Mike Dankert, Director

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• Mike Dankert, Director
• Bureau of Health Systems
• Michigan Department of Community Health
• Michigan Association of Homes Services to the
  Aging
• Annual Conference
• April 28, 2008

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Facility Reported Incidents
FY 2007 1480 FRIs with harm referred to
CIU 1813 FRIs non harm referred to NHM Teams
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Complaint vs. FRI Intake History(Including
UpNorth Team Data)FY2008 data, through March 31,
2008
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Facility Reported IncidentsSubstantiated
Allegations
Source ACO, 4-16-08
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CMS Reporting Requirements

• 42 CFR 483.13(c)(2)
• The facility must ensure that all alleged
  violations involving mistreatment, neglect, or
  abuse, including injuries of unknown source, and
  misappropriation of resident property are
  reported immediately to the administrator of the
  facility and to other officials in accordance
  with State law through established procedures
  (including to the State survey and certification
  agency).

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• 42 CFR 483.13(c)(4)
• The results of all investigations must be
  reported to the administrator or his designated
  representative and to other officials in
  accordance with State law (including to the State
  survey and certification agency) within 5 working
  days of the incident, and if the alleged
  violation is verified appropriate corrective
  action must be taken.

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Facility Reported Incident Policy

• All reportable incidents must be reported within
  24 hours to the Bureau of Health Systems on a
  BHS-OPS-362 and the results of the investigation
  must be reported to the Bureau of Health Systems
  on the BHS-OPS-363 within 5 working days. These
  forms may either be submitted electronically
  through the Bureau of Health Systems website
  http//www.michigan.gov/bhs (the preferred
  method) or, if necessary, by faxing the documents
  to the Bureau of Health Systems at (517)
  241-0093.
• Remember, the five day investigation findings
  (BHS-OPS-363) report should be faxed to the same
  office as the incident (BHS-OPS-362) report.

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Facility Reported Incidents Policy (continued)

• As an alternative FOR NON-HARM INCIDENT
  REPORTS ONLY, FACILITY REPORTED INCIDENTS THAT DO
  NOT INVOLVE HARM TO A RESIDENT MAY BE FAXED
  DIRECTLY TO THE LICENSING OFFICER WITH
  RESPONSIBILITY FOR YOUR FACILITY
• Gaylord Fax [phone]
• Detroit Fax [phone]
• Lansing Fax [phone]

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MICHIGAN DEPARTMENT OF COMMUNITY HEALTHBUREAU OF
HEALTH SYSTEMS REPORTABLE EVENTS GUIDELINE

• REPORTABLE EVENTS INCLUDE ALLEGED
• ABUSE, INCLUDING A RESIDENT TO RESIDENT , STAFF
  TO RESIDENT, VISITOR TO RESIDENT ABUSIVE ACT THAT
  IS WILLFUL, OR
• NEGLECT, OR
• MISTREATMENT WITH PHYSICAL HARM, PAIN, OR MENTAL
  ANGUISH
• INJURIES OF SUSPICIOUS ORIGIN AND
• MISAPPROPRIATION.

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Reportable Events Guidelines (continued)

• A. EXAMPLES OF ABUSIVE ACTS ARE
• HITTING,
• SLAPPING,
• KICKING,
• UNREASONABLE CONFINEMENT, INVOLUNTARY SECLUSION
• INTIMIDATION,
• DELIBERATE INFLICTION OF PAIN INTENDED AS
  CORRECTION OR PUNISHMENT,
• PHYSICAL THREATS,
• USE OF ORAL, WRITTEN, OR GESTURED LANGUAGE THAT
  WILLFULLY INCLUDES DISPARAGING OR DEROGATORY
  TERMS TO RESIDENTS OR THEIR FAMILIES,
• HUMILIATION, HARASSMENT, THREATS OF PUNISHMENT OR
  DEPRIVATION,
• SEXUAL ABUSE, SEXUAL HARASSMENT, SEXUAL COERCION,
  OR SEXUAL ASSAULT, UNWELCOME TOUCHING OF A SEXUAL
  NATURE, REQUEST FOR SEXUAL FAVOR,
• INTENTIONALLY WITHHOLDING FOOD, CARE,
  MEDICATIONS, ASSISTANCE,
• FAILURE TO PROVIDE GOODS AND SERVICES NECESSARY
  TO AVOID HARM, MENTAL ANGUISH, MENTAL ILLNESS,
• SEPARATION OF A RESIDENT FROM OTHER RESIDENTS OR
  OTHER CONFINEMENT AGAINST THE RESIDENTS WILL.

