Long Term Care Advisory Committee

Health Facilities Unit
Long Term Care Advisory Committee Meeting April 1, 2024
1:00 pm to 4:00 pm

Committee Members Present:

Tim Wiedrich, Chief, Health Response & Licensure, ND Department of Health & Human Services Bridget Weidner, Director, Health Facilities Unit, ND Department of Health & Human Services Kathy Laxdal, Program Manager, Health Facilities Unit, ND Department of Health& Human Services Rocksanne Peterson, Recorder, Health Facilities Unit, ND Department of Health& Human Services Amy Kreidt, Chairman of the NDLTC Association, St. Luke’s Home, Dickinson
Peggy Krikava, Education Director, ND Long Term Care Association Nikki Wegner, Executive Director, ND Long Term Care Association
Karla Backman, State LTC Ombudsman, ND Department of Health & Human Services Pete Antonson, Chair, Board of Examiners for Nursing Home Administrators
Kelly Beechie, Health Facilities Unit, ND Department of Health& Human Services Rick Boehm, RPh, President of the ND LTC Pharmacy Academy
Jenifer Lauckner, Quality Health Associates
Faye Salzer, HAI/AR Activities Coordinator and IP Coordinator, Disease Control Natasha Green, Quality Health Associates
Steve Hoepfner, Obernel Engineering

Also, present:

No additional people present.

Committee Members Absent:

Representative Gary Kreidt, ND House of Representatives (New Salem) 
Lisa Thorp, Quality Health Associates
Marina Spahr, Medicaid Fraud Unit
Dr. Bruce Hetland, Bismarck Medical Director, Nursing Home Medical Directors Association LeeAnn Thiel, Administrator, Division of Medical Services, DHS
Karla Aldinger, Life Safety & Construction Unit, ND Department of Health & Human Services

Welcome

• Bridget Weidner called the meeting to order at 10:01 am. Introductions were made. Tim Wiedrich gave an overview of our video conferencing technology.

Public Comment (10:10 am)

No comments.

Review and Approval of the November 17, 2023, Meeting Minutes:

Peggy Krikava motioned to approve the minutes as written, Nikki Wegner second. Motion carried.

Organizational Update – Tim Wiedrich

Tim reported that we have a new DHHS commissioner. His name is Wayne Salter. His has background in Long Term Care. His plan is to locate full-time to North Dakota. Our organizational structure is still the same. The health officer is serving the whole organization as a liaison and is no longer apart of the operational side of Public Health. The committee would like a copy of the organization chart.

