 Welcome to Survey and Certification 101 for Orientation of Newly Employed Surveyors. I'm Tracy Momert with the Survey and Certification Group here in the CMS Central Office, and I am pleased to be able to bring this course to you today via our own satellite broadcast facilities here in Baltimore. In addition to viewing this broadcast by satellite, this broadcast is also available for viewing over the Internet at http://cms.internetstreaming.com. You'll need the Windows Media Player software on your computer in order to view this broadcast via the Internet. The Media Player software is available as a free download from the internetstreaming.com website, and will allow you to watch this broadcast live, as well as replay it for one year after today's broadcast from the same website. Just log on to the internetstreaming.com website and follow the link that says, Click Here to view the broadcast. Handouts for today's instruction are also available at the internetstreaming.com website. Now today's broadcast will last approximately one and a half hours. You'll have additional time at the end of this broadcast after you've attended all of today's classes to ask our panel of experts your questions. So please hold them until that time. We'll be taking your questions by phone and by fax. In preparation for the question and answer period, please note the following numbers. To ask a question by phone, please call 1-800-953-2233. To fax in your question, please dial 1-410-786-0123. You don't need to write these numbers down as they'll be periodically shown on your screen throughout the broadcast. Today's program will consist of three classes. I'll be your instructor for the first class, while two of our New York regional office staff, Ms. Kathleen Gormley and Ms. Stephanie Sr., will be teaching classes two and three. Before you hurry off to the first class, I'd like to introduce Thomas Hamilton, Director of the Survey and Certification Group, who is with us today to formally welcome you to this broadcast. Thomas? Thank you, Tracy, and thank you, Walt, for coming to today's class. As Tracy just mentioned, I am Thomas Hamilton, the Director of the Survey and Certification Program here at CMS in Baltimore. I'd like to welcome you all to today's broadcast. The goal of today's broadcast is to help each new surveyor better understand what the Survey and Certification Program is all about. This will include understanding the respective roles of the central office, the regional offices, and the state survey agencies. The information in today's broadcast serves as a supplement to the detailed instruction you get in your state agency or regional office orientation program or at the CMS-sponsored basic training. During the first part of this broadcast, you will learn what Survey and Certification is about and where it fits into the overall scheme of CMS. You will also be introduced to some definitions that are common to the Survey and Certification Program, terms such as providers versus suppliers and certification versus licensure. Finally, our first instructor today will describe some of the different programs that fall under the purview of Survey and Certification here in our office. Let's see how many programs you already recognize. Tracy? Thanks, Thomas. As I mentioned briefly before, in classrooms two and three, Kathleen Gormley and Stephanie Sr., who are from our CMS Regional Office in New York, will describe for you the important roles of the regional offices and state survey agencies in carrying out the work of the Survey and Certification Program. Now, let's go to classroom one for a general overview of Survey and Certification. I'll be your instructor in classroom one. Well, I'm Tracy Momert. I'd like to welcome you all to Survey and Certification 101. I'll be your instructor for the first part of this course that will focus on a general overview of the Survey and Certification Program. We'll begin today's lesson by looking at the CMS structure and describe for you where the Survey and Certification Program resides in that structure. Then we'll look at how it's organized to promote the effective implementation of the program nationwide. Then we'll describe the program in general and its relation to the state survey agencies. Along the way, I'll provide a few basic definitions and then conclude this portion of the lesson by describing the different program offices here in the CMS Central Office that will include examples of the many programs we oversee on behalf of the Medicare program. If at any time during my instruction you have a question, please raise your hand and I will do my best to answer your questions. Let's start with a big picture. Here's an organizational chart for the Department of Health and Human Services, one of the 15 departments that make up the President's Cabinet. Within the Department of Health and Human Services, you will find the Centers for Medicare and Medicaid Services, or CMS. Our acronym is asynchronous in that one would guess that it would be C-M-M-S, but it's not. It's just not. It's CMS. As you can see, we are in good company with other agencies under the umbrella of the department that you might recognize such as the Food and Drug Administration, the National Institutes of Health, the Centers for Disease Control and Prevention, and the Indian Health Service. All of which also have a three-letter acronym. So there you go. Here we see a picture of the current Secretary of the Department of Health and Human Services, Tommy Thompson. As of today's date, which is May 7, 2004, Secretary Thompson oversees the administration of the entire Department of Health and Human Services, or as it is also known, HHS. Now Mr. Thompson and his staff work from their offices in Washington, D.C. However, with the exception of the administrator and a few CMS senior staff, the staff here at CMS work out of an office in Baltimore. Let's have a look. While Secretary Thompson oversees the administration of HHS, the administrator oversees the administration of CMS. Recently, we welcomed Dr. Mark B. McClellan to CMS to replace Tom Scully, who left CMS this past December. Dr. McClellan comes to us from the FDA, where he recently served as FDA's commissioner. Yes, there's a question. What does CMS actually do? I know it has something to do with Medicare, but is it just Medicare? Good question. To put it simply, CMS's role is to administer and oversee the Medicare, Medicaid, SCHIP and CLIA programs. Not to worry, I'll explain those acronyms for you. Now most of you probably already have a pretty good idea of what the Medicare program is. It's a program that provides healthcare insurance for the people in our nation who are 65 and older. But how many of you knew that