Through a partnership with Bullet Screening Services, ALTC's clients are able to purchase discounted special employment screening packages, including a $7.00 per employee charge for a background check.  The investment of performing an annual background check on each employee would be an investment in quality control for residents and possibly reduce the significance of a claim for negligent hiring, training, and supervision. You can learn more about the services that Bullet Screening Services provides tor the Senior Care Industry by going to their website at www.bulletscreening.com or calling them at 205-823-5551.

Medical Records Release Policy Procedures for Senior Living Facilities

Tuesday December 2, 2014

It is the policy of the facility to safeguard the privacy and security of protected health information (PHI) and to protect the resident's right to confidentiality of clinical information by releasing resident information or protected health information (PHI) only to authorized persons/agencies, in compliance with state and federal regulations covering treatment, payment, health care operations and/or other mandatory reporting requirements and in accordance with facility policy. The attached link is a sample Release of Medical Records Policy that may help you and your staff comply with these requirements.          

Click here for Release of Medical Records Policy sample.

Recognizing the Role of Delirium in Preventing Rehospitalization

Wednesday December 3, 2014

Delirium will complicate a hospital stay for more than 2.2 million Americans this year, with estimated costs of as much as $8 billion annually. The attached white paper from Relias Learning provides you and your staff with information on how to recognize the role of delirium in preventing Rehospitalization.  

View the Whitepaper

Disaster Management Services Insurance Coverage

Thursday December 4, 2014

New insurance coverage for Disaster Management Services is available through Arthur J. Gallagher and underwritten by Lloyds of London. This coverage will respond in the event of a sudden, unforeseen natural disaster or man-made catastrophe which affects five or more lives, results in multiple fatalities and/or injuries, and/or where the company is directly responsible for the population which is directly affected by the event. To learn more about this coverage and how to obtain a quote you can open the article in the link below.

Read The Article

Violent Malicious Acts Insurance Coverage

Thursday December 4, 2014

New insurance coverage for Violent Malicious Acts is now available through Arthur J Gallagher and is designed to help you and your facility move forward after a tragedy. Violent Malicious Acts coverage insures the necessary Extended Loss of Revenue and Extra Expense you incur in order to continue the normal conduct of the facility's operations following a Violent Malicious Act. To learn more about this coverage and how to obtain a quote you can open the article in the link below.

Read The Article

Gaps Continue to Exist in Nursing Home Emergency Preparedness and Response During Disasters

Thursday December 18, 2014

This study from the Department of Health and Human Services (OIG) found that even though most nursing homes met Federal requirements for written emergency plans and preparedness training there were many gaps in these plans. These emergency plans lacked relevant information, including only about half of their tasks on the CMS checklist. Nursing Homes faced challenges with unreliable transportation contracts, lack of collaboration with local emergency management, and residents that developed health problems. The attachment below contains the entire study from the OIG.

Nursing Home Disaster Prepardness and Response during Disasters 2007-201.pdf

Emerging Environmental Risks in the Healthcare Industry

Thursday December 18, 2014

This report was published by Advisen and sponsored by Ace Insurance. Healthcare in the United States is in the midst of unparalleled transformation, driven in large measure by the Patient Protection and Affordable Care Act. Many of the environmental exposures of healthcare organizations may fall under core EPA programs or similar state regulations, making it important that healthcare organizations maintain a sharp focus on environmental compliance. Maintaining this focus and identifying emerging environmental exposures while in a period of growth and rapid change will be a continuing challenge for risk managers, compliance officers, and administrators. The attachment below contains the report on these merging environmental risks.

Advisen Emerging Healthcare Environment Risk WhitePaper.pdf

Mandatory OSHA 300 Log Reporting and Record Keeping for 2015 and OSHA in 2015 and Beyond

Monday January 5, 2015

There are new OSHA Reporting Requirements now in effect. Beginning on January 1, 2015, there is a change to what covered employers are required to report to OSHA. Employers are now required to report all work related fatalities within 8 hours and all inpatient hospitalizations, amputations, and losses of an eye within 24 hours of finding out about the incident. The attachments below provide more information about the new Mandatory OSHA Reporting and Record Keeping requirements for 2015.

Mandatory OSHA 300 Log Reporting and Recordkeeping for 2015
OSHA in 2015 and beyond

Documenting After an Incident

Wednesday January 7, 2015

Recently, an incident was reported where a resident suffered a fall.  Unfortunately, after the incident the facility failed to document the resident's overall status during the next 24 hours.  As a result, it is difficult to   determine whether the change in status was related to the incident or another event/condition.  Attached is a resource for your facilities as a reminder and guidance for documenting after an incident. 

Click here for file.

Winter Weather Preparedness Checklist

Wednesday January 7, 2015

The winter season is right around the corner and it is a good time to plan for and mitigate the property damage, employee illness and injury, and even business closures that can be caused by severe winter weather.The following checklist will help you identify the areas of your business that are most susceptible to winter hazards.

Click here for Winter Weather Preparedness Checklist

Disclaimer: I would like to emphasize that the discussions, examples and templates set forth above are from an insurance/risk management perspective and is NOT legal advice.  We do not provide legal advice as we are not qualified to do so.  I highly recommend that you seek the advice of legal counsel in order to become fully apprised of the legal implications related to these issues. The information contained herein was obtained from sources which to the best of the writer's knowledge are authentic and reliable.  Arthur J. Gallagher makes no guarantee of results, and assumes no liability in connection with either the information herein contained, or the safety suggestions herein made.  Moreover, it cannot be assumed that every acceptable safety procedure is contained herein, or that abnormal or unusual circumstances may not warrant or require further or additional procedures, resources or advice. 

Arthur J Gallagher’s Risk Management Strategies Webcasts

Monday January 12, 2015

Arthur J Gallagher put together a series of webcasts on risk management strategies that included Generating a Culture Change Mindset in Workplace Safety, Simple Steps for Creating a Strong Safety Structure, and Safety Communication for Speakers of Spanish and Other Languages.

View the three Risk Management Strategies Webcasts. 

Disclaimer: I would like to emphasize that the discussions, examples and templates set forth above are from an insurance/risk management perspective and is NOT legal advice.  We do not provide legal advice as we are not qualified to do so.  I highly recommend that you seek the advice of legal counsel in order to become fully apprised of the legal implications related to these issues. The information contained herein was obtained from sources which to the best of the writer's knowledge are authentic and reliable.  Arthur J. Gallagher makes no guarantee of results, and assumes no liability in connection with either the information herein contained, or the safety suggestions herein made.  Moreover, it cannot be assumed that every acceptable safety procedure is contained herein, or that abnormal or unusual circumstances may not warrant or require further or additional procedures, resources or advice.  

Responding to an OSHA Inspection – Document Production

Monday January 12, 2015

In many cases, employers are experienced with the walk around and employee interview aspect of an OSHA Inspection, but are unsure of what documents the compliance officer is entitled to inspect and to request copies. The article in the link below is intended to give guidance in this area.

Click here for article  - Responding to An OSHA Inspection IV.

Disclaimer: I would like to emphasize that the discussions, examples and templates set forth above are from an insurance/risk management perspective and is NOT legal advice.  We do not provide legal advice as we are not qualified to do so.  I highly recommend that you seek the advice of legal counsel in order to become fully apprised of the legal implications related to these issues. The information contained herein was obtained from sources which to the best of the writer's knowledge are authentic and reliable.  Arthur J. Gallagher makes no guarantee of results, and assumes no liability in connection with either the information herein contained, or the safety suggestions herein made.  Moreover, it cannot be assumed that every acceptable safety procedure is contained herein, or that abnormal or unusual circumstances may not warrant or require further or additional procedures, resources or advice. 

Responding to an OSHA Inspection – Employee Interviews and Employee Interview Rights

Monday January 12, 2015

During an OSHA inspection, the Compliance Officer will request employee interviews in order to gather facts as to whether there may have been violations of the Agency's regulations. Many employers fail to advise their employees of their rights during such interviews and these rights are never exercised. The links below provide you with the general rights of employees during employee interviews.

 Click here for article - RMSI - Responding to An OSHA Inspection II - Employee Interviews

 Click here for article - RMSI - Responding to An OSHA Inspection III - Employee Interview Rights

Disclaimer: I would like to emphasize that the discussions, examples and templates set forth above are from an insurance/risk management perspective and is NOT legal advice.  We do not provide legal advice as we are not qualified to do so.  I highly recommend that you seek the advice of legal counsel in order to become fully apprised of the legal implications related to these issues. The information contained herein was obtained from sources which to the best of the writer's knowledge are authentic and reliable.  Arthur J. Gallagher makes no guarantee of results, and assumes no liability in connection with either the information herein contained, or the safety suggestions herein made.  Moreover, it cannot be assumed that every acceptable safety procedure is contained herein, or that abnormal or unusual circumstances may not warrant or require further or additional procedures, resources or advice. 

