OHCA - Ohio Health Care Association



ICF/IID Streamlining Project

DRAFT Proposal to CMS

The State of Ohio is proposing to develop and implement a combined certification survey and licensure review process for ICF/IIDs. The joint process would consist of a facility visit that would be conducted by a team of surveyors made up of staff from the Ohio Department of Health (“ODH”) and the Ohio Department of Developmental Disabilities (“DODD”). It is strongly believed that the streamlining of the two separate survey processes would result in a process that is more efficient for the involved state agencies and the ICF/IID operators. The process should also yield improved results as the experience and expertise of both agencies will be combined.

In Ohio, the current certification survey and licensure review processes are conducted completely separate from each other. ODH conducts the annual certification survey of ICF/IIDs while DODD conducts the licensure review of the facility every one to three years depending on the outcome of the licensure review. In addition, these two distinctly different surveys often result in contradictory findings due to variations between state laws and federal regulations. Separate surveys also affect the delivery of services to Medicaid recipients in that the typical routine of facility operations is interrupted for two to five working days while the surveyors are on-site.

The following chart illustrates the current number of surveyors and number of days on site at a facility based on its size.

|Number of Beds |ODH | |DODD |

| |Number of Surveyors |Number of Days | |Number of Surveyors |Number of Days |

|4-8 |1 |2 | |1 |1 |

|9-16 |1-2 |2-3 | |1-2 |1 |

|17-50 |2-3 |3-4 | |2-4 |1 |

|50-100 |3-4 |4 | |4 |1 |

|≥ 100 |5-7 |4 | |4-5 |2 |

We believe that combining our efforts would lead to some reduction in the number of surveyors for DODD and some reduction in the number of days and perhaps surveyors for ODH. This would be accomplished by allotting certain responsibilities to one of the agencies as lead (but not exclusive) and also allowing surveyors to rely on each other’s information and conclusions.

DODD and ODH propose the development of an ICF/IID survey process that would result in the facility undergoing its certification survey and licensure review at one time. The combined survey would be conducted by a team of surveyors consisting of both ODH and DODD staff. All DODD staff, who conduct the ICF/IID reviews are classified as Rehabilitation Program Specialists (RPS2s) and are members of SEIU 1199 Union. All ODH staff who conduct the ICF/IID certification surveys are classified as Health Care Facility Surveyors (HCFS) and are also members of SEIU 1199. ODH survey staff currently conducts certification surveys for both ICF/IIDs and skilled nursing facilities/nursing facilities. DODD review staff currently conducts reviews of both ICF/IIDs and HCBS Waiver settings.

It is recommended that a group of 5 DODD reviewers and all ODH surveyors who conduct ICF/IID surveys be trained to conduct ICF/IID reviews utilizing the new process. The following work, identified as Preparation Tasks, will need to be developed in order to create this new ICF/IID review process which combines licensure and certification.

Preparation Tasks

1. Develop a system for schedule sharing – ODH/DODD

2. DODD develops a system and the criteria for sharing and use of Level of Care info - DODD

3. DODD develops a system for sharing Individual Assessment info – DODD

4. Develop criteria for using LOC and IAF data for selecting sample – ODH/DODD

5. Obtain access to ODH Gateway for sharing of certification survey info – ODH/DODD

6. Share access to DODD regulatory software for sharing of licensure info – ODH/DODD

7. Share access to DODD Incident Tracking System (ITS) for purposes of Task 2 compliance – DONE

8. Make necessary updates to ITS to meet Task 2 requirements - DODD

a. Date/Time incident reported to Administrator

b. ICF/IID Internal investigation completed within 5 days

9. Make necessary changes to DODD ICF/IID review tool - DODD

10. Develop training curriculum for providers – ODH/DODD

11. Develop training curriculum for reviewers/surveyors (share findings on-site) – ODH/DODD

12. Develop teleworking policy for HCF5s conducting ICF/IID surveys – ODH

Scheduling

1. ODH will share their survey schedule with DODD

2. The facility licenses will be extended when necessary during the first year of the new survey process in order to ensure that the facility’s term license expires on a date consistent with the ODH survey schedule.

3. ODH will share their survey date(s) with DODD at least 6 weeks prior to the survey date

a. ODH will identify team coordinator

4. Based on the ODH survey schedule, DODD will assign reviewers to conduct the Licensure

survey alongside the ODH surveyors.

