2017 MDS, CMS & REGULATORY UPDATES NELIA ADACI RN, BSN CDONA, - - PDF document

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2017 MDS, CMS & REGULATORY UPDATES

NELIA ADACI RN, BSN CDONA, C-NE, RAC-CT VICE PRESIDENT

The CHARTS GROUP

QUOTES ABOUT CHANGE

 “The first step toward change is awareness. The second step is acceptance. - Nathaniel Branden  “Your success in life isn't based on your ability to simply change. It is based on your ability to change faster than your competition, customers, and business”. - Mark Sanborn  “Resistance at all cost is the most senseless act there is”. - Friedrich Durrenmatt

• “Change before you have to”. - Jack Welch

KEY POINTS: KEEPING THINGS IN PERSPECTIVE

I. Do not get overwhelmed.

What is coming is better than what is gone. Let this belief aim you in the direction you need to go. – Karen Salmansohn

II. Choice to be POSITIVE OR NEGATIVE

If you don’t like change, you will like irrelevance even less. – Gen. E. Shinseki In order to carry a positive action, we must develop here a positive vision. – Dalai Lama

• III. Look at the “Big Picture”

Nothing is coincidence in strategical perception

• IV. Focus on “INTENT”, instead of just Paper Compliance

Always ask: “Why do we need to do this? What outcome do we want in doing this?”

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2 LEARNING OBJECTIVES

• 1. Obtain a working knowledge and understanding of the

recent updates in SNF Regulatory Changes and Medicare Updates

• 2. Learn the 2017 Updates in MDS 3.0 RAI Manual Version

1.15

• 3. Get familiar with the New Requirements of Participation,

specifically the New Survey Process

• 4. Understand the importance and significant impact of

accurate MDS and UB-04 Coding in ensuring a facility’s fiscal survival

AGENDA

MDS 3.0 RAI USER’S MANUAL VERSION 1.15 NEW REQUIREMENTS OF PARTICIPATION

• Overview of Regulation Reform & 3 Phases of

Implementation

• Phase 2: F-Tag Renumbering; New Interpretive

Guidance (Appendix PP); Comparison between Old versus New

LONG-TERM CARE SURVEY PROCESS: A Practical Approach

AGENDA (CONTINUATION)

MEDICARE/CMS UPDATES & CLINICAL REIMBURSEMENT CHALLENGES

• Claims and Appeals Updates
• A Notation on Managed Medicare Audits
• Revision of CMP’s
• Quality Measures (Data and Outcomes): The

New Currency

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2017 MDS 3.0 UPDATES

VERSION 1.15

MDS 3.0 CHANGES & UPDATES

EFFECTIVE OCTOBER 1, 2017

New MDS 3.0 Items: Sections N & P New Coding Guidance, Revisions, or Clarifications to MDS Sections and Items Review NPE Requirements

SECTION N: MEDICATIONS

CMS added “OPIOIDS” as a classification in N0410 CMS added MDS questions pertaining to an “Antipsychotic Medication Review”

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4 SECTION N: OPIOIDS

Prevalence of Long-T erm Opioid Use in Long-Stay Nursing Home Residents: First published: 21 September 2017 Jacob N Hunnicutt, Stavroula A Chrysanthopoulou, Christine M Ulbricht, Anne L Hume, Jennifer Tjia and Kate L Lapane

One in seven NH residents was prescribed opioids long-term. Recent guidelines on opioid prescribing for pain recommend reducing long-term

• pioid use, but this is challenging in NHs because residents may not benefit

from nonpharmacological and nonopioid interventions. Studies to address concerns about opioid safety and effectiveness (e.g., on pain and functional status) in NHs are needed.

SECTION N: OPIOIDS SECTION N: OPIOIDS

N0410H, Opioid: Record the number of days an

• pioid medication was received by the resident at any

time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

• Same coding rules as other listed medication

types

• Applies to all item sets except: NO, NPE, NS/SS,

NY/SS

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5 MOST COMMON OPIOIDS

Codeine Fentanyl (Actiq, Duragesic, Fentora) Hydrocodone (Hysingla ER, Zohydro ER) Hydrocodone/Acetaminophen (Lorcet, Lortab, Norco, Vicodin) Hydromorphone (Dilaudid, Exalgo) Meperidine (Demerol) Methadone (Dolophine, Methadose) Morphine (Astrammorph, Avinza, Kadian, MS Contin, Ora-Morph SR) Oxycodone (Oxycontin, Oxecta, Roxicodone) Oxycodone and Acetaminophen (Percocet, Endocet, Roxicet) Oxycodone and Naloxone (Targiniq ER)

SECTION N: ANTIPSYCHOTIC MED REVIEW SECTION N: ANTIPSYCHOTIC MED REVIEW CMS added MDS questions pertaining to an Antipsychotic Medication Review Consists of 5 questions Applies to Comprehensive (NC) and Quarterly (NQ) item sets only

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SECTION N: ANTIPSYCHOTIC MED REVIEW

NO45OA: Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent?

• Code 0, no: if antipsychotics were not received: Skip to O0100, Special

Treatments, Procedures, and Programs.

• Code 1, yes: if antipsychotics were received on a routine basis only:

Continue to N0450B, Has a GDR been attempted?

• Code 2, yes: if antipsychotics were received on a PRN basis only:

Continue to N0450B, Has a GDR been attempted?

• Code 3, yes: if antipsychotics were received on a routine and PRN basis:

Continue to N0450B, Has a GDR been attempted?

SECTION N: ANTIPSYCHOTIC MED REVIEW

NO45OB: Has a Gradual Dose Reduction been attempted?

• Code 0, no: if a GDR has not been attempted. Skip to

N0450D, Physician documented GDR as clinically contraindicated.

• Code 1, yes: if a GDR has been attempted. Continue to

N0450C, Date of last attempted GDR.

SECTION N: ANTIPSYCHOTIC MED REVIEW NO45OC: Date of Attempted GDR

Enter the date of the last attempted Gradual Dose Reduction.

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SECTION N: ANTIPSYCHOTIC MED REVIEW

NO45OD: Physician documented GDR as clinically contraindicated

Code 0, no: if a GDR has not been documented by a physician as clinically contraindicated. Skip to O0100, Special Treatments, Procedures, and Programs. Code 1, yes: if a GDR has been documented by a physician as clinically contraindicated. Continue to N0450E, Date physician documented GDR as clinically contraindicated.

SECTION N: ANTIPSYCHOTIC MED REVIEW

NO45OE: Date Physician documented GDR as clinically contraindicated

Enter date the physician documented GDR attempts as clinically contraindicated. SECTION N: ANTIPSYCHOTIC MED REVIEW

Coding Tips and Special Populations

Any medication that has a pharmacological classification or therapeutic category as an antipsychotic medication must be recorded in this section, regardless of why the medication is being used. In this section, the term physician also includes physician assistant, nurse practitioner, or clinical nurse specialist. Do not include Gradual Dose Reductions that occurred prior to admission to the facility (e.g., GDRs attempted during the resident’s acute care stay prior to admission to the facility).

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SECTION N: ANTIPSYCHOTIC MED REVIEW

Coding Tips and Special Populations Physician documentation indicating dose reduction attempts are clinically contraindicated must include the clinical rationale for why an attempted dose reduction is inadvisable.This decision should be based on the fact that tapering of the medication would not achieve the desired therapeutic effects and the current dose is necessary to maintain or improve the resident’s function, well-being, safety, and quality of life.

SECTION N: ANTIPSYCHOTIC MED REVIEW

Coding Tips and Special Populations Within the first year in which a resident is admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless physician documentation is present in the medical record indicating a GDR is clinically contraindicated. After the first year, a GDR must be attempted at least annually, unless clinically contraindicated.

SECTION N: ANTIPSYCHOTIC MED REVIEW

Coding Tips and Special Populations Do not count an antipsychotic medication taper performed for the purpose of switching the resident from one antipsychotic medication to another as a GDR in this section. In cases where a resident is or was receiving multiple antipsychotic medications on a routine basis, and one medication was reduced or discontinued, record the date of the reduction attempt or discontinuation in N0450C, Date of last attempted GDR. If multiple dose reductions have been attempted since admission/entry

• r reentry or the prior OBRA assessment, record the date of the most

recent reduction attempt in N0450C, Date of last attempted GDR.

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SECTION P: RESTRAINTS AND ALARMS

 CMS incorporated the capture of Alarm Use in Section P  Section Title was changed to Restraints and Alarms  Addition of Alarms has no impact on Restraint QM

• YET

SECTION P: RESTRAINTS & ALARMS SECTION P: RESTRAINTS & ALARMS

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SECTION P: RESTRAINTS AND ALARMS

Steps for Assessment

• 1. Review the resident’s medical record (e.g., physician orders,

nurses’ notes, nursing assistant documentation) to determine if alarms were used during the 7-day look-back period.

• 2. Consult the nursing staff to determine the resident’s

cognitive and physical status/ imitations.

• 3. Evaluate whether the alarm affects the resident’s freedom of

movement when the alarm/device is in place. For example, does the resident avoid standing up or repositioning himself/herse f due to fear of setting off the alarm?

SECTION P: RESTRAINTS AND ALARMS

Coding Instructions: Identify all alarms that were used at any time (day or night) during the 7-day look-back period. After determining whether or not an item listed in P0200 was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the device was not used during the 7-day look-back period. Code 1, used less than daily: if the device was used less than daily. Code 2, used daily: if the device was used on a daily basis during the look-back period.