A Minute For Safety

Wednesday March 4, 2015

A close call or an accident without injury is easy to shrug off and forget. But there is a danger in brushing off accidents that don't hurt, harm or cause damage. This article provides you with information on what you should consider doing when an accident or close call occurs.    

Read the article.

Whistleblower Claims Under the Patient Protection and Affordable Care Act: An Emerging Concern for Employers and Insurers

Thursday March 5, 2015

This article provides information about the rise in OSHA related whistleblower claims and Affordable Care Act whistleblower protected activities.

Read the article.

Legionella Prevention Plan Introduction

Friday March 6, 2015

Legionella 101

Legionellae are rod-shaped, gram negative bacteria. Over 40 species of Legionella have been identified; L. pneumophila appears to be the most virulent and is associated with approximately 90% of cases of Legionellosis. The risk of acquiring Legionnaires' disease is greater for older persons and for those who smoke tobacco or have chronic lung disease. Persons whose immune system is suppressed by certain drugs or by underlying medical conditions appear to be at particularly high risk.

Legionellae bacteria are commonly present in natural and man-made aquatic environments. The organism is occasionally found in other sources, such as mud from streams and potting soils. In natural water sources and municipal water systems, Legionellae are generally present in very low or undetectable concentrations. However, under certain circumstances within manmade water systems, the concentration of organisms may increase, a process termed "amplification." Conditions that are favorable for the amplification of legionellae growth include water temperatures of 25-42 degrees Celsius (°C) (77-108 degrees Fahrenheit), stagnation, scale and sediment, biofilms, and the presence of amoebae. Legionellae infect and multiply within several species of free-living amoebae, as well as ciliated protozoa. The initial site of infection in humans with Legionnaires' disease is the pulmonary macrophage. These cells engulf Legionellae, provide an intracellular environment that is remarkably similar to that within host protozoa, and allow for multiplication of the bacterium. Growth in nature in the absence of protozoa and/or in the absence of complex microbial biofilms has not been demonstrated.

There is an indication that growth of Legionella is influenced by certain materials. Natural rubbers, wood, and some plastics have been shown to support the amplification of Legionella, while other materials such as copper inhibit their growth. Generally, Legionella thrive in diverse, complex microbial communities because they require nutrients and protection from the environment. Controlling the populations of protozoa, and other microorganisms may be the best means of minimizing Legionella.

Transmission of Legionnaires' Disease

Most data on the transmission of Legionnaires' disease are derived from investigations of disease outbreaks. These data suggest that, in most instances, transmission to humans occurs when water containing the organism is aerosolized in respirable droplets (1-5 micrometers in diameter) and inhaled by a susceptible host. A variety of aerosol-producing devices have been associated with outbreaks of Legionnaires' disease, including cooling towers, evaporative condensers, showers, whirlpool spas, humidifiers, decorative fountains, and a grocery store produce mister. Aspiration of colonized drinking water into the lungs has been suggested as the mode of transmission in some cases of hospital-acquired Legionnaires' disease. Numerous investigations have demonstrated that cooling towers and evaporative condensers have served as the sources of Legionella-contaminated aerosols causing outbreaks of community- and hospital- acquired infection. A number of outbreaks of Legionellosis associated with cooling towers and evaporative condensers have occurred after these devices have been restarted following a period of inactivity. Shower heads and tap faucets can also produce aerosols containing legionellae in droplets of respirable size.

Common amplifiers (growth factors) associated with building water systems, including the treatment recommended to minimize the risk of Legionellosis, are discussed below.

Potable Water Systems

Factors associated with the plumbing system that may influence the growth of legionellae are as follows:

• Chlorine concentration;
• Temperature; and
• Plumbing system design and materials

Municipal potable water supplies are generally chlorinated to control the presence of microorganisms associated with sewage. Legionellae are more tolerant of chlorine than many other bacteria, and may be present in small numbers in municipal water supplies. Potable water can also support legionellae growth if the water temperature is in the range of 77-108°F. Plumbing design and materials also influence the growth of legionellae.

Growth of legionellae may occur in portions of the system with infrequent use, in stagnant water, and in portions of the system with tepid temperatures. Growth may also occur in dead-end lines, attached hoses, shower nozzles, tap faucets, hot water tanks, and reservoirs. Rubber washers and fittings, including water hammer arrestors and rubber hoses with spray attachments, have been shown to provide sites for growth of legionellae. Organic compounds leached from plumbing materials may contribute to growth of heterotrophic bacteria, including legionellae.

Contaminated potable water sources present the greatest risk when dispersed into the air in a very small droplet size (less than 5 micrometers) that can be inhaled deeply into the lungs. Actions that may generate small droplets are those that break up the water stream, i.e., shower nozzles, aerators, spray nozzles, water impacting on hard surfaces, and bubbles breaking up. Both dead and living microorganisms, biofilms, and debris may provide nutrient sources for legionellae growth. When legionellae are found in plumbing systems, it is common to detect the microbes in the sediment in hot water tanks, and in peripheral plumbing fixtures that accumulate sediment.

Where practical in high-risk situations, cold water should be stored and distributed at temperatures below 20°C (68°F), while hot water should be stored above 60°C (140°F) and circulated with a minimum return temperature of 124°F. However, great care should be taken to avoid scalding problems. One method is to install preset thermostatic mixing valves. Where buildings cannot be retrofitted, periodically increasing the temperature to at least 66°C (150°F) or chlorination followed by flushing should be considered. Systems should be inspected annually to ensure that thermostats are functioning properly. Where practical in other situations, hot water should be stored at temperatures of 120°F or above. Those hot or cold water systems that incorporate an elevated holding tank should be inspected and cleaned annually. Lids should fit closely to exclude foreign materials.

Where decontamination of hot water systems is necessary (typically due to implication of an outbreak of Legionellosis) the hot water temperature should be raised to 160~170°F and maintained at that level while progressively flushing each outlet around the system. A minimum flush time of five minutes has been recommended by the Center for Disease Control. However, the optimal flush time is not known and longer flush times may be necessary.

Emergency Water Systems-safety Showers, Eye Wash Stations, And Fire Sprinkler Systems

These systems are generally plumbed to the potable water system, have little or no flow with resulting stagnant conditions, and may reach temperatures warmer than ambient. The presence of legionellae, heterotrophic bacteria, and amoebae in these systems has been documented. When the devices are used, aerosolization is expected.

Safety shower and eye wash stations should be flushed at least monthly. In the case of fire sprinkler systems, it is recommended that fire-fighting personnel wear protective respiratory gear and that non- firefighting personnel exit the burning area. Appropriate precautions should be taken when checking the operation of fire sprinkler systems.

Architectural Fountains And Waterfall Systems

In these systems, water is either sprayed in the air or cascades over a steep media such as rocks, and then it returns to a man-made pool. These systems are sometimes operated intermittently with on-time often scheduled only during certain time periods. Systems that are operated intermittently may encourage greater biocontamination.

Because of the high temperature ranges needed for proliferation of legionellae bacteria, outdoor fountains and pools in hotter climates, and indoor fountains and pools subject to sources of heat may be susceptible to legionellae growth. Temperature increases may be facilitated by heat from pump/filter systems themselves. Intermittent operation may also create situations where temperature increases occur in isolated areas of the system. Fountains are subject to contamination from a wide variety of potential nutrient sources, including materials scrubbed from the air and returned to the pool with the falling water droplets as well as organic and inorganic materials dropped, thrown, or blown into the pool.  

The recommended treatment for fountains includes:

• Regular cleaning is recommended; and
• Use of filters should be considered; however, systems with a small water volume may be drained, and refilled with fresh water every few weeks in lieu of filtering.

Microbial fouling control is important, especially where the conditions are such that there are significant periods of time when the temperature of the fountain water is in the range that is favorable for the amplification of legionellae growth. When biocidal treatment is employed for microbial fouling control, the biocide must be registered with the United States Environmental Protection Agency (USEPA) for use in decorative fountains.

Cooling Towers Including Fluid Coolers (closed-circuit Cooling Towers) And Evaporative Condensers

Evaporative heat rejection equipment such as cooling towers and evaporative condensers have been implicated in numerous outbreaks of Legionnaires' disease, and studies have shown that detectable levels of legionellae are present in many of these devices.

A cooling tower is an evaporative heat transfer device in which atmospheric air cools warm water, with direct contact between the water and the air, by evaporating part of the water. Air movement through such a tower is typically achieved by fans, although some large cooling towers rely on natural draft circulation of air. Cooling towers typically use some media, referred to as "fill," to achieve improved contact between the water and the cooling air. The typical temperature of the water in cooling towers ranges from 85°F to 95 °F although temperatures can be above 120 °F and below 70°F depending on system heat load, ambient temperature, and system operating strategy.

