www.kdheks.gov

Our Vision - Healthy Kansans living in safe sustainable environments

AgendaAgenda** Kinds of SurveysKinds of Surveys

** Rural Health Clinic LocationsRural Health Clinic Locations

** Budget IssuesBudget Issues

** Helpful Web SitesHelpful Web Sites

Here is your survey. Here is your survey. No big deal. Or is it?No big deal. Or is it?

This is the CMS-2567This is the CMS-2567Statement of DeficiencyStatement of Deficiency

How to be a recipient of a 2567How to be a recipient of a 2567

In order to receive a prestigious In order to receive a prestigious CMS-2567 suitable for framing, CMS-2567 suitable for framing, KDHE will need to conduct an on-KDHE will need to conduct an on-site survey. Surveys are generally site survey. Surveys are generally one of three types:one of three types: Re-SurveyRe-Survey ComplaintComplaint Validation SurveyValidation Survey

Survey Progression ….Survey Progression ….Good advice would be to stay centered. Good advice would be to stay centered.

Survey triggered by Re-survey,

complaint or validation survey

Immediate Jeopardy(IJ) and COP- 23 daytermination notice

from CMS

Survey results inNo deficiencies or

Findings.One or more COP’s

Provider submits Plan of Correction

POC

CMS-2567 comes from CMS with Termination notice. Abating IJ

Removes 23 notice

CMS-2567 comes from SAWith Termination Notice.SA to Revisit in 45 days.

Don’t go LEFT …….Don’t go LEFT …….23 Day Termination Time Frames23 Day Termination Time Frames

Survey triggered by Re-survey,

complaint or validation survey

Immediate Jeopardy(IJ) and COP- 23 daytermination notice

from CMS

………… ……………….

Day 1 Survey completeDay 2 NotificationDay 3 Info to RO

Day 5 Public NoticeDay 10 Other info to CMS

Day 23 Termination

Don’t go RIGHT either …….Don’t go RIGHT either …….90 Day Termination Time Frames90 Day Termination Time Frames

Survey triggered by Re-survey,

complaint or validation survey

………………. …………

One or more Conditions of Participation

C.O.P.

Day 1 Date of SurveyDay 10 SA Send Letter

Day 45 SA RevisitsDay 55-65 Continued COP’s

Day 70 Public NoticeDay 90 Termination

Stay Centered …..Stay Centered …..

Survey triggered by Re-survey,

complaint or validation survey

…………………

Survey results inNo deficiencies or Minimal Findings

Or Standards.

……………….

Provider submits Plan of Correction

POCGenerally no revisit.

Why complete the CMS-2567?Why complete the CMS-2567?

The Statement of DeficienciesThe Statement of Deficiencies

Surveyors visit your facility, write any deficiencies on the Surveyors visit your facility, write any deficiencies on the Statement of Deficiencies form, and then provide it to you. Statement of Deficiencies form, and then provide it to you. Write your plans for corrections on the form and return it to Write your plans for corrections on the form and return it to KDHE. The Statement of Deficiencies:KDHE. The Statement of Deficiencies:

••Is the basic document available to the public about Is the basic document available to the public about your facility's deficiencies and what is being done to remedy your facility's deficiencies and what is being done to remedy them.them.

• • Provides an opportunity for you to furnish Provides an opportunity for you to furnish documentation that requirements have been met.documentation that requirements have been met.

Lets talk about rural health clinics!Lets talk about rural health clinics!

Rural Health Clinic (RHC)Rural Health Clinic (RHC)42 CFR 491.2 …. Means 42 CFR 491.2 …. Means a clinica clinic that is located in a that is located in a

rural area designated as a shortage area, is not a rural area designated as a shortage area, is not a rehabilitation agency or a facility primarily for the rehabilitation agency or a facility primarily for the care and treatment of mental disease, and meets all care and treatment of mental disease, and meets all other requirements of this subpart. other requirements of this subpart.

CMS has advised KDHE that a CMS has advised KDHE that a RHC can operateRHC can operate one rural health clinic from separate suite one rural health clinic from separate suite numbers within the same building with the same numbers within the same building with the same street address. street address.

For example , one or more RHC’s on the For example , one or more RHC’s on the first floor of this building and/or ……first floor of this building and/or ……

RHC #2 17-8918

RHC #1 17-8918

… … a RHC on the second floor could operate with a RHC on the second floor could operate with a single Medicare Provider Numbers.a single Medicare Provider Numbers.

RHC #3 17-8918

42 CFR 491.5 Location of 42 CFR 491.5 Location of ClinicClinic

If clinic or center services are furnished at If clinic or center services are furnished at permanent units in more than one location, permanent units in more than one location, each unit is independently considered for each unit is independently considered for approval as a rural health clinic. approval as a rural health clinic.