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Reportable Events Guidelines (continued)

• B. EXAMPLES OF PHYSICAL HARM, PAIN OR MENTAL
  ANGUISH ARE
• CUTS, SKIN TEARS, BRUISING, PUFFINESS, TENDERNESS
  THAT IMPAIR FUNCTION OR LIMIT RANGE OF MOTION OR
  MOBILITY,
• SPRAINS,
• FRACTURES,
• BROKEN BONES,
• 1ST OR 2ND DEGREE BURNS,
• ANY INJURY THAT IMPAIRS FUNCTION OF ARM, LEG,
  HAND,
• VISIBLE EMOTIONAL DISTRESS WITHDRAWAL OR FEAR.
• C. WILLFUL MEANS DELIBERATE OR INTENTIONAL, NOT
  ACCIDENTAL.

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Reportable Events Guidelines (continued)

• D. INSTANCES OF ABUSE OF ALL RESIDENTS, EVEN
  THOSE IN A COMA, CAUSE PHYSICAL HARM, PAIN OR
  MENTAL ANGUISH.
• E. USE OF DISPARAGING AND DEROGATORY TERMS CAN BE
  ABUSE REGARDLESS OF AGE, ABILITY TO COMPREHEND,
  OR DISABILITY OF RESIDENT.
• RULES
• INCIDENTS ARE REPORTABLE ON BHS-OPS-362
• INVESTIGATION RESULTS ON BHS-OPS-363 ARE REQUIRED
  IF A BHS-OPS 362 REPORT IS FILED.
• (Rev. 04/08)

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ABUSE, NEGLECT, MISTREATMENT, MISAPPROPRIATION AND
INJURY OF UNKNOWN SOURCE INVESTIGATION GUIDE
START HERE WITH AN ?ALLEGATION OR SUSPICION OF
ABUSE, NEGLECT, OR MISAPPROPRIATION OF RESIDENT
PROPERTY, OR AN ?INJURY OF SUSPICIOUS ORIGIN
(FROM PAGE 2)

• IMMEDIATELY
• ? Secure residents safety
• ? Assess the resident, provide medical and/or
  psychosocial treatment as necessary
• ? Examine the residents injury and/or
  psychosocial changes and document the description
  in the medical record
• ? Remove alleged perpetrator (staff, family, or
  visitor) from contact with all residents and
  staff pending outcome of investigation
• ? Take measures to prevent recurrence if alleged
  perpetrator is a resident
• Document date and time injury was discovered in
  the residents medical record
• ? Notify physician if the injury (physical and/or
  psychosocial) has the potential to require
  physician intervention
• ? Notify the residents legal representative if
  there is a significant change in health status
• Immediately (no later than 24 hours) notify the
  administrator
• ? Administrator or designee notifies BHS, local
  law enforcement, and/or other state agencies as
  required
• Immediately (no later than 24 hours) notify BHS
  of all allegations by one of the following
  methods
• 1) complete the BHS-OPS-362 online submission
  form found on the BHS website, 2) fax the
  BHS-OPS-362 form, or 3) call BHS to report
  followed by a fax of the completed BHS-OPS-362
• Facility Incident Report - 24 Hours (BHS-OPS-362)

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• INVESTIGATE
• ? Document date and time of all notifications per
  facility policy
• ? Interview and/or obtain statement from person
  reporting allegation or suspicion
• ? Interview and/or obtain statement from
  victim/resident
• ? Interview and/or obtain statement from alleged
  perpetrator
• ? Interview and/or obtain statements from
  potential witnesses as determined by the scope of
  the investigation
• ? Review the residents medical record for
  relevant information (diagnosis, history, similar
  injuries, etc.)
• ? Review materials and complete investigation
  (refer to abuse investigation protocol and
  facility policy)