Closed-circuit cooling towers and evaporative condensers are also evaporative heat transfer devices. Both are similar to conventional cooling towers, but there is one very significant difference. The process fluid (either a liquid such as water, an ethylene glycol/water mixture, oil, etc., or a condensing refrigerant) does not directly contact the cooling air. Rather, the process fluid is contained inside a coil assembly. Water is drawn from the basin and pumped to a spray distribution system over the coil assembly while the cooling air is blown or drawn over the coil by fans. Removal of heat is achieved by evaporating part of the water. Water temperature in closed-circuit cooling towers and evaporative condensers is similar to that in cooling towers.

Cooling towers and evaporative condensers incorporate inertial stripping devices called drift eliminators to remove water droplets generated within the unit. While the effectiveness of these eliminators can vary significantly with the design (new state-of-the-art eliminators are significantly more efficient than older designs) and the condition of the eliminators, it should be assumed that some water droplets in the size range of less than 5 micrometers leave the unit. In addition, some larger droplets leaving the unit may be reduced to 5 micrometers or less by evaporation.

Because cooling towers and evaporative condensers are highly effective air scrubbers and because they move large volumes of air, organic material and other debris can be accumulated. This material may serve as a nutrient source for legionellae growth. Diverse biofilms, which can support the growth of legionellae, may be present on heat exchanger surfaces, structural surfaces, sump surfaces, and other miscellaneous surfaces.

The key recommendations are that the system be maintained clean and that a biocidal treatment program be developed and implemented. It is also recommended that the services of a qualified water treatment specialist be used to define and oversee the treatment. Keeping the system clean reduces the nutrients available for Legionella growth. Regular visual inspections should be made for general cleanliness. The cold water basin of the unit should be cleaned when any buildup of dirt, organic matter, or other debris is visible or found through sampling. Mechanical filtration may be used to help reduce these solids. Strainers, cartridge filters, sand filters, centrifugal-gravity-type separators, and bag-type filters can be used to assist in removal of debris. The drift eliminators should also be inspected regularly and cleaned if required or replaced if deteriorated or damaged.

An effective water treatment program allows more efficient operation due to lower fouling, a longer system life due to decreased corrosion, and safer operation of the system due to reduced chances of microbial exposure to the public.

Control of scaling and corrosion is necessary in many water treatment programs. Scale such as calcium carbonate and/or other minerals containing silica, magnesium, and phosphate may precipitate onto heat exchanger and piping surfaces. Scaling can be minimized by use of inhibitors containing phosphonates, phosphates, and polymers to keep calcium and carbonate and other minerals in solution. Corrosion can be minimized by the use of inhibitors such as phosphate, azoles, molybdenum, and zinc. Scale and corrosion inhibitors are effective if microbial fouling and biofilm development are properly controlled. Microbial fouling can influence scaling and corrosion processes and can affect the performance of inhibitors. Microbial biofilms on surfaces can consume certain inhibitors (such as phosphates, phosphonates, and azoles), prevent access of inhibitors to surfaces, create localized oxygen-depleted zones, change the pH near surfaces, and accumulate or trap deposits onto surfaces.

Microbial fouling is controlled by the use of biocides, which are compounds selected for their ability to kill microbes while having relatively low toxicity for plants and animals. In the USA, the Environmental Protection Agency has regulatory authority for biocides and requires registration of all biocides. In addition, registration is required in each state where the biocide will be distributed. Non-oxidizing biocides include many organic compounds registered with the USEPA for cooling water applications. These biocides function in a number of ways, including reacting with intracellular enzymes, solubilizing cell membranes, and precipitating essential proteins in microbial cell walls. Properly used, non-oxidizing biocides are effective for control of the microbial fouling process in cooling water systems. It is generally good practice to regularly alternate the biocides used for a cooling water system to avoid the selection and growth of resistant strains of microbes. The alternating biocide approach has been emphasized with the rationale that the population that survives the biocide treatment one week is susceptible to the alternate biocide a week or two later. Alternating the dose and frequency of the same biocide is also used to achieve this goal.

Equally important to controlling scale and corrosion is keeping the system clean and free of sediment. Common sources of sediment include materials scrubbed from the air (dirt, leaves, paper, kitchen or other organic exhaust), precipitated solids (calcium, magnesium, carbonate silica), and corrosion products (rust). Microbes including bacteria, protozoa, algae, and (infrequently) fungi can grow in cooling systems and use the above materials as nutrients. Consequently, it is desirable to either prevent the entry of the material into the system or to remove it from the system.  

When the system is to be shut down for a period of more than three days, it is recommended that the entire system (cooling tower, system piping, heat exchangers, etc.) be drained to waste. When draining the system is not practical during shutdowns of short duration, the stagnant cooling water must be pretreated with an appropriate biocide regimen before tower start-up.

OSHA Updates Guidance for Protecting Healthcare and Social Service Workers from Workplace Violence

Wednesday April 15, 2015

This article provides guidance from OSHA for protecting healthcare and social service workers from workplace violence.    

Click here to view the article

CMS Data Submission Payroll Based Journal (PBJ)

Wednesday April 15, 2015

CMS has developed a system for facilities to submit staffing and census information - Payroll Based Journal (PBJ). This system will allow staffing and system information to be collected on a regular and more frequent basis than currently collected. It will also be auditable to ensure accuracy. All long term care facilities will have access to this system at no cost to facilities. The following links contain technical information related to the PBJ and are available below. 

Click here for pdf.

Click here for link.

Chubb (Federal Insurance Company) Policyholder Loss Control Services

Wednesday July 1, 2015

If you are a Chubb Policyholder then you have access to valuable loss prevention information. Chubb designs comprehensive risk management services to accurately fit a client's risk needs. Many of these value added services are available to Chubb clients at no additional fee. The attachment to this News Article includes a list of the risk management services that are available to Chubb clients.  

Download the attachment

ICD-10 Quick Start Guide

Tuesday July 7, 2015

This guide outlines 5 steps health care professionals should take to prepare for ICD-10 by the October 1, 2015, compliance date. You can complete parts of different steps at the same time if that works best for your practice.

Download the attachment

ICD-10 Compliance Date October 1, 2015

Wednesday July 8, 2015

In response to requests from the provider community, CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set. For more details, please see the joint announcement on the CMS ICD-10 website. The website link is included in the attachment to this News Article.        

Download the attachment

Article From McKnight’s on the Increasing Importance of Statistical Analysis in Defending Against Fraud and Abuse Allegations and Billing Errors & Omissions Liability Insurance Coverage

Friday August 14, 2015

The article below is from a recent edition of McKnight's and addresses the importance of Statistical Analysis in defending fraud and abuse allegations in long term care facilities. To learn more about Arthur J Gallagher's Billing Errors & Omissions Liability Insurance Program please open the attachment below. Please contact Gerry Gilbert in our office to discuss this Liability Insurance Program and its availability. He can be reached at 205-414-6184 or by email at gerry_gilbert@ajg.com.

In this month's McKnight's article, the author reviews the increasing importance of statistical analysis in defending against fraud and abuse allegations.

False Claims Act enforcement, and the attendant risk of financial liability, is on the rise. The United States Department of Justice has obtained almost $44 billion in FCA settlements and judgments since 1986, and almost $6 billion in 2014 alone. Significantly, roughly $2.5 billion of the funds recovered in 2014 came from the health care industry, marking the fifth straight year of fraud recoveries in excess of $2 billion. If FBI estimates that 3% to 10% of all federal healthcare billings are lost to fraud, then it would appear that these eye-popping numbers still have room to grow.

FCA enforcement in the long term care industry has been no exception. The industry has been squarely in the sights of government enforcement attorneys following a 2012 report from the Office of Inspector General that found roughly 20% of all Medicare Part A SNF claims were upcoded to a higher RUG group in 2009, resulting in $1.2 billion in improper payments. Recent FCA complaints have relied on a number of arguments to substantiate the submission of false claims for Medicare reimbursement: systematic upcoding to higher RUG levels due to corporate pressure on front line care providers; targeting therapy at or around RUG thresholds; increasing therapy during look back periods; and providing skilled therapy that was not required for improvement in functioning.
Although long-term care providers and other FCA defendants have raised a wide range of reasonable explanations for the billing patterns identified in recent complaints, the DOJ and private whistleblowers have been emboldened by a series of significant settlements. Enforcement attorneys have also been given a new, and potentially game-changing, tool thanks to a series of recent court opinions involving the use of statistical sampling and extrapolation to demonstrate FCA liability.

Wait, don't they need to identify an actual claim?

