Long-term care facilities need to start thinking about the future when it comes to their operations — especially from a corporate culture perspective. The regulatory climate threatens to become cloudier over the next few years.
A wave of corporate compliance initiatives — to be enforced by the Department of Justice and Office of Inspector General — is included in the Patient Protection and Affordable Care Act. The new measures are due to go into effect in March 2013. The intent of the compliance initiative, policy analysts say, is to make it easier for the government to crack down on healthcare fraud by enacting a proactive enforcement approach. As a result, the healthcare reform law has relaxed previous legal restraints and boosted federal funding for fraud activities.
For facility managers, it has become paramount to stay abreast of all germane regulations and their potential consequences. They must review organizational procedures and protocols for training and compliance issues, along with assessing the facility’s information technology capabilities. The consequences of not doing so could quickly be devastating to an operator, experts say.
“The current regulatory climate is much faster paced today than it was 10 years ago,” says Steven Littlehale, executive vice president and chief clinical officer of Point-Right. “More frequent changes are being implemented at faster rates. There has also been a shift to being more data-driven. There is a greater willingness to look at data and analytics to identify needed changes and to monitor and measure the impact of change.”
“Data is now the biggest driver in regulatory compliance,” says Jim Rock, president of Vocollect Healthcare Systems. He says the only way providers can improve compliance rates is to document accurately, at the point of care.
“Capturing and analyzing data is the Number One driver for reform and providers need to get their arms around their data immediately, particularly in the areas of demonstrating patient outcomes tied to cost and hospital readmissions,” he adds.
Compared to 10 years ago, “the regulatory climate has become more focused,” says Debi Damas, senior director of regulatory compliance and content for Silver Chair Learning.
“As interpretive guidelines are enhanced, there are more examples of compliance and non-compliance, as well as deeper connections to other regulations,” Damas says. However, on the positive side there is an attempt by CMS to remove some of the subjectivity from the survey process by using the [Quality Indicator Survey]. Still, every decision that providers make is made with the regulations in mind and the impact a survey — good or bad — may have on their organization.”
Today’s regulatory environment has changed dramatically because of the haste with which regulations are issued and the extra layers of rules they contain, says Teresa Chase, president of American HealthTech.
“Also, regulatory changes are at times recommended with less-than-adequate data and experience behind them,” she says. “There are also assumptions that providers are ‘working the system’ or doing something wrong and this new viewpoint shapes the current climate.”
Tamar Abell, president of Upstairs Solutions, contends that the regulatory landscape “looks a lot scarier and more overwhelming than it really is” and that providers most need to be “looking at your systems and seeing what you have.” By examining individual components of each regulation, providers can “take bites out of the process” in order to properly digest them, she says.
Facing down regulations
Awareness of new regulations is the most difficult challenge for long-term care facilities, believes Louis Lenzmeier, director of marketing for MDI Achieve.
While the long-term care industry just endured one of the largest regulatory requirements changes in history with MDS 3.0, Lenzmeier reminds that the regulation is still in its infancy.
“While a large piece of the requirement is in the rearview mirror, there are still more regulations as a result of MDS 3.0 that are being handed down at the federal and state levels,” he points out. “Obviously, everyone has their hand on the pulse of MDS 3.0 and what this means, but it is those small regulations that providers need to really pay attention to. Something that may appear to be a small regulatory change may actually be quite large.”
The increase and enforcement of state staffing minimums is one regulatory change with a lasting impact on providers, says Mark Woodka, CEO of OnShift.
“We are entering a period in which continued downward pressure on Medicare and Medicaid reimbursements for skilled nursing facilities is a reality and at the same time, greater emphasis is being placed on appropriate staffing levels and the enforcement of minimum staffing requirements,” Woodka says. “While the staffing ratios are very good for the residents and quality of care, they can put tremendous financial pressure on providers. States such as California have recently stepped up audit and enforcement efforts of staffing requirements and this is a trend I would expect to see to cascade across the country.”