SECTION P: RESTRAINTS AND ALARMS

Coding Tips: Bed alarm includes devices such as a sensor pad placed on the bed or a device that clips to the resident’s clothing. Chair alarm includes devices such as a sensor pad placed

• n the chair or wheelchair or a device that clips to the

resident’s clothing. Floor mat alarm includes devices such as a sensor pad placed on the floor beside the bed. Motion sensor alarm includes infrared beam motion detectors. Page 10 of 90

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SECTION P: RESTRAINTS AND ALARMS

Coding Tips:

Wander/Elopement Alarm includes devices such as bracelets, pins/buttons worn on the resident’s clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building. This includes devices that are attached to the resident’s assistive device (e.g., walker, wheelchair, cane) or other belongings. Other Alarm includes devices such as alarms on the resident’s bathroom and/or bedroom door, toilet seat alarms, or seatbelt alarms. Code any type of alarm, audible or inaudible, used during the look-back period in this section. If an alarm meets the criteria as a restraint, code the alarm use in both P0100, Physical Restraints, and P0200, Alarms.

SECTION P: RESTRAINTS AND ALARMS

Coding Tips:

Motion sensors and wrist sensors worn by the resident to track the resident’s sleep patterns should not be coded in this section. While wander, door, or building alarms can help monitor a resident’s activities, staff must be vigilant in order to respond to them in a timely

• manner. Alarms do not replace necessary supervision.

Bracelets or devices worn or attached to the resident and/or his or her belongings that signal a door to lock when the resident approaches should be coded in P0200F Other alarm, whether or not the device activates a sound. Do not code a universal building exit alarm applied to an exit door that is intended to alert staff when anyone (including visitors or staff members) exits the door.

MDS REVISIONS AND CLARIFICATIONS FOR 2017

SNF PPS DISCHARGE ASSESSMENT (NPE) SECTION G SECTION GG SECTION H SECTION I SECTION J SECTION M SECTION N SECTION O

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SNF PPS DISCHARGE ASSESSMENT (NPE) When is an NPE Item Set Required?

• 1. Resident ends a Part A Stay and remains in the SNF.
• 2. Resident ends a Part A Stay and is physically discharged.

a) Planned or unplanned is not a deciding factor. b)May be combined with OBRA Discharge assessment if physical discharge is on or the day after the date at A2400C.

When is an NPE Item Set NOT Required?

• 1. When resident dies.

SECTION G: RULE OF 3 SECTION G: ADL ALGORITHM

CMS updated Section G Self-Performance Algorithm

• Better corresponds with the Rule of 3
• Addresses the confusion related to Independent

Episodes that occur at least 3 times, but not every time. Page 12 of 90

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SECTION G: RULE OF 3 EXAMPLE

Resident Bed Mobility documentation reveals the following:

• Independent – 8 EPISODES
• Limited Assistance – 2 EPISODES
• Extensive Assistance – 1 EPISODE

RULE #1 APPLIES

SECTION G: RULE OF 3 EXAMPLE

Resident Bed Mobility documentation reveals the following:

• Independent – 3 EPISODES
• Limited Assistance – 2 EPISODES
• Extensive Assistance – 2 EPISODES
• T
• tal Dependence – 2 EPISODES

RULE #1 APPLIES

SECTION G: RULE OF 3 EXAMPLE

Resident Bed Mobility documentation reveals the following:

• Independent – 2 EPISODES
• Limited Assistance – 2 EPISODES
• Extensive Assistance – 1 EPISODE
• T
• tal Dependence – 2 EPISODES

RULE #3a APPLIES

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SECTION G: RULE OF 3 EXAMPLE

Resident Bed Mobility documentation reveals the following:

• Independent – 2 EPISODES
• Limited Assistance – 2 EPISODES
• Extensive Assistance – 1 EPISODE
• T
• tal Dependence – 1 EPISODE

RULE #3b APPLIES

SECTION G: OTHER CLARIFICATIONS

Some residents are transferred between surfaces, including to and from the bed, chair, and wheelchair, by staff, using a full-body mechanical lift. Whether or not the resident holds onto a bar, strap, or other device during the full-body mechanical lift transfer is not part of the transfer activity and should not be considered as resident participation in a transfer. Transfers via lifts that require the resident to bear weight during the transfer, such as a stand-up lift, should be coded as Extensive Assistance, as the resident participated in the transfer and the lift provided weight-bearing support.

SECTION G: OTHER CLARIFICATIONS

How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of T

• ileting.

When a resident is transferred into or out of bed or a chair for incontinence care or to use the bedpan or urinal, the transfer is coded in G0110B, Transfers. How the resident uses the bedpan or urinal is coded in G0110I, T

• ilet use.

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SECTION G: OTHER CLARIFICATIONS Check G0600C, wheelchair (manual or electric): if the resident normally sits in wheelchair when moving about. Include hand- propelled, motorized, or pushed by another

• person. Do not include geri-chairs, reclining

chairs with wheels, positioning chairs, scooters, and other types of specialty chairs. SECTION GG: CLARIFICATIONS No real changes to how this section is coded CMS provided language/text revisions to clarify current coding directives

When is SECTION GG REQUIRED:

• On any assessment coded as a 5-Day SNF PPS assessment

(A0310B = 1)

• On any OBRA/NPE Discharge Assessment except the following:
• D/C is UNPLANNED
• D/C is to the hospital
• SNF Part A Stay is < 3 days

SECTION GG: CLARIFICATIONS

Combined 5-Day with Discharge assessment example:

• Resident admitted on Sunday, D/C back to hospital on T

uesday. Provider is completing a 5-Day/DC assessment.

• Admission Performance GG is still required.
• Admission Goal (1) is still required.
• Discharge Performance is NOT required.

Provided further clarification related to wheelchair coding:

• If the resident walks and is not learning how to mobilize in a

wheelchair, and only uses a wheelchair for transport between locations within the facility, code the wheelchair gateway items at admission and/or discharge items—GG0170Q1 and/or GG0170Q3, Does the resident use a wheelchair/scooter—as 0,

• No. Answering the question in this way invokes a skip pattern

which will skip all remaining wheelchair questions.

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SECTION H: HO100D Self-catheterizations that are performed by the resident in the facility should be coded as intermittent catheterization (H0100D). This includes self-catheterizations using clean technique. SECTION I: Item I2300 Urinary Tract Infection (UTI):

The UTI has a look-back period of 30 days for active disease instead of 7 days. Code only if both of the following are met in the last 30 days:

• 1. It was determined that the resident had a UTI using evidence-based

criteria such as McGeer, NHSN, or Loeb in the last 30 days, AND

• 2. A physician documented UTI diagnosis (or by a nurse practitioner,

physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days.

SECTION I:

In accordance with requirements at §483.80(a) Infection Prevention and Control Program, the facility must establish routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility’s surveillance system must include a data collection tool and the use of nationally recognized surveillance criteria. Facilities are expected to use the same nationally recognized criteria chosen for use in their Infection Prevention and Control Program to determine the presence of a UTI in a resident. Example: if a facility chooses to use the Surveillance Definitions of Infections (updated McGeer criteria) as part of the facility’s Infection Prevention and Control Program, then the facility should also use the same criteria to determine whether or not a resident has a UTI.

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MCGEER UTI CRITERIA MCGEER UTI CRITERIA: SECTION J:

INTERCEPTED FALLS: An intercepted fall occurs when the resident would have fallen if he

• r she had not caught him/herself or had not been intercepted by

another person – this is still considered a fall. CMS understands that challenging a resident’s balance and training him/her to recover from a loss of balance is an intentional therapeutic intervention and does not consider anticipated losses

• f balance that occur during supervised therapeutic interventions as

intercepted falls.

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SECTION M:

Last year, the NPUAP changed the terminology used when referring to pressure ulcers. The new term of PRESSURE INJURY was adopted instead of the use of Pressure Ulcer. CMS is aware of the array of terms used to describe alterations in skin integrity due to pressure. Some of these terms include: pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore.  It is acceptable to code pressure-related skin conditions in Section M if different terminology is recorded in the clinical record, as long as the primary cause of the skin alteration is related to pressure.

SECTION M: OTHER CLARIFICATIONS

Mucosal pressure ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made. Therefore, mucosal ulcers (for example, those related to nasogastric tubes, nasal

• xygen tubing, endotracheal tubes, urinary catheters, etc.)

should not be coded here. Do not code pressure ulcers, venous or arterial ulcers, diabetic foot ulcers or skin tears under M1040D. These conditions are coded in other items on the MDS.

SECTION N: OTHER CLARIFICATIONS

N0410 Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. For example, prochlorperazine is dually classified as an antipsychotic and an antiemetic. Therefore, in this section, it would be coded as an antipsychotic, regardless of how it is used.

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SECTION N: OTHER CLARIFICATIONS

N0410 In circumstances where reference materials vary in identifying a medication’s therapeutic category and/or pharmacological classification, consult the resources/links cited in this section or consult the medication package insert, which is available through the facility’s pharmacy or the manufacturer’s website.

SECTION N: OTHER CLARIFICATIONS

N0410E: ANTICOAGULANTS Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not require laboratory monitoring, should be coded in N0410E, Anticoagulant. e.g.

• Eliquis
• Pradaxa
• Xaralto

SECTION N: OTHER CLARIFICATIONS

N0410D: HYPNOTIC

Herbal and alternative medicine products are considered to be dietary supplements by the Food and Drug Administration (FDA). These products are not regulated by the FDA (e.g., they are not reviewed for safety and effectiveness like medications) and their composition is not standardized (e.g., the composition varies among manufacturers). Therefore, they should not be counted as medications (e.g., melatonin, chamomile, valerian root). Also, Do NOT Code OTC Medications in this section (e.g. Benadryl) – Not New

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SECTION O: PHYSICIAN EXAMINATIONS/ ORDERS (O0600 & O0700)

CMS will no longer require completion of these 2 items! However, some States continue to require their completion. Y

• u

must know your State’s requirements for completing this item. These items are qualifiers for the “CLINICALLY COMPLEX” RUG Category under the RUG-III System. CHECK WITH YOUR STATE RAI COORDINATOR ON COMPLETION REQUIREMENTS! If the State does not require the completion of this item, use the standard “no information” code (a dash, “-”).

