The Department of Health (DOH) is Pennsylvania's State Licensing Agency for nursing homes. Its Division of Nursing Home Facilities carries out the functions of the State Survey Agency for the federal Center for Medicare and Medicaid Services (CMS). As such, the DOH conducts surveys and makes recommendations to CMS for certification of nursing homes.
Pursuant to federal regulations the DOH has established a process for the informal review of nursing facility deficiencies (the items of non-compliance discovered during the surveys). This review process, referred to as informal dispute resolution (IDR) offers nursing homes an opportunity to request information on recently issued deficiencies and provide documentation to demonstrate that the deficiency should not have been cited.
If an IDR review results in the removal or revision of any deficiencies, DOH issues a revised statement of deficiencies and any penalties that were imposed on the nursing home are amended or withdrawn. From the period January 2010 to September 2011 DOH received requests from nursing homes to review 199 deficiencies. Of these 19 (about 10%) were removed and another 19 revised or reworded based on the information submitted by the nursing home.
Under Act 128 of 2011 nursing homes will now have the option to utilize an alternative form of deficiency review, called an Independent Informal Dispute Resolution review (IIDR). The IIDR reviews will be conducted by an independent entity, Quality Insights, which is the federally designated Quality Improvement Organization (QIO) for Pennsylvania. A nursing home now has the option to request that the deficiency in question be reviewed by the QIO agent. While the state pays for the IDRs conducted by the DOH, nursing homes will pay for IIDR reviews conducted by QIOs.
The IIDR does not replace the IDR process which remains available – it provides another optional path of review that the nursing facility can utilize. The nursing home decides whether to proceed by IDR or IDRR. After it completes its review the QIO provides its written decision to the facility and to the DOH. The DOH reviews the results of the IIDR, decides whether it agrees or disagrees, and makes the final decision. If the IIDR agent sustains the deficiencies, its decision must include the rationale and provide recommended action that facility can implement to achieve compliance. If the IIDR agent disagrees with DOH citation, DOH is required to provide a written explanation for its decision to nullify the IIDR report.
The hope is that independent reviews conducted by the QIO will improve the timeliness and efficiency of the review process and that Quality Insights expertise will improve the ultimate decisions made. Use of IIDR will also help reduce the burden on the DOH and ease provider frustration with perceived subjectivity by DOH surveyors by giving nursing homes an option for an independent review. Nursing homes (and possibly residents) may also benefit to the extent that the QIO can provide ongoing guidance to help nursing homes limit deficiencies and improve quality.
Act 128 became effective in April 2012.