Each RHC requires their Each RHC requires their

own provider number if they are own provider number if they are located in separate buildings.located in separate buildings.

The key to our (or CMS) The key to our (or CMS) determination about whether or not determination about whether or not

one number will suffice is this …one number will suffice is this …

As long as both RHCs are provider-based and located on the campus of the main provider, they could be considered as one location.

The clinic would need to ensure the requirements located at 42 CFR 491.6(a) are met. Specifically, the clinic must be "constructed, arranged, and maintained to insure access to and safety of patients, and provides adequate space for the provisions of direct services."

Separate Buildings – Separate NumbersSeparate Buildings – Separate Numbers

RHC 17-8524

RHC 17-8534

Budget IssuesBudget Issues

Health Facility Survey staffHealth Facility Survey staff

October 1, 2008October 1, 2008

11 FTE’s11 FTE’s

July 10, 2009July 10, 2009

8 FTE’s8 FTE’s

Federal FundsFederal Funds Since federal funding was Since federal funding was

only sufficient at the only sufficient at the outset to support outset to support approximately 6.5 FTE’s, approximately 6.5 FTE’s, KDHE has opted to KDHE has opted to conduct more risk conduct more risk management surveys and management surveys and not replace staff that have not replace staff that have terminated in 2009. Our terminated in 2009. Our federal fiscal year ends federal fiscal year ends September 30, 2009.September 30, 2009.

One time special funds for …..One time special funds for …..

Kansas has applied for Kansas has applied for one time funding from one time funding from CMS to assist in CMS to assist in conducting surveyors for conducting surveyors for providers that have no providers that have no accrediting bodyaccrediting body to turn to turn to for certification to for certification surveys. This would surveys. This would include such entities as include such entities as RHC, ESRD, OPPT, RHC, ESRD, OPPT, Swing Beds, etc.Swing Beds, etc.

What do the What do the federal regulations federal regulations

require that we require that we absolutely must absolutely must

survey?survey?

The priority with which we The priority with which we conduct surveys is conduct surveys is

categorized into categorized into TIER’s.TIER’s.

TIER-ITIER-I is the first and is the first and highest priority.highest priority.

The Tiers are contained in The Tiers are contained in the budget that is also the budget that is also

referred to as …referred to as …

““THE MISSION and THE MISSION and PRIORITY PRIORITY

DOCUMENT”DOCUMENT”

Tier StructureTier StructureTier I Tier I

Tier IITier II

Tier IIITier III

Tier IVTier IV

High (do first)High (do first) HHA, Hospital Val & complaintsHHA, Hospital Val & complaints

High MediumHigh Medium 10% ASC, 5% hospitals & 10% 10% ASC, 5% hospitals & 10%

ESRDs, 5% Targ. Samples. ESRDs, 5% Targ. Samples.

Mid-LevelMid-Level Non AO initials, 4 & 7 year Non AO initials, 4 & 7 year

requirementsrequirements

Lowest PriorityLowest Priority Remaining initials and greater Remaining initials and greater

FreqFreq

Helpful WebsitesHelpful Websites

INTERPRETIVE GUIDELINESINTERPRETIVE GUIDELINES

The Interpretive Guidelines and Survey Procedures for various The Interpretive Guidelines and Survey Procedures for various providers or suppliers are located in the Appendices to the providers or suppliers are located in the Appendices to the State Operations Manual (SOM). For example: Hospitals = State Operations Manual (SOM). For example: Hospitals = Appendix A, Psychiatric Hospitals = Appendix AA, Appendix A, Psychiatric Hospitals = Appendix AA, EMTALA= Appendix V, or Critical Access Hospitals = EMTALA= Appendix V, or Critical Access Hospitals = Appendix W. There are many other appendices. One way to Appendix W. There are many other appendices. One way to obtain a specific Appendix is to go to the webpage for the obtain a specific Appendix is to go to the webpage for the Table of Contents page for the Appendices to the SOM. Once Table of Contents page for the Appendices to the SOM. Once at that page ‘click’ on the Appendix you wish to access. The at that page ‘click’ on the Appendix you wish to access. The Table of Contents Page for the SOM is found at:Table of Contents Page for the SOM is found at:

www.cms.hhs.gov/manuals/downloads/www.cms.hhs.gov/manuals/downloads/

som107_Appendixtoc.pdfsom107_Appendixtoc.pdf

SURVEY AND CERTIFICATION SURVEY AND CERTIFICATION LETTERSLETTERS

CMS Survey and Certification (S&C) releases information CMS Survey and Certification (S&C) releases information related to survey and certification guidance for various related to survey and certification guidance for various providers and suppliers to its Regional Offices and the State providers and suppliers to its Regional Offices and the State Survey Agencies through communications called Survey and Survey Agencies through communications called Survey and Certification Letters. The letters are released on an ongoing Certification Letters. The letters are released on an ongoing basis. Once a letter is released, it is posted on the CMS basis. Once a letter is released, it is posted on the CMS website. The letters are organized by Federal fiscal years. For website. The letters are organized by Federal fiscal years. For example, the first letter released for fiscal year 2009 would be example, the first letter released for fiscal year 2009 would be labeled “S&C 09-01”. The S&C letters can be obtained at:labeled “S&C 09-01”. The S&C letters can be obtained at:

www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.aspwww.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp

