Protecting Michigan’s Health through Licensing and Certifications

Discover how the Bureau of Community and Health Systems and the Bureau of Survey and Certification protect Michigan’s health through licensing, certifications, and inspections.

Transcript

Larry Horvath: 0:00

Thank you.

Anastasha Osborn: 0:20

Welcome back to the LARA Living Room, where we have real conversations about the work happening every day to keep Michigan safe, healthy, and thriving. I'm your host, Anastasha Osborn. And today we're going to be stepping into a world most of us rarely see, but all of us rely on. That's the behind the scenes work that keeps our healthcare systems trustworthy. Now, from the moment you walk into a care facility, there's already been a quiet, thorough process to make sure it's a place that you can count on. And joining me today to walk us through it are two leaders who make that all happen. And that's Larry Horvath from the Bureau of Community and Health Systems, also known as BCHS, and Jennie Belden from the Bureau of Survey and Certification, also known as BSC. Now they're going to show us how their teams protect public health, what it takes to keep facilities in check, and then why their work matters to every single Michigander. So go ahead and fill up your coffee, grab a seat, and get comfortable because you are now in the LARA Living Room. Welcome to the LARA Living Room. Before we dive in, could you each introduce yourselves and share a little bit about your role and what your bureau focuses on? And Jennie, why don't you go ahead and kick us off?

Jennie Belden: 1:28

Hi, Anastasha. Thank you for inviting me to the LARA Living Room. In my role as Bureau Director of Survey and Certification, I oversee 121 surveyors and 51 administrative staff. And our bureau's focus is to ensure that health and long-term care facilities in Michigan that participate in Medicare and Medicaid services maintain quality standards set forth by the Centers for Medicare and Medicaid Service, or CMS is what you'll hear me refer to it throughout the podcast. BSC is responsible for regulating 14 different provider types. And here's a fun fact. 70% of our BSC staff are field staff, and they travel all over the state of Michigan surveying facilities in their role. Wonderful.

Anastasha Osborn: 2:13

Thank you. And Larry, what about you?

Larry Horvath: 2:16

My name is Larry Horvath, the Bureau Director for the Bureau of Community and health systems. One of the things with our bureau is kind of look at our name and we have a facility that are more community oriented and then we have facilities that are health oriented. Like Jennie's group, our focus is on state licensing of these facility agencies and programs. In addition to that, we also have a few people. So I've always talked about our agency as one that facility agencies and programs. But in recent years, we've picked up a portfolio of individuals that we also regulate. So we issue certifications and permits to individuals such as qualified interpreters, certified nurse aides, and medication aides.

Anastasha Osborn: 3:08

And Larry, you kind of mentioned this a little bit that BCHS has such a huge range of responsibilities. For someone who's never heard of your bureau, how would you sum up what you do in a way that connects to our listeners everyday lives?

Larry Horvath: 3:22

Sure. So we do regulate a lot of health facilities. The health facilities that we regulate are like hospitals, nursing homes, hospice residents, hospice agencies, inpatient psychiatric hospitals and units, nursing homes. So those are on the healthcare side. And we also regulate substance use disorder programs. Those are on the healthcare side. So people receiving healthcare services from those licensed providers we try to make sure that the quality of services is good and that they follow the regulations and if they have a concern about that covered provider that we could initiate a complaint investigation on the community side we oversee adult foster care adult foster care camps and homes for the aged and those are really programs and agencies that focus on assistance with daily living instead of delivering direct health care. So we feel that one is a lot of individuals put their loved ones or seek services in our covered facilities. So we're there to make sure the laws basically spell out what they should be doing to provide quality health care and assistance with daily living. And we're there to make sure that these providers are providing those services.

Anastasha Osborn: 4:46

Wonderful. And Jennie, your bureau, BSC, not to be confused with BCHS, they have very similar acronyms, is more focused on the federal side of regulations. And can you explain what that means and how that ties into CMS?

Jennie Belden: 5:01

BSC is unique in that although we're state of Michigan employees, our bureau is solely focused on ensuring health and long-term care facilities are following federal regulations. And without going too much into a history lesson, the federal government delegates the authority for us to do that through Section 1864 of the Social Security Act, or what we refer to as the 1864 Agreement. Acting on behalf of CMS, our Bureau, which also is referred to as the state agency, so you may hear that as well, performs survey and certification functions to ensure that providers and suppliers comply with all conditions of participation to ensure the health and safety standards are maintained. And if you think about it in that 27% of Michigan's population is enrolled in Medicaid and 22% is enrolled in Medicare. It's essential that the work that we allocate our resources strategically to meet the increasing workload.