5. DODD team assignments will be as follows;

a. 4-16 Beds – 1 DODD Reviewer

b. 17-109 – 2 DODD Reviewers

c. 110+ - 3 DODD Reviewers

6. All DODD staff will attend the first day of the ICF/IID review with the option to extend if necessary.

7. DODD will share their ICF/IID review assignments with ODH 2 weeks prior to the review date

a. DODD will identify review lead

8. The survey date/time will not be shared with the provider so it will remain unannounced.

The Survey Process

The ICF/IID certification and licensure survey will entail both pre-survey procedures as well as on-site procedures.

Pre-survey Procedures

Task 1 – Sample Selection - utilizing existing state ICF/IID data systems

Task 2 – Abuse, Neglect, Mistreatment & Resolution of Complaints - utilizing existing ITS data system

On-site Survey Procedures

Task 3 – Individual Observations

Task 4 – Interviews

Task 5 – Drug Pass Observation

Task 6 – Area Visits

Task 7 – Record Review

Task 8 – Team Assessment

On-site Review Assignments

An ICF/IID will continue to undergo an annual certification survey and a licensure survey that will be conducted based on the term of their license (every 1, 2, or 3 years). The Ohio Administrative Code allows a facility to maintain their license until such a time that the either the Director of DODD revokes the license or the facility voluntarily relinquishes the facility licensed. Based on this, the facility licenses, if necessary, can be extended so that a schedule is developed that makes the license date and the certification dates consistent. The combined survey will take place over a period of days, as determined by ODH and based on the SOM, with DODD staff conducting the licensure portion of the survey on the first day. The survey structure will be as follows:

CERTIFICATION SURVEY (ODH) LICENSURE SURVEY (DODD)

- Sample Selection - Personnel

- Individual/Guardian Interviews - Individual Interviews

- Observations - Observations

- Drug Pass - Incidents of abuse, neglect, mistreatment

- Site Visits - Behavior Support

- Record Review - Administration

- LSC - Delegated Nursing

All tasks completed as part of the certification survey by ODH staff would be done consistent with the SOM. The tasks completed as part of the licensure survey by DODD staff would consist of a review of personnel records to ensure compliance with state rules that address hiring and training, including Ohio Administrative Code (“OAC”) Rules 5123:2-2-02, 5123:2-3-07 and 5123:2-3-08, a review of behavior support policies and procedures and implementation as required by OAC Rules 5123:2-3-25, and rules related to the operation of the ICF/IID, including, but not limited to OAC Rules 5123:2-3-25, 5123:2-9-09 and any other rules relevant to the administrative operations of the ICF/IID. On the years in-between, when the licensure term is still in place, ODH surveyors will conduct the certification survey on-site with the provider while DODD staff will conduct an internal review of the Task 2 requirements prior to the on-site survey and provide a written report to the ODH team at least 10 working days prior to the scheduled on-site survey. During the certification survey, personnel and behavior support would continue to be reviewed by ODH surveyors using the appropriate tags as part of the fundamental survey process and incorporated as currently occurs as part of the interviews, observations, site visits, and record review.

Task 1 - Sample Selection

Ohio requests the ability to use an Alternative Sampling Procedure as outlined in J-7 of the SOM. As DODD is the agency designated by the Ohio Department of Medicaid to manage the ICF program in Ohio, DODD has access to individual specific data that could be utilized in selecting a sample prior to the review. In order to ensure the sample reflects a proportionate representation of the individuals residing in the facility, ODH would be given access to DODD data that identifies the individual’s functional level as determined at the time of the admission to the ICF. The LOC is done at the time of admission and is required to be updated whenever the individual has a substantial change in functioning. In addition, DODD will share the most recent assessment of individuals by strengths and needs as assessed via the Individual Assessment Form (IAF). This will allow the licensure reviewers/certification surveyors to create a sample representative of the functional levels and assessed needs of the individuals as required in J-6 of the SOM. The sample which is developed approximately 2 weeks prior to the on-site review can be modified as needed once the survey/review team is on-site. This change would only deviate from Task 1 of the SOM in that the data necessary to select the review sample would be available to the reviewer prior to the survey/review team going on-site, thus increasing the efficiency of the survey/review team’s time on-site and the since the survey will continue to be unannounced, the provider would be made aware of the individuals in the sample on the first day of the survey/review. It is our opinion that, even given the current sample selection process, providers are able to easily determine based on interview and observations, record review, and other parts of the process, which individuals are part of the survey sample. We contend that the provider knowing the individuals who are part of the sample on the first day of the survey does not compromise, in any way, the outcome of the survey. In 2008, DODD changed its licensure review process to give provider’s a 90 day notification for an upcoming review with a copy of the review tool and the names of the individual’s in the sample. This process has found little to no change in the outcomes of the reviews and has facilitated a process in which providers are self-reviewing their systems prior to the on-site review and working proactively to create systems change and internal quality controls. In addition to that, we believe that this change in sample selection has the potential to decrease the amount of time on-site necessary to select the sample and increase the amount of time available for the team to conduct other tasks which are part of the review process.