While courts have long recognized statistical sampling as a valid method of proof, its use in FCA cases has been, until recently, fairly limited. The reasons for this limitation are somewhat intuitive, as sampling has typically been used to prove the amount of damages resulting from a fraudulent billing scheme (i.e., the amount the government was overbilled). This status quo, however, was disrupted in late 2014 when the Eastern District of Tennessee gave its blessing for prosecutors in U.S. ex rel. Martin v. Life Care Centers of America to use statistical sampling and extrapolation to prove not only damages, but actual liability under the FCA.

Life Care operates over 200 skilled nursing facilities nationwide that received $4.2 billion in Medicare reimbursement between 2006 and 2011. In Martin, the company is alleged to have engaged in a systematic practice of upcoding and providing medically unnecessary services that resulted in the submission of 150,000 false claims involving over 54,000 patients. In the typical FCA case, the government would have needed to demonstrate which of those 150,000 claims were false (i.e., submitted for medically unnecessary services) and whether the defendant knew those claims were false at the time they were submitted to a federal health care program. In Martin, however, the government analyzed just 400 representative sample cases and then sought to extrapolate the percentage of claims identified as false to the larger universe of 150,000 unidentified claims. Not surprisingly, Life Care sought summary judgment (i.e., that there is no factual dispute and the law requires a judgment in its favor) as to the unidentified claims, arguing that the falsity of an individual claim cannot be determined through statistical means.

Contrary to established expectations, the court denied Life Care's motion and allowed the case to go to trial. While granting that using extrapolation to establish damages when liability has been proven is different than using extrapolation to establish liability and finding no definitive precedent for doing so, the court still found that the government could use the evidence to prove its case due to the general acceptability of statistical analysis. Life Care, meanwhile, would be free to argue that the jury should not credit the government's analysis because it is wrong or flawed.

As a practical matter, the use of statistical analysis to prove liability instead of damages would do two things. First, it would dramatically reduce the time and scrutiny of individual claims that is usually necessary to prosecute a credible FCA case. Second, and relatedly, it would allow the government and/or private whistleblowers to expand vastly the universe of allegedly false claims and set the stage for an environment where, once a handful of allegedly false claims is identified, every claim a defendant made within a specific time period could be fair game. And in this sort of environment, long-term care providers could see their FCA exposure driven less by pesky details like fact and medical necessity, and more by their ability to hire a better mathematics expert than their whistleblower.

This is not good news for providers, especially in light of the other recent changes to the FCA statute that have made it easier for whistleblowers to extract significant settlements.

A slippery slope ahead

Already, Life Care is beginning to bear fruit for whistleblowers and their attorneys. In U.S. ex rel. Ruckh v. CMC II LLC, for example, a federal judge in the Middle District of Florida cited Life Care in an order allowing the relator to use statistical evidence to prove liability in an FCA case involving roughly identical allegations of upcoding and medically unnecessary procedures. If Life Care continues to gain traction in cases such as Ruckh, it will create a dangerous precedent for long term care providers.

Download the attachment

Helping Victims of Mass Violence and Terrorism

Sunday October 4, 2015

The link below contains a website developed by the Office of Justice Programs designed to help victims of mass violence and terrorism. This website's toolkit provides tools and resources for developing a comprehensive victim assistance plan that can be incorporated into your facility's existing emergency response plan. Victim assistance plans support and enhance your response and recovery efforts. The toolkit's Partnership and Planning Section reviews how to create and maintain partnerships, addresses resource gaps, and develop victim protocols, and its Response and Recovery Section covers how to use the protocols after an incident of mass violence or terrorism. The Tools Section includes checklists, samples, a glossary, and a collection of victim assistance resources.   

http://www.ovc.gov/pubs/mvt-toolkit/   

Article from McKnight’s on new proposed rules from CMS that will establish specific requirements when a long term care facility uses bed rails on a resident’s bed.

Thursday October 8, 2015

The link below contains a good article from McKnight's on new proposed rules from CMS that will establish specific requirements when a long term care facility uses bed rails on a resident's bed.

http://www.mcknights.com/guest-columns/examining-bed-rail-use-in-long-term-care/article/443728/?DCMP=EMC-MCK_Daily&spMailingID=12611976&spUserID=NDM1NzE4MTg1NTMS1&spJobID=640492421&spReportId=NjQwNDkyNDIxS0

Article from McKnight’s on different ways to provide good customer service at your long term care facility.

Thursday October 8, 2015

The link below contains a good article from McKnight's on different ways to provide good customer service at your long term care facility.

http://www.mcknights.com/guest-columns/delivering-good-customer-service-in-long-term-care/article/442886/?DCMP=EMC-MCK_Daily&spMailingID=12589489&spUserID=NDM1NzE4MTg1NTMS1&spJobID=640364571&spReportId=NjQwMzY0NTcxS0

Article from McKnight’s on resident’s chronic pain in long term care facilities and the use of opioids as part of the pain management treatment.

Thursday October 8, 2015

The link below contains a good article from McKnight's on resident's chronic pain in long term care facilities and the use of opioids as part of the pain management treatment.

http://www.mcknights.com/guest-columns/america-should-talk-about-chronic-pain/article/442864/

Investigation and Reporting of Visitor Injuries Checklist

Friday October 9, 2015

The attachment below contains an Investigative and Reporting Visitor Injuries Checklist that can be used as a resource to help develop or revise your facility's Visitor Injury Guidelines. These guidelines should not be interpreted as facility policy and should only be used as a resource.

Download the attachment

Billing Errors & Omissions Coverage for Healthcare Providers

Thursday November 12, 2015

Healthcare is one of the most regulated industries in the U.S. and healthcare providers are extremely vulnerable to allegations of improper billing by both governmental payers and private commercial payers. The Gallagher Billing E&O Program provides important protection to healthcare providers against such allegations .This exclusive program provides the following key benefits:

·         Indemnity and Defense Protection from regulatory fines & penalties associated with billing errors

·         Protection includes both governmental payers and private payers

·         Qui Tam Plaintiffs

·         Coverage for EMTALA, Stark, or HIPAA Proceedings

·         Expert panel defense counsel

·         Prior acts coverage available

·         Expeditious Quotation and Underwriting process


Please contact Gerry Gilbert for questions and to secure a quote for this coverage. Gerry can be reached by telephone at 205-414-6184 or by email at gerry_gilbert@ajg.com.  

What You Should Know for the 2015-2016 Influenza Season

Wednesday November 18, 2015

The link below contains information from the CDC that you should know about the 2015-2016 influenza season.     

http://www.cdc.gov/flu/about/season/flu-season-2015-2016.htm

Active Shooter/Workplace Violence

Friday August 12, 2016

With the recent shooting tragedies in healthcare facilities, businesses, schools, etc., it is apparent that no facility/business is immune to these acts of violence.  These tragedies should be an alert for all businesses to evaluate current policies, practices and drills in order to prepare staff on how to respond in these potential situations that place residents and staff at risk.  Attached please find sample resources relating to Active Shooter policies, Workplace Violence policies, and a resource published by FEMA, HHS, US Department of Homeland Security, and the Assistant Secretary for Preparedness and Response.  Please feel free to utilize these tools as you evaluate your current procedures.  

Active Shooter Policy-AJG 2015

Active-shooter-planning-eop2014

Workplace Violence Policy-AJG 2014

Winter Weather Preparedness

Friday December 4, 2015

With the winter weather season upon us it's time to review your winter weather preparedness procedures to make sure your facility is ready for winter weather. The attachment below contains a Winter Weather Preparedness presentation that was developed by Arthur J Gallagher and Agility Recovery. This information may be helpful to you when you are making sure your facility is ready for winter weather.

Agility Winter Weather Preparedness Webcast Handouts 2015

Are Pregnant Employees Entitled to Light Duty?

Friday December 11, 2015

Probably, as a result of the Supreme Court's recent decision in Young v. UPS.

Many employers have had a long-standing policy or practice of providing temporary light duty only to employees who are returning to work from an on-the-job injury. "Light duty" is typically a job or project that is specially created to help an injured worker that would otherwise not exist. Limiting these special assignments to workers who get hurt at work makes sense. Employers feel an obligation to their employees that get hurt at work, and employers have a financial interest in these employees coming back to work as soon as possible. Also, most employers have limited light duty opportunities and, therefore, want to preserve them for employees who are recovering from work-related accidents. Someone with a condition unrelated to the job, such as injuries from a car accident or pregnancy, does not get light duty under the typical policy. If the employee with a non-occupational injury cannot do the essential functions of the job, even with accommodation, he must go on leave of absence.

That is what happened to the pregnant UPS driver in Young v. UPS. Her doctor put her on a lifting restriction that prevented her from lifting some UPS packages. Although it would have allowed someone injured at work with the same lifting restriction to perform light duty, Young had to go on unpaid leave and could not afford to keep her health insurance.