Medicare also pays for medical care for people with kidney disease who need dialysis in order to live? In fact, Medicare pays for services related to the treatment of kidney disease regardless of that person's age. All in all, Medicare pays for medical care for some 40 million people in the United States. Medicaid is a jointly run federal and state assistant program that is overseen here at CMS. It's supported with federal and state dollars, and its purpose is to provide certain standard types of healthcare services to our nation's poor regardless of age whose income levels are such that they cannot afford private health insurance and have no other means to pay for healthcare. As long as a state provides certain core medical services required by CMS, the state can decide what other kinds of services they want to provide based on the needs of their own population. For instance, states where the average age of a person is older on average than another state may want to focus their state programs on healthcare related to the elderly. While states with a younger population may want to place more emphasis on preventive care programs. All in all, they say if you know one Medicaid program, you know one Medicaid program. They're all different. S-CHIP stands for the State Children's Health Insurance Program. This is a relatively new program having been born from a law passed in 1997. Again, it's a jointly run federal and state assistance program that provides healthcare for children of families whose income is too much to qualify for traditional Medicaid coverage, but not enough to afford private insurance. And there are about four million children currently enrolled in the S-CHIP program. CLEA stands for the Clinical Laboratory Improvement Amendments, and it's a regulatory program that ensures the quality of testing in our nation's laboratories. It's actually part of the Survey and Certification Program. It's one of the divisions under the Survey and Certification Umbrella here at CMS. The reason it gets special recognition is that it's a program that is not necessarily related to Medicare or Medicaid. The CLEA regulations apply to any medical laboratory with a few exceptions that do medical testing. If you are one of these kinds of laboratories, you must be CLEA certified, regardless of whether you wish to receive Medicare or Medicaid payment for your services. And we'll talk a little bit more about this later. Now that I've described for you what CMS does, suffice it to say that CMS is made up of numerous centers that focus on such things as Medicare payment, Medicaid payment, research, study initiatives, beneficiary outreach programs, publications, and compliance with certain Medicare standards. We have accountants, actuaries, researchers, lawyers, doctors, reporters, think tanks, teachers, graphic artists, clinicians, and even a professional broadcast studio. This picture shows you the structure of the Center for Medicaid and state operations or CMSO, which is where you'll find the survey and certification program. This is where CMS folks who work with compliance issues reside. And it's the only group in CMSO that is not primarily focused on Medicaid program issues. I'll explain more about that in a minute. Like many activities and programs developed and monitored in the central office, CMS gets lots of help implementing these programs through its regional offices. We don't do it by ourselves. There are 10 of them, as you see here, conveniently located across the country. Each regional office is responsible for carrying the messages, policies, and procedures of the Medicare, Medicaid, SCHIP, and CLIA programs in a consistent fashion. As part of that effort to maintain consistency, each region, in turn, has certain states that they are responsible for making sure the program's policies and procedures are carried out consistently. In the survey and certification program, this relationship with the states is unique and that it's the only program at CMS where we actually contract with state agencies to do the work of the program on behalf of the federal government. This is one of the reasons why the program resides in CMSO, this direct relationship with state agencies and their personnel. Remember it's not a Medicaid program as the name CMSO suggests, but it is a state-operated program, hence its location in CMSO. So there you go. Now the regions are further grouped into what we call consortia in order to further help the folks in central office with the consistent application of all of its programs and policies. And finally, here is a picture of the states. Remember that the survey and certification program is unique in that it is a federal program that is carried out through the use of state agency personnel. This is where the rubber meets the road. It's here that state agency personnel on behalf of CMS visit all kinds of different providers as representatives of the federal government to determine compliance with Medicare health and safety standards. The states have the hardest job of all since they are the ones who are actually in the facilities doing this determination and it is not an easy job. Do we have any questions so far? Yes, over here. We've talked about CMS, we've talked about its structure and we've talked about its purpose, but just what is survey and certification? Good question. The Social Security Law says this, that HHS will survey for the purpose of certifying to the secretary compliance and non-compliance of providers and suppliers of services and resurveying such entities at such time as the secretary may direct. In other words, we inspect or we survey health care providers for compliance with the Medicare health and safety standards. And if that provider is in compliance with those standards, they get paid for the services they provide to Medicare and Medicaid beneficiaries. That is the nuts and bolts of survey and certification. If you remember nothing else, remember that. In compliance, get paid. Not in compliance, you don't get paid. Providers and suppliers wanting to receive payment for services they provide to Medicare and Medicaid beneficiaries must meet the Medicare health and safety standards. And where do we find these health and safety standards? Well, we find them in the 42 Code of Federal Regulations or CFR for short. Let me show you what that CFR looks like. Here's a current copy of the 42 CFR. Something you should know, class, is that providers choose to participate in the Medicare program. Nobody forces them to do that, but if they want to receive payment for CMS for the services they provide to Medicare and Medicaid beneficiaries, they must agree to do certain things, one of which is to comply with the Medicare health and safety