Anastasha Osborn: 6:05

So it sounds like both of your teams are really doing a lot of the behind-the-scenes safety net, making sure that these care facilities meet these really high standards that are put in place for safety reasons, of course. What's one example of something you've caught or improved that really made a difference for people's health or safety. And Larry, we're going to go ahead and start with you.

Larry Horvath: 6:25

Yeah, one of the things that we always talk about is our state statute and our administrative rules. Our job is really to administer the laws and rules as written. But one of the things that we really tried to do over probably the last four years, four to five years, is actually the concept that you hear a lot now is about educate before we regulate. So in our bureau, we have created two sections. And in those two sections, their primary focus is to not only educate our internal staff to make sure that we have consistency in the way we apply the law and the way we do our surveys, but they're also educating the providers to make sure that they comply with the requirements. And so these two sections have done a lot. Our one section in the healthcare world has focused primarily on nursing homes. We hope to start to focus on other health care providers and then on the adult foster care side. So we're doing online videos where people can go there 24-7 because we know a lot of staff can't attend a training, in-person training. So we wanted to make it available for the provider staff to be able to access these 24-7 because most of our providers actually office service 24-7. So it's nice that a certified nurse aide on the third shift or a house manager on the third shift could actually go to our sites and do some education and learn about what the regulations are. So we've been very excited. We hope that the long-term outcome is actually a reduction in the citations, that people are more compliant, therefore less enforcement action.

Anastasha Osborn: 8:07

I really love that you guys are going a little more digital. We talk a lot about making things more virtual, more digital, so they're easy to access versus doing a lot of those in person where people may not be able to either travel to them or they don't have the time to make it to those in-person training. So I really like that. That's awesome.

Larry Horvath: 8:24

And one of the things that we have added of late is to actually incorporate testing inside our videos. So it's just not that you're turning on the video and, you know, did they really listen to it or not? We have some actual quizzes inside some of our trainings, and that, I think, makes it more interactive.

Jennie Belden: 8:41

Absolutely. And Jennie, what about you? Well, for Bureau of Survey and Certification, our focus is primarily federal. so that we do not have much discretion to alter the program or our survey processes. CMS is very prescriptive. We have the state operations manual, which is our roadmap for how we conduct surveys. But when I think about it, I really can't think of just one example where we've made a difference. Our team really shines in the day-to-day activities of the survey process. They truly care about the residents and the patients they interact with, and they're tireless advocates for them. When I took my role and I started going out with the survey teams, one thing that came to mind, I was so impressed with the compassion that they showed. I'm not sure if you've ever heard of the starfish story, where it's a little boy who is picking up starfish on the beach and throwing them back in the ocean. And they're just from eye to eye to see starfish on the beach. as far as the eye can see. And there was an old man that came up and said, what are you doing? And he said, I'm throwing the starfish back. And he said, you're never going to make a difference. Look how many there are. And he picked up one and put it in the ocean and said, I made a difference for this one. And that's really the way I think of my team. When I think of the work that they do, they're showing up every day and making a difference one person at a time.

Anastasha Osborn: 10:15

I love that story. I'm So, Larry, let's kind of talk a little bit about something that also makes a difference, licensing inspections. These might sound routine or might seem like they're not making a big difference even, but in practice, they're really about protecting people's lives. And can you walk us through what happens during maybe like a typical inspection for your team?

Larry Horvath: 10:38

Yes. So what we have is, for the most part, and I'm going to talk about the facility agencies and programs, because how we regulate individuals is a little bit different. different because we don't do on-site inspections of certified nurse aides or medication aides. We will do that for our medication aid training programs and our nurse aid training programs, but like qualified interpreters and trainers, you know, we issue the certifications and we don't do inspections on those. We would take complaint investigations. But similar, probably our process is similar to Jennie's as well. The initial state license is in a announced visit because we want the provider to be prepared. They haven't started providing services. We want to make sure that they have all of their paperwork ready when we come on site. So the initial inspection for a license is announced. Once they're licensed, however, all of our inspections are unannounced. So when we do a post-inspection after the license and they start receiving residents or patients, that would be unannounced. A renewal inspection, which the law requires us to go out at certain times based on the individual provider type and a complaint investigation. All of those would be unannounced. But once we get on site, what we're really doing is it doesn't matter if you're talking about adult foster care or a hospital or a training program. What we're going to do is we're going to do direct observations. We're going to walk through the facility and we're going to be looking for things that might not be compliant. So our staff are trained to do the direct observation Another factor that we will use is interviews, and we will interview the patient or the resident, the family members, friends that might be in the building. We always ask those individuals what we're doing here. We'll tell them what we're doing there. Then we'll ask them if they want to participate in an interview, and we keep that information confidential. And then we'll interview the staff themselves. And so from observations to interviews, and then we will do record reviews. We'll start to pull a sample of files. We'll look at their policies and procedures. We'll look at individual patient records and we'll look at their care plans and to make sure that the provider, if somebody is supposed to be getting certain types of medications during the day and a certain period of time during the day, we'll be looking to make sure that that has been documented. We can even go as far as doing a tracer patient where we actually follow a patient from the time they register all the way to post-op. We could follow of them all the way through their surgery. But most of this is really direct observation. Other than the record review, a lot of it is direct observation and talking with people inside the facilities.