Reports & Updates

• Legislative Update – No report available.
• Long Term Care Association – Nikki reported on the quality award program; 37 facilities have participated so far. They are looking for a facility to collaborate with Bridging the Dental Gap. The spring Long Term Care Association conference will be held on May 7-10, 2024. Rocksanne Peterson has discount codes for state employees. Just short of 600 attendees have signed up for May conference so far. Kathy Laxdal and Kelly Beechie will be presenting as well as Duane Ell and LeeAnn Thiel. Peggy will make sure Health Response & Licensure (HRL) will have a booth at the Expo. Tim inquired if there is anything else we could be doing anything else for the association. Nikki stated staging areas need to be identified in the facilities as they need to be more prepared if something happens. Bridget asked Nikki if she heard anything more on the comments on the 24/7 nursing rule. Nothing has been released yet.
• Quality Health Associates of North Dakota – Jenifer Lauckner gave a report on the quality health measures. She stated they have been working with facilities on the use of antipsychotic medications and the side effects; as well as giving them some alternatives they can use. They are also providing them with some education as to when an antipsychotic should be used. She has some of the concern as the use of the medication is up and the UTI’s have increase. Hospitalizations and pressure ulcers are other measures they have been working on. Natasha Green reported on the current QUIN/QUIO contract on goes until November 2024. It covers most Northwest region (14 state region). The new measures will be coming out and she will let the facilities know what they are once they have come out. The Dakota Geriatrics Work the grant funding will be ending come June. The new proposal for Dakota Geriatrics Age Friendly Care Work is to primarily the focus is educating staff members, preceptors, facility member and community members on how to integrate age friendly concepts. So what matters, focusing on deep prescribing with antipsychotics. As soon as they hear back as to whether that work has been awarded to the Dakota Geriatrics team at UND once they have an update Natasha will provide us with the information. Bridget had a couple of questions: Is there any concern with losing the focus on the needs of North Dakota now they are a part of a 14-state region; especially the use of antipsychotic medications? The model that will be used, as a state we will be able to choose what we want to focus and prioritize on, so it is equitable for us. We will be able to learn from other states. Bridget asked what is being seen as the culprit or root cause for the use of antipsychotic medication. Natasha stated the percentage is high. When they take a closer look, it is often one resident, and the denominator is low. It is also a problem because of residents or patients being prescribed the antipsychotic medication while they are hospitalized and then discharged back to the nursing facility. The use of antipsychotic medications has remained the same or gotten worse. It is felt that staffing is part of the problem as well as they don’t know the resident because the staff is coming and going. Pete asked if they have looked at the facilities who are doing well with their medications so other facilities can learn from what they are doing right. Jenifer was just looking at this. The committee discussed the use of antipsychotic medications in the facilities. Rick asked if the use of antipsychotic use has been tracked. They seeing providers not wanting deprescribe medications prescribe by other providers. They haven’t had enough time to look at the data. They are seeing higher numbers in facilities with gero-psych units. Kathy stated we are seeing more behaviors in every level of care but doesn’t pull into the nursing facility data. North Dakota has a higher rate of dementia than other state. Many of them are veterans, they are an underserved group. They are hoping to find an intervention that is realistic and helps meet the needs. It would just be working with the hospitals to change their workflow and prescribing something to help patients to sleep and ensuring the medication is deprescribe at discharge. There is a need to find a balance for the use of antipsychotic medications. There was a discussion regarding the use of the antipsychotic medications, the need for education, using alternative measures, and providers being involved as well as the medical directors. Please feel free to reach out Rick for support or to collaborate with Quality Health Associates of North Dakota.
• Nursing Home Medical Directors Association – No report available.
• Board of Examiners for Nursing Home Administrators (BOE) – Pete Antonson/Peggy Krikava reported the biggest thing is the labor commission studying how long it takes to get licensed. The association has pulled a report together and will be presented at their July meeting. North Dakota is so quick at getting a person licensed. The study is looking to consolidate licensing boards. The board had their annual licensing on December 31, 2023. North Dakota is down for with the number of licensees. There are several administrators who have retired or are retiring. There are quite a few people in the AIT program, but they have no experience. Kathy Laxdal asked about the length of time a person can be an interim administrator. Some administrators oversee more than one facility. Peggy stated there is no time constraint or a certain number of facilities they can be an administrator at. Tim and Pete spoke about the representation of Health Response & Licensure and the Attorney General’s office on the board and what can be brought forth from (HRL). They have felt it has been good. Peggy feels they need that representation on the board. They are looking at a mentorship for in the AIT program. Tim asked if COVID was a factor in the drop of administrators; not any longer.
• State Ombudsman – Karla Backman reported their office continues to be busy. Chris Garver left the temporary ombudsman position. Shannon Nieuwsma took over many of Chris’ duties. The Dickinson position has always been a .75 FTE it is now 1.0 FTE. Peggy was willing to picked up the .25 FTE grant funding. They were given the position but wasn’t given the money. The money needs to come with the position. Always hate swapping staff around. Legislative session is coming up. We are looking at proposing legislative changes to Century Code 50-10.2 Resident Rights Law. A workgroup will be put together to work on the law. There is another project in development.
• Medicaid Program – No report available.
• Disease Control – Faye Salzer gave a presentation on Infection Control Assessment & Risk (ICAR)s skill clinics and fit testing; Project Firstline Mini Trainings; process of creating 20 educational videos, interactive info graphs, educational games for infection prevention, infection prevention app and 10 digital brochures. The upcoming Infection Prevention Conference is April 24-25, 2024. Seeing a lot of turnovers in facilities of Infection Preventionist. The committee discussed the enhanced barriers precautions in nursing homes QSO-24-08-NH memo that went into effect today, storage for PPE, providing education to the facilities and how the memo will affect the nursing facilities. The QSO memo came out on March 20, 2024; and went into effect April 1, 2024. Faye stated anything stored inside the room is considered dirty.

Facilities are struggling with the cost. Faye understands the concerns of the facilities. Infection control was the number one cited tag; cited 19 times or surveys October 1 – March 22. Hand hygiene is the most cited deficiency because staff is touching everything. Faye stated there are complaints from facilities that they are starting to look like medical facilities because of the hand sanitizers inside and outside of the resident rooms. The facilities feel they are losing the home look. There is a pull and tug on the regulations. If hand sanitizer is not readily available staff will not do hand hygiene; especially if it is a shared room and at the front of the room.

Faye feels it will be the same with the PPE if it is not right there if they need it. Peggy stated there will be a session at the Long-Term Care conference on enhance barrier precautions and hand hygiene. Kathy will be talking about infection control and reading little scenarios. Health Facilities Unit also needs to see the updates in our systems so we can help facilities move forward as well as our surveyors. Please keep promoting the ICARS. Disease Control will do audits and in-services at facilities. They are there to make their work easier. Nikki asked Faye to send her testimonials. Faye will reach out to facilities.