Damas observes that “regulations have always been a challenge for providers” because any time there’s a change, analysis is needed.
“Sometimes this entails changes in policy, which means that staff needs to be re-educated on policy changes,” she says. “Quality assurance committees may need to change — or be formed — in order to make sure new regulations are being followed correctly.”
Building up technology
With data collection and reporting an increasingly important function of regulatory compliance, providers need to assess their information technology capabilities and what improvements they may need to make. Ryan Sparks, general manager and vice president of enterprise sales for Care2Learn, advises providers equip themselves with IT tools that “collect, aggregate and report all activities and actions performed by the entire staff most relevant to regulatory compliance.”
He says a program for tracking training should report all training, “whether it is delivered in a classroom, as part of a morning standup or completed online.”
While regulations are minimal requirements for long-term care, technology goals should well exceed those minimums, believes John Ederer, the president of American Data.
“This lets regulatory compliance become a byproduct of the facility’s purpose of business – high-quality patient care,” he says. “A ‘one-size-fits-all’ approach to technology homogenizes long-term care where the technology controls the facility rather than the facility controlling the technology.”
Rock recommends providers consider adopting voice technology that enables the care team to interact in real time.
“Nothing gets caregivers closer to the bedside than voice technology, which leapfrogs keystrokes and uses audio prompts for documentation by prompting the caregiver on the custom care plan of each resident,” he says.
Sidestepping errors
There are a number of common mistakes providers make when encountering surveyors, inspectors and auditors on premises, compliance specialists say. Most can be avoided, they emphasize.
“Perhaps the biggest mistake providers make is viewing the annual survey as a separate activity and using survey success as a proxy for quality of care,” Littlehale says. “Survey readiness is a 24/7, 365-day experience. Don’t use the survey window as an opportunity to ‘get the house in order’ during the process. Providers should set their own quality goals and not define success through the survey process. A successful survey implies that minimal standards are being met, but certain facilities will never perform as well as others due to non-modifiable factors that influence the survey.”
In Lenzmeier’s view, one of the biggest missteps is not allowing surveyors access to more data.
“The survey process requires access to more and better data — this data translates into being more informed about what’s going on in the facility,” Lenzmeier says. “Informed and comprehensive data allows a health check to occur and ensure that organizations are targeting the items that will be addressed during the survey process itself. This is crucial, as surveyors will see if something isn’t documented, they will assume it never happened.”
Under the QIS survey, the biggest slip-up is not preparing staff appropriately for the interview portion, Damas says.
“Survey expectations have not changed under the QIS, but the surveyors’ methodology has. There are more resident, family and staff interviews,” she said. “Failing to prepare for this important aspect may be problematic since staff is not generally accustomed to being spoken to during a survey.
“They have usually perceived the survey as something that their managers have to participate in. But now the entire staff is an integral part of the survey process.”
Going forward
Though Abell believes provider fears about future regulations are overblown, that doesn’t mean they shouldn’t be cautious and methodical.
“The DOJ and OIG are getting involved with regulating the industry and that is serious because it includes criminal liability,” she says. “The key is to perform internal audits — find your own problems before the government does. Do everything possible to display transparency.”
Of all the regulatory challenges providers face, Chase believes the biggest one may be “the challenge of the unknown.”
“Outcomes are about proving quality of care and this is a new world for many providers,” she says. “Not having a firm grip on what to expect is unsettling. Many providers worry that by the time they comply, there will be even more changes to contend with.”
Not surprisingly, long-term care providers must face an increasingly complex regulatory future while sporting the disadvantage of lower revenues, Damas says.
“Find cost-effective and efficient ways to manage business processes, especially training and compliance,” she says. “Educating staff on how to properly handle regulations changes and related policy changes is critical. Another education element is family engagement and managing resident family expectations – establishing good relationships with families is a positive way to help manage potential risk.”
From the September 01, 2011 Issue of McKnight's Long-Term Care News