Ultimately, the United States Supreme Court rejected both parties' positions and created a new standard for judging the legality of such policies. If a company's policy "significantly burdens" pregnant workers (as most light duty policies do), the company must advance "sufficiently strong" reasons to justify the burden. Cost and inconvenience are not sufficient, the Court said. The Supreme Court sent the case back to the lower court for further litigation under this new standard. Given what the Court has required that it prove, however, UPS is not likely to be able to successfully defend its policy.

Policies like UPS's, which are common, will now be very difficult, if not impossible, to defend. Even if such a policy can be successfully defended, an employer will spend a lot of money doing it. In our opinion, an employer would have to have substantial operational reasons, apart from cost and inconvenience, to limit light duty opportunities to only those who have been hurt at work and to the exclusion of pregnant workers. All employers should review their policies and consult with counsel about the ability to defend them after this important change in the law.

Click on the link to read the Young v. UPS U.S. Supreme Court decision.

http://www.supremecourt.gov/opinions/14pdf/12-1226_k5fl.pdf

Electronic Submission of Staffing Data through the Payroll-Based Journal (BPJ) will soon be mandatory:

Monday December 14, 2015

CMS has allowed nursing homes to voluntarily submit staffing and census data through the PBJ system since October 1, 2015.  As of July 1, 2016, collecting this staffing and census data will be mandatory for all nursing homes.  Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data.  The data, when combined with census information , can be used to not only report on the level of staff in each nursing home, but also to report on employee turnover and tenure, which can impact the quality of care delivered.  (Resource: www.CMS.gov )

For registration and training, please refer to the attached PDF. 

Payroll Based Journal

Friday January 8, 2016

In accordance with Section 6106 of the Affordable Care Act facilities are required to electronically submit staffing information to drive accountability effective July 1, 2016.

Providers will be required to submit their staffing and census data quarterly. They will have 45 days after the last day in each fiscal quarter to submit - making the due date for the first PBJ submission November 14, 2016

Get Ready With These Five Steps:   

1.  Identify & Classify All Direct Staff - all direct care staff (including agency and contract staff), does not include individuals whose primary duty is maintaining the physical environment (example housekeeping).
CMS defines direct care staff as those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

· Create a Unique Employee ID - for each direct care employee; should not contain any personally identifiable information, such as a Social Security Number (SSN).

· Hire Date - the first date of a staff member's employment and is paid for services rendered, either through direct employment or under contract. Note: Contract Employees -first date worked at the facility and billed for.

· Termination Date - the last date of a staff member's employment and is paid for services rendered either through direct employment or under contract. Note: Contract Staff - the last date the facility communicates that the contract employee will no longer be providing services (either voluntary or involuntary).

· Pay Type Code - categorizes the staff member as a direct employee of the facility (exempt or non-exempt), or hired under contract and paid by the facility. Note: non-exempt - entitled to overtime pay, exempt - not entitled to overtime pay, contract - individuals under contract and individuals who provide services through organizations that are under contract.

2.   Assign CMS Job Codes - identifying and assigning a CMS job code to an employee for each and every shift to ensure a payroll-based reporting submission is accurate and complies with CMS requirements. CMS has defined 37 job Codes to be used when reporting direct care hours worked. Facilities should report the hours worked based on an employee/s primary function for that shift.

There must be a job code attached for every hour submitted through the PBJ system. Job responsibilities can change multiple times throughout the day and CMS recognizes that most roles have a variety of non-primary duties that are provided throughout the day.

Assign each position and shift a job code, this job code should be used and paired with the direct care staff including agency and contract staff, which works those shifts.

See Attached CMS PBJ Version 1.0 Policy Manual Table 1: Labor and Job Codes and Descriptions.

3.   What Should Be Counted, What Should Not Be Counted? - It is important for facilities to know what should and should not be reported in the PBJ when compiling a complete an accurate file for submission. CMS has provided situations where direct care hours worked should not be reported:

· Hours paid for any type of leave or non-work related absence from the facility.
· Any unpaid overtime (a salaried employee works 10 hours but is only paid for 8 hours).
· Hours for services performed that are billed to FFS Medicare or other payer.
· Hours providing services to residents in non-certified beds.

One of the biggest challenges for submission of the PBJ will be to gather and aggregate staffing data from disparate sources. Direct care hours are usually tracked through time and attendance systems. The following situations could possibly be overlooked but should be reported:

· Contract and Agency work.
· Corporate staff at a facility performing task/duties that fit into a CMS job category (e.g. Regional Director fills in for the Administrator that's out on vacation or leave).
· Salaried staff that do not clock in or clock out.

4.   Create a Checks and Balances System - CMS provided examples of the difficulty facilities may experience in their ability to appropriately track and allocate exact hours.

· For Medical Directors, it might be difficult to allocate the exact hours spent performing medical director duties as opposed to primary care duties.
· For Consultants, it might be difficult to identify the exact hours a specialist contractor (e.g. non-agency nursing staff) is on-site.

(Note: It is important for facilities to define their expectations within their service provider contract.)

(CMS has stated that the hours reported should be based on payments made for services and be verified through payroll, invoices and/or tied back to contract).

5.   Start Now and Be Ready - Your success will be determined based on staffing with the PBJ staffing measurements by implementing a proactive process to identify and adjust staffing levels. Staffing is a challenging process with constant shift updates including call-offs, time-off requests, employee no-shows, and fluctuations in census, activity, acuity and workload.

Set up a process that allows staffing information to be easily accessed, create dashboards that identifies staffing requirements based on census, against budgeted hours. If gaps are identified adjustments should be made.

CMS has identified staffing as a key component in delivering quality care and positive resident outcomes. They use staffing information in the Nursing Home Five Star Quality Rating System to help consumers understand the level and differences of staffing in nursing homes. CMS requires facilities to submit CMS Form 671 and CMS Form at the time of survey to calculate the Staffing Domain of the Five Star Rating System.

Hopefully utilizing these 5 steps will help your facility achieve the staffing and management goals that will enable you to correctly document and report direct care hours worked.

 Payroll Based Journal

CMS Scheduled Extended Maintenance – March 16, 2016 – March 21, 2016

Wednesday January 20, 2016

Just a quick heads-up from the team at eHDS. See below for a notice received from CMS. Please plan accordingly!

Please be aware that CMS has planned an off-schedule extended maintenance period for all of the national QIES systems, which include the MDS 3.0 Submission and CASPER systems, for Wednesday, March 16, 2016 beginning at 8:00 PM ET and continuing through Monday, March 21, 2016 at 11:59 PM ET.

This makes for a 5+ day window where all of the national QIES systems will be offline and providers will be unable to transmit any MDS assessments or obtain reports. This also applies to vendors who submit assessments on the providers' behalf. CMS has started to post notices to the related application and support websites that encourage vendors and providers to take this downtime into account and plan their business around it.

This information is also noted on your Care Watch home page. We recommend making sure your team is well informed and is planning for this scheduled downtime.

For access to the original CMS notice, please click here. 

eHealth Data Solutions 

Zika Virus

Tuesday February 9, 2016

The link below contains information from the Centers for Disease Control (CDC) about the Zika Virus including areas with Zika, Prevention, and Symptoms, Diagnosis and Treatment.

http://www.cdc.gov/zika

MDS 3.0 Staffing Focus Survey

Tuesday March 1, 2016

MDS 3.0 Focused Pilot Surveys were conducted in June and July of 2014 in 5 states, and in 2015 the MDS Focus Surveys were conducted in all states.  The Surveys consist of a review of MDS 3.0 assessments, medical records, interviews with staff and residents, and resident observations.  This enables Surveyors to review the nursing home resident assessment processes in-depth, more so than during an annual survey. The MDS Focus Survey, the Focused Survey Facility Worksheet, the Electronic Staffing Data Submission Payroll Based Journal, and the Preparation for MDS Focus Survey are included in the attachments below. 

Click here to download "MDS Focus Survey Entrance Conference Worksheet"
Click here to download "MDS Focus Survey Facility Worksheet"
Click here to download "MDS FOCUS SURVEY 5-27-2015"
Click here to download "PBJ-Policy-Manual-Draft"
Click here to download "Preparation for MDS Focus Survey Checklist"

Phase 2 HIPPA Audits

Wednesday June 15, 2016

In an effort to review and examine compliance with the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations ("HIPAA"), the Department of Health and Human Services Office for Civil Rights ("OCR") is conducting Phase 2 HIPAA audits for both covered entities and business associates. OCR is conducting the audits to assess new risks, identify effective privacy and security measures, and develop targeted guidance on specific areas of concern.

The first step in the audit phase is a pre-audit screening email sent to potential auditees. We have seen several of these delivered recently. A sample of the pre-audit screening email can be found here. The email contains a questionnaire addressing size, entity type, services, contact information, and other background information. The online questionnaire must be completed and returned to OCR within 30 days. Based on the responses received and the information gathered, OCR will create a smaller, representative sample audit pool. Thus, not all entities that receive the initial pre-audit screening email will be audited. However, failure to respond to the questionnaire will not remove an entity from the audit selection pool. OCR will use publicly available information about an entity if it receives no response within the 30-day timeframe.