• Health Facilities – Bridget Weidner, Tim Wiedrich, Kathy Laxdal, Kelly Beechie
• Bridget reported we have had a couple of calls with CMS regarding a nursing home nurse staffing campaign. More information will be coming; they are looking at using CMP funds across the nation. It is $75 million in the CMP funds for all the states. They are looking at how they can best reinvest it into the nursing home program. They are talking about doing an awareness campaign as well as financial incentives such tuition reimbursement or scholarships for RNs, LPNs, and CNAs in nursing homes or the state survey agencies having difficulty recruiting RNs. Bridget will share information when it becomes available.
• Bridget reported we have over $1 million our state specific CMP funds. If there are any projects facilities are interest in; let them know there is a CMP application template to ask for funds. Karla Backman stated Carmen Bauman is interested in partnering with North Dakota on Person Centered Care project. This is a 3-year project, which would involve 5 facilities. This project is still in development.
• Bridget and Tim have been involved with the Basic Care – Assisted Living Study.
• Tim Wiedrich stated he will have a final report from the Basic Care – Assisted Living Study sometime in April.
• Kathy Laxdal reviewed the most frequently cited deficiencies; these will be reviewed at the Long-Term Care Association conference, QSO-24-08-NH memo, and the Special Focus Facility (SFF). CMS is tracking a facility after a has graduated from being a SFF for 3 years. There is more focus on the SFF data from the RO, and there is enforcement that we can put in place. We can recommend temporary management other than CMP. The feds want to know why the data has increased. She talked about the facility reported incidents and complaints. We have the five candidates that we pick from for the SFF.
• We’ve had a great winter for travel to getting to our survey’s completed. We are fully staffed.
• iQies is our web-based computer program. It will change our LTC survey process.
• Kathy spoke about the number of nursing facilities (75) and basic care facilities (66). She also spoke about the number of beds in layaway (600) and that some of the skilled facilities are adding basic care beds. We’ve had some beds in layaway that expired. Kathy about the basic care survey process and how it has changed since 2019. The focus has been on complaints and the facility incident reports in the basic care facilities. Rick asked if there will be monthly medication reviews for assisted living like in Minnesota. He feels what happens in Minnesota eventually trickles into North Dakota. North Dakota does yearly medication reviews in basic care.
• Kelly Beechie gave an update on the Facility Reported Incidents (FRIs). Our average intake of FRIs was 86; December 74, January 88, February 93, and March 88. One or two every week are prioritized as non-IJ high, which is doesn’t rise to the level of prioritizing as an IJ. But we have 10-day to get into the facility to look at them. That depends on what the facility has done to protect the resident. It does mess with our schedule sometimes. We have a process that we follow, especially if it was an unwitnessed fall. The State Operations Manual (SOM) gives us guidance as to what would be harmful for the resident. Bridget will have the SOM sent out.
• Kelly reported our number of CNA’s are down since last quarters report. She reported on the challenging test going away as of July 1, 2024. Everyone will be required to take an approved CNA training program. That happened the same time Headmaster implemented a new software program. We have a lot of facilities interested in the NATP. Kelly also spoke about the hybrid training programs (online) TrainND NE. TrainND NE is willing to go into other facilities to train staff. Peggy stated ACA has a program Kelly isn’t sure how it would work but she will look into it.
• Kelly gave an update on the RN signature on the CNA application, this is not in regulation. We have had some push back on having a RN signature, found that this changed in 2015. We are reverting to previous verbiage prior to 2015 but we still need to verify the employment. We don’t have a hard date as to when this change will go into effect other than the very near future.
• Life Safety and Construction (LSC) – Tim Wiedrich reported in Karla Aldinger’s absence regarding the plan review for construction projects and the review fees. Some projects have ended up on hold after the review process has already begun. In the past the review fee has been collected at the end of the review process. We are looking at changing that process in which the fees would be collected the prior to the project being reviewed. Tim, Nikki Wegner, Tim Blasal and Karla Aldinger will work together on a process especially if there are change orders involved in the project. West Segment Assisted living, Mandaree is one project that is in limbo.
• Consumer Representatives – nothing to report.

Old Business

• Marina Spahr, Medicaid Fraud Unit was added as a member of the committee.
• Shelly Peterson was going to check Basic Care/Assisted Living Representative; Bridget asked Nikki Wegner if she will follow-up with that.
• Tim Wiedrich reported Assisted Living has transitioned to Health Response & Licensure, 328-8655. If there is a complaint for an assisted living facility, Todd Friesz is the program person for assisted living.

New Business

• None.

Next Meeting

Next meeting date in October

Health Facilities Unit
Long Term Care Advisory Committee Meeting November 17, 2023
10:00 am to 1:00 pm

Committee Members Present:

Tim Wiedrich, Chief, Health Response & Licensure, ND Department of Health & Human Services 
Bridget Weidner, Director, Health Facilities Unit, ND Department of Health & Human Services 
Kathy Laxdal, Program Manager, Health Facilities Unit, ND Department of Health& Human Services 
Rocksanne Peterson, Recorder, Health Facilities Unit, ND Department of Health& Human Services 
Amy Kreidt, Chairman of the NDLTC Association, St. Luke’s Home, Dickinson
Peggy Krikava, Education Director, ND Long Term Care Association 
Shelly Peterson, Executive Director, ND Long Term Care Association 
Nikki Wegner, Executive Director, ND Long Term Care Association
Karla Backman, State LTC Ombudsman, ND Department of Health & Human Services
Karla Aldinger, Life Safety & Construction Unit, ND Department of Health & Human Services
LeeAnn Thiel, Administrator, Division of Medical Services, DHS
Pete Antonson, Chair, Board of Examiners for Nursing Home Administrators 
Kelly Beechie, Health Facilities Unit, ND Department of Health& Human Services 
Rick Boehm, RPh, President of the ND LTC Pharmacy Academy
Steve Hoepfner, Obernel Engineering
Dr. Bruce Hetland, Bismarck Medical Director, Nursing Home Medical Directors Association 
Jennifer Lauckner, Quality Health Associates
Faye Salzer, HAI/AR Activities Coordinator and IP Coordinator, Disease Control