CMS HOME PAGECMS HOME PAGE

www.cms.hhs.govwww.cms.hhs.gov

CMS SURVEY AND CMS SURVEY AND CERTIFICATION HOME PAGECERTIFICATION HOME PAGE

The page provides general information The page provides general information regarding the activities of CMS Survey and regarding the activities of CMS Survey and Certification. The Interpretive Guidelines and Certification. The Interpretive Guidelines and S&C letters may also be accessed from this S&C letters may also be accessed from this page.page.

www.cms.hhs.gov/www.cms.hhs.gov/SurveyCertificationGenInfoSurveyCertificationGenInfo

ELECTRONIC CFR (e-CFR)ELECTRONIC CFR (e-CFR)

The e-CFR is an electronic version of the Code The e-CFR is an electronic version of the Code of Federal Regulations (CFR). The CFR is of Federal Regulations (CFR). The CFR is divided into “Titles”, with “Title 42 Public divided into “Titles”, with “Title 42 Public Health”, containing CMS regulations. The Health”, containing CMS regulations. The Federal Register within the Government Federal Register within the Government Printing Office publishes the CFR of an annual Printing Office publishes the CFR of an annual basis. The e-CFR is updated on an ongoing basis. The e-CFR is updated on an ongoing basis. The web address for the e-CFR is: basis. The web address for the e-CFR is:

http://ecfr.gpoaccess.gov http://ecfr.gpoaccess.gov

SOCIAL SECURITY ACTSOCIAL SECURITY ACT

The laws that apply Medicare, Medicaid and other The laws that apply Medicare, Medicaid and other CMS programs are located in the Social Security CMS programs are located in the Social Security Act (referred to as “The Act” or “SSA”). The Act Act (referred to as “The Act” or “SSA”). The Act is divided up into “Titles”. Medicare is Title is divided up into “Titles”. Medicare is Title XVIII and Medicare is Title XIX. The web XVIII and Medicare is Title XIX. The web address to obtain the online SSA is:address to obtain the online SSA is:

http://www.ssa.gov/OP_Home/ssact/ssact-toc.htmhttp://www.ssa.gov/OP_Home/ssact/ssact-toc.htm

Who to call:Who to call:

Charles Moore, Director Medical ServicesCharles Moore, Director Medical ServicesBureau of Child Care & Health FacilitiesBureau of Child Care & Health Facilities

1000 SW Jackson, Suite 2001000 SW Jackson, Suite 200Topeka, KS 66612Topeka, KS 66612

e-mail: e-mail: cmoore@kdhe.state.ks.uscmoore@kdhe.state.ks.us

Charles Direct Line Charles Direct Line 785-296-0131785-296-0131FAX:FAX: 785-291-3419785-291-3419

Web site for Critical Access Hospital Web site for Critical Access Hospital (CAH) Federal Regulations and (CAH) Federal Regulations and

Guidelines Guidelines Appendix WAppendix W

http://www.kdheks.gov/bcchf/index.htmlhttp://www.kdheks.gov/bcchf/index.html

Click on Bureau of Health Facilities and then forms to Click on Bureau of Health Facilities and then forms to get to the above. get to the above.

Other contacts in our Bureau:Other contacts in our Bureau:

Anita Hodge RN, State Survey Manager Anita Hodge RN, State Survey Manager 296-0127 296-0127Lynn Searles, Risk Management SpecialistLynn Searles, Risk Management Specialist 291-3552 291-3552Tamara Wilkerson, Licensure & Certification 296-1263Tamara Wilkerson, Licensure & Certification 296-1263CoordinatorCoordinatorLois Wilkins, Sr. Admin Assist-LicensureLois Wilkins, Sr. Admin Assist-Licensure 296-1258 296-1258Theresa Carter, Sr. Admin Assist-Certification 296-1249Theresa Carter, Sr. Admin Assist-Certification 296-1249

(all are Area code 785) (all are Area code 785)

QUESTIONS?QUESTIONS?

                                                            

www.kdheks.gov

Our Vision - Healthy Kansans living in safe sustainable environments