SECTION O: PHYSICIAN EXAMINATIONS/ ORDERS (O0600 & O0700)

DEFINITION OF PHYSICIAN HAS CHANGED RELATED TO CODING OF O0700

Includes orders written by medical doctors, doctors of

• steopathy, podiatrists, dentists, and physician assistants,

nurse practitioners, clinical nurse specialists, qualified dietitians, clinically qualified nutrition professionals or qualified therapists, working in collaboration with the physician as allowable by state law.

SECTION O: RESPIRATORY THERAPY (O0400)

Respiratory therapy—only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident evaluation/assessment, treatment administration and monitoring, and setup and removal of treatment equipment. Time that a resident self-administers a nebulizer treatment without supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS. Do not include administration of metered-dose and/or dry powder inhalers in respiratory minutes.

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THANK YOU!

QUESTIONS???

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NEW REQUIREMENTS OF PARTICIPATION

THE CHARTS GROUP THE CHARTS GROUP

AGENDA

• 1. Overview of Regulation Reform & 3

Phases of Implementation – Key Themes

• 2. Phase 2:

F-Tag Renumbering New Survey Process: What to Expect Interpretive Guidance for Numerous F- Tags

• 3. Practical Strategies to Prepare for the New

Survey Process

OVERVIEW OF NEW REQUIREMENTS OF PARTICIPATION

KEY THEMES

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OVERVIEW

The regulation reform implements a number

• f pieces of legislation from the Affordable

Care Act (ACA) and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, including the following: Quality Assurance and Performance Improvement (QAPI) Reporting suspicion of a crime Increased discharge planning requirements Staff training section

IMPLEMENTATION GRID

Implementation Date Type of Change Details of Change Phase 1: November 28, 2016 (Implemented) – upon effective date of Final Rule Nursing Home Requirements for Participation New Regulatory Language was uploaded to the Automated Survey Processing Environment (ASPEN) under current F Tags Phase 2: November 28, 2017 (1 year following the effective date of Final Rule) F Tag Numbering Interpretive Guidance (IG) Implement new survey process New F Tags Updated IG Begin surveying with the New Survey Process Phase 3: November 28, 2019 (3 years following the effective date of Final Rule) Requirements that need more time to implement Requirements that need more time to implement

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KEY THEMES

Understand the themes in order to implement properly Understand the Purpose and INTENT Do the Right Things for the Right Reasons

• Do you know your residents?
• Do you know your staff?
• Do you know your partners?

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3 KEY THEME: Person-Centered Care

THEME REQUIREMENTS OF PARTICIPATION NEW SURVEY PROCESS PERSON- CENTERED CARE

• Greater involvement
• f the patients (and

their representatives)

• More notifications
• Engagement of IDCP

Team

• Structured

Interviews with residents, families and staff

• Observations about

delivery of person- centered care

*Lots of interviews: CONDUCT MOCK INTERVIEWS

KEY THEME: ALIGNING RESOURCES WITH RESIDENT NEEDS

THEME REQUIREMENTS OF PARTICIPATION

NEW SURVEY PROCESS ALIGNING RESOURCES WITH RESIDENT NEEDS

• Facility Assessment: Know

your facility; Know your Residents; Know your Staff

• Competency-Based

Staffing

• Day-to-Day and in

Emergencies

• Staff competencies

linked to residents needs (Observation; Interview)  Core Competencies  Specialized needs

• Staff Training and

KSA s

COMPETENCIES: Checklists are no longer enough; Need EVIDENCE of SKILLS CHECKS

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4 KEY THEME: SYSTEMS IMPROVEMENT

THEME REQUIREMENTS OF PARTICIPATION NEW SURVEY PROCESS

SYSTEMS IMPROVEMENT

• Preventing Adverse

Events

• Transitions of care
• Prioritization
• Systems of Care
• Attention to

SYSTEMIC CONCERNS

• High Risk, High

Volume, Problem Prone

• Role of QAA

Committee

• Good Faith Efforts –

Doing the right things for the right reasons

Focus on SYSTEMS!!!

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5 KEY THEME: CONTINUOUS MONITORING & TIMELY MONITORING

THEME REQUIREMENTS OF PARTICIPATION NEW SURVEY PROCESS

CONTINUOUS MONITORING & TIMELY MONITORING

• Staff Competencies;

Adverse Events; Medication Prescribing

• Data Driven
• Feedback and Corrective

Action

• Unnecessary

medications; Psychotropic medications; Drug Regimen Review

• Infection Control and

Antibiotic Stewardship

• Linkage with QAPI

Huge Focus on Medications: “Why are meds given? Were alternative non-pharmacologic measures tried first?

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PHASE 2:

F-TAG RENUMBERING

“OLD” VERSUS “NEW”

PHASE 2 OF LTC REGULATIONS

Implement by November 28, 2017 Providers must be in compliance with Phase 2 regulations All States will use new computer– based survey process for LTC surveys  All training on new survey process needs to be completed before go live date (Last Day of Surveyors’ Training: 10/19/2017)

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PHASE 2 OF LTC REGULATIONS

Phase 2 includes: Behavioral Health Services Quality Assurance and Performance Improvements (QAPI Plan Only) Infection Control and Antibiotic Stewardship Physical Environment – Smoking Policies

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PHASE 2 OF LTC REGULATIONS

Phase 2 includes: Resident Rights and Facility Responsibilities – Required Contact Information Freedom from Abuse, Neglect, and Exploitation Admission, Transfer, and Discharge Rights – Transfer/Discharge Documentation

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F-TAG RENUMBERING

The image above is the F Tag Crosswalk showing:

• The original regulatory grouping and the new

associated grouping

• The original regulation number and the new

associated regulation number

• The original F Tag and the associated new F

Tag

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F-TAG RENUMBERING CURRENT SURVEY PROCESS (QIS or Traditional) versus NEW SURVEY PROCESS AUTOMATION

Traditional Quality Indicator Survey (QIS) New Survey Process

• Survey team

collects data and records the findings on paper

• The computer is
• nly used to

prepare the deficiencies recorded on the CMS-2567 Each survey team member uses a tablet PC throughout the survey process to record findings that are synthesized and

• rganized by the

QIS software Each survey team member uses a tablet or laptop PC throughout the survey process to record findings that are synthesized and

• rganized by new

software

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SAMPLE SELECTION

Traditional QIS New Survey Process

• Sample size determined

by facility census

• Residents are pre-

selected based on QM/QI percentiles (total sample)

• Sample may be adjusted

based on issues identified on tour

• Maximum sample size is

30 residents

• Includes complaints

The ASE-Q provides a randomly selected sample

• f residents for the

following:

• Admission sample is a

review of up to 30 current or discharged resident records

• Census sample includes

up to 40 current residents for

• bservation, interview,

and record review

• With QIS 4.04,

complaints can be included in census sample

• Sample size is

determined by the facility census

• 70% of the total sample

is MDS pre-selected residents and 30% of the total sample is surveyor-selected

• residents. Surveyors

finalize the sample based on observations, interviews, and a limited record review.

• Maximum sample size

is 35 residents

25

OFF-SITE

Traditional QIS New Survey Process

• Review Casper 3 and 4

reports

• Survey team uses QM/QIs

report offsite to identify preliminary sample of residents areas of concern

• Review the Casper 3

report and current complaints

• Download the MDS

data to PCs

• ASE-Q selects a

random sample of residents for Stage 1 from residents with MDS assessments in past 180 days

• Each team member

independently reviews the Casper 3 report and other facility history information

• Review offsite

selected residents and their indicators and the facility rates.

26

INFORMATION NEEDED UPON ENTRANCE

Traditional QIS New Survey Process

• Roster Sample Matrix

Form (CMS-802)

• Obtain census

number and alphabetical resident census with room numbers and units

• List of new

admissions over last 30 days

• Completed

matrix for new admissions over the last 30 days

• Facility census

number

• Alphabetical list
• f residents
• List of residents

who smoke and designated smoking times 27

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SLIDE 31

10

INITIAL ENTRY TO FACILITY

Traditional QIS New Survey Process

• Gather information

about pre-selected residents and new concerns

• Determine whether

pre-selected residents are still appropriate

• 1 – 3 hours on

average

• No sample selection
• Initial overview of

facility, resident population and staff/resident interactions.

• 30 – 45 minutes on

average for initial

• verview
• No formal tour process
• Surveyors complete a full
• bservation, interview all

interviewable residents, and complete a limited record review for initial pool residents:

• Offsite selected residents
• New admissions
• Vulnerable residents
• Identified Concern that

doesn’t fall into one of the above subgroups

• 8 hours on average for

interviews, observations, and screening.

28

SURVEY STRUCTURE

Traditional QIS New Survey Process

• Resident sample is about

20% of facility census for resident observations, interviews, and record reviews

• Phase I: Focused and

comprehensive reviews based on QM/QI report and issues identified from

• ffsite information and

facility tour

• Phase II: Focused record

reviews

• Facility and

environmental tasks completed during the survey

• Stage 1:

Preliminary investigation of regulatory areas in the admission and census samples and mandatory facility tasks started

• Stage 2:

Completion of in- depth investigation

• f triggered care

areas and/or facility tasks based on concerns identified during Stage 1

• Resident sample size is

about 20% of facility census

• Interview, observation and

limited record review care areas are provided for the initial pool process; surveyors can ask the questions as they would like

• Surveyors meet to discuss

and select sample, may have more concerns than can be added to the sample; may need to prioritize concerns

29

SURVEY STRUCTURE

Traditional QIS

New Survey Process

Investigations are then completed during the remainder of the survey for each sample resident using CE pathways Facility tasks and closed record reviews are completed during the survey

30

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SLIDE 32

11

GROUP INTERVIEWS

Traditional QIS New Survey Process

• Meet with

Resident Group/Council

• Includes Resident

Council minutes review to identify concerns

• Interview with

Resident Council President or Representative

• Includes Resident

Council minutes review to identify concerns

• Resident Council

Meeting with active members

• Includes

Resident Council minutes review to identify concerns

31

PHASE 2:

NEW LTC SURVEY PROCESS

NEW INTERPRETIVE GUIDANCE

WHY IS CMS CHANGING THE LTC SURVEY PROCESS?