standards. Yes? You mentioned that the survey and certification program is actually carried out by the states. What authority allows CMS to do that? Another very good question. CMS contracts with state survey agencies to carry out the survey and certification program as part of what we call the 1864 contract or agreement. In the Social Security Act or the law, there is a provision that grants the secretary of HHS the authority to enter into an agreement with the states for the purpose of surveying providers for compliance with the Medicare requirements. And then they report that compliance or non-compliance, as the case may be, back to CMS. That provision happens to be in what section of the act? Can you guess? Yes? Section 1864? That would be correct. And here is a copy of the Social Security Act, in case you were interested in seeing what that looks like. Section 1864 of the Social Security Act describes the kinds of providers and suppliers that are subject to survey, what the state's specific functions are as part of the survey process, and that CMS will provide the funding to carry out those functions. Now, how many of you notice that I've used the term providers and suppliers pretty much interchangeably? Yes? Well, here's the deal. Providers and suppliers are both entities that provide health care to Medicare beneficiaries. However, the Medicare law differentiates between them. Generally speaking, providers include places where practitioners provide care, like hospitals, nursing homes, hospices, intermediate care facilities for the mentally retarded or ICF-SMR, and home health agencies. Providers are entities that supply goods and services used in providing care, like dialysis facilities, which provide dialysis machines, labs, which provide blood-drawing equipment and testing services, ambulatory surgery centers, which provide surgical supplies and surgical procedures, and organ procurement organizations, which provide organs for transplantation. You can probably tell by that description that providers are usually places where people stay, while suppliers provide services on a more temporary and sporadic basis. An easy way to remember the difference is that providers provide the place, while suppliers provide the services. Providers place suppliers' services. And they get paid differently, but we won't go into that in today's lesson. Interestingly enough, Medicaid doesn't distinguish between the terms. Under Medicaid, all providers of care are called providers. While we're on the topic of definitions, let me clarify another set of terms that will help you in your understanding of survey and certification activities. Remember a little while ago that I described survey and certification as a program where we inspect or survey health care providers for compliance with the Medicare health and safety standards. And if that provider is in compliance with those standards, they get paid for the services they provide to Medicare and Medicaid beneficiaries. When a provider or supplier is determined to be in compliance with the Medicare health and safety standards, then we say they are certified to be in compliance. The term certification connotes compliance with federal requirements. If a provider or supplier meets any applicable state requirements strictly under state laws, then we say they are licensed. The term licensure connotes compliance with state requirements. Yes? What kinds of activities are included in the survey and certification program? Well, let's see. In the CMS central office, there are six program areas that comprise the survey and certification program. The Division of Nursing Homes, the Division of Acute Care Services, the Division of Continuing Care Services, the Division of Labs, the Budget Staff, and the Training Staff. Let me tell you a little bit about each one, and I think you'll be able to recognize at least some of the different programs and activities survey and certification is involved in. Remember, we said that the purpose of the survey and certification program is to survey or inspect providers and suppliers for compliance with the Medicare health and safety standards, which we said are in 42 CFR. That's correct. While in the Division of Nursing Homes, the primary function is to ensure compliance with the Medicare health and safety standards for nursing homes, and is probably survey and certification's most high-profile division. As part of their overall compliance function, the Division of Nursing Homes oversees the process where nursing homes collect resident assessment data to create quality indicators. That resident assessment set is called the MDS, or the Minimum Data Set. Nursing homes use the MDS to collect data from their residents at periodic intervals during the time they are there, and then they send it into the state survey agencies. About once a month, the central office comes along and sucks the data up into its own coffers. We wave the magic wand and outcomes quality indicators that both nursing homes and surveyors can use to monitor and prove the quality of care in that home. These quality indicator reports show how a particular nursing home is doing over time with things like urinary tract infection rates, pressure soar rates, restraint use, fall rates, and they are available using the same dial-up function that nursing homes used to send in their data. This MDS data and the data used on survey are also used to create the profiles you see on the Nursing Home Compare website. Nursing Home Compare is a relatively new website that allows family and friends to search for the most appropriate nursing home for their loved ones by providing information concerning routine survey results and complaint results if there have been any. MDS is also used to create the Nursing Home Data Compendium, which is a manual of tables and charts that CMS started publishing annually beginning a couple of years ago. These tables and charts display things like number of residents per state, average use of restraints in nursing homes broken down by state, pressure soar occurrence by state, and lots of other data that states and regulators and researchers have found to be very useful in helping themselves compare their own states with other states and with national averages. Some other projects of note include the recent development and implementation of a national automated complaint tracking system called ACS, which allows for the consistent intake and tracking of complaints received by state survey agencies for all providers, not just nursing homes. And this system just went live for all states this past January. We also, not too long ago, published the Feeding Assistant Regulation that allows states to train and hire people to help feed