Based on this process, the only change to the SOM would be that the sample would be selected, utilizing existing data from DODD approximately 2 weeks prior to the on-site review, but could still be modified as needed once the review team arrives on-site at the ICF/IID.

Task 2 – Abuse/Neglect/Mistreatment

Currently, surveyors utilize the morning of the first day to review incident data. Depending on the size of the facility and/or the number of incidents, this may take several hours of on-site work. Ohio would like to change the process by which Task 2 is completed by the survey team. As CMS is aware, DODD uses a system called the Incident Tracking System (ITS) to collect, review, and analyze data related to incidents of abuse, neglect, mistreatment and others. The ITS system allows for data to be analyzed on an individual basis, a facility basis, a statewide basis per provider, and a statewide basis for all providers/individuals. Currently, as part of the certification survey, there is no data, other than the on-site data maintained by the provider, to use in determining compliance with Task 2 requirements. The use of ITS would allow for a pre-survey review of incidents prior to the on-site review, thus creating a more efficient on-site review process. In addition, the information available in ITS is a compilation of all investigatory entities including the ICF/IID, the local County Board of DD and law enforcement or children’s services if applicable, thus providing the surveyor with a complete synopsis of the incident from date of discovery until the completion of the investigation as required by law.

Page J-8 of the SOM requires that the surveyor determine how the facility resolves complaints and allegations of abuse, mistreatment and neglect. The SOM goes on to clearly state that no specific system is required, only that the facility must ensure that all investigations are reported to the administrator and in accordance with State law. Since state law regarding the reporting of incidents is part of the DODD authority in Ohio, we would ask that the process for ensuring compliance with Task 2 incorporate a pre-survey component. Ohio believes that the requirements of OAC Rule 5123:2-17-02 sets a system of required compliance related to the reporting and investigation of incidents that meets or exceeds the requirements as outlined in the SOM for Task 2. We have attached for review, a copy of a crosswalk illustrating ODH/DODD responsibilities for Task 2 and the state rule which governs the reporting of major unusual incidents and unusual incidents as well as a document comparing the federal definitions of abuse, neglect, and mistreatment as defined in the CFR 42 and the SOM, and state law.

Based on this, the process for determining compliance with Task 2 of the SOM would be determined by reviewing the data collected and maintained in the ITS system. A member of the combined survey team would conduct a pre-survey review of the information in ITS and would provide a written report to ODH. If ODH finds the ICF/IID to be systemically non-compliant or if an MUI requires further inquiry, follow up would occur on-site by the review team. In the case of a facility that obtains a license term of more than 1 year, this review of reports in the ITS system would occur as an internal review by DODD review staff with the report shared with members of the ODH survey team at least 10 days prior to the on-site survey.

In addition to this review of the facility’s process for the handling of complaints and allegations of abuse, mistreatment, and neglect, DODD will conduct a review of the unusual incidents log and pull any incidents which warrant further review. The unusual incident log includes those incidents not required to be reported as a Major Unusual Incident by state law.

As part of Task 7, which is conducted on-site, an ODH surveyor will review incident reports specific to the individual identified in the sample.