Every covered entity and business associate is eligible to receive the pre-audit screening email and to be entered into the audit selection pool. However, at this point, we believe the screening e-mail is being sent to entities who have filed a breach notification report with OCR. Based on the responses to the pre-audit questionnaire contained in the screening e-mail, OCR will choose a representative sample of auditees. Entities will be notified if selected.

Phase 2 audits will target areas of frequent non-compliance with HIPAA, such as risk management, privacy practices, individual access to protected health information ("PHI"), breach notifications, and electronic security. Most audits will not involve site visits, though some may. Once an entity is selected for the audit process, it has only 10 days to respond to OCR's audit request, submit all requested documentation through OCR's online portal, and provide a listing of its business associates. While OCR has not stated the exact information that will be requested, we suspect the information requests will include, among other things, HIPAA policies, procedures, and plans, listing of systems that house electronic PHI, risk assessment(s), breach notification documents, Notice of Privacy Practices and other HIPAA forms, and a business associate listing.

Depending on an entity's size, the 10-day window may leave little time to compile and provide the requested information. Thus, while receiving the pre-audit screening e-mail does not guarantee that an entity will be audited, it is recommended that receiving entities take proactive steps to prepare in the event they are ultimately audited. Recommended steps include the following:

·         Assemble a HIPAA response team and hold an initial meeting so that everyone may be prepared in the event of an audit. Potential team members may include your privacy officer, security officer, compliance officer, IT department supervisor, and administrator.

·         Locate all HIPAA-related materials so that they can be gathered quickly in the event of an audit.

·         Review HIPAA policies and procedures to make sure they are up to date, operating effectively, and do not contain any gaps.

·         Review HIPAA forms to make sure they are up to date and are being properly used.

·         Compile a listing of business associates, which, for larger entities, could take a significant amount of time. There are several pieces of information OCR has indicated it will request with respect to business associates. A template form for gathering this information is available here. While use of the template is not required, it does ensure inclusion of all the business associate information OCR is seeking.

·         In relation, confirm that a business associate agreement is in place for each instance where one is required. We have seen some recent enforcement actions whereby covered entities have been fined for not having a business associate agreement in place when one was required.

·         Compile and review the latest risk assessment(s) to make sure they are still valid and cover all the systems that house, transmit, and store electronic PHI. (We have seen recent enforcement actions whereby covered entities have been fined for not having a risk assessment or a series of risk assessments that cover all relevant systems.)

·         Compile an inventory of systems and system assets that house, transmit, and store electronic PHI.

OCR has indicated that the Phase 2 audits are not designed to determine an entity's compliance with HIPAA. Nonetheless, OCR has retained the right to initiate a compliance review based on information received during an audit. Thus, we believe it is worthwhile to take the steps mentioned above in order to help reduce the risk of a compliance investigation. 

For more information on the Phase 2 HIPAA audits, please contact any of the Burr & Forman attorneys listed below.

Howard Bogard

Partner ~ AL
(205) 458-5416
hbogard@burr.com

Richard Brockman

Counsel ~ AL
(205) 458-5175
rbrockman@burr.com

Kelli Fleming

Partner ~ AL
(205) 458-5429
kfleming@burr.com

Jim Hoover

Partner ~ AL
(205) 458-5111
jhoover@burr.com

Chet Hosch

Partner ~ GA
(404) 685-4279
chosch@burr.com

Matt Kroplin

Partner ~ TN
(615) 724-3248
mkroplin@burr.com

Jack Mooresmith

Counsel ~ AL
(334) 387-2072
jmooresmith@burr.com

Angie Smith

Partner ~ AL
(205) 458-5209
asmith@burr.com

Jerry Taylor

Partner ~ TN
(615) 724-3247
jtaylor@burr.com

Chris Thompson

Associate ~ AL
(205) 458-5325
cthompson@burr.com

Rob Williams

Partner ~ FL
(813) 367-5712
rwilliams@burr.com

Tom Wood

Partner ~ AL
(251) 345-8203
twood@burr.com 

No representation is made that the quality of services to be performed is greater than the quality of legal services performed by other lawyers. ADVERTISEMENT



What Do Long Term Care Organizations Need to Do to Comply With the New Overtime Regulations

Friday June 17, 2016

The article below from Starnes Davis Florie LLP addresses the new overtime regulations for Long Term Care Organizations that will go into effect on December 1, 2016.

Click here to download "New Overtime Regulations"

Workplace Violence

Tuesday October 18, 2016

Introduction:  Workplace Violence is the second leading cause of work-site deaths in the United States according to the Bureau of Labor Statistics, and is one of the most frightening exposures companies face. Such an incident can devastate a company, destroying its bottom line and even threatening it survival. Workplace Violence Expense Insurance will help you prepare for an unthinkable event like this if it should happen at your facility. Here are some of the reasons why your facility should consider buying workplace violence expense insurance:

·         The expenses incurred in the aftermath of a workplace violence incident are often staggering and unforeseen

·         Unexpected expenses can stem from crisis management, independent security, employee counseling, public relations, medical care for employees, salaries for victim employees and for replacement employees and loss of business income

·         Long term care facilities are at an increased risk of workplace violence because they deal with members of the public and operate late at night

The attachment below contains Chubb Insurance Company's Forefront Portfolio Risk Analyzer which may help you uncover some of the biggest potential threats to your facility's bottom line. Gerry Gilbert in our office can assist you in identifying possible financial exposures your facility might have. Gerry can be reached at 205-414-6184 or by email at gerry_gilbert@ajg.com .

Click here to download "Workplace Violence Risk Analyzer"

Dementia Focus

Tuesday November 29, 2016

The article below focuses on CMS's national goal to reduce the use of antipsychotic medication use in long term care nursing homes by 30% by the end of 2016.With the improvement of dementia care in nursing facilities, there have been significant reductions in the prevalence use of antipsychotics for long term care residents. This article will provide you with the requirements that facilities must follow to make sure residents don't have unnecessary declines in the development of their Dementia.   

Click here to download Dementia article. 

Infection Prevention

Wednesday January 4, 2017

"Infection Prevention"

An Infection Prevention and Control Program (IPCP) is currently required by Federal Regulations, that state all facilities must establish a program that investigates, controls, and prevents infections in the facility.  The program, at a minimum, would adopt procedures to follow with individual residents such as residents exhibiting specific symptoms, or are diagnosed with certain types of infections.  The facility would also be responsible for maintaining a record of any infectious incident and what corrective measures were implemented to manage the infection. The facility is also charged with the task of determining ways to prevent the possible spread of infections to other individuals within facility.

The Federal Register/Vol. 81, No. 192/Tuesday, October 4, 2016/Rules and Regulations indicate that CMS put the foundation in place for the Infection Prevention rule changes.  These changes will be implemented in "Phases",  Phase 1:   timeframe is effective date of  the final rule November 28, 2016, Phase 2: 1 year following the effective date of the final rule (November 2017), and Phase 3: 3 years following the effective date of the final rule (November 2019).

Phase 1:

Each facility must establish and maintain an infection prevention and control program designed to provide:

• a safe, sanitary, and comfortable environment and,

• to help prevent the development and transmission of communicable diseases and infections.

   

A system of surveillance should be developed by each facility to identify possible communicable diseases or infections before they can spread to other persons in the facility.  The plan for surveillance may be a stand-alone policy or it may be included in the facility's infection prevention and control program. The facility should: a) identify what data should be collected; b)when the data should be collected; c)how the data should be collected; d)how the data will be analyzed; and e)how the results of the analyzed data will be documented and implemented.  This is not an all-inclusive list and should be viewed as an example only.

Phase 2:

Assessments for Infection Control and Antibiotic Stewardship are two of the items that will be required in this phase.  Assessments for Infection Control is an assessment tool developed by the facility to evaluate the potential risk for acquiring and transmitting infections, identifying opportunities for improvement, identify threats to residents health and identify gaps in facility practices.  The assessment should be completed by a multidisciplinary team and is one of the key building blocks of the Infection Prevention and Control Plan.  The assessment is used to establish goals and objectives, identify focus areas for surveillance, prioritize infections and control activities and/or initiatives.  The Antibiotic Stewardship Program includes protocols for antibiotic use and a system to monitor antibiotic use.  These policies and practices are in place to protect residents and improve clinical care as it relates to the use of antibiotics in nursing homes.

Phase 3:

Infection Control and Prevention Offices (ICPO) is defined as one or more individuals who are responsible for the facility's Infection Prevention and Control Program.  Facilities should be designating the ICPO in Phase 3.   This individual(s) must: Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; be qualified by education, training, experience or certification; work at least part-time at the facility; have completed specialized training in infection prevention and control; and participate in the quality assessment and performance improvement committee.   The individual designated as the Infection Preventionist must be a member of the facility's Quality Assessment and Performance Improvement committee with the responsibility to report to the committee on the Infection Prevention and Control Plan on a regular basis.