Anastasha Osborn: 13:32

Thank you. Now, Jennie, on the certification side, how do you ensure that facilities, whether they're hospitals or nursing homes or anything actually, you know, that are meeting these federal requirements day in and day out, how do you guys ensure that they are doing that?

Jennie Belden: 13:48

Well, very, very similar to BCHS. We conduct annual or recertification surveys, and those take place anywhere from annually to up to three years, depending on the provider type. We also conduct complaint investigations. One key difference is both are unannounced. So all of our surveys are unannounced. For our annual or recertification surveys, we usually have a team of three to four surveyors usually. And again, they are looking at all of the conditions of participation, all of the federal regulations and the facility as a whole when they're going in just to make sure that they're in compliance. They also do interview record review and direct observation. That's the way that they gather their information. And it usually takes three or four days to conduct a recertification survey. Complaint investigations, their focus is, it's very much smaller and it really is on that complaint allegation. We can have one surveyor go out to do the complaint investigation or it could be added with the recertification survey. Further complicating things with the federal side, providers, many provider types are allowed to have accrediting organizations. So you may have heard the term deemed and that means that a provider has elected to contract with an accrediting organization like the Joint Commission to conduct their recertification surveys. And so for those providers we do not go out and conduct those investigations. We do conduct complaint investigations if they arise to a severity level where it would jeopardize the health and safety of the patient or resident.

Anastasha Osborn: 15:33

Now, do BCHS and BSC ever work together on a case or a project? And what does that collaboration look like? And Larry, I'll have you go ahead and start us off.

Larry Horvath: 15:45

Yeah, I think on collaboration, you know, this... Our two bureaus are unique in the sense that we share common provider types. BSC and BCHS all have oversight of things like hospice agencies, hospitals, and nursing homes. So one of the things that we've tried to do is figure out a way to streamline the work so we can be more efficient. And so BSC oversees the complaint intake for not only their bureau but also our bureau when it comes to like providers. So when somebody has a complaint about a hospital, they'll file that with BSC. BSC will triage that. And our requirements are similar, but they can be different. So if BSC has a similar requirement, they would actually do the investigation first. And that's actually, we wrote that in administrative rules for efficiency purposes. Not having state licensing and in the federal certification do the same investigations where you could have two different outcomes and then you're trying to explain to the provider why was I cited under the federal requirements but not cited under the state side. So there was an administrative rule that basically said if there's a like provider that BSE would be the lead in investigating that complaint. If the complaint comes in in a hospital and there's not a regulation on the federal side but there is a regulation on the state side then we will coordinate that complaint investigation The other thing is, you know, we try to look from our side, we try to look at some of the recent inspections and investigations that the BSC side did because there can be in these facilities more frequent than us. So we try to look at patterns by looking at their report to look at areas that we might be wanting to focus on when we go into a provider for estate licensing. So we share information, especially when there's things of a hospital strike, a nurse nursing home change of ownership. So we try to collaborate in those areas. So make sure everybody's on the same page, either from state licensing or federal certification.

Jennie Belden: 17:59

Well, in addition to the partnership that Larry just mentioned, you know, BCHS really does have a wonderful advantage of being able to be more consultative and provide a greater degree of education than what we are allowed to do. And so our bureau has partnered with their state licensing consultative section or the SLICS team, as we like to call it. They do go into the facilities and provide that education. And it's such a valuable resource. We've partnered with them on webinars. So for our mutual providers to provide that education. And then our bureau just works very closely together with new and existing providers because state licensing and federal certification activities often go hand in hand.

Anastasha Osborn: 18:43

Yeah, it's exciting. And kind of in the same vein of talking about all these trainings and compliance. When either of your teams, and we'll start with you, Jennie, but when either of your teams find something that's not in compliance, how do you balance enforcement with also helping those facilities improve?

Jennie Belden: 19:02

We don't actually balance it. Unfortunately, federal regulation prohibits us from being consultative or providing any type of education during the survey process. So we have to get pretty creative about how we can educate before we regulate. So how we do that is by providing those education and trainings outside of the survey process. We have long-term care special focus series webinars that provide free education on various topics that are relevant to nursing homes. And then we also have our managers and our staff that go onsite to facilities and provide that education and training one-on-one. But again, it has to be outside of the survey process.

