The Patient Protection and Affordable Care Act has created greater transparency with respect to complex ownership structures as well as enhanced data available to consumers and regulators on quality of care, staffing profiles and training issues.
The recently enacted federal Patient Protection and Affordable Care Act (PPACA) includes significant fraud fighting and program integrity initiatives, in addition to the more widely publicized provisions dealing with health insurance coverage. Some of these provisions apply to all providers and suppliers under federal health care programs, while others are aimed at specific health industry sectors. By far the most extensive provider-specific terms are aimed at skilled nursing facilities (SNFs) and nursing facilities (NFs, collectively referred to as facilities). For example, Section 6401 of the PPACA requires the Secretary of the U.S. Department of Health and Human Services to implement requirements for providers or suppliers to adopt a compliance program as a condition of enrollment, but permits the Secretary to determine the timeline for implementation and required elements of such compliance programs. However, the requirements for facilities are much more specific and detailed. Section 6102 requires facility operators to develop a “compliance and ethics program” within 36 months of enactment, and includes explicit requirements for such programs. Other facility-specific program integrity provisions are briefly summarized below. These provisions are designed to create greater transparency with respect to complex ownership structures as well as create enhanced data available to consumers and regulators on quality of care, staffing profiles and training issues.
Transparency (Section 6101)
Each facility must immediately make available to the federal and state governments, and eventually to the public (pursuant to regulations that must be promulgated within two years), information about ownership and management of the facility. The required information includes all information currently required under Section 1124 of the Social Security Act, plus the following:
Governing body members, officers, directors, members, partners, trustees and managing employees
“Additional disclosable parties,” which include any person or entity that exercises operational, financial or managerial control over the facility; provides policies or procedures for the facility, financial or cash management services; leases or subleases real property to the facility or owns a 5 percent or greater interest in such real property; or provides management, administrative, clinical consulting, accounting or financial services to the facility
The organization structure of each “additional disclosable party.” “Organizational structure” is a defined term that includes extensive governing body and ownership information.
Compliance Program (Section 6102)
As noted above, facilities must implement compliance and ethics programs within 36 months after enactment of the PPACA, pursuant to regulations to be promulgated by the Secretary within two years. Within three years after promulgation of the regulations, the Secretary is required to evaluate whether the compliance and ethics programs have affected quality of care.
In addition to compliance programs, the PPACA also requires implementation of a quality assurance and performance improvement (QAPI) program for facilities.
Nursing Home Compare Website (Section 6103)
Section 6103 mandates enhancements to the Nursing Home Compare website, including additional information on staffing, substantiated complaints, and the number of adjudicated criminal violations by a facility or its employees. The additional data must be provided in a manner that is easily accessible, readily understandable to consumers of long-term care services and searchable.
Reporting of Expenditures (Section 6104); Ensuring Staffing Accountability (Section 6106)
For cost reporting periods beginning two years after enactment, facility cost reports must show wages and benefits for “direct care staff,” and must break out registered nurses, licensed professional nurses, certified nurse assistances, and other medical and therapy staff. Facilities must also electronically submit direct care staffing information, including the category of work performed, resident census and case mix data, information on employee turnover and information on the hours of care provided by each category of certified employee per resident per day.
Standardized Complaint Form (Section 6105)
The Secretary must establish a standardized complaint form for use by residents or persons acting on a resident’s behalf to file complaints about a facility with the state survey and certification agency and the state long-term care ombudsman program. The state must establish a complaint resolution process that ensures tracking of complaints, timely response to the complaint and no retaliation against complainants.
Enforcement and Training Matters (Sections 6111 to 6114, 6121, 6201)
The following additional facility-related provisions appear under the heading “Targeting Enforcement”:
In order to encourage prompt self-reporting, the Centers for Medicare & Medicaid Services (CMS) may discount civil monetary penalties for self-reported deficiencies which are corrected within 10 days.
The Secretary must establish a demonstration project to test a national independent monitor program of interstate and intrastate chains of nursing facilities.
A facility administrator must give at least 60 days notice of closure of a facility, and must establish a plan for transfer and relocation of residents.
The Secretary must conduct two facility-based demonstration projects to test best practice models in facilities that are involved in the “culture change” movement and best practices in using information technology to improve resident care.
Section 6121 requires facilities to include dementia management and abuse prevention training as part of pre-employment initial training. Finally, Section 6201 requires establishment of a nationwide program for long-term care providers to conduct background checks on direct patient access employees.
In addition to the program integrity provisions, the PPACA includes a number of initiatives related to SNF reimbursement, including requirements for:
The Secretary to submit a plan to U.S. Congress in 2012 on value-based purchasing payment systems for SNFs
The Secretary to report to U.S. Congress on the appropriateness of applying health care acquired conditions payment policy to SNFs
Full market basket updates under the SNF PPS in 2010 and 2011
Implementation of a productivity adjustment factor which reduces the market basket adjustment beginning in 2012
Delay of implementation of RUG-IV
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