Two different survey processes existed to review for the Requirements of Participation (Traditional and QIS) Surveyors identified opportunities to improve the efficiency and effectiveness of both survey processes. The two processes appeared to identify slightly different quality of care/quality of life issues. CMS set out to build on the best of both the Traditional and QIS processes to establish a single nationwide survey process.

33

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SLIDE 33

12

NEW SURVEY PROCESS

The new survey process builds on the best of both survey processes: Modeled after QIS with elements

• f Traditional Survey (STRUCTURE + AUTONOMY)

Relies on new interpretive guidance documents based on the Requirements of Participation Emphasized Observation of Care and Resident Interviews starting on DAY 1; Focus on Residents’ experiences & outcomes and less on paper compliance Computer and software-based with investigative pathways: Surveyors will use tablets and laptops

34

CMS TESTING

Approximately 16 States: 25 to 30 facilities – but includes variations in types of facilities

• Small & Large Facilities
• Urban & Rural facilities
• Variations in 5-Star ratings
• Geographically diverse facilities

Used RO, SA & Contract Surveyors to test process & software Equal use of QIS & Traditional States Use of analytic teams

35

3 PARTS TO NEW SURVEY PROCESS: High Level Overview of the Process The new survey process is computer- based with 3 Major Parts: 1. Initial Pool Process 2. Sample Selection 3. The Investigative Process

36

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SLIDE 34

13

INITIAL POOL PROCESS

 Sample Size based on Census: 20% but maximum

• f 35 residents
• 70% offsite selected
• 30% selected onsite by team:

Vulnerable New Admission Complaint FRI (Facility Reported Incidents- Federal

• nly)

Identified concerns

37

SAMPLE SELECTION

Select Sample

• Survey team selects sample
• Must be completed by the survey

team at the end of the first day or beginning of the 2nd day

• Survey Team meets and finalizes the

SAMPLE

38

INVESTIGATIONS

Once the sample is selected, the remainder of the survey is spent investigating all concerns requiring further investigation for the residents in the sample. Facility tasks and closed-record investigations will also be conducted.

39

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SLIDE 35

14

LONG-TERM CARE SURVEY PROCESS (LTCSP) GUIDE : What the Surveyors Follow

A resident-centered, outcome-oriented inspection that relies

• n case-mix stratified sample of residents to gather

information about the facility’s compliance with participation requirements Organized into 7 Parts

• 1. Off-Site Preparation
• 2. Facility Entrance
• 3. Initial Pool Process
• 4. Sample Selection
• 5. Investigations
• 6. On-going and Other Survey Facilities
• 7. Potential Citations

OFF-SITE PREPARATION

OFF-SITE PREPARATION: SOFTWARE

IT-Related TASKS:

• Survey Agency creates a survey shell in ASPEN Central

Office & exports into ASPEN Survey Explorer. Must be done as close to the survey start date as possible but no more than 5 Business Days before the start date.

• Includes most up-to-date MDS Data. If there are

residents not included in the survey shell due to late submissions it will generate a WARNING ALERT. State’s RAI Coordinator will be notified - who will in turn address the submission concerns with the facility. Survey will be rescheduled (Not Good for the Facility)

• Survey Team Members picked - name of the Team

Coordinator highlighted

• Access the Survey Software by clicking on the “LTC

Survey Button”

42

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SLIDE 36

15

OFF-SITE PREPARATION: REVIEW OF DATA

Team Coordinator (TC) completes offsite preparation. Includes review of the following:

• Administrator’s Name & Previous Survey Date
• CASPER 3 Report for pattern of Repeat Deficiencies
• Results of Last Standard Survey
• Complaints since last Standard Survey – includes

active/outstanding complaints.

• FRIs (Facility Reported Incidences) since last Standard Survey
• History of abuse/allegations or citations since the last survey
• Variances/waivers
• Active enforcement cases

 Contact Ombudsman to notify of proposed day of entrance into facility

43

OFF-SITE PREPARATION: FACILITY UNIT ASSIGNMENTS

Team Coordinator (TC) indicates the unit assignment for each surveyor.

• Assign all units equally across the team members

using the last year’s floor plan

• Do not assign same surveyor to the Rehab and

Alzheimer’s Unit

• Keep surveyors on one unit as much as possible.
• Assign Complaint/FRI residents to the surveyor who

has the resident on their unit.

• Assign units by discipline, if possible (e.g. Social

Worker to the Dementia Care Unit)

44

OFF-SITE PREPARATION: MANDATORY FACILITY TASK ASSIGNMENTS

Team Coordinator (TC) assigns mandatory facility tasks:

• 1. Beneficiary Protection Notification Review
• 2. Dining Observation*
• 3. Infection Control*
• 4. Kitchen

5. Medication Administration 6. Medication Storage

• 7. QAA/QAPI
• 8. Resident Council Meeting
• 9. Sufficient and Competent Nurse Staffing*

*Assign all surveyors but communicate that one surveyor has primary responsibility.*

45

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SLIDE 37

16 OFF-SITE PREPARATION: MANDATORY FACILITY TASK ASSIGNMENTS

Team Coordinator (TC) prints documents

• 1. Facility Matrix with Instructions (1 Copy)
• 2. Entrance Conference Worksheet (1 Copy)
• 3. Beneficiary Notices Worksheet (3 Copies)

Team Coordinator (TC) shares off-site prep data with team members Team members independently review the Offsite Prep information prior to the survey.

46

FACILITY ENTRANCE

FACILITY ENTRANCE

• 1. After entering the facility and prior to conducting the

Entrance Conference - Team Coordinator discusses the need for facility to address the 1st 4 items in the Entrance Conference Worksheet.

• #1 Census Number: Exclude Bed Holds
• #2 Complete Matrix for New Admissions in the last

30 days (still residing in the facility)

• #3 Alphabetical List of Residents
• #4 List of residents who smoke, designated

smoking times and locations. (Includes Smoking Policy)

48

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SLIDE 38

17

FACILITY ENTRANCE: Entrance Conference Worksheet

• 2. Team Coordinator (TC) conducts an Brief Entrance
• Conference. Review documents/information that facility

has to furnish the survey team - as outlined in the “Entrance Conference Worksheet” (Refer to Hand-out)

• #1 - #4: Immediately upon Entrance
• #5 - #11: During the Entrance Conference
• #12 - #17: Within One Hour of Entrance
• #18 - #33: Within 4 Hours of Entrance*
• #34: By the End of the First Day of Survey (EHR)
• #35 - #37: Within 24 Hours of Entrance

49

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SLIDE 39

18

Page 39 of 90

SLIDE 40

19

UPDATED FACILITY MATRIX

55

FACILITY ENTRANCE

• 3. Kitchen Observation: Surveyor assigned to the

kitchen will conduct an initial brief visit to the kitchen and then goes to his/her assigned area. (Kitchen Task Pathway)

• 4. Each surveyor goes to his/her assigned area.

Surveyors will ask for a resident roster for their respective assigned areas. They will indicate the “New Admissions” in the last 30 days and they will then begin their Initial Pool Process.

56

INITIAL POOL PROCESS

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SLIDE 41

20

INITIAL POOL PROCESS

 1st 8-10 on-site hours primarily spent completing the initial pool process: Based on Complete observation, Interview and Limited Record Review  Identify initial pool—about eight residents

• Offsite selected
• Complaints or FRIs (Facility Reported Incidences) – No

more than 5

• Vulnerable: e.g. Quadriplegic; Alzheimer’s
• New Admissions in last 30 days
• Identified residents with other serious concerns

58

RESIDENT INTERVIEWS

Process: Room-to-Room WITHOUT Staff Screen every resident (full observation, interview, and limited record review) Suggested questions—but not a specific surveyor script Must cover all Care Areas. Identify potential MDS coding discrepancies. Includes Residents’ Rights, Quality of Life & Quality of Care Investigate further if issue identified. If addressed, then no issue

e.g. Resident says he lost weight because loose dentures unaddressed by facility; then this is a problem Resident says that she has an issue with her roommate but facility addressed; therefore, no issue

59

SURVEYOR OBSERVATIONS

Cover all Care Areas and Probes Conduct rounds; identify repositioning & incontinence care concerns based on whether resident is in same positioning extended periods

• f time during your rounds

Complete formal observations Investigate further or no issue

e.g. Surveyor may complete formal observations for wounds or incontinence care if the situation presents itself or is necessary—for example, if a resident has not been assisted to the bathroom for a long period of time or is covered in bed.

60

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SLIDE 42

21 RESIDENT REPRESENTATIVE / FAMILY INTERVIEWS

Non-interviewable residents Familiar with the resident’s care Complete at least three during initial pool process or early enough to follow up on concerns Sampled residents if possible Investigate further or no issue

61

LIMITED RECORD REVIEW

Conduct limited record review after interviews and

• bservations are completed prior to sample

selection. All initial pool residents: advance directives and confirm specific information If interview not conducted: review certain care areas in record Confirm insulin, anticoagulant, and antipsychotic with a diagnosis of Alzheimer’s or dementia, and PASARR (Pre-Admission Screening and Resident Review)

62

LIMITED RECORD REVIEW

New admissions – broad range of high-risk medications Extenuating circumstances, interview staff Investigate further or no issue

63

Page 42 of 90

SLIDE 43

22 ADDITIONAL INITIAL POOL PROCESS INFORMATION

The facility should complete the facility matrix within four hours Once the matrix is received, each surveyor will review the matrix for residents in their assigned area to identify any substantial concern that should be followed up on. At least 1 resident who Smokes, 1 resident who is receiving Dialysis, 1 resident on Hospice, 1 resident on a Ventilator, and 1 resident who is on Transmission-Based Precautions should be included in the initial pool for the team if available.