Anastasha Osborn: 19:47

And what about from your experience, Larry? O

Larry Horvath: 19:50

One of the things that I've learned over the years is it's always been interesting that we'll get a complaint that calls in and says, you know, my loved one had a terrible experience at this facility. And we will go and investigate it and we will find some deficient practices. And our requirement is if there's a deficient practice, you need to correct it. But a lot of people have a kind of perceived, you know, perception that that facility should be closed down. Their license should be revoked. And that's usually the enforcement action of last resort. Because you think about it, if you have a nursing home with 80 residents in there, one person has a bad experience. And that doesn't diminish that person's bad experience. But there's 79 other people that love the facility or are happy with the facility. So one of the balances is what is the right enforcement action when you have a deficient person? You know, is it as extreme as closing the facility and relocating everybody? Is it just, hey, you need to correct it and we'll come back and follow up on it? You know, in state licensing, we don't have a lot of remedies other than to make them correct or to close the facility. We have very limited finding ability. We can do things like maybe a ban on emissions and things of that nature. But it is a delicate balance to figure out what is the right remedy for the deficient practice? Is it so egregious? Is it so systemic that maybe the facility does need to close? Or is it, it was tragic, it was unfortunate, but they can correct and continue to be a good operator. So it's always been a struggle. And it's always been a struggle to explain that to families that are not happy with the outcome.

Anastasha Osborn: 21:42

And I think that we might have time for one more question. And I really think that our listeners will find this valuable If someone, kind of following up from what you were just saying, Larry, if someone is curious about how to report a concern or to learn more about licensing and certification, where should they start? And I'll have you go first, Jennie.

Jennie Belden: 22:03

All right. Well, if you have a concern that you would like to report, you're welcome to report that to the Complaint Intake Unit. We do accept complaints for health and long-term care facilities, both for the Bureau of Community and Health Systems as well as BSE, and then we triage it to the appropriate area. And they can call 1-800-882-6006. That is one way that they can call and speak to someone with their concern. For more information on certification activities, I would say visit our website. That probably is the best opportunity to get yourself comfortable with the certification activities that we have. And they can go to michigan.gov slash LARA and select the Bureau of Survey and Certification to find out more. Perfect.

Anastasha Osborn: 22:48

And then what about you, Larry? L

Larry Horvath: 22:49

It's similar to Jennie's approach. I mean, one is we encourage people to go onto our website to look for how to file a complaint with the state. And then the other thing I would add is I encourage people to talk with their care delivery provider. Or, you know, if you're an adult foster home and you're having a problem, talk to the provider first. If you're in a hospital, talk to the hospital first. The other thing I encourage people to do is actually research before before you put your loved one in a facility, especially if it's going to be long-term care, residential care. Research. Look at the state website. Look at the facility reports. See how that provider is doing. Do they have a lot of complaints? Have there been a lot of investigations? What were the outcome of those investigations? What was the outcome of the recent inspection? So I always encourage people to, first, you should go visit the facility. I mean, some things like an acute care emergency event you're going to go to the nearest hospital to the emergency room but you want to really look at the facility and learn about the facility before you place your loved one in a facility you know and so I think that's really an important point for people to to understand and I also think it's an another important point is to ask very point-blank questions which are are you state licensed are you federally certified because there are provider types so in Michigan we'd don't license or certify independent living and assisted living facilities. Now, if the assisted living facility offers a level of care, they might be required to have an adult foster care license or a homes for the aged license. Things like memory care units license could be required just for that part of the facility. But people have to understand that there are many care facilities out there that are not licensed and you don't have a remedy like coming to the state to lodge your complaint and have an invest So understanding if the facility is licensed and certified and what right does that bring you if they are.

Anastasha Osborn: 24:55

Yeah, that's a really good point. Well, I think that's all that we have for today. I really appreciate both of your time, your education, your wealth of knowledge. I think this is very helpful, especially for people who maybe are looking into some of these long-term care facilities and kind of knowing where they need to start, whether it's for themselves or for their loved ones. But I really do appreciate it. And thank you both for being here and taking the time. Thank you. Now the work Larry and Jennie's teams do may not always make headlines, but it does shape the care that we all depend on. Every single inspection, certification, and license is a safeguard. It's a promise that health and safety always come first. So if you'd like to learn more or find out how to report a concern, you can go ahead and visit our show notes in this episode for a couple of resources. And I just want to thank you as a listener for spending time with us. From our living room to yours, we'll see next time.