nursing home residents, which then frees up the nurses and aides to focus their time and attention on patient care. Yes, question over here. What about requirements for medical buildings? I read in the paper about a fire in a nursing home. Not in compliance with current requirements. Is CMS nursing home division involved in these kinds of things? It is. This division is actively involved in development and implementation of what we call life safety code requirements, which are building requirements primarily created to prevent fire related injuries and deaths in medical facilities, such as nursing homes, hospitals, hospices, ICF-SMR, and surgery centers. And others, generally speaking, survey and certification is frequently challenged about the burden we place on providers in order for them to be compliant with Medicare requirements. That is, until there's a death, then the requirements are not stringent enough. Right now, we've been dealing with a lot of attention thrust upon us due to several recent fire related deaths in nursing homes, where the issue surrounds current life safety code requirements on sprinkling. Believe it or not, not all buildings are required to have a sprinkling system if they meet certain other building requirements, which was the case in the unfortunate event you just mentioned. These recent fires have spurred lots of talk about requiring sprinklers in medical buildings no matter what, which will be very expensive. A requirement like that could cost a billion, billion with a B dollars, but it should prevent deaths. This particular situation is an excellent representation of the balancing act that all of survey and certification is constantly challenged with, burden versus outcome. And finally, the nursing home division here at CMS oversees a contract that provides help in monitoring state nursing home surveys by sending in a specialized team of surveyors who periodically look behind the state's survey for any particular areas of the survey process that might need improvement. Kathleen will be telling you a little bit more about that in the next class. Next, in our acute care services division, the focus is on ensuring compliance with the Medicare health and safety standards for hospitals, ambulatory surgical centers, rural health clinics, and critical access hospitals. As the name implies, these are places that provide short term stays for patients with medical needs. In addition to this, this division monitors compliance with the Emergency Medical Treatment and Labor Act or EMTALA requirements. These are the requirements that require hospitals to see patients in their emergency departments, regardless of their ability to pay, and must at least stabilize a patient in the event they need to transfer them somewhere else. This division also monitors deemed status programs. These are programs provided by accrediting organizations that have been approved by CMS as having requirements or standards that are at least as stringent as the Medicare requirements when taken as a whole. A familiar example of this is the Joint Commission on Accreditation of Health Care Organizations, which is an organization that accredits hospitals, home health agencies, hospices, and ambulatory surgery centers. Providers that are accredited by the Joint Commission or other approved accrediting organizations can use their accreditation as a substitute for a state agency Medicare survey, and the state doesn't routinely survey these providers. Now periodically, the state will do a look behind survey after the accrediting organization's inspection to verify that the accrediting organization's survey process at a minimum assures compliance with equivalent Medicare requirements. We call this a validation survey. And finally, the Division of Acute Care Services assists the nursing home division with implementation of life safety code requirements. Remember, we talked about these just a few minutes ago and said that they were requirements related to fire safety. In this division, the focus of the life safety code requirements is on acute care facilities, like hospitals. In the Division of Continuing Care Providers, as the name implies, the main focus is on ensuring that the Medicare health and safety standards for providers of care that is not short-term are met. Providers like home health agencies, hospices, dialysis facilities, ICSMR, psychiatric hospitals, and rehabilitation facilities, which does not include nursing homes. Remember, we have a separate division for that. This division is a very busy division simply because of the variety of providers it monitors. In addition to the monitoring responsibilities of this division, some of the other functions this division is involved in include overseeing the collection of home health patient data to create quality indicators using the Outcome and Assessment Information Set or OASIS. With the MDS in nursing homes, home health agencies collect patient data at certain points during a patient's stay, and they send it in electronically to the state survey agency. And once again, central office comes along about once a month and sucks the data into the big data banks housed here at CMS. We wave the magic wand and we turn the data into quality indicator reports that are available to the home health agencies and the state survey agencies to monitor and improve quality of care in home health agencies. The OASIS data, together with survey data, is used to provide the information on the Home Health Compare website where, like nursing home compare, people can go to get a rough idea of the quality of care provided by individual home health agencies. And finally, this division oversees a contract that provides help in monitoring state ICFMR and psychiatric hospital surveys by sending in a specialized team of surveyors who periodically look behind the state survey for any particular areas of the survey process that might need improvement. As the name implies, the division of laboratories ensures compliance with the clinical laboratory improvement amendments or clear requirements for all laboratories. The clear program is unique in that participation is mandatory. Any laboratory, anywhere, doing any kind of testing for the purpose of testing human specimens for medical purposes, that is for the purpose of diagnosis, prevention, or treatment of disease, must be clear certified. It doesn't matter if the lab wishes to participate in Medicare or Medicaid, it must be clear certified. And a lab is no longer just that place in the basement of a hospital where people in white coats run around, or a giant national lab like Quest Diagnostics or Lab Corps. A nursing home doing urine dipstick testing is considered a lab. A home health agency doing