• WITHIN FIVE WORKING DAYS OF INDCIDENT
• ? Report the results of investigation to the
  administrator
• ? Report the results of investigation to BHS on
  the BHS-OPS-363 form and submit by fax with
  supporting documentation
• ? Initiate corrective measures (if applicable) to
  prevent recurrence
• Facility Investigation Report - 5 Working Days
• (BHS-OPS-363)

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INJURY OF UNKNOWN SOURCE (IUS) DETERMINATION
The source of injury is known AND abuse or
neglect is alleged or suspected return to 1 on
Page 1 of the Investigation Guide and proceed
with immediate action, investigation and report
of alleged abuse/ neglect finding.
1. Was the injury observed by any person or
explained by the resident?
RESIDENT INJURY (source to be investigated)
YES
NO
The director of nursing (or designated licensed
staff) should determine the scope of
investigation based on the nature of the injury
and professional judgment with the following, "Is
the injury suspicious ? A. Because of the
extent or location of the injury (e.g., the
injury is located in an area not generally
vulnerable to trauma), or ? B. Due to the number
of injuries observed at one particular point in
time or the incidence of injuries over time?"
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2. Is there a suspicion that abuse/neglect may
have occurred? (Box A or B checked)
Return to 1 on Page 1 of the Investigation
Guide and proceed with immediate action,
investigation and report of alleged abuse/neglect
finding.
YES
NO

• Document summary of conclusion of investigation.
• Review the residents plan of care and revise as
  necessary to prevent recurrence of injury.
• ? Complete determination within 24 hours of
  incident no report to BHS is necessary if
  answers to questions 1 and 2 are NO.

Revised 9/07
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Number of Michigan Nursing Homes by Ownership Type
Source CMS Nursing Home Data Compendium 2007
18
Average Number of Deficiencies by Ownership Types
in Michigan
Source CMS Nursing Home Data Compendium 2007
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Percentage of Michigan Nursing Home Surveys
Resulting in Immediate Jeopardy to Residents by
Ownership Type
Source CMS Nursing Home Data Compendium 2007
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Percentage of Michigan Nursing Home Surveys
Resulting in Substandard Quality of Care by
Ownership Type
Source CMS Nursing Home Data Compendium 2007
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Percentage of Michigan Nursing Home Surveys
Resulting in a Deficiency of Abuse of Residents
by Ownership Type
Source CMS Nursing Home Data Compendium 2007
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Percentage of Michigan Nursing Home Surveys
Resulting in a Health Deficiency of Actual Harm
or Immediate Jeopardy to Residents by Ownership
Type
Source CMS Nursing Home Data Compendium 2007
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Complaint/FRI Comparison by Category
Category 1 abuse, neglect, serious injury
(immediate jeopardy) Category 2 actual
harm Category 3 non-urgent Complaints/FRI
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Average Number of DeficienciesStandard Surveys
Source CMS SC PDQ
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Termination

• 23 days when Immediate Jeopardy (IJ) is
  determined and the IJ is not removed.
• 180 days when deficient practices are not
  corrected to close an enforcement cycle.
  Non-compliance cycle cannot exceed 6 months.
• Discretionary termination may be imposed by the
  state or CMS at any time.
• Special Focus Facility terminated for a poor
  survey if significant compliance progress is not
  made (2 standard surveys with no deficiencies
  above S/S E and no complaint surveys with no
  deficiencies above S/S E) no harm, no SQC.