For more comprehensive information on Infection Control and the Final Rule including the Phases and Timelines for Implementation, you should contact the Alabama Nursing Home Association for Seminars/Trainings/Workshops or review the list of references/resources provided below.

References:

Federal Register/Vol. 81, No. 192/Tuesday, October 4, 2016/Rules and Regulations

Alabama Nursing Home Association Weekly Round Up

CDC Long Term Care Antibiotic Stewardship

Arthur J Gallagher & Co/12-2016



2017 Alzheimer’s Disease and Dementia Care Seminars

Wednesday January 4, 2017

AJG Educational Services will be hosting Alzheimer's Disease and Dementia Training Seminars in four Alabama cities in 2017. These seminars are required for those pursing CDP Certification and who qualify through the National Council of Certified Dementia Practitioners.

To see if you qualify please visit the NCCDP website at www.nccdp.com. All participants must attend the entire seminar to receive a certificate of completion and all participants will be provided an application to apply for CDP (Certified Dementia Practitioners) through the National Council of Certified Dementia Practitioners.

Seminars will be held in Birmingham, Montgomery, Mobile, and Huntsville later in the year.

                                            Alzheimer's Disease & Dementia Care Seminar

                                                              July 13 & 14, 2017

Mobile, AL

Alzheimer's Disease & Dementia Care Seminar

October 19 & 20, 2017

Huntsville, AL 



Cyber Insurance - Protecting Your Business & Financial Viability

Monday May 15, 2017

The attachment below contains a flyer from Arthur J Gallagher that will provide you with information about potential cyber risks as well as the percentage of customers lost by companies due to cyber-attacks, and the cyber security vulnerability by industry including the healthcare industry. Please contact either Gerry Gilbert or Billy Dodson on how you can protect your business from cyber risks. Gerry and Billy can be reached at: 

Gerry Gilbert -

phone : 205-414-6184

email : gerry_gilbert@ajg.com

Billy Dodson -

phone 205-414-2653 

email billy_dodson@ajg.com

Click here to Download  the attachment

Cyber Incident Preparedness for Healthcare

Monday May 22, 2017

The healthcare sector saw 310 cyber related incidents in 2016 with 16,100,000 individuals affected by those data breaches. As you know healthcare records have valuable personal information that can be used by cyber criminals in a variety of malicious ways. With access to healthcare information and other personal data, attackers can access healthcare services on behalf of the individual, file fraudulent claims, or use the victim's identity to commit other crimes. The flyer below contains five steps that will help you mitigate your risk of a cyber incident occurring at your facility. Please contact Martha Acker, Gerry Gilbert, or Billy Dodson if you would to learn more about how you can protect your facility from a cyber incident. Martha, Gerry and Billy can be reached at

Martha Acker -

phone : 205-414-2640

email : martha_acker@ajg.com

Gerry Gilbert -

phone : 205-414-6184 

email gerry_gilbert@ajg

Billy Dodson -

phone : 205-414-2653 

email billy_dodson@ajg.com

Click here to Download  the attachment

Certified Quality Risk Management Specialist Training

Thursday June 1, 2017

October 10-13, 2017

Location:

AJG Education Center

2200 Woodcrest Place

Birmingham. AL 35209

                         October 10- 13, 2017

                        8:00 am-5:00 pm

                       Registration7:45 am - 8:00 am

                       Space is limited- 40

Registration fee:

• CCC AL Nursing Home Insurance Program Members Only: $650 (required at the time of registration)

• NON-CCC AL Nursing Home Insurance Program Members Only:$750(required at the time of registration)

• For additional Information, please contact:

• Nancy Lee,

  Registration Coordinator

  205-414-6169

  nancy_lee@ajg.com

  The ALTCQIreservestherighttocancelthis training on thebasisof low registration.If thist raining is cancelled,all those registered will be notified and registration fees will be refunded.

    To cancel your registration you must email

  no later than September 29, 2017 to:

  NancyLee, Registration Coordinator

  nancy_lee@ajg.com

  You will be refundedyourregistrationfee minus$100.00administrationfee.

•      Norefundswillbegiven after September 29,2017. 

•     Substitutes are welcomed.

•     ALL NO SHOWSforfeit registration fees

  This comprehensive course is designed to arm you with a practical knowledge of Risk Management strategies in the Senior Living Industry.

Certified Quality Risk Management Specialist Training – October 10-13, 2017

Friday June 2, 2017

This comprehensive program will train each student to identify, assess, and prioritize risks in a coordinated effort within the Senior Living environment. The e-brochure below contains more information about these training sessions and an application that will allow you to enroll your staff in this course. Training sessions will be held at the AJG Training Center in Birmingham, AL on October 10-13, 2017.  

Click here to download the attachement

2017 Alzheimer’s Disease and Dementia Care Seminars

Sunday June 11, 2017

AJG Educational Services will be hosting Alzheimer's Disease and Dementia Training Seminars in Atlanta Georgia in 2017. These seminars are required for those pursuing CDP Certification and who qualify through the National Council of Certified Dementia Practitioners.

To see if you qualify please visit the NCCDP website at www.nccdp.com. All participants must attend the entire seminar to receive a certificate of completion and all participants will be provided an application to apply for CDP (Certified Dementia Practitioners) through the National Council of Certified Dementia Practitioners. The attachments contain additional information about these seminars and how to sign up for them.

Seminars will be held in Atlanta Georgia on:

Alzheimer's Disease & Dementia Care Seminar

August 15, 2017

Atlanta Georgia 

Click here to download the attachement

Alzheimer's Disease & Dementia Care Seminar

August 17, 2017

Atlanta Georgia 

Click here to download the attachement

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities

Tuesday June 27, 2017

Nursing home surveys are conducted in accordance with survey protocols and Federal requirements to determine whether a citation of non-compliance is appropriate. Consolidated Medicare and Medicaid requirements for participation (requirements) for Long Term Care (LTC) facilities (42 CFR part 483, subpart B) were first published in the Federal Register on February 2, 1989 (54 FR 5316). The requirements for participation were recently revised to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. The revisions were published in a final rule that became effective on November 28, 2016.

The survey protocols and interpretive guidelines serve to clarify and/or explain the intent of the regulations. All surveyors are required to use them in assessing compliance with Federal requirements. Deficiencies are based on violations of the regulations, which are to be based on observations of the nursing home's performance or practices.

The attachment below contains the PowerPoint from CMS relating to the new survey process effective November 28, 2017.

Click here to download the attachment

Active Shooter Options

Tuesday June 27, 2017

One of the worst forms of workplace violence is an active shooter situation. Policy may respond promptly to your 911 call but, in the interim, lives are at risk. The article below will provide you with things that you and your staff can do to protect these lives.    

Click here to download the attachment

OSHA Delays Electronic Filing Date for Injury and Illness Records Until December 1, 2017

Thursday June 29, 2017

The attached article will provide you with information on OSHA's proposal to delay the reporting compliance deadline, until December 1, 2017, for certain employers to electronically file injury and illness data.    

OSHA Delays Electronic Filing Date for Injury and Illness Records Until December 1, 2017

Does your staff need training on F-Tags?

Monday September 11, 2017

Relias Learning offers you and your staff over 500 interactive, online continuing education courses to meet the educational and licensure requirements of their profession.  At Relias Learning their one-of-a-kind management system allows you and your staff to search courses by F-Tags to quickly and effectively resolve deficiencies.  Attached is a tool to help you navigate through the Relias Learning center to identify a variety of modules related to Long Term Care regulatory topics.  New F-Tag modules will be forthcoming to meet the Phase 2 CMS regulations.  If you need additional information, please contact Dena Humphreville, Tier II Client Success Manager at Relias Learning, 919-655-7832 or email dhumphreville@reliaslearning.com.

Is My Staffing Adequate?

Friday October 27, 2017

Staffing has become one of the biggest challenges encountered in the senior housing industry. Proper staffing is not only integral to the day-to-day mission and operations of providing quality care to residents, but also crucial to meeting the ever-increasing staffing-targeted regulations.

Click here to download the attachment

Survey and Certification Group at CMS issues Two Memos November 2017

Monday December 4, 2017

On November 24, 2017, the Survey and Certification Group (S&C) at CMS issued two memos that further delay enforcement of provisions of the new requirements but falls short of a complete delay. These memos indicate that CMS is delaying some enforcement provisions of the Phase 2 requirements, but CMS will proceed with implementing the new survey process beginning on November 28.