finger stick blood glucose testing is a lab. And now most doctors' offices are considered labs because most of them do both finger stick blood glucose and urine dipstick testing. OK, we're coming down the home stretch here. Briefly, the budget staff develops and executes the state certification and CLIA budgets. They serve as the central point for all state certification and CLIA budget matters. And they are the ones who send out the budget call letters every year. And finally, the training staff manages the operational aspects of all of the survey and certification training. They find and book the hotels where we do our training. They negotiate room rates, manage the technology, keep track of surveyors in need of training, and work with the program staff here in central office to design the curriculum and provide training manuals, among lots of other details that make for well-run courses. Basically, the training staff provides the courses that teach surveyors the hands-on skills necessary for successfully surveying Medicare and Medicaid facilities. And they facilitate our satellite training courses like these. In fiscal year 2004, the training staff is scheduled to put on 56 on-site courses. These are live, face-to-face courses scheduled all across the country that range from 3 to 5 days in length. We are also on target to produce 26 satellite broadcasts. That is a lot of courses that you have the training staff to thank for. Well, class, I've provided you with the basics of survey and certification and the origin of many of the programs that you might be familiar with. In a nutshell, the CMS central office provides guidance to implement the Medicare health and safety standards. We write and we rewrite the state operations manual, which is an ongoing project. We draft and issue survey and certification policy memos. We provide national training, and we monitor state agency performance. OK, class, it's getting late. Thank you for all of your attention. This class is now dismissed. In your next class, you will learn more about the regional office and state agency roles in the survey and certification program. Tracy, you mentioned that providers and suppliers who wish to participate in the Medicare program must be certified to do so, but that laboratories must be clear certified. Is there a charge for providers and suppliers to be certified? That's a good question. And there are really two answers to that question. Generally speaking, a provider or supplier wanting to participate in the Medicare and Medicaid programs in order to get paid for the health care services they provide for Medicare and Medicaid beneficiaries must go through a paperwork process that involves documentation of financial and historical information. The financial information is used to verify that the provider can afford to be in business. While the historical information is used to check to see if the applicant has any history of fraudulent activities, once this step has been successfully completed, the provider applicant must then demonstrate that he or she can provide care in compliance with applicable Medicare health and safety standards. And they do this by caring for a certain minimum number of patients, usually around 10, before a survey is done. Once the survey is done and it's determined that the applicant is in compliance with all of the applicable standards, the applicant is recommended for certification and payment or reimbursement begins effective the date of compliance. So while the provider applicant doesn't pay for certification, it does incur costs associated with becoming a new Medicare provider. Now, CLIA is a little different. Laboratories wishing to be CLIA certified must pay a fee for their certification. And this fee is based on the type and number of tests a lab conducts per year. Testing under CLIA is categorized as simple, moderate or high complexity. Labs doing only testing categorized as simple apply for a certificate of waiver, meaning they are waived from the quality control and personnel requirements reserved for more complex testing. These labs pay a flat nominal fee to be a waived lab. Labs doing more complex testing apply for a higher level of certification are subject to more stringent quality control and personnel requirements and pay a fee consistent with the complexity and the volume of testing that they do. The more testing they do, the more the fee is for their CLIA certificate. Okay? Tracy, that was a lot of information. Are there any websites where someone can find out more information about the Survey and Certification Program? There are a number of pertinent websites that you can explore at your leisure to find out more about what is going on in the Survey and Certification Program. The first one you see here on your screen is the Survey and Certification Home page. Keep this address close by because it's almost impossible to try and find on the CMS website if you don't know where to look. Now, we're working on that, making it more accessible, but for right now, you'll want to type it in as you see it here and then save it as a favorite place. The second one, the http colon double slash cms.internetstreaming.com is where you can go to replay broadcasts such as this one for up to a year. The third is the Nursing Home Compare website that we mentioned earlier during class. The fourth is the Home Health Compare website that we also mentioned earlier. What I didn't mention earlier was that we also have a Dialysis Compare website for the same purpose as the other two to help people search for appropriate facilities, in this case, Dialysis Facilities. The fifth one listed is the Oasis website, a very well-developed and managed website for providers wanting up-to-date information on Oasis. And finally, you see the MDS website, the Nursing Home Counterpart 2 Oasis, where providers can find all kinds of information related to the MDS. I hope you were all able to get a better understanding of what the Survey and Certification Program is all about, the structure of the agency, the programs involved, and how the states are involved in the program during Classroom 1. Now let's continue and go to Classroom 2, where Kathleen Gormley will give you a little bit more information on the role of the regional offices in carrying out the goals of the Survey and Certification Program. Let's join Kathleen's Classroom now. Hello everyone, and welcome to Survey and Certification 101, Part 2. I'm Kathleen Gormley, and I will be your instructor for this part of the course. Since Tracy has given you a very good overview of CMS, the Survey and Certification Program, and has explained the role of the central office, I will now focus on the role of CMS Regional Office. As