Also, present:

Marnie Walth, Sanford Health and Good Samaritan Society

Committee Members Absent:

Representative Gary Kreidt, ND House of Representatives (New Salem) Natasha Green, Quality Health Associates

Lisa Thorp, Quality Health Associates

Welcome

• Bridget Weidner called the meeting to order at 10:02 am. Introductions were made. Tim Wiedrich gave an overview of our video conferencing technology.

Public Comment (10:10 am)

No comments.

Review and Approval of the October 25, 2022, Meeting Minutes:

Bruce Hetland motioned to approve the minutes as written, Shelly Peterson second. Motion carried.

Organizational Update – Tim Wiedrich

Tim gave an update on the recent leadership change for the Department of Health and Human Services (DHHS), Chris Jones recently left his position has commissioner. Sara Stoltz is the interim commissioner. They are actively searching for commissioner. We will have Renee Loh send out new organization chart.

Reports & Updates

• Legislative Update – Bridget reported on updated rules there will be going forward to the rules committee on December 11, 2023. Bridget will also be presenting some changes to the hospital rules. Bridget will clarify if the rules will be in effect January 1, 2024.
• Long Term Care Association – Amy Kreidt is the new chairman of the board as of 1/1/24 and Nikki Wegner will be the new president of the association. Shelly shared the LTCA legislative report as well as their Basic Care and Assisted Living Report.
• Shelly stated they are concerned about the campaign on the new CMS’ 24/7 staffing rule. They are waiting to hear what the final rule will be regarding this. Public comment was due to CMS on November 6, 2024. North Dakota generated almost 200 comments that went through American Health Care action center against the rule. There were about 18,000 comments that went through the action center as well. It is almost impossible for facilities to have 27/7 nursing or RN coverage. They didn’t consider LPNs in the rules, just RNs and CNAs. Tim asked if there will be any waiver process for the staffing shortage. The group discussed how this rule will impact the nursing facilities. Facilities barely have enough staff to provide coverage. Facilities under 100 bed compacity will struggle and may even closed. Behavioral health is also an issue in facilities, the residents are suffering as well. Rick stated that it is medication is an issue with the behavioral health. It is recommended facilities work with physicians and consulting pharmacists. There are not enough behavioral health officials in nursing facilities and basic care facilities. Assisted living facilities also have people with behavioral health issues.
• Shelly talked about the Basic Care study; Guide House has been awarded the contract to come up with solutions. No dates regarding for the study yet.
• Shelly reported the Medicaid payment system is not quite working yet.
• Nikki reported on the office of immigration regarding the out of the country workforce.
• There will be $50,000 in nursing scholarship given away this fall and more grants will be given away this spring.
• Peggy reported on the upcoming webinars and the spring Long-Term Care Association conference on May 7-10, 2024.
• Quality Health Associates of North Dakota – Jennifer Lauckner gave a report from quality Health associates. She has been working with all the nursing homes on their quality measures on pneumococcal and influenza vaccination rates. The newest report is out now, she is in the process of sending those to the nursing homes. She is looking at where they are falling out and providing some education. She is focusing on the preventable emergency department visits and hospitalizations. She is finding the reporting of pneumococcal and influenza vaccination rates are higher than the reports are showing. She feels the information is being entered wrong because of staff turnover and a lot of new people enter the data in the MDS. It is getting entered incorrectly. They are offering the vaccinations, but they are not being administered, but staff are offering the vaccination. Jenifer is providing education to the facilities, and they are voicing they are struggling with the staff.
• Nursing Home Medical Directors Association – Bruce Hetland gave a report from the Nursing Home Med Directors Association. The association is trying to set up a mentoring service and CMD to get physicians certified as geriatric or nursing home medical director. Many medical directors in North Dakota cover several facilities in rural settings. Struggling to get some of the younger people to get on board. Bridget mentioned that we still updating our medical director list on Health Facilities Unit website. Bruce has not heard any complaints from the medical directors about the list on the website. Bruce mentioned there was an article done on it, a lot of states have noticed and are following our example.
• Board of Examiners for Nursing Home Administrators (BOE) – Pete Antonson/Peggy Krikava reported they just got back from a national conference. Dealing with a couple of complaints and issued some letters to the licensed administrators on the state side. Some states are getting rid of their board of examiners and going with an all-inclusive policy board for regulation of various types of industries. Staffing rule was discussed at the national conference. Tim stated that legislation was introduced in North Dakota to consolidate boards into a single entity as well. That resulted in a study that is being done by the Department of Commerce. They did visit with the Board of Examiners, but he is not aware of any recommendations that came as a result. It may become a consideration in the next legislative session. The Department of Labor is coming to the July Board of Examiners meeting. The biggest thing they are looking at is licensure, required hours of training, reciprocity, and the length of time to get registered for licensure.