Click here to download the attachment

FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes

Monday August 20, 2018

The Food and Drug Administration (FDA) is strengthening the current warnings in the prescribing information that fluoroquinolone antibiotics may cause significant decreases in blood sugar and certain mental health side effects. The low blood sugar levels can result in serious problems, including coma, particularly in older people and patients with diabetes who are taking medicines to reduce blood sugar. We are making these changes because our recent review found reports of life-threatening low blood sugar side effects and reports of additional mental health side effects.

Please click on the link bellow to review more on this topic:

https://www.fda.gov/Drugs/DrugSafety/ucm611032.htm

CMS Update: Requirements to Reduce Legionella Risk in Water Systems

Wednesday August 1, 2018

Center for Clinical Standards and Quality/Quality, Safety and Oversight Group

Ref: QSO -17-30- Hospitals/CAHs/NHs

DATE: June 02, 2017 REVISED 07.06.2018

TO: State Survey Agency Directors

FROM: Director

Quality, Safety and Oversight Group ( formerly Survey & Certification Group )

SUBJECT: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)

***Revised to Clarify Expectations for Providers, Accrediting Organizations, and Surveyors***

  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO17-30-HospitalCAH-NH-REVISED-.pdf    

Facility Requirements to Prevent Legionella Infections

Wednesday February 14, 2018

Facility Requirements to Prevent Legionella Infections: Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water.

Facility Requirements to Prevent Legionella Infections Document

ALF and SCALF Residents: Appropriate vs. Inappropriate?

Wednesday March 21, 2018

Assisted Living, Specialty Care Assisted Living, Memory Care Facility, Resident Care Homes - whatever title they go by, each state has its own set of rules and regulations for these care facilities. The criteria for admission and retention for any of these centers will vary depending on the state in which you live.

Inappropriate Residents in ALF and SCALF Whitepaper

Care Plans: Is your facility going in the right direction?

Wednesday March 21, 2018

It seems that long-term care providers are struggling to stay the course in developing thorough, comprehensive, "Person-Centered Care" plans. Amid all the numerous regulatory changes, nursing and rehabilitation facilities are attempting to find a balance between shifting the care model while also maintaining regulatory compliance.

Person Centered Care Plans

ANHA LTC Preparedness Toolkit

Monday May 6, 2019

The Alabama Long Term Care (LTC) Preparedness Toolkit was developed to assist with emergency preparedness planning for this specialized health care population. LTC facilities, as they are referred to in the toolkit, include nursing homes, skilled nursing facilities, and assisted living facilities. This toolkit was originally created by the Minnesota Dept. of Health, Care Providers of Minnesota, Aging Services of Minnesota, and regional representation from the Health Care Preparedness Program who developed this tool to assist LTC facilities in emergency preparedness. The toolkit was revised with permission by members of the Alabama Nursing Home Association to assist Alabama facilities in preparing for disasters. 

ANHA LTC Preparedness Toolkit

Health System Boards and Cultures that Support Effective Enterprise Risk Management

Wednesday June 5, 2019

The common law and regulatory climates of North American health systems have been shaped by an Anglo-Saxon heritage regarding the role of the corporation. This view of the corporation has, in turn, shaped the role and responsibilities of corporate bards as they perform certain key fiduciary duties wisely. At the 2018 Cayman Captive Forum, our session on governance trends and best practices for risk management sought to position the role of boards to not so much be experts in risk management, but to be enablers of a superior risk management culture that supports talented executives and risk management professionals to master and continuously enhance the use of modern Enterprise Risk management principles, policies and practices.

This paper has been modified from discussions at the recent Cayman Captive Forum organized by the Insurance Managers Association of Cayman (MAC). Requests at the Forum for materials that might help stimulate health systems boards to enhance the effectiveness of their enterprise risk management encouraged the authors to assemble and share this collection of ideas and insights about governing modern risk management strategies and structures.

2019 Health System Boards and Cultures that Support Effective Enterprise Risk Management White paper

Guidance on Emerging Infection Candida Auris

Wednesday June 5, 2019

Some of you may have heard about Candida auris in recent media stories based on a recent New York Times article. C. auris is an emerging yeast that can be misidentified as other organisms, is multidrug-resistant, and can spread in health care settings. It is important to know how to identify, treat, and control the spread of this organism.

Guidance on Emerging Infection Candida Auris

Homeland Security Active Shooter How to Respond Guide

Tuesday July 23, 2019

Active Shooter situations are often over within 10 to 15 minutes, before law enforcement arrives on the scene, individuals must be prepared both mentally and physically to deal with an active shooter.

Below is a link to the U.S. Department of Homeland Security "Active Shooter How to Respond" guide.

https://www.dhs.gov/sites/default/files/publications/active-shooter-how-to-respond-508.pdf

Strategies to Prevent the Spread of COVID-19 in Long-Term Care Facilities (LTCF)

Monday March 9, 2020

A new respiratory disease - coronavirus disease 2019 (COVID-19) - is spreading globally and there have been instances of COVID-19 community spread in the United States. The general strategies CDC recommends to prevent the spread of COVID-19 in LTCF are the same strategies these facilities use every day to detect and prevent the spread of other respiratory viruses like influenza.

Strategies to Prevent the Spread of COVID-19

Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19)

Monday March 9, 2020

Coronavirus disease 2019 (COVID-19), caused by the COVID-19 virus, was first detected in Wuhan, China, in December 2019. On 30 January 2020, the WHO Director-General declared that the current outbreak constituted a public health emergency of international concern.
This document summarizes WHO's recommendations for the rational use of personal protective equipment (PPE) in healthcare and community settings.

Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19)

About 2019 Novel Coronavirus (2019-nCoV)

Wednesday February 5, 2020

The Centers for Disease Control and Prevention (CDC) is closely monitoring an outbreak of respiratory illness caused by a novel (new) coronavirus first identified in Wuhan, Hubei Province, China. Chinese authorities identified the new coronavirus, which has resulted in thousands of confirmed cases in China, including cases outside Wuhan City. Additional cases have been identified in a growing number of other international locations, including the United States.

About 2019 Novel Coronavirus

Will your COVID-19 documentation protect your facility

Wednesday May 20, 2020

Document, document, document - a phrase that is familiar in the senior living industry and many other healthcare arenas. During the COVID-19 pandemic, documentation is critical in order to provide a historical timeline of the facility's response to the COVID-19 pandemic.
Many facilities may be at risk for lawsuits and CMS Infection Control Focused Surveys in the future, and the documentation process for providing a historical timeline of each facility's individual response is key.

COVID-19 Documentation whitepaper 5-14-20

Responding to the Coronavirus (COVID-19)

Tuesday June 9, 2020

As news headlines about the coronavirus (COVID-19) disease continue to increase, so has concern over its potential to affect employee welfare, disrupt global supply chains and slow business operations. Gallagher's experts are here to support you in the development and implementation of risk management policies and procedures during a pandemic.

Responding to the Coronavirus (COVID-19)

Care Plans: Is your facility going in the right direction?

Tuesday June 9, 2020

It seems that long-term care providers are struggling to stay the course in developing thorough, comprehensive, "person-Centered Care" plans. Amid all the numerous regulatory changes, nursing and rehabilitation facilities are attempting to find a balance between shifting the care model while also maintaining regulatory compliance.

Person Centered Care Plans

ALF and SCALF Residents: Appropriate vs. Inappropriate?

Thursday June 11, 2020

Assisted Living, Specialty Care Assisted Living, Memory Care Facility, Resident Care Homes - whatever title they go by, each state has its own set of rules and regulations for these care facilities. The criteria for admission and retention for any of these centers will vary depending on the state in which you live. The State of Alabama is no exception; it has its own set of rules and regulations; especially when it comes to admission and retention of a resident into one of its Assisted Living Facilities (ALF) and Specialty Care Assisted Livings (SCALF).

Inappropriate Residents in ALF and SCALF Whitepaper

Is my Staffing Adequate?

Thursday June 11, 2020

Will I be able to cover this shift next week? Is the weekend coverage in place? These are questions every person working in the Senior Living industry has asked. Staffing has become one of the biggest challenges encountered in the senior housing industry. Proper staffing is not only integral to the day-to-day mission and operations of providing quality care to residents, but also crucial to meeting the ever-increasing staffing-targeted regulations.

Senior Living Staff Whitepaper

Dealing with Stress in Senior Living

Wednesday December 16, 2020

"Global pandemic," "COVID-19" and "mask" are all familiar terms that have become a part of our daily (and sometimes hourly) conversations with friends, family and colleagues. And, unfortunately, as COVID-19 cases increase and new restrictions are implemented in some areas, your staff may be feeling fear, stress, panic and anxiety. Developing a strategy to adequately address these feelings in the healthcare space can be daunting. Long-term care (LTC) nurses are managing the emotional wellbeing of residents along with their own personal troubles each day. Similarly, members of nursing facility staffs are under immense pressure, not to mention handling situations their profession has never experienced before.

Dealing with Stress in Senior Living