you know, CMS has 10 regional offices. Each regional office has Survey and Certification staff who are divided into individual branches, each having a defined role. The Survey branch is made up of healthcare professionals, including nurses, pharmacists, social workers, nutritionists, life safety specialists, laboratorians, physical therapists, and ICF MR specialists. These surveyors conduct surveys in Medicare providers, usually in conjunction with the state surveyors. As you know, CMS contracts with the state agencies to conduct surveys. CMS in turn is then mandated by Congress to evaluate whether the state agencies are following the federal regulations and implementing the federal survey process. In order to evaluate this, CMS must do a certain percentage of the surveys that are conducted by the state agency. Surveys conducted by the regional office staff for skilled nursing facilities, CMS must do a sample of 5% of all the surveys that are done by the state. For other specified providers, CMS conducts a 1% sample of surveys conducted by the state. Yes? So how many nursing home surveys would each regional office conduct? Well, it depends on how many Medicare-certified nursing homes are in the state. For example, New York has approximately 660 skilled nursing facilities. So 5% of 660 breaks down to 33. Therefore, the New York Regional Office, would surveyors, would conduct 33 surveys in New York this year. The 5% surveys are accomplished by two different types of surveys. The majority of these surveys are what we call FOS surveys or Federal Oversight Support Surveys. The rest of the surveys that are conducted by the regional office are called Comparative Surveys. CMS Central Office decides how many FOS and Comparative Surveys will be conducted each year by the regional office. To give you an idea as to how the FOS and Comparatives might break down, I will again use New York as my example. Of the 33 surveys that will be done in New York this year, 29 will be FOS surveys and four will be Comparative Surveys. Yes? So what is a FOS survey? Sure, a Federal Oversight Support Survey or FOS means that the regional office surveyors accompany the state surveyors on the survey. The state agency sends a list each month to the regional office as to what surveys they will conduct. The regional office then notifies the state agency in which survey or surveys they will participate. It's important to remember that the survey is still a state survey and the regional office staff is basically just there to observe and evaluate. The FOS survey is outcome-based, not process-based. So in other words, while the process is important, the desired outcome of identification and substantiation of the facility's compliance with Medicare and Medicaid requirements is what the regional office team will be evaluating. The RO surveyors will accompany the state surveyors on all survey tasks and will be present for observations, record reviews, environmental tours, staff and resident interviews, team meetings and decision-making. While this may not be the most comfortable process and I know it can be anxiety producing, I think if we remember that while each may have a different role during the survey, we're all there for the same reason which is to assure a good outcome for the beneficiaries. Yes. Will the state agency surveyors each receive a grade on how well they conduct the survey? No. The evaluation that is completed by the regional office surveyors is in evaluation of how well the state survey team conducted the survey. For example, did the team do appropriate off-site preparation? Did the members of the team share information? Did each team member participate in team decision-making? There are no individual scores given out, only team scores. Yes. Does the regional office send a report to the state agency? Absolutely. But first, while still at the facility, the regional office surveyors will debrief the state team and will review with them all the areas of strength and the areas that may need some improvement. When the regional office surveyors complete the report, it will be forwarded to the state agency. This will occur in approximately 30 days after the survey is completed. It's important to remember that this report will only contain a score for the entire team, not for individual surveyors. Yes. So what are comparative surveys? A comparative survey means that the federal surveyors will survey the same facility that was surveyed by the state within a 30-day timeframe. The regional office surveyors will utilize the same information that the state surveyors used in identifying areas of concern and residents who will be included in the sample. The federal surveyors will follow the federal survey process and complete the survey. The results of both surveys will then be compared to evaluate whether the same outcome was reached and if it was not, then why not? The results of the federal survey will be sent to the state agency. When the surveyors are not out on survey, they are busy in the regional office reviewing complaints, analyzing data, reviewing draft policies, working with our central office, reviewing surveys where enforcement action has been recommended, and reviewing plans of correction as well as assisting the Office of General Counsel on appeals. So now let's discuss the other staff who make up the certification and enforcement branch. The certification and enforcement staff is responsible for all certification activities, such as initial surveys, changes in ownership, mergers, PPS exclusions, distinct part decisions, as well as data systems, budgets, performance standard reviews, enforcement activities for all Medicare providers and suppliers. The certification staff receives the survey packages from the state agency, and after reviewing the documentation and in consultation with other staff, we'll implement the enforcement recommendations from the state agency. This staff works closely with the survey branch, the state agency, provider suppliers, our legal counsel, and beneficiaries. Well, that concludes my presentation on the role of the regional office. Thank you very much. Thanks, Kathleen. Kathleen, in your presentation about Federal Oversight Support Surveys or FOSS, you talked about how the state agency informs the regional office about its schedule of surveys, and then the regional office informs the state agency which ones it will participate in. Is the state agency always notified when a FOSS survey will be conducted by the regional office? Generally, that is true. However, the regional office has the authority to conduct unannounced FOSS surveys and may on occasion exercise its right to do that. Thanks, Kathleen. All right, now let's move on to Classroom 3 where