64

DINING –FIRST FULL MEAL

Dining – Observe First Full Meal Cover all dining rooms and room trays Observe enough to adequately identify concerns If feasible, observe initial pool residents with weight loss If concerns identified, observe another meal

65

TEAM MEETINGS

 Surveyors have a brief meeting (15 to 30 minutes) at the

end of each day

• Workload; Coverage; Concerns
• Synchronize/share data (if needed)

If SQC (Substandard Care) is suspected, sample is expanded as necessary to determine scope and whether there is sufficient evidence to rule out SQC. If the team verifies the existence of SQC, the Administrator should be informed that the facility is in SQC and an extended survey will be conducted.

66

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SLIDE 44

23

SAMPLE SELECTION

SAMPLE SELECTION

SELECT SAMPLE. After Initial Pool Process, the Survey Team will meet for about an hour to select the sample. Prioritize using sampling considerations:

• Replace discharged residents selected offsite with those

selected onsite

• Can replace residents selected offsite with rationale
• Harm, SQC if suspected, IJ if identified
• Abuse Concern
• Transmission Based precautions
• All MDS indicator areas if not already included

Closed Record Reviews (Death; Hospitalization; Community D/C)

68

SAMPLE SELECTION UNNECESSARY MEDICATION REVIEW

System selects five residents for full medication review Based on observation, interview, record review, and MDS Broad range of high-risk medications & adverse consequences Residents may or may not be in sample *The selection process considers all psychotropic medications, insulin, anticoagulants, opioids, diuretics and antibiotics, as well as some adverse consequences, including falls, weight loss, and sedation. There are exclusions; for example, a resident would be excluded if they had a diagnosis of Huntington’s or Schizophrenia and was receiving an antipsychotic.

69

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SLIDE 45

24

INVESTIGATIONS

RESIDENT INVESTIGATION GENERAL GUIDELINES

Conduct investigations for all concerns that warrant further investigation for sampled residents Continuous observations, if required Interview representative, if appropriate, when concerns are identified

71

INVESTIGATIONS

Majority of time spent observing and interviewing with relevant review of record to complete investigation Use Appendix PP and Critical Element (CE) Pathways

72

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SLIDE 46

25

ON-GOING & OTHER SURVEY ACTIVITIES

CLOSED RECORD REVIEWS

Complete timely during the investigation portion of survey Unexpected death, hospitalization, and community discharge last 90 days System selected or discharged resident Use Appendix PP and CE pathways

74

FACILITY TASK INVESTIGATIONS

Complete any time during investigation Use facility task pathways CE compliance decision

75

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SLIDE 47

26 DINING – SUBSEQUENT MEAL, IF NEEDED

Second meal observed if concerns noted Use Appendix PP and CE Pathway for Dining Dining task is completed outside any resident specific investigation into nutrition and/or weight loss

76

INFECTION CONTROL

Throughout survey, all surveyors should

• bserve for infection control

Assigned surveyor coordinates a review

• f influenza and pneumococcal

vaccinations Assigned surveyor reviews infection prevention and control, and antibiotic stewardship program

77

SNF BENEFICIARY PROTECTION NOTIFICATION REVIEW

A new pathway has been developed List of residents (home and in- facility) Randomly select three residents Facility completes new worksheet Review worksheet and notices

78

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SLIDE 48

27

KITCHEN OBSERVATION

In addition to the brief kitchen

• bservation upon entrance, conduct

full kitchen investigation Follow Appendix PP and Facility Task Pathway to complete kitchen investigation

MEDICATION ADMINISTRATION

Medication Administration Recommend nurse or pharmacist Include sample residents, if opportunity presents itself Reconcile controlled medications if observed during medication administration Observe different routes, units, and shifts Observe 25 medication opportunities

80

MEDICATION STORAGE

Medication Storage Observe half of medication storage rooms and half of medication carts If issues, expand medication room/cart

81

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SLIDE 49

28

RESIDENT COUNCIL MEETING

Group interview with active members of the council Complete early to ensure investigation if concerns identified Refer to updated Pathway

82

SUFFICIENT AND COMPETENT NURSE STAFFING REVIEW

Is a mandatory task, refer to revised Facility Task Pathway Sufficient and competent staff Throughout the survey, consider if staffing concerns can be linked to QOL and QOC concerns

83

TRIGGERED TASKS COMPLETED IF CONCERNS ARE IDENTIFIED

Personal Funds Environment Resident Assessment (e.g. Late Completion or late Submission of MDS Assessments)

84

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SLIDE 50

29

ENVIRONMENT

Investigate specific concerns Eliminate redundancy with LSC

• Disaster and Emergency

Preparedness

• O2 storage
• Generator

85

POTENTIAL CITATIONS

POTENTIAL CITATIONS

Team makes compliance determination.

• Compliance decisions reviewed by team
• Scope and Severity (S/S)

The meeting takes about an hour on average. Team makes a compliance decision for every Tag that came forward from each surveyor. Survey Team conducts exit conference and relay potential areas of deficient practice

87

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SLIDE 51

30

ENFORCEMENT DELAYS

CMS planning to freeze:

• The use of remedies (CMPs, Denial Payment,

Termination) for PHASE 2 REQUIREMENTS (e.g. QAPI, FACILITY ASSESSMENT, ANTIBIOTIC STEWARDSHIP, etc.) for ONE YEAR.

NOTE: Citations will still be given. And we don’t know yet what CMS will do with those.

• SURVEY SCORE in Five Star Rating System for 12

months (NOTE: ONLY the Health Inspection Domain will be frozen. Staffing & QM Domain Components will still be recalculated)

88

GOODBYE, SURVEYORS!

UNTIL NEXT YEAR…..

Page 51 of 90

SLIDE 52

1

THE CHARTS GROUP

STRATEGIES in PREPARING for the NEW SURVEY PROCESS

NELIA ADACI RN, BSN, CDONA, C-NE, RAC-CT VP, The CHARTS Group

LET’S GET TO WORK!

• 1. Prepare Checklists (Focus on Phase 1 & 2

Requirements)

• 2. Prepare a SURVEY BINDER and establish who in

your organization/facility is responsible for what

• 3. Write Policies & Procedures that mirror the

requirements – Do NOT ADD unless you are certain that you can comply. (Do not create your

• wn problems!)
• 4. Review your tools and forms

PREPARE CHECKLISTS

TO GET ORGANIZED

Page 52 of 90

SLIDE 53

2

PREPARE CHECKLISTS FOR THE FOLLOWING:

• 1. Policies & Procedures
• 2. Programs
• 3. Plans
• 4. Forms & Documents
• 5. In-services & Staff Trainings
• 6. Staff Positions & Certification Requirements
• 7. Notifications and Resident Rights
• 8. Resident Care Plan & Discharge Plan
• 9. Processes, Systems & Assessments
• 10. Physical Environment

4 4

POLICIES & PROCEDURES

POLICIES & PROCEDURES (Ask Have you created the NEW required P&P’s?” PHASE (Date Enforced)  Visitation Rights of Residents 1  Grievance Policy 1  Loss or Damage of Dentures 2  Use & Storage of foods brought to residents by family/others 1  Infection Prevention & Control Program 1  Compliance & Ethics 3  Monthly Drug Regimen Review 1 & 2  Notifying Clinicians 1  QAPI Feedback, Data Collection, & Monitoring 3  QAPI Systematic approach for quality improvement 3  Smoking 2  Arrangements with other LTC facilities & other providers to receive resident residents during an event November 15, 2017

5 5

POLICIES & PROCEDURES

POLICIES & PROCEDURES (Ask “Have you updated & modified existing P&P’s that are required by the new Requirements of Participation?” PHASE (Date Enforced)  Advanced Directives 1  Bed Hold Policy 1  Room Changes 1  Abuse, Neglect & Exploitation of Residents & Property 1  Reporting of Crime 2  Permitting Residents to Return to Facility 1  Admissions Policy 1  Staff Treatment of Residents 1  Influenza & Pneumococcal Immunizations 1  Disaster and Emergency Preparedness 3  Facility Closure 1  Administrator’s Duties and Responsibilities 1

6

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SLIDE 54

3 PROGRAMS

PROGRAMS (Do you have ALL the “PROGRAMS” as required?) PHASE (Date Enforced)  Compliance and Ethics Program 3  Activities Program 1  QAPI Program 1, 2 & 3

(Some sections are in Phase 2 & 2 Components in Phase 1 Disclosure of Info to Survey Agency and Sanctions

 Infection Prevention and Control Program 1, 2 & 3

(Linking to Facility Assessment & Antibiotic Stewardship – Phase 2) Requirement for an Infection Preventionist – Phase 3)

 Antibiotic Stewardship Program 2  Staff Training Program (Refer to Training and In-service Section) 1 & 3

7

PLANS

PLANS (Have you created ALL the NEW required facility plans?) PHASE (Date Enforced)  Infection Control Plan 1  QAPI Plan 2  Emergency Plan November 15, 2017  Communication Plan about Emergencies November 15, 2017

8

FORMS AND DOCUMENTS

POLICIES & PROCEDURES (Ask Have you updated or created all the New Forms or Tools?” PHASE (Date Enforced)  Discharge Summary 1 & 2  Discharge Plan for Each Resident 1  Resident Assessment 1  Baseline Care Plan 2  Drug Regimen Review Report 1  Facility-wide Assessment 2  Other Tools that you might find helpful:

• Side Rail Assessment
• Side Rail Use Informed Consent Form
• Smoking Safety Assessment
• Decision-Tree on whether device is a restraint or not

