Condition: From a sample of sixty providers, nine of the providers did not have a recertification survey completed within the required timeframe which is used to meet the provider health and safety standards.
Recommendation: We recommend the State train all staff members to properly verify provide...
Condition: From a sample of sixty providers, nine of the providers did not have a recertification survey completed within the required timeframe which is used to meet the provider health and safety standards.
Recommendation: We recommend the State train all staff members to properly verify providers are meeting the prescribed health and safety standards before making payments to those providers.
Views of responsible officials: KDHE/Bureau of Facilities and Licensing (BFL) recognizes the recertification survey deadlines was not met for nine of the sixty non-deemed acute and continuing care providers and supplier types included in this audit consisting of Hospitals, Critical Access Hospitals (CAH), Ambulatory Surgery Centers (ASC), End Stage Renal Disease Facilities (ESRD), Rural Health Clinics (RHC), Hospice and or Home Health Agencies (HHA).
The KDHE/BFL would like to clarify that Section 1865(a)(1) of the Social Security Act (the Act) permits providers and suppliers "accredited" or "deemed" by an approved national accreditation organization (AO) to be exempt from routine surveys by State survey agencies to determine compliance with Medicare conditions. Accreditation by an AO is voluntary and is not required for Medicare certification or participation in the Medicare Program.)
There is no disagreement with the audit finding but KDHE/BFL does want to identify some of the challenges the State Survey Agency (SSA) faces hindering continued progress with corrective action plans.
CMS’s annual appropriation to the SSA has remained unchanged since FY 2015. This has significantly limited the SSA’s capacity to conduct initial, complaint, recertification, and validation surveys. This limitation in funding, coupled with the continuing effects of the COVID-19 Public Health Emergency (PHE), accelerated the loss of SSA surveyor resources and resulted in an ongoing survey backlog. As complaints about provider and supplier quality of care increases, non-statutory recertification surveys and less severe complaint allegations receive a lower priority. Complaint surveys, especially those alleging immediate jeopardy or actual harm to patient health and safety are the primary oversight provided, outside of statutory recertification surveys. These investigations of the most serious allegations also lead to more severe findings, higher numbers of revisits, and additional enforcement workload. Complaint surveys are the primary oversight mechanism for most provider types.
CMS has established the following priorities for the SSA’s:
1. Investigation of patient complaints, as these are active quality concerns that must be reviewed to protect the health and safety of the public.
2. Survey and recertification of statutory facilities such as home health agencies (HHAs), and hospices as required by current law; and
3. Survey and recertification of non-statutory facilities, as required by CMS policy with consideration of available funding once priorities one and two have been accomplished.
Action taken in response to finding: At the beginning of each federal fiscal year including current FFY24, the BFL utilizes the CMS Mission and Priority Document (MPD) which directs and outlines the work of the SA based on regulatory changes, adjustments in budget allocations, and new initiatives, as well as new requirements based on statutes to prioritize and categorize survey plans.
During this current FFY we have begun to restructure the program adding additional program manager positions, health facility surveyors, contracted services, and other support staff. Our goal is always to be able to consistently meet our Tier 1 priority with an emphasis on Tier 2. Recruitment, training, fiscal management & strategies are always a priority and part of action plans to meet these goals.
The SSA goals for FFY24:
• Complete 100% of the ESRD surveys in Tier 2 provided on the required Outcomes List. Kansas currently has approximately 60 non-deemed ESRD suppliers.
• Complete to the extent possible 5% of non-deemed RHCs based on state judgment prioritizing those RHCs most at risk of quality problems for Tier 2. Kansas currently has approximately 135 RHC suppliers.
• Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey with a maximum interval between surveys for any one particular HHA of 36.9 months to meet Tier 1 requirements. Kansas currently has approximately 70 non-deemed, certified HHA’s.
• Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey with a maximum interval between surveys for any one particular Hospice of 36 months to meet Tier 1 requirements. Kansas currently has approximately 50 non-deemed, certified Hospice providers
• Complete to the extent possible based on the state’s judgement prioritizing those at risk of quality problems a standard recertification survey at least one, but not less than 5% of the non-deemed hospitals, 5% of the non-deemed psychiatric hospitals, and 5% of non-deemed CAHs. Kansas currently has approximately 74 non-deemed CAHs, 2 Psychiatric/Rehab non-deemed hospitals and 12 non-deemed hospitals.
Name(s) of the contact person(s) responsible for corrective action:
Jerry Smith, Bureau Director, Bureau of Facilities and Licensing, KDHE, Gerald.Smith@ks.gov
Marilyn St Peter, RN, Deputy Director, Bureau of Facilities and Licensing, KDHE, Marilyn.St.Peter@ks.gov
Planned completion date for corrective action plan: June 30, 2024