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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| HOUSE BILL |
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| INTRODUCED BY GINGRICH, BEAR, CALTAGIRONE, COHEN, CREIGHTON, CUTLER, DAY, DENLINGER, GEIST, HARHART, HESS, KAUFFMAN, MILNE, MOUL, MYERS, RAPP, SWANGER, J. TAYLOR AND VULAKOVICH, MARCH 14, 2011 |
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| REFERRED TO COMMITTEE ON AGING AND OLDER ADULT SERVICES, MARCH 14, 2011 |
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| AN ACT |
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1 | Establishing an independent informal dispute resolution process |
2 | for long-term care nursing facilities to dispute Department |
3 | of Health survey findings; and providing for the powers and |
4 | duties of the Department of Health. |
5 | The General Assembly of the Commonwealth of Pennsylvania |
6 | hereby enacts as follows: |
7 | Section 1. Short title. |
8 | This act shall be known and may be cited as the Long-Term |
9 | Care Nursing Facility Independent Informal Dispute Resolution |
10 | Act. |
11 | Section 2. Purpose and intent. |
12 | The purpose of this act is to establish an informal review |
13 | process for long-term care nursing facilities to dispute |
14 | Department of Health survey findings using an independent agent. |
15 | This informal review process is intended to ensure that a |
16 | statement of deficiencies, as maintained in Federal and State |
17 | data systems, accurately identifies a long-term care nursing |
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1 | facility's actual state of compliance with applicable |
2 | regulations by providing nursing facilities with the opportunity |
3 | to redress grievances arising during the survey process prior to |
4 | the entry of the survey results in the Federal data system and |
5 | without need to engage in formal litigation. |
6 | Section 3. Definitions. |
7 | The following words and phrases when used in this act shall |
8 | have the meanings given to them in this section unless the |
9 | context clearly indicates otherwise: |
10 | "Deficiency." The failure of a long-term care nursing |
11 | facility to meet a requirement of the Social Security Act (42 |
12 | U.S.C. § 301 et seq.), 42 CFR Pt. 483 Subpt. B (relating to |
13 | requirements for long term care facilities), the act of July 19, |
14 | 1979 (P.L.130, No.48), known as the Health Care Facilities Act, |
15 | or 28 Pa. Code Pt. IV Subpt. C (relating to long-term care |
16 | facilities). |
17 | "Department." The Department of Health of the Commonwealth. |
18 | "Facility." A long-term care nursing facility. |
19 | "Findings." Items of noncompliance noted in a statement of |
20 | deficiencies. |
21 | "Independent IDR." An appeal process conducted by an |
22 | independent IDR agent, in compliance with 42 CFR 488.331 |
23 | (relating to informal dispute resolution), by which a long-term |
24 | care facility may challenge deficiencies cited during a survey |
25 | and certification inspection by the Department of Health. |
26 | "Independent IDR agent." The entity under contract with the |
27 | Department of Health that conducts an independent IDR. |
28 | "Informal dispute resolution " or "IDR." An appeal process |
29 | within the Department of Health, in compliance with 42 CFR |
30 | 488.331 (relating to informal dispute resolution), by which a |
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1 | long-term care facility may challenge deficiencies cited during |
2 | a survey and certification inspection by the Department of |
3 | Health. |
4 | "Plan of correction." A facility's response to deficiencies |
5 | that explain: |
6 | (1) The manner by which corrective action will be |
7 | accomplished. |
8 | (2) The manner by which the facility will identify other |
9 | residents who might be affected by the deficient practice. |
10 | (3) The measures that will be used or systemic changes |
11 | that will be made by the facility to ensure that the |
12 | deficient practice will not recur. |
13 | (4) The manner by which the facility will monitor its |
14 | operations to ensure that corrective actions are sustained. |
15 | "QIO." A federally-designated medicare quality improvement |
16 | organization. |
17 | "State Operations Manual." The Centers for Medicare and |
18 | Medicaid Services State Operations Manual. |
19 | "Statement of deficiencies." Written notice by the |
20 | Department of Health to a facility specifying the facility's |
21 | operational and program deficiencies found upon completion of a |
22 | survey. |
23 | "Survey." An inspection of a facility conducted by |
24 | representatives of the Department of Health in accordance with |
25 | procedures outlined in Chapter 7 of the Centers for Medicare and |
26 | Medicaid Services State Operations Manual, relating to survey |
27 | and enforcement process for skilled nursing facilities and |
28 | nursing facilities. |