9 9

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SLIDE 55

4 IN-SERVICES & STAFF TRAINING

Do you have in-services for all the newly required in-services? PHASE (Date Enforced)  Abuse, Neglect and Exploitation 1  QAPI 3  Compliance and Ethics 3  Behavioral Health 3 Have you updated existing in-services with the new information or new staff required to be included in these in-services?  Nurse Aide Training to include the following components:

• Dementia Management
• Resident Abuse
• Care of the Cognitively Impaired, if applicable

1  Nurse aide training on areas of weakness determined by performance reviews and the facility assessment 3  Communication 3  Resident Rights and Facility Responsibilities 3  Infection Control 3  Emergency Preparedness Training and Testing 11/15/17 10

STAFF POSITIONS & CERTIFICATION REQUIREMENTS

Do you have a person designated for the NEW required positions? PHASE (Date Enforced)  Compliance Contact (in each facility) 3  Person to Oversee Compliance (must be high-level person within the organization) 3  Compliance Officer (for Organization when the Organization has >5 Facilities) 3  Compliance Liaison (for Organization when the Organization has >5 Facilities) 3  Infection Preventionist 3  Grievance Officer 1 Does your existing staff who are currently in a required position meet new changes to those positions?  Dietitian (If hired before 11/28/16, has 5 years to comply) 1  Food Service Director(If hired before 11/28/16, has 5 years to comply) 1  Social Worker 1

11

RESIDENT NOTIFICATION & RESIDENT RIGHTS

Have you updated required notification information to be include at time of ? PHASE (Date Enforced)  Admission 1  Before Transfer or Discharge 1  Orientation about Transfer or Discharge 1  Resident Rights (including how to file grievance or complaint) 1  Participating and Updating Care Planning process 1 Have you updated required notification information about ?  Baseline Care plan developed within 48 hours of admission 2  Bed Hold Policy 1  Facility Charges 1  Choosing their physician 1  Signing of care plan 1  Significant change in mental health – notify State Mental Health Authority 1  Abnormal lab or radiology results to the clinician 1

12 12

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SLIDE 56

5

RESIDENT CARE PLAN & DISCHARGE PLAN

Have you created a BASELINE CARE PLAN to be developed within 48 hours of admission? (Must include 5 elements below) PHASE  (1) Does it include resident’s goals? 2  Does it include all of the required orders

• (2) Physician (3) Dietary (4) Therapy
• (5) Social Services (6) PASARR

2 Have you updated the format of your RESIDENT CARE PLAN to incorporate resident-centered information and Discharge Plan?  Have you updated the resident assessment to incorporate person- centered? 1  Have you incorporated resident-centered goals and wishes about their care, activities, and lifestyle into the resident’s care plan? 1  Have you included resident’s preferences for future discharge? 1  Baseline Care plan developed within 48 hours of admission 2  Have you added new staff to the DT in signing off on care plan? 1  Are the services in the care plan culturally competent? 1  Have you incorporated trauma-informed care into the care plan? 1

13 13

RESIDENT CARE PLAN & DISCHARGE PLAN

Have you added a Discharge Plan as part of the resident’s care plan?  Does your Discharge Plan contain all the information required in a plan? 1  Have you incorporated resident discharge goals and wishes into the resident’s care plan? 1  Have you involved the interdisciplinary team in developing and signing off on the Discharge Care Plan? 1  Have you shared the discharge plan with the resident and their representative? 1

14 14

REVIEW OF PHASE 2 REQUIREMENTS

• 1. Contact Information for State & Local Advocacy

Organizations, Medicare & Medicaid Eligibility Information, Aging & Disability Resource Center, & Medicaid Fraud control Unit

• 2. Document Transfer/Discharge in medical

Record and share information with receiving provider

• 3. Develop Baseline Care Plan within 48 hours of

admission – INCLUDE 6 KEY ELEMENTS and SHARE WRITTEN COPY

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6

REVIEW OF PHASE 2 REQUIREMENTS

• 4. Policies & Procedures for Reporting Suspicion of Crimes

 Within 2 Hours if serious bodily injury; within 24 hours if no serious bodily injury  Focuses on individuals responsible for reporting

• Ensure reporting of crimes by covered individuals
• Annual Reminder/Re-education

 Facility must educate covered individuals  Report to State and at least 1 Law Enforcement Entity  No retaliation  Poster with Employee Rights (No retaliation for Reporting)

REVIEW OF PHASE 2 REQUIREMENTS

• 5. Pharmacy Services

 Drug Regimen Review includes Medical Chart (Not just the MAR)  Limits on Use of Psychotropic Drugs

• 6. Dental Services

 Policy for when loss or damage of dentures is facility’s responsibility and prompt referral for Dental Services (within 3 days)

• 7. QAPI Plan – Keep it simple
• 8. Smoki

king Policy cy - prepare and review applicability - applies to both residents and staff

REVIEW OF PHASE 2 REQUIREMENTS

• 9. Complete FACILITY ASSESSMENT –

 Do not go overboard. Just make sure that you meet the 16 Components  Use info to develop your QAPI Plan, Infection Control Program, etc.

• 10. Sufficient & C

Competent Staffing Requirements tied to FA  Nursing Services  Food and Nutrition Services  Behavioral Health Services

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7

REVIEW OF PHASE 2 REQUIREMENTS

• 11. Behavioral Health

Care and services for residents with mental and psychosocial disorders as well as Dementia Implementing Non-Pharmacological Interventions Provide needed rehab services

• 12. Infection Prevention and Control Program

System with key Elements for Preventing, Identifying, Reporting, Investigating and Controlling – Linked to Facility Assessment and National Standards Antibiotic Stewardship Program

• Antibiotic Use protocols (to address prescribing

practitioners) and system to monitor their use)

PREPARE SURVEY BINDER

“YOU HAVE ONE CHANCE TO MAKE A FIRST IMPRESSION”

SURVEY BINDER

ITEMS listed in the Entrance Conference Worksheet Include: Facility Assessment: A center-wide assessment that would determine what resources a facility needs to care for its residents competently both during Day-to-Day Operations and in Emergencies QAPI Plan: Must have 5 Elements of QAPI

• DESIGN AND SCOPE
• GOVERNANCE AND LEADERSHIP
• FEEDBACK, DATA SYSTEMS & MONITORING
• PERFORMANCE IMPROVEMENT PROJECTS
• SYSTEMATIC ANALYSIS & SYSTEMIC ACTIONS

21 21

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8

REVIEW AND/OR WRITE POLICIES & PROCEDURES

“MIRROR THE REQUIREMENTS”

(NOTE: THIS IS NOT THE TIME TO SHOW OFF YOUR CREATIVE & EXTENSIVE WRITING SKILLS!)

REVIEW YOUR TOOLS AND FORMS

“BE PRACTICAL AND REALISTIC. IT IS NOT ABOUT QUANTITY; IT IS ABOUT ACCURACY AND QUALITY!”

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FINAL NOTE

Disclaimer: In our on-going effort to help facilities survive in these challenging times, we are sharing a binder with sample tools that we have gathered and worked on. Use of these specific tools is NOT mandated by CMS. Completion of these tools does NOT ensure or guarantee regulatory compliance What do you see, nurses, what do you see? Are you thinking, when you look at me -- A crabby old woman, not very wise, Uncertain of habit, with far-away eyes, Who dribbles her food and makes no reply, When you say in a loud voice -- "I do wish you'd try." Who seems not to notice the things that you do, And forever is losing a stocking or shoe, Who unresisting or not, lets you do as you will, With bathing and feeding, the long day to fill. Is that what you're thinking, is that what you see? Then open your eyes, nurse, you're looking at ME... I'll tell you who I am, as I sit here so still;

SEE ME!!!

THIS POEM WAS FOUND AMONG THE POSSESSIONS OF AN ELDERL Y LADY WHO DIED IN THE GERIATRIC WARD OF A HOSPITAL NO INFORMATION IS AVAILABLE CONCERNING HER -- WHO SHE WAS OR WHEN SHE DIED

As I rise at your bidding, as I eat at your will. I'm a small child of ten with a father and mother, Brothers and sisters, who love one another, A young girl of sixteen with wings on her feet. Dreaming that soon now a lover she'll meet; A bride soon at twenty -- my heart gives a leap, Remembering the vows that I promised to keep; At twenty-five now I have young of my own, Who need me to build a secure, happy home; A woman of thirty, my young now grow fast, Bound to each other with ties that should last; At forty, my young sons have grown and are gone, But my man's beside me to see I don't mourn; At fifty once more babies play 'round my knee, Again we know children, my loved one and me.

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Dark days are upon me, my husband is dead, I look at the future, I shudder with dread, For my young are all rearing young of their own, And I think of the years and the love that I've known; I'm an old woman now and nature is cruel -- 'Tis her jest to make old age look like a fool. The body is crumbled, grace and vigor depart, There is now a stone where one I had a heart, But inside this old carcass a young girl still dwells, And now and again my battered heart swells. I remember the joys, I remember the pain, And I'm loving and living life over again, I think of the years, all too few -- gone too fast, And accept the stark fact that nothing can last -- So I open your eyes, nurses, open and see, Not a crabby old woman, look closer, nurses -- SEE ME!

QUESTIONS???

THANK YOU!!!