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Special Enforcement Review Guidelines(Draft)

• I. A. 3 CONSECUTIVE STANDARD SURVEYS _at_ 12 OR
  MORE HEALTH CITATIONS, D-L
• B. 3 CITATIONS AT IMMEDIATE JEOPARDY OR
  HARM ON LAST 3 STANDARD SURVEYS, OR INTERVENING
  SURVEYS

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Special Enforcement Review Guidelines (continued)

• II. OR FACTORS
• OF HEALTH CITES AT G-H
• OF HEALTH CITES AT J-L
• OF LSC CITES G-H
• OF LSC CITES J-L
• OF CITES _at_ PATTERN AND WIDESPREAD
• PROGRESS IN REDUCING CITATIONS EACH CYCLE
• STABLE ADMINISTRATION ADMIN DON OVER 6 MONTHS
  TENURE
• RECORD OF ADMINISTRATOR AT PRIOR FACILITIES
• SELF-HELP RECOGNITION OF PROBLEM ASSIST PRIOR
  TO SURVEY
• SUBSTANTIATED COMPLAINTS
• DISCRETIONARY DENIAL OF PAYMENT FOR NEW
  ADMISSIONS
• MANDATORY DENIAL OF PAYMENT
• DPOC
• DIT
• REPEAT CITATIONS FOLLOWING DPOC OR DIT
• TEMPORARY MANAGER
• CLINICAL ADVISOR
• ADMINISTRATIVE ADVISOR

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Delegation of Authority

• BHS Director has the authority to take emergency
  license action, issue correction notices, impose
  (state) civil penalties, impose sanctions for CON
  non-compliance.
• DCH Director retains the authority for decisions
  on license revocations, suspensions based on
  non-compliance.
• BHS makes recommendations on federal enforcement
  remedies, including denial of payment, civil
  money penalties, termination to State Medicaid
  Agency/CMS as applicable.
• BHS imposes federal enforcement remedies when
  authorized by State Medicaid Agency/CMS.

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333.20165.amended Denying, limiting, suspending,
or revoking license or certification notice of
intent imposition of administrative fine.
Sec. 20165. (1) Except as otherwise provided
in this section, after notice of intent to an
applicant or licensee to deny, limit, suspend, or
revoke the applicant's or licensee's license or
certification and an opportunity for a hearing,
the department may deny, limit, suspend, or
revoke the license or certification or impose an
administrative fine on a licensee if 1 or more of
the following exist (a) Fraud or deceit in
obtaining or attempting to obtain a license or
certification or in the operation of the licensed
health facility or agency. (b) A violation of
this article or a rule promulgated under this
article. (c) False or misleading advertising. (d)
Negligence or failure to exercise due care,
including negligent supervision of employees and
subordinates. (e) Permitting a license or
certificate to be used by an unauthorized health
facility or agency. (f) Evidence of abuse
regarding a patient's health, welfare, or safety
or the denial of a patient's rights.
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Section 20165 cont. (g) Failure to comply with
section 10115. (h) Failure to comply with part
222 or a term, condition, or stipulation of a
certificate of need issued under part 222, or
both. (i) A violation of section 20197(1). (2)
The department may deny an application for a
license or certification based on a finding of a
condition or practice that would constitute a
violation of this article if the applicant were a
licensee. (3) Denial, suspension, or revocation
of an individual emergency medical services
personnel license under part 209 is governed by
section 20958. (4) If the department determines
under subsection (1) that a health facility or
agency has violated section 20197(1), the
department shall impose an administrative fine of
5,000,000.00 on the health facility or agency.
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333.20168 Emergency order limiting, suspending,
or revoking license limiting reimbursements or
payments hearing contents of order order not
suspended by hearing. Sec. 20168. (1) Upon a
finding that a deficiency or violation of this
article or the rules promulgated under this
article seriously affects the health, safety, and
welfare of individuals receiving care or services
in or from a licensed health facility or agency,
the department may issue an emergency order
limiting, suspending, or revoking the license of
the health facility or agency. If the department
of public health issues an emergency order
affecting the license of a nursing home, the
department of public health may request the
department of social services to limit
reimbursements or payments authorized under
section 21718. The department shall provide an
opportunity for a hearing within 5 working days
after issuance of the order. (2) An order shall
incorporate the department's findings. The
conduct of a hearing under this section shall not
suspend the department's order.
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Nursing Home Closures January 1998 to present
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Nursing Home Closures (continued)
34
Nursing Home Closures (continued)