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Date ArticleType
11/1/2015 Regulatory
ISDH Updates

IHCA met with the ISDH in mid-October and the following items were discussed:

• IJ Interpretation:  CMS has communicated to the ISDH that CMS is changing its interpretation of how to cite IJs that occur prior to the start of a survey and for which a deficiency still exists but at a lower scope and severity.  Essentially, CMS is again saying that an “IJ is an IJ” no matter when the issue occurred.  Until now, when at the beginning of a survey an IJ in the past was identified and had been removed prior to ISDH entrance, but the deficiency not totally corrected, ISDH was told only cite the level of deficient practice that existed while ISDH was in the building.  The new interpretation will require ISDH to cite the past deficient practice as an IJ no matter when the practice occurred, although the IJ does not exist at the time of survey, and when the deficient practice still exists at the time of survey (so long as the noncompliance occurred after the last annual survey).  This interpretation change does not impact the citation of IJs as past-noncompliance.  A facility that finds an IJ and removes it and corrects the deficiency prior to the beginning of the survey will still be cited at the IJ level as past non-compliance.

• Sprinklers:  An interpretation has changed with NFPA concerning sprinklers in attic spaces, technically defined as “concealed spaces”, and CMS as well as ISDH will be enforcing this new definition. See the article in this month’s IHCA Impact for details.

• MDS Surveys:  All MDS Focus Surveys have been completed for Indiana.  A total of 16 surveys were performed, 12 by ISDH and 4 by CMS.  CMS is setting up a conference call with all State Survey Agencies in the coming weeks to discuss findings from the surveys and next steps.  From the surveys, F278 (Accuracy of Assessments) and F356 (Nurse Staffing Information) (were the most frequently cited tags.  ISDH expects that MDS surveys will be worked into future survey protocol and be part of the “normal” process.

• LTC Collaboratives:  ISDH’s Healthcare Quality Improvement Regional Collaborative Project is entering its second project phase.  7 collaborative groups of nursing facilities have formed around the state and are nearing completion on their first projects. The first projects have focused on reducing Healthcare Acquired Infections and Urinary Incontinence, both topics were “assigned” by the ISDH.  The second projects will be chosen directly by the participants, and guidance by ISDH and University of Indianapolis.

• Abuse and Neglect:  ISDH will be revising its 2009 guidance on abuse and neglect in the coming months, perhaps by the end of the year. That 2009 guidance is encapsulated in the November 30, 2009 and December 11, 2009 ISDH Newsletters.  IHCA/INCAL will be a resource to the ISDH and we expect that a draft of the guidance will be given to us for review prior to being finalized.  ISDH is doing this as CMS has expressed disagreement with the ISDH guidance and because ISDH does not expect CMS to issue the long-awaited guidance on the subject any time soon.  CMS has been on record lately of saying state survey agencies are not citing abuse and neglect enough and further that abuse of any kind requires at least one deficiency to be cited.  More to come in the future…

• Psychosocial Harm:  It is being reported the CMS does not feel that psychosocial harm is being cited enough within the survey process and are looking at revisions to the State Operations Manual as well as additional surveyor training.