Task 3 & Task 4 – Interviews and Observations

The only modification to these tasks would be that when the facility undergoes a combined certification survey and licensure review, any member of the joint team, regardless of which process they are completing, can conduct interviews and observations and the outcome of those observations may be shared between surveyors/reviewers for inclusion on either the certification survey report or the licensure report. This would allow for increased efficiency in ensuring compliance with both state and federal rules and regulations. It is anticipated that regardless of which surveyor/reviewer observes or identifies an area of non-compliance, the team will rely on that surveyor’s/reviewer’s experience, expertise, and appropriate follow up, to issue the citation. The joint team would conduct a pre-exit conference and follow the SOM as it relates to Task 8 to bring together the outcome of the interviews and observations.

Task 5 – Drug Pass Observation

This would continue to be conducted, as outlined in the SOM, by ODH surveyors.

Task 6 & Task 7 – Area Visits and Record Review

The only modification to these tasks would be that when the facility undergoes a combined certification and licensure survey, any member of the team, regardless of which process they are completing, can conduct an area visit or record review the outcome of which may be shared between surveyors/reviewers for inclusion on either the certification report or the licensure report. This would allow for increased efficiency in ensuring compliance with both state and federal rules and regulations. It is anticipated that regardless of which surveyor observes or identifies an area of non-compliance, the team will rely on that surveyors experience, expertise, and appropriate follow up, to issue the citation. The team would conduct a pre-exit conference and follow the SOM as it relates to Task 8 to bring together the outcome of the interviews and observations.

Task 8 – Team Assessment

As previously noted, the combined survey team would consist of both ODH surveyors and DODD reviewers. The length of the survey would be dictated by the SOM. DODD reviewers would attend on the first day of the review with the ability to lengthen the stay if outcomes dictate. It is anticipated that ODH and DODD staff would conduct a joint entrance conference with the provider at which time the sample would be identified and the timelines of the survey would be shared. Immediately after the entrance conference, the team would conduct the survey with ODH surveyors focusing on the certification components of the survey and DODD reviewers focusing on the licensure components of the survey as identified on Page 3. At the end of day one, a briefing would be held with DODD reviewers sharing the outcomes of the licensure review with the ODH surveyors. DODD reviewers would then conduct a licensure exit conference with the provider. The ultimate goal of the process would be for the provider, at the conclusion of the joint survey process, to receive a single communication from the survey team which would include the certification and licensure report. The provider would then be expected to submit a Plan of Correction to address all areas of non-compliance. Each agency would review the Plan of Correction and make a determination as to what verification of the POC would be necessary to ensure implementation of the Plan of Correction.

Expected Efficiencies

We believe that this combined certification/licensure process would not only meet or exceed the requirements of the certification survey as outlined in the SOM, but would also result in measurable efficiencies to the state agencies, the ICF/IID operators, and the Medicaid recipients. We believe that the development of this process would lead to;

1. Clearer expectations of compliance for the provider.

2. The ability of the providers in Ohio to develop a system of on-going compliance, based on clear expectations, that can be duplicated statewide and result in an increase in quality services and positive outcomes for individuals receiving services.

3. Increased efficient use of staff time for both state employees as well as employees of the ICF/IID.

4. No more than one regulatory visit per year for each facility unless special conditions or complaints arise which would necessitate additional surveys.

5. Access to data through the pre-survey process is anticipated to decrease the amount of time the survey team would spend on-site.

6. Less intrusion on the operations of the facility and the routines of the individuals receiving services, including an expectation that the amount of time required on-site to conduct the survey could be reduced. This determination will be based on the outcome of a time study to be conducted during a 6 month pilot of the proposed survey process.

7. Adherence to a state system for the identification, reporting, and investigation of incidents which we feel not only meets, but exceeds the federal regulations.

8. The potential to create a facility scoring system that not only determines the length of the facility’s license term, but provides consumers with measures that could be used to facilitate consumer choice in selecting an ICF/IID for themselves or someone else.

In Conclusion

Ohio recognizes that there is additional system development that must occur before this proposal could be implemented, but we would respectfully request that CMS provide us with feedback on this initial proposal to assist us in developing an efficient system of federal and state regulatory review for ICFs/IID in Ohio. It is our desire to implement a pilot program for a period of 6 months during which time DODD and ODH would work together to test the new process, gather feedback from customers, conduct a time study of the process, and, based on the outcome of the pilot, adjust the process as needed to ensure that changes to the survey process continue to meet the desired outcomes of CMS, while increasing efficiencies for both state agencies, providers, and the recipients of services.

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