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1 THE CHARTS GROUP

MEDICARE/CMS UPDATES & CLINICAL REIMBURSEMENT CHALLENGES

NELIA ADACI RN, BSN, CDONA, C-NE, RAC-CT VP, The CHARTS Group

CLAIMS AND APPEALS WHAT WE HAVE NOTICED

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2

WHAT WE HAVE NOTICED

CMS has implemented unprecedented TECHNOLOGICAL UPGRADES in Claims Processing & Management:  Automatic Denials due to increase in “EDITS” (NCCI Edits; Medically Unlikely Edits; MAC Medical Review Edits)  Enhanced Coordination of Benefits: To detect

• verlapping of claims (sequencing), avoid duplication
• f services, follow the beneficiary across care settings

 Determine compliance with Medicare regulations via “data” (e.g. Dates, Codes, Modifiers) in the MDS 3.0 & UB-04 (electronic claims submitted as reflected in FISS)

4

MEDICARE AUDITS

 MAC PROBES & ADR’S: Focus on facilities with a history of Ultra High RUG Utilization  RAC AUDITS: Based on PUF Reports  UPIC/ZPIC AUDITS: Focus on medical necessity

• f daily skilled services

 CERT/PERM/QIO AUDITS: Error Rates  Increased Scrutiny on New or Change in Ownership  Heightened Focus on “TRANSITIONS OF CARE” – Request for Hospital Records

5

MEDICARE AUDITS

Most Common Reasons for Denials and/or Recoveries:  Billing Errors  MDS Coding NOT supported by documentation in Medical Records  Insufficient Hospital Records  MD Certs and Re-certs  Documentation does not support Medical Necessity

• f Skilled Services

6

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3

MEDICARE ADVANTAGE/HMO

 Unprecedented Increase in Medicare Advantage/HMO Audits: e.g. United Health Care, Humana, AETNA, Clover * Note: Appeals Process for Traditional Medicare A & B is different from Medicare Part C

7

MEDICARE AUDITS

• What Has Gone Wrong?
• Why are we here?
• What do we do now?

RIPPED FROM THE HEADLINES

 A national nursing home chain agreed to pay $145 Million to Resolve False Claims Act Allegations Relating to the Provision of Medically Unnecessary Services  A nursing home operator and its Director

• f Long Term Care agreed to pay $2.5

million related to inflated Medicare claims

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4

WE KNOW THAT….

 The claim form (UB04) communicates the type of care you are billing for. The MDS and the medical record documentation must support the claim.

MOST UP-TO-DATE “REASONS FOR MEDICARE CLAIM DENIALS OR RECOVERIES”

UPDATES ON REASONS FOR DENIAL: BILLING ERRORS

We have observed that numerous claims are being denied due to billing errors that were noted by the MAC in the FISS System.

• “Admission Date entered in FISS does not correlate

with the admission date on medical record”.

• “The ARD date (Occurrence Span Code 50) entered in

FISS would be a prohibited assessment due to the beneficiary Admission Date in FISS”.

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UPDATES ON REASONS FOR DENIAL: BILLING ERRORS

• “Medical records lacks records to support 3-day

qualifying stay as coded in FISS (Occurrence Span Code 70). Dates submitted for qualifying stay documentation are from previous SNF admission”.

• “The ARD dates in FISS do not correlate with the ARD

dates in the National Repository”.

• “The dates of the qualifying hospital stay in FISS do

not correlate with the medical records submitted”.

UPDATES ON REASONS FOR DENIAL: BILLING ERRORS

• “Admission Date on FISS does not correspond with

admission date on SNF Certification or SNF Records”.

• “The medical record lacks pertinent records to

support the qualifying hospital stay that was entered into FISS. The medical records submitted were for a different hospital stay. These records were insufficient in supporting medical necessity of the hospital and SNF stay.

COMMON BILLING ERRORS ACCORDING TO THE MACS

 Incorrect qualifying hospital stay entered

• Dates for the 70 occurrence span code not

reflecting the correct qualifying hospital stay dates Assessment dates and RUG levels are not entered correctly

• Occurrence code 50 and RUG levels are

not submitted in the correct order

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COMMON BILLING ERRORS ACCORDING TO THE MACS

Correct coding is not submitted for Medicare Advantage patients

• Condition code 04 reported when the SNF

patient is enrolled in a Medicare Advantage plan Incorrect patient discharge status

• Ex: Patient status code is to Home Health

(06) and the claim was billed with patient status to home (01)

COMMON BILLING ERRORS

Leave of absence (LOA) days not being reported on the claim

• Occurrence span code 74
• Non-covered days in FL 39-41 with value code

81

• Revenue code 018X with number of LOA days

and $0.00

• Do not include LOA days in 0022 rev code line
• r 12X revenue code line

COMMON BILLING ERRORS

Reason code EA031 – claim processing system shows patient has an HMO

• Add Condition code 04 to the claim if patient has

an HMO Reason code C7010- claim overlaps a hospice election period

• If services are unrelated to the terminal illness

include Condition code 07 on the claim

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COMMON BILLING ERRORS

Reason code 12206 – Sum of covered days and non- covered days must equal the statement covers period

• Verify the following:
• Covered and non-covered days
• Statement from and through dates
• Patient status

COMMON BILLING ERRORS: REASON CODE 38119

SNF claims should be billed in sequence A SNF claim submitted, however, the statement covers from date is greater than the admission date and there is no claim pending with a through date

• ne day less than this claim from

Resolution:

• SNF and non-PPS providers are required to

bill in sequential order

• This claim cannot process until the prior

bill(s) is processed

• Resubmit this claim once the previous

month’s claims have processed

UPDATES ON REASONS FOR DENIAL: LACK OF MEDICAL NECESSITY R/T HOSPITAL RECORDS

There has been a dramatic increase in claim denials related to issues with hospital records (i.e. “qualifying hospital days were not medically necessary”; “Skilled PT/ Skilled OT /Skilled ST were not related to a condition that was treated in the hospital”; “No referral in the hospital for in-patient skilled therapy intervention”; “Intensity of Rehab services did not warrant in-patient SNF stay”, etc.)

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UPDATES ON REASONS FOR DENIAL: LACK OF MEDICAL NECESSITY R/T HOSPITAL RECORDS

• “Medical records do not support beneficiary was

evaluated by, treated by, or referred for inpatient skilled therapy while receiving inpatient hospital care”

• “There is no documentation within the content of the

qualifying hospital record to support a new profound weakness or necessity of in-patient skilled care”.

• “Medical record lacks some pertinent qualifying hospital

stay records. QHS record submitted does not support beneficiary was evaluated by, treated by, or referred for inpatient skilled therapy intervention.”

UPDATES ON REASONS FOR DENIAL: LACK OF MEDICAL NECESSITY R/T HOSPITAL RECORDS

• “Medical record has conflicting documentation as to level of
• care. Transfer documentation from the hospital and Physician’s

Orders indicate long-term care while SNF Certification lists Skilled PT/OT. Hospital records do not support that skilled therapy was recommended.”

• “Nursing notes support beneficiary is able to feed self, propels

self in wheelchair and bed mobility, and is 1 assist in ADL’s. Unable to validate services billed were reasonable & necessary in treating a condition related to the condition for which beneficiary received in-patient hospital care.”

MOST UP-TO-DATE “REASONS FOR CLAIM DENIALS OR RECOVERIES FROM MEDICARE ADVANTAGE/HMO’S”

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MOST COMMON DENIALS FROM MEDICARE ADVANTAGE/HMO’S  Missing scheduled (PPS-like) assessments and/or unscheduled assessments like COT & EOT OMRAs.

• “CMS’s RAI Manual requires a COT OMRA assessment

to reflect changes in therapy intensity. Not found in Medical Records”.

• “CMS’s RAI Manual requires an EOT OMRA

assessment when resident misses 3 consecutive days

• f therapy. Not found in Medical Records”.
• “No 14-day MDS Assessment submitted to justify level
• f skilled services rendered and billed for”.
• “No 30-day MDS Assessment submitted to justify level
• f skilled services rendered and billed for”.

MOST COMMON DENIALS FROM MEDICARE ADVANTAGE/HMO’S RUG Score billed is different from RUG score in MDS Assessment MDS Coding of Late-Loss ADL’s not supported by documentation according to RAI MDS 3.0 Coding Instructions Frequency of treatments different than POC Reason for concurrent minutes not documented RECOMMENDATIONS FOR MEDICARE ADVANTAGE/HMO’S

Appropriate and Prompt Completion of Scheduled and Unscheduled MDS Assessments (if indicated) for all Medicare Advantage/HMO beneficiaries:

• Please note, the assessments should be

COMPLETED, BUT NOT TRANSMITTED, as per CMS regulations!

• “Assessments that are completed for purposes
• ther than OBRA and SNF PPS reasons are not to

be submitted, e.g., private insurance, including but not limited to Medicare Advantage Plans” (RAI Manual, Chapter 5, p. 5-1)”.

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RECOMMENDATIONS FOR MEDICARE ADVANTAGE/HMO’S Include discussion of Medicare Advantage/HMO beneficiaries in Weekly UR Meetings Perform Triple Check on all Medicare Advantage/HMO Claims prior to Billing Review the details of your Medicare Advantage/HMO Plan Contracts or Single Case Agreements – to ensure that you are following all Technical & Documentation Requirements.

MANAGING MCO’S

Revenue generation begins with accurate identification and verification of the payer PRIOR TO Admission Profit projection begins with an effective patient cost-out strategy 12%- 19% of revenue is lost during the admissions process due to incorrect or unverified information. PRE-ADMISSION  Receipt of Inquiry  Payor Eligibility Verification  Determination of Level of Care Coverage  Contract Determination  Authorization  Case Management

MANAGING MCO’S

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MANAGING MCO’S

PRE-ADMISSION - Insurance Verification  When does this process begin?  Training  Is your facility using a standardized form for each managed care resident?  Whom does admissions verify with health plan and or/medical group?  What question is asked to identify payor?

MANAGING MCO’S’S

PRE-ADMISSION Insurance Verification  Does Business Office check and verify information?  How often do we check?  Does Admissions understand different product types and know what health plans you are contracted with? ISSUE: Are you contracted? If not, was an SCA secured prior to admission? ISSUE: Which benefits are you calling on? Custodial, Part B, or Skilled?

MANAGING MCO’S

PRE-ADMISSION  Costing out patient?  High cost meds, specialty services, etc...  Do you have the contract in place?  Level versus RUGs, Exclusions, etc...  SCA negotiated ????  Did the facility receive reports of recent labs, x- rays, etc...?  Has someone verified eligibility and benefits correctly?