Stephanie will provide us with additional information on the role of the state agency and the surveyor. Stephanie? Welcome to Survey and Search 101, Classroom 3. I'm Stephanie Sr., and I will be your instructor for this final series of classes that make up Survey and Search 101. I will focus on the role of the state agency and the role of the surveyor. First, let's take a look at statute, titles 18 and 19 of the Act. As mentioned, use of state agencies is unique to the Survey and Certification Program. This federal program is carried out through the use of state agency personnel. The functions which the state agency performs under the agreement are referred to collectively as the certification process. Certification is when the state agency officially certifies its findings whether health care entities meet the act's provider or supplier definitions and whether the entities comply with standards required by federal regulations. Surveys are necessary for the state agency to be able to certify. Their certification is the crucial evidence relied upon by the regional offices in approving health care entities to participate in Medicare and CLEAR. State agencies do not have Medicare determination making functions or authorities. What is a survey? A survey is a realistic focus in ascertaining that the responsible provider, officials and key personnel are effectively doing all they must do to protect health and safety. The role of the state agency also includes but is not limited to identifying potential participants. The law guarantees to Medicare beneficiaries that payment will be made for health services furnished in or by entities which meet stipulated requirements of the act. Conducting investigations and fact-finding surveys. This verifies how the health care entities comply with the conditions of participation requirements. Surveys are conducted on specified cycles or as a consequence of a complaint. Explaining requirements. The state agency advises providers and potential providers in regard to applicable federal regulations to enable them to qualify for participation in the programs and to maintain standards of health care consistent with the conditions of participation or requirements. Operating toll-free home health hotline. The state agency maintains a toll-free telephone hotline to collect, maintain and continually update information on Medicare certified home health agencies. This hotline is also used to receive complaints and answer questions about home health agencies in the state. Also, the state must conduct periodic educational programs for the staff and residents and their representatives of skilled nursing facilities and nursing facilities in order to present current regulations, procedures and policies. The state is also authorized to perform numerous other functions under the blanket clause of its state agency agreement by special agreement or by statute. This includes identifying prospective payment system excluded institutions. Certification information helps in identifying institutions that meet special requirements, qualifying them to be excluded from Medicare prospective payment system. Participation on validation surveys of accredited facilities. These surveys are intended to furnish the Department of Health and Human Services and Congress a monitoring of the validity of deeming that accredited entities meet the conditions of participation. Proficiency testing. The state agency monitors programs of proficiency testing in laboratories and contributes laboratory compliance findings to use in the clear laboratory certification program. Direct data entry. The state agency enters data from surveys, follow up visit and complaint investigation into the Oscar OD system. This is a national mainframe computer system that is used for maintaining and retrieving certification data. The state agency is also responsible for updating information about providers, suppliers and clear laboratories when indicated. Nurse Aid Training. The state agency specifies and reviews nurse aid training and competency evaluation programs. Nurse Aid Registry. It establishes and maintains a registry for all individuals who have satisfactorily completed the nurses aid training on competency programs. Resident Assessment Instrument. It specifies a resident assessment instrument for use in long-term facilities participating in the Medicare and or Medicaid programs and records and reports. The state agency maintains pertinent survey and certification, statistical or other records for a period of at least four years and makes reports available in the form and content as the secretary may require. Let's turn to the role of the surveyor. A surveyor conducts on-site inspections of healthcare delivery provided to beneficiaries in order to evaluate quality of care, quality of life and the provisions of other services. How is this accomplished? Many aspects of the survey process are accomplished by scrutinizing the provider's records to show that professional staff members have been properly noting and evaluating the progress of patient care or managing provider operations with continuous vigilance. Surveys of skilled nursing facilities, nursing facilities, home-held agencies and immediate care facilities mentally retarded are conducted in accordance with outcome-orientated survey protocols. These tools were designed to concentrate on patient, resident, client outcomes of care in determining the provider's compliance with the federal requirements rather than focusing on process-orientated requirements. In addition, surveyors analyze facilities specific statistical and historical data, claims data and other sources of information prior to an on-site survey. Utilize survey protocols to measure compliance with federal requirements, conduct surveys in accordance with the appropriate protocols and look to the substantive requirements in the statute and regulations to determine whether a citation of non-compliance is appropriate. Decide whether there is a violation of the statute or the regulations. This must be based upon observations of the facility's performance, practices or conditions in the facility. Surveys prepare facility certification for the regional office. They send the institution a statement of deficiencies if there is a determination of non-compliance. The facility is given 10 days in which to respond with a plan of correction. Plans of correction are either acceptable or unacceptable. If an institution has not come into compliance with all conditions or requirements within the time period accepted as reasonable, the state agency certifies non-compliance notwithstanding the plan of correction. It recommends termination of federally certified providers and suppliers when