• State Ombudsman – Karla Backman reported their office continues to be busy. They are doing individual resident direct advocacy as well as doing a system advocacy with the facility. They have patients that fear retaliation if they report an issue. The state ombudsmen are seeing more medication issues across all levels of care which is concerning. Karla also talked about processing transfer/discharge notices. They track transfers related to falls; they are seeing a lot of it in the facilities. She is wondering if some falls prevention education should be done within the facilities. Facilities are sending people to hospital due to falls. Karla has been asking her supervisor to increase her staff and so they have a higher visibility.
• Medicaid Program – LeeAnn Thiel reported personal needs allowance was increased 7/1/23 by $35 so residents get to keep additional funds for personal expenses.
• Disease Control – Faye Salzer gave an update on the outbreaks of COVID in the nursing homes. They need to be aware what is going on in their communities. Staff and guests should wear masks. They continue to work with facilities. Offering a professional infection prevention conference on April 24-25, 2024. Also, offering trainings to facilities for their needs. ICARS have slowed down. There is a need to build relationships with facilities for best practices with administrators, DONs, and infection preventionists. We are seeing a decline in participation of having Disease Control assist facilities. Jennifer has also offered to help with building the relationship. Tim talked about the crisis team to assist in the staffing gap. Please still reach out to the Department of Operation Center and we will reach out to the medical reserve core to help with staffing. There is a new agreement for emergency assistance that clarifies the role of the facility and Health Response and Licensure (HRL).
  Health Facilities – Bridget Weidner reported Health Facilities is in the middle of annual licensing for nursing facilities, basic care, home health agencies, hospice, and hospitals. The signature thing from last year has been resolved. There still are some bumps in the road but every year things are getting better. CMS reopened the Civil Money Penalty program. Bridget was wondering if all facilities have internet access. It is thought that all the facilities have internet access.
• Tim Wiedrich reported the assisted living licensure transfer will be completed some time in January or February. We will be working with the legacy Department of Human Services to make sure this is a smooth transition. We do not want to disrupt the current licensure process. Once it is transferred over it will be carried out in the same fashion, but it will be a slightly different application process as it will be converted to an electronic format. There won’t be any changes in regulations and complaints filed will be referred to other authoritative entities. There is a need to have a concrete conversation as to how we are going to handle complaints and what the regulatory expectations are. A communication plan will be put together once it has been solidified.
• Kathy Laxdal spoke about Health Facilities workload. The workload consists of complaints, VAPS reports, facility reported incidents, recertification surveys. Health Facilities surveyors are cross trained so that we can get our workload done. The average month between surveys is 15, we are doing very good. Only doing basic care complaint surveys, if a basic care facility has a lot of complaints, we will do a full survey. Kathy reviewed the QSO memos; QSO-23-01-NH, QSO-23-05-NH, QSO-23-10-NH, QSO-23-18-NH, QSO-23-21-NH, and QSO-23-23-NH. QSO-23-01-NH talks about the Special Focus Facility program, The Meadows on University is currently our Special Focus Facility. The group discussed QSO-23-21-NH and MDS coding. Tim stated Health Facilities and staff have no control over the requirements. If you have recommendations for physician involvement in the diagnosis, the nurse needs to go back to the provider. It is more a QI issue versus a payment issue. Most frequently cited health deficiencies are F0689, F0880, F0884, F0641, F0657, F0761, F0812, and F0609. The average number of deficiencies: 2.25 North Dakota, 2.03 Region VIII, 1.37 Nation. The deficiency count report by scope &severity; most severe 18 G, 40 F, 77E, 296 D, and 3 C.
• Kelly gave an update on the Nurse Aide Registry, 18,801 registered CNA’s. Facility reported incident were increasing but they have tapered off. In October, Kelly received 93 reports; June and July she received 140/month. Before COVID, Health Facilities received about 40 reports. We will prioritize the facility reported incidents and may go into the facility sooner than the facilities recertification survey. Some of the facility reported incidents will involve CNA’s. Since January 1, 2023, we have done 40 CNA investigations. Of those 40 registrations we have revoked 6 registrations, encumbered 5, sent 6 letters of concern, 10 still being investigated, and 13 unsubstantiated. Kelly spoke about the incident of a person impersonating her friend as a CNA at a facility. Kelly will make sure Nikki and LTCA are copied on emails going out to facilities. Amy Kreidt talked about her facility’s process for verifying contract staff. She also stated that her facility is now checking ID’s. She stated the problem is that most of the time the person doesn’t look anything like their ID. But sometimes the person does not look like their picture. This is a difficult situation.
  Life Safety and Construction (LSC) – Karla Aldinger reported LSC is fully staffed. The LSC surveys follow the Health Facilities surveys. Life Safety & Construction is able to get into survey Basic Care Facilities every two years. We have two good sized LTC projects that we are currently reviewing. We have several smaller projects that have been reviewed and are under construction. We have about 26 skilled projects that are under construction for long-term care, Plan review fees are currently sufficient. Our newsletter has been well received. Shelly would like to make sure LTCA is on the newsletter list. Tim spoke about facilities that have not paid their review fees. We have had to send out notifications the project has been reviewed but can’t approve until we receive payment. Kathy also spoke about the new facilities, and they are not able to move because the MAC has not approved. We want the facilities to be able move.
   