29 | Section 4. Informal dispute resolution process. |
30 | (a) Establishment of an independent IDR process.-- |
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1 | (1) The department shall establish an IDR process to |
2 | determine whether a cited deficiency contained in a statement |
3 | of deficiencies against a facility should be upheld. |
4 | (2) The department shall contract with Pennsylvania's |
5 | QIO, or the QIO of another state that has experience in |
6 | conducting informal dispute resolutions for a state survey |
7 | agency, should Pennsylvania's QIO not seek the contract to be |
8 | the independent IDR agent. |
9 | (3) The department shall obtain all necessary approvals |
10 | from the Centers for Medicare and Medicaid Services to |
11 | contract with the independent IDR agent. |
12 | (4) The independent IDR agent shall offer facilities |
13 | that provide the independent IDR process a choice of the |
14 | following levels of review: |
15 | (i) desk review; |
16 | (ii) telephone review; or |
17 | (iii) expert review. |
18 | (5) The independent IDR process may not replace or be a |
19 | substitute for the existing informal dispute resolution |
20 | process conducted by the department, but shall be an optional |
21 | process that can be selected by facilities on a fee-for- |
22 | service basis. |
23 | (6) The fee for the independent IDR process shall be |
24 | established by the independent IDR agent, provided that the |
25 | fees are approved by the department. |
26 | (7) Independent IDR recommendations made by the |
27 | independent IDR agent shall be subject to final review and |
28 | approval by the department. |
29 | (b) Minimum requirements of the independent IDR process.-- |
30 | The department shall establish written policies and procedures |
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1 | governing the independent IDR process that comply with the |
2 | provisions of 42 CFR 488.331 (relating to informal dispute |
3 | resolution) and the State Operations Manual regarding the |
4 | informal dispute resolution process. The independent IDR |
5 | procedures shall include, but are not limited to, the following: |
6 | (1) Within ten business days of the end of the survey, |
7 | the department shall, by certified mail or by the intranet of |
8 | the department, if the facility is connected to the intranet, |
9 | transmit to the facility a statement of alleged deficiencies. |
10 | (2) A facility that may request an informal dispute |
11 | resolution review be conducted by either department staff not |
12 | associated with the survey at no charge or an independent IDR |
13 | by the independent IDR agent under contract with the |
14 | department on a fee-for-service basis. A facility may select |
15 | only one method of review. A facility must submit its request |
16 | for an independent IDR review and indicate its selection of |
17 | the type of review and level of review in writing within the |
18 | same ten-day period applicable to the facility for submission |
19 | of the plan of correction. |
20 | (3) (i) Within 45 days of receipt of the request for an |
21 | independent IDR by a facility, the independent IDR agent |
22 | shall issue a written decision to the facility based upon |
23 | its review of the facts, survey findings, State |
24 | Operations Manual and applicable law. |
25 | (ii) If the independent IDR agent sustains the |
26 | deficiency, the independent IDR agent's written |
27 | determination shall include the rationale for its |
28 | decision and provide recommended action that the facility |
29 | can implement to achieve compliance. |
30 | (iii) If the department disagrees with an |
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1 | independent IDR agent's determination that reverses a |
2 | deficiency, the department shall provide a written |
3 | explanation for its decision to nullify the independent |
4 | IDR agent's report to the independent IDR agent and to |
5 | the facility. |
6 | Section 5. Data collection. |
7 | The department shall collect and maintain the following data: |
8 | (1) The total number of review requests received on an |
9 | annual basis, including the number of independent IDR |
10 | requests and the number of State informal dispute resolution |
11 | review requests. |
12 | (2) The total number of independent IDRs completed, |
13 | including the number of reviews that resulted in the removal |
14 | of a deficiency, the number of reviews that resulted in the |
15 | downgrade of a deficiency and the number of reviews that |
16 | upheld a deficiency. |
17 | (3) The total number of State informal dispute |
18 | resolution reviews completed, including the number of reviews |
19 | that resulted in the removal of a deficiency, the number of |
20 | reviews that resulted in the downgrade of a deficiency and |
21 | the number of reviews that upheld a deficiency. |
22 | Section 6. Effective date. |
23 | This act shall take effect in 120 days. |
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