quality of services are not in compliance with federal standards. Are there any questions? You mentioned the importance of protecting health and safety when describing the role of a survey. Who and or what were you referring to? We are not only responsible for the health and safety of the residents, but also the physical and environmental structures of the facility. Are there any more questions? Okay, if there are no more questions, this has been an overview of the role of the state agency and the role of the surveyor. And it's the last part of our survey and certification 101 course. Thank you all for your attention. Wow, that was a lot of information that you covered. Thanks, Stephanie. Now, before we conclude our program, I'd like to give you an opportunity to ask us any questions that you may have. The number to call is 1-800-953-2233. To fax in your question, dial 1-410-786-0123. While we're waiting on our first caller, Stephanie, let me ask you a question. During the presentation, you spoke about accreditation surveys and deeming. Could you explain what is meant by deeming and give us an example of a provider that would be deemed? Yes, Tracy. The term deeming means that a provider, for example, an acute care hospital, is accepted as being in compliance with the Medicare conditions of participation because they are in compliance with the survey conducted by an approved accrediting organization. We refer to that as being deemed. For example, an acute care hospital that is accredited by the Joint Commission on Accreditation of Healthcare Organizations would receive a survey by that organization approximately every two to three years. And as long as they remain in compliance on these surveys, Medicare accepts this deeming as being in compliance with the Medicare conditions of participation. When I spoke about validation surveys, which relates to deeming, I meant that in order to verify the findings of the accrediting organization, a small percentage of surveys are repeated by the state agency. This would be similar to CMS doing a comparative survey following a state survey. Hearing no questions yet from the audience, I have a question for you, Kathleen. When the regional office conducts the FAR survey, that's the one where the regional office and the state agency staff go into a facility together. Is the regional office team the same size as the state team? No, Tracy. The regional office will generally have only one regional office surveyor for every two to three state agency surveyors. For that reason, it's very important for the state surveyors to coordinate their daily survey activities with the regional office surveyor. Let me ask you one more question. During the FAR survey, can the state agency surveyor ask for guidance from the regional office surveyor? Good question. Normally, the regional office surveyor will provide no input prior to the debriefing at the end of the survey, except in a very unusual circumstance such as intermediate jeopardy. Okay. Stephanie, I have a question for you. We haven't had any questions coming in from the audience yet. Let me ask you this question, Stephanie. I've heard about FAR surveys and comparative surveys. How many different types of surveys are there? Tracy, there are quite a few actually. There is the initial survey when a provider or supplier applicant is surveyed by the state for the first time to determine whether or not the provider should be certified. There is the recertification survey, which is done periodically by the state to determine if a provider or supplier should continue to be certified. There is a complaint survey, which is done by the state when there is an allegation made to the state agency or regional office that would indicate non-compliance with applicable Medicare requirements. There is a revisit survey done by the state to check on the compliance status of a provider or supplier that has been previously non-compliant but has made corrections to return to compliance. And then there is a validation survey where the state conducts a random surveys of deemed providers, that is, providers or suppliers using their accreditation as a substitute for the state agency Medicare survey to see if that deemed provider is operating in such a manner that would, at a minimum, be in compliance with Medicare standards. And then there are the federal monitoring surveys that the regional office does to monitor the effectiveness of the state survey process. These are the FOSS and comparative surveys that Kathleen explained to you. Okay, so in summary, we have initial surveys, recertification surveys, complaint surveys, revisit surveys, validation surveys, and then as we talked about the FOSS and the comparative surveys. Okay, you spoke about certification and recertification. Could you explain what recertification means? What is involved and how often it has to be done? Recertification, Tracy, is when the state agency officially recertifies its findings about whether the healthcare entities meet the Social Security Acts provider or supplier definitions and whether they comply with standards required by federal regulations. This process involves another survey specific to the provider, for example, 10 to 15 months for skill-nasing facilities and at least every 36 months for home health agencies. Okay, one more for you, Stephanie. You said in your presentation that the state must conduct periodic educational programs for staff, residents, and their representatives in nursing homes. Could you give us an example of a program that the state has presented? Yes, any changes in policy or regulations that affect the quality of care or quality of life are conducted by the state agencies to the staff, residents, and their representatives in nursing homes. Best practices are also shared among nursing home staff. Well, hearing no questions from our viewing audience, that concludes our program for today. I'd like to thank our panel and viewers who participated in this broadcast. I hope that it has been helpful and informative. As a reminder, this broadcast can also be viewed in its entirety on the internet at http://cms.internetstreaming.com up to one year from today. If you prefer videotaped copies of this program, they can be purchased from the National Technical Information Services at 5285 Port Royal Road, room 1008, the Sills Building, Springfield, Virginia, 22161. The phone number there to request a videotape is area code 703-605-6186. Again, I would like to thank our panel members and our viewing audience for participating in this broadcast today. I'm Tracy Momert from CMS, saying goodbye until the next time, and good luck in your role as surveyors. You are the most important part of the survey and certification team.