Health Facilities Unit
Long Term Care Advisory Committee Meeting October 25, 2022
9:00 am to 12:00 pm

Committee Members Present:

Tim Wiedrich, Chief, Health Response & Licensure, ND Department of Health & Human Services 
Bridget Weidner, Director, Health Facilities Unit, ND Department of Health & Human Services 
Kathy Laxdal, Program Manager, Health Facilities Unit, ND Department of Health& Human Services 
Rocksanne Peterson, Recorder, Health Facilities Unit, ND Department of Health& Human Services 
Cynthia Tredwell, Chairman of the NDLTC Association, Hatton Prairie Village, Hatton
Peggy Krikava, Education Director, ND Long Term Care Association 
Shelly Peterson, Executive Director, ND Long Term Care Association
Karla Backman, State LTC Ombudsman, ND Department of Health & Human Services
Karla Aldinger, Life Safety & Construction Unit, ND Department of Health & Human Services
LeeAnn Thiel, Administrator, Division of Medical Services, DHS
Pete Antonson, Board of Examiners for Nursing Home Administrators
Kelly Beechie, Health Facilities Unit, ND Department of Health& Human Services 
Rick Boehm, RPh, President of the ND LTC Pharmacy Academy
Steve Hoepfner, Obernel Engineering
Dr. Bruce Hetland, Bismarck Medical Director, Nursing Home Medical Directors Association Lisa Thorp, Quality Health Associates
Faye Salzer, HAI/AR Activities Coordinator and IP Coordinator, Disease Control

Also, present:

Shawn Stuhaug, Administrator, Bethany Retirement Living Mary Dillman

Committee Members Absent:

Representative Gary Kreidt, ND House of Representatives (New Salem) Natasha Green, Quality Health Associates

Welcome

• Introductions were made.

Public Comment – Shawn Stuhaug was present for public comments. He is asking for the board chairs signatures to be removed from the basic care and skilled nursing license applications. He feels the administrator should be able to sign them. Bridget stated our system is not working the way it should be and we will look into it. Bridget will do some research to see what we can and cannot change within the century code. Health Facilities licensing went live on October 17, 2022. We have had some issues and expect more issues. We have been wanting to do this for a long time. We will continue to work to streamline the process. Cindy Tredwell stated the process went well for her. Bridget trusts that we will be able to make the signature piece go smoothly.

Review and Approval of the November 17, 2021, meeting minutes., Peggy Krikava motioned to approve the minutes as written, Cindy Tredwell second. Motion carried.

Organizational Update – Tim gave an organizational update from Health and Human Services. Deloitte was hired to help with the reorganization. Dr. Wehbi and Chris Jones, HHS Commissioner report to Governor Doug Burgum. There are four program divisions: Public Health Division, Medical Services, Behavioral Health, And Human Services. Dirk Wilke is the executive director for the Public Health Division. There are five sections under Public Health Division, Health Response & Licensure Section is one of those section and there are 5 units within that section: EMS, EPR, HF, LSC and F&L.

Shelly Peterson was wondering where Aging Services fell in the organization. Karla Backman stated she is currently under Human Services.

Bridget stated it has been nice having John Alm to help with rules process. The development of administrative rules has been very taxing in the past.

Reports & Updates

• Legislative Update – No update.
• Long Term Care Association – Shelly Peterson gave a report from the association regarding their priorities and outstanding issues.
  • For the priorities Shelly spoke about the increasing in the personal needs allowance; support in keeping Basic Care and nursing home moratorium; keep the bed layaway program; asking that the Basic Care review continue and changing how limits are set; changing base rate for Basic Care; asking for a minimum for a 4% increase for Basic Care each year; guardianship standards were updated giving the guardians authority to make decisions, more guardians are needed, supporting legislation for more and to increase the pay for them.
  • Issues: contract nursing; 91% nursing homes using contract nursing. Majority of contract nursing is CNA’s. There is not support of limiting contract nursing, but support transparency of the percentage of contract nursing. Several options were discussed regarding contract nursing. Some of them are having an office of immigration for health care workers to be funded by fees; putting a cap on the dollar amount for contract nursing or agency; contract staff vs. temporary NA; the $2000 incentives for the temporary NA’s and possibly extending that. It was felt that $2000 was not much of an incentive. Cindy felt $5000 would have been a better incentive. Also, discussed drug and diversion issues facilities are having, criminal history checks for CNA’s, and opposition to a systematic check by the state. There are challenges with the new payment system. Fifty percent of the nursing facilities are operating at a deficit. Some facilities have given five salary increases and have not been able to keep pace. The impact of the pandemic has continued to affect facilities, Shelly asked whether we need to go back to a bed buy program. This is a discussion to have with Chris Jones. Shelly does not want facilities to fail with the new payment system. Rick asked anything is being done to address the workforce issue. Shelly thinks immigration is a good way to go.
• First in person regional meeting will be in December, Human Service Centers and Behavioral Health will be invited. Facilities are seeing more behavioral health issues. Hospitals are struggling as well. A broken system that is not working well, reaching out to crisis teams to do justice for the residents.
  • Peggy spoke about dementia care training; they are trying to have this training two times a year. Fall conference was held the end of September. 375 attended the conference. Webinar coming up regarding quality awards. Are the providers using utilizing QESP? Bridget will send that to Peggy. There are all kinds of training regarding survey process.
• Quality Health Associates of North Dakota –Lisa Thorp gave update Jenifer Lauckner will join meeting in the future. Lisa gave a report from Quality Health. She talked about working with facilities regarding emergency preparedness plans as well as the quality measures. Lisa works with NDHIN and facilities.
• Nursing Home Medical Directors Association – Bruce gave background history on the ND Medical Directors Association. ND and SD merged the two chapters. He talked about other states having troubles getting qualified medical directors. He also spoke about getting education for the medical directors and memberships in the medical director associations in the United States. Medical Directors directory is on our website and will be updated quarterly. It has been a struggle to have coverage for nursing homes. Dr. Don Jurvich has been a help with the educational portion. Chris Henderson does a lot of the nursing home coverages in the Grand Forks area.
• Board of Examiners for Nursing Home Administrators – Pete Antonson stated there has been a change in some rules for the AIT program effective January 1, 2023. A special meeting is being held this afternoon to address some issues. Pete and Peggy heading to Nashville next week to the National Meeting.
• State Ombudsman – Karla Backman reported the ombudsman are continuing to visit residents at the facilities. They have four volunteers going through training and additional two that want to get started. They are in the process of hiring a new position in the Bismarck area, will be doing interviews on Monday. It is a Temporary, hopefully it will receive funding to continue the position.
• Medicaid Program – LeAnn Thiel reported the budget has been submitted and they are working on second phase of the payment system. There will be an increase in the property rate of the payment system.
• Disease Control – Faye Salzer reported they have a new person working with the NHSN, Diego. There are new requirements coming out, but they may not be new for LTC. Currently, interviewing for an anti-microbially lead and hope to have that person on in January. They are still offering the infection control prevention assessments. They are appreciative to Vanessa for getting information to the LTC facilities. Pete would like to have the reporting the of HSN data reduced. He feels there is a lot of waste of time and doesn’t feel the dynamic is there anymore.
• Health Facilities – Bridget Weidner/Kathy Laxdal
  • There are 65 basic care and 77 skilled nursing facilities. We just finished certification for Elim. There are rumblings for Mott to reopen. Kathy gave a report on the most frequently cited tags; F888 – citing on almost every survey, F658 second highest, F761 drug storage, expired items; F884 missing reports to NHSN this is being cited from the Feds. There were 421 deficiencies cited in 2022, greatest at D level, and the average number of deficiencies were 3.1.

Division of Health Facilities
Long Term Care Advisory Committee Meeting Minutes Virtual Meeting
November 17, 2021
1:00 pm to 3:00 pm

Committee Members Present:

Tim Wiedrich, Chief, Health Resources & Response Section, ND Department of Health 
Bridget Weidner, Director, Division of Health Facilities, ND Department of Health
Kathy Laxdal, Program Manager, Division of Health Facilities, ND Department of Health 
Rocksanne Peterson, Recorder, Division of Health Facilities, ND Department of Health 
Cynthia Tredwell, Chairman of the NDLTC Association, Hatton Prairie Village, Hatton 
Peggy Krikava, Education Director, ND Long Term Care Association
Shelly Peterson, Executive Director, ND Long Term Care Association
Karla Backman, State LTC Ombudsman, ND Department of Human Services Dave Nelson, Division of Life Safety & Construction, ND Department of Health Lisa Thorp, Quality Health Associates
Natasha Green, Quality Health Associates
LeeAnn Thiel, Administrator, Division of Medical Services, DHS
Dr. Bruce Hetland, Bismarck Medical Director, Nursing Home Medical Directors Association

Also, present:

Committee Members Absent:

Michelle Lauckner, Quality Health Associates
Pete Antonson, Board of Examiners for Nursing Home Administrators Char Schmidt, Regional Vice President, Edgewood Healthcare
Carole Watrel, AARP
Joan Ehrhardt, Consumer Representative Randal Albrecht, Consumer Representative
Representative Gary Kreidt, ND House of Representatives (New Salem)

Welcome

A meeting of the Long-Term Care Advisory Committee was called to order at 1:00 p.m. on November 11, 2021. The meeting was held virtually via Microsoft Teams. Tim welcomed everyone and introductions were made; each of us explained who we represent.

Public Comment (1:07 pm) 
No Comments.

Approval of Minutes

The minutes of the July 8, 2021, the Long-Term Care Advisory Committee meeting were distributed and reviewed. Bruce Hetland made the motion to approve minutes; Shelly Peterson second.
Motion carried.

Organizational Update – Tim Wiedrich

• Tim Wiedrich gave an organization update regarding the integration of the Department of Human Services and the Department of Health. A governance structure has been established; Executive Steering Committee (Tammy Miller, Dr. Wehbi, Chris Jones), Integration Leadership Team (Chris Jones, Dr. Wehbi, Krista Fremming, Stacey Breuer, Dirk Wilke, Sara Stolt, Brenda Weisz, Arnold Strebe, Marie Moe, Lynn Bargmann, Doran Eberle, Caprice Knapp). We are currently in the decide phase. This will be completed in December and in January/February we will be in the designing phase. Once the design process has been completed will need to start the implementation phase this will start around June.

Vision Setting – Tim Wiedrich

Purpose of the Advisory Committee: we want to be transparent and address issues and concerns when they arise. The major area we would like to look at is to look at is programs and program areas and to make improvements or make changes where we have control over. Tim hopes this can be more where we have a dialogue versus reporting.

Reports & Updates

Legislative Update: – Rep. Gary Kreidt

• No report.

Long Term Care Association: Shelly Peterson

• Shelly gave a legislative update from the special session. They were very efficient in their work; one area was spending their billion dollars. She spoke about the amount of money that went to basic care and skilled nursing and when it will go into effect. Shelly spoke about the vaccination bills related to COVID-19 and her concerns. Number of lawsuits have been filed nationally related to COVID-19. She is concerned with what will happen in the next two weeks regarding the lawsuits. Shelly asked how the exemptions will impact facilities that have multiple facility types within their building/facility. Bridget did reach out to the DOH attorney general regarding the question, what is the impact on basic care facilities/assisted living? Do they have to follow the legislative rules in HB1511 and SB2345?
• The new visitation guidance QSO-20-39 Revised: 11/12/2021. What does that mean? Looking forward to the guidance on the tactical call. They have singing groups that want to come back into the facilities. Are singing groups volunteers or visitors? Are there definitions on volunteers?
• Shelly asked about the 24-hour RN requirement, there is a three-year phase in for that.
• Bed layaway went into effect October 1, 2021; there has never been such a drop in bed capacity before. Heart of America Medical Center, Rugby, ND is building a new hospital and will care for residents in Swing bed, so will be closing their nursing home. There are currently 746 beds in lay away.
• Shelly stated the new rate setting system will begin on January 1, 2022. Facilities will have the option to run under either the old system or new system for a couple of years.
• Vaccination mandate goes into effect on December 6, 2021. Cindy Tredwell stated they have a vaccination rate of 80%. If this goes into effect, she stated they will lose employees. Most of those in LTC are supportive of the vaccination. Shelly is wondering if the state has enough staff available to help with staffing issues. The committee discussed the religious exemption, this is pretty open right now; at this time Bridget has no guidance from CMS on the religious exemption. Bridget stated CMS is accepting comments related to concerns regarding the federal rule.
• Shelly spoke about being interested in the strike team money, HCA, and price gouging of contract nursing.
• The Long-Term Care Association will be holding an in-person conference in December. It will be held in Fargo; Kathy Laxdal, Kelly Beechie, and Karla Backman will be presenting. Their spring conference will be held on May 3-6, 2022. That will be a hybrid conference which will be a combination of in-person and virtual.

Quality Health Associates (QHA) of North Dakota: Michelle Lauckner/Lisa Thorp/Natasha Green

• Natasha gave an update from Quality Health Associates of North Dakota on the projects and education they are providing to facilities in the state. They have been providing education to staff regarding vaccination. She also talked about getting weekly reports regarding NHSN data.
• Natasha reports they have a new staff member that will be helping Michelle.

Nursing Home Medical Directors Association: Dr. Bruce Hetland

• Bruce gave an update from the Nursing Home Medical Directors Association. Some of the things they have been doing is establishing is a medical directory, as well as national medical directory. Shelly asked if the medical director information could be collected; the DOH is already collecting the information and is a part of the licensing process.

Board of Examiners for Nursing Home Administrators

• The Board of Examiners for Nursing Home Administers is going through administrative rule changes. They will be following the national standard of AIT training.

State Ombudsman: Karla Backman

• Karla reported that it is a crazy time for the ombudsman. With the current CMS memo coming out, they are hoping they will be able to meet with residents again.
• Karla reported they are trying to keep their fingers on the pulse of psychiatric facilities taking residents with behavioral health issues.
• Karla also reported they were fortunate to be able to have received some funding. These funds will go towards a marketing campaign.

Medicaid Program: LeeAnn Thiel

• LeeAnn reported they are working on the new payment system and looking at basic care payments.

Division of Health Facilities: Bridget Weidner/Kathy Laxdal/Kelly Beechie

• Bridget gave an update on the new licensing database. This year facilities are still having to mail in their paperwork for their annual facility licensing. Licensing applications and bed fees are due by November 15, 2021. Next year the licensing renewal will be done electronically.