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MANAGING MCO’S

ADMISSION Did we receive authorization? Is the correct level authorized? Is specialty equipment ordered? Who will discuss co-payment with the patient and/or family? Passing on the info to the team – BOM, DOR, CM

MANAGING MCO’S

ADMISSION ER / Home / Weekend Admits –Do we have protocol in place for all? Can we take 24/7? Do we know what paperwork is needed for each admit (Ex. Packet to inform doctor of what paperwork is needed)? Is our admission process clean, clear, and quick?

MANAGING MCO’S

MANAGING PATIENT’S STAY Levels correct on a daily basis? Capturing exclusions on a daily basis Using the correct vendors?

• Transport
• Pharmacy
• DME

Consistent collaboration with DOR on minutes approved? Utilizing the correct vendors for discharge?

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MANAGING MCO’S

MANAGING PATIENT’S STAY Shorter Length of Stay (LOS) Request for changes/extensions in authorization Review high cost medication – exclusions – pharmacy Respond to appeal

MANAGING MCO’S

MANAGING PATIENT STAY CASE MANAGEMENT SYSTEM COLLABORATION MANAGED CARE TEAM

• Insurance Verification
• Contract terms – Levels of Care, Rates, Exclusions
• Initial Evaluations
• Authorizations
• Changes in Condition
• Capturing Exclusions
• Medical Necessity – Skilled Stay
• Internal Communication – Weekly Meetings,
• External Communication – Concurrent Reviews Driven by

Skilled Needs

• Advocacy

MANAGING MCO’S

 Managed care weekly meetings

• Resident goals
• Barriers
• Discharge plans

 The DOR, BOM, CM and Admissions Director MUST develop a very clear and efficient system of communication  Consistent communication with the managed care entity is also very critical  Teamwork= successful stay and well- managed resident

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UB-04: SHOULD TELL THE STORY OF THE BENEFICIARY OF CARE PROVIDED ACROSS SETTINGS

UB-04 (Reimbursement, Compliance & Data Analytics)

MDS CLINICAL DOCUMENTATION CARE (Based on Individual Characteristics of Patient)

VULNERABILITES: PROVIDER ATTITUDE

“We’ve been getting paid for that service - no problem!” *The problem is usually NOT about getting paid. It is about KEEPING the money and MORE…” “Paper Compliance (without regard for the intent of the regulations)”: *It is NOT just about “Paper Compliance.” Use of “Critical Thinking Skills” & “Inter-disciplinary Collaboration” are IMPERATIVE. Medical Records need to reflect the above.

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UB-04: FORM (FRONT)

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UB-04: (BACK) ATTESTATION

“The Submitter of this Form Understands That Misrepresentation or Falsification of Essential Information as Requested by this Form, May Serve as the Basis for Civil Monetary Penalties & Assessments and May Upon Conviction Include Fines and/or Imprisonment Under Federal and/or State Law(s).”

PROCESS OF BILLING

5 STEP PROCESS FOR BILLING MEDICARE

• 1. Decide that the service is medically

necessary.

• 2. Provide the best service to meet, but not

exceed, the patient’s need.

• 3. Document the service provided in the

medical record.

• 4. Select the most appropriate coding for the

services provided.

• 5. Submit your claim to Medicare.

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“MUST HAVES” BEFORE BILLING

• 1. Technical Components meet:

3-Day Qualifying Hospital Stay (unless there is a waiver) Practical Matter (Why in a SNF?) Daily Skilled Services

• 2. CWF/HETS
• 3. MSP
• 4. Assignment of Benefits
• 5. Release of Information

“MUST HAVES” BEFORE BILLING

• 6. Physician Certification
• 7. Validation Report – Proof of transmission and

acceptance of MDS in the QIES-ASAP Server

• 8. Authorizations – if required
• 9. Signed and dated MD Orders

10.Signed and Dated Therapy POC 11.Diagnosis Validation 12.Beneficiary Notices – if appropriate * NOW YOU CAN BILL!!!!

OVERVIEW: CMS CLAIM FORM 1450 OR UB-04

The UB-04, also known as Form CMS-1450, is the uniform institutional provider hard copy claim form. Requires specific codes for each form locator (FL) on the UB-04 form. Multiple pages of the UB-04 can be utilized for one patient’s monthly bill if necessary. The UB-04 is the only hard copy claim that CMS accepts from institutional providers. Can also be used to bill other payers (e.g. Medicaid)

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OVERVIEW: CMS CLAIM FORM 1450 OR UB-04 837 Institutional Electronic Version of the UB-04 Form – Electronic Submission Each Form Locator has a specific requirement and code associated with it. Medicare Part A & Part B claims are billed on the UB-04 and some of the elements are the same.

FOCUS ON ACCURACY OF CLAIMS (UB-04)

I. CLAIM DENIALS/RECOVERIES: Billing errors submitted in FISS automatically generate denials in claims that go on medical review. A big part of this presentation was obtained from a Federal Medical Review Auditor’s Perspective

• II. PAYMENT REFORM: Quality & Value is the new

currency: It’s all about DATA!

 Sources of Data? MDS 3.0 and UB-04

UB-04

PROVIDER & PATIENT INFO

BILLIN G INFO PAYER INFO

DIAGNOSES

REMARKS

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OVERPAYMENT

 Section 1128(d) of the Act “…any funds that a person received or retains under title XVIII…to which the person, after applicable reconciliation, is not entitled under such title.”  An overpayment occurs when Medicare pays you more than you should have been paid.  Where does an overpayment start? Submission of UB- 04 or 1500 [Medicare Claim]

MEDICARE ADVANTAGE***

SNF providers must submit covered claims with condition code 04 (information only bill) for beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from beneficiary and/or update beneficiary’s benefit period in Common Working File(CWF) Submission of claims are not required for beneficiaries that are receiving non-skilled care and are enrolled in an MA plan

MEDICARE SECONDARY PAYER (MSP) AND THE MDS

Beneficiaries with other primary insurance coverage MSP rules will affect the use of RUG codes and the MDS

• When a specific time period is guaranteed by

another insurer, typically by an employer group health plan (EGHP), the assessment schedule begins when the other coverage ends

Day 1 of Medicare coverage is day 1 of the MDS assessment schedule

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FINANCIAL FOLDERS BEST PRACTICES:

• Maintaining a central source of information

relating to each resident is necessary to assure claims are submitted correctly AND

• An organized source of information leads to

quicker payment and lower accounts receivable FINANCIAL FOLDER

Financial Folder audit Checklist [Admission] Signed Admission agreement Medicare Secondary Payer Questionnaire Power of Attorney [POA] REP Payee Information Assignment of Benefits From [AOB] Prior stay information

• Dates in Hospital
• Dates in SNF

FINANCIAL FOLDER Financial Folder audit Checklist [Billing] Copy of Identification [DL, Passport, Other] Medicare card Other insurance cards Common Working File Printout Insurance Authorizations Medicaid notification to state if applicable Medicaid award letter if applicable Online Medicaid eligibility verification

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FINANCIAL FOLDER Financial Folder audit Checklist [Payment] Remittance Advice from insurance company

• MSP amounts paid

Collection letters and collection notes Medicare bad debt log TRIPLE CHECK

The purpose of triple is to assure the Medicare claim correctly reflects the care provided to the resident and that all items on the claim are supporting by various records maintained at the facility.

• Triple check is not the time to audit underlying

systems and reports [e.g. therapy minutes, ADL coding] those items should be audited through independent processes.

• Triple check is the final system check against

the UB-04

TRIPLE CHECK PREPARATION Preparation

• Prior to Triple Check the MDS reviews should

be completed and each MDS should be transmitted and ACCEPTED.

• Prior to Triple Check the Therapy logs should

have been reviewed by the rehab manager and certified as accurate

• Prior to Triple Check the Financial Folders

should be reviewed and accurate

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TRIPLE CHECK PREPARATION

Census

• Admission and discharge dated or accurate
• Type of bill [TOB] is appropriate
• Leave of absence is entered if required
• Revenue codes and days are entered correctly

Charge Master

• Posted room rate
• Ancillary charges

Admission Information

• Occurrence codes / significant events
• Prior Hospital Stay [Inpatient days]
• Primary reason for admission
• Reason for admission [Accident]

TRIPLE CHECK PREPARATION

MDS – Review Process: All MDS are on UB-04 Therapy Review: Therapy Visits / Minutes; Therapy Cap; Functional Outcome Modifiers Diagnosis Coding:

• Diagnosis are all included
• Correctly sequenced
• Coding should be completed to the 7th digit when appropriate
• It is not appropriate for the biller to change diagnosis codes

from what is officially reported in the medical record

• It is just as wrong to exclude a necessary Dx code as it is to

include one that is incorrect

TRIPLE CHECK PREPARATION

Financial Folder

• Medicare number match
• DOB matches
• AOB on file
• Insured information correct
• Medicare correctly billed as primary
• Notice of non-coverage and Financial Liability Notice, if

appropriate

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SUBMITTING “CLEAN” CLAIMS

Clean Claim: One that holds up to FI edits Claims paid within 30 days, not before 14 days Decrease claims Returned to Provider(RTP) Reduces chance of Medical Review Increases cash flow of facility

SUBMITTING “CLEAN” CLAIMS

It’s a Team Effort!!! Ensure preadmission verification complete Resident Name, Medicare # Qualifying Hospital Stay Prior SNF Stays HIPPS Codes, including appropriate Modifier (& Sequencing) Ensure MDSs are submitted & accepted PRIOR to billing Assessment Reference Dates # of Days Billed

SUBMITTING “CLEAN” CLAIMS

It’s a Team Effort!!! # covered days, non-covered days Verify LOA days Ancillary Charges, supported by Medical Record Include ALL covered ancillary charges paid by facility. Verify and update ICD-10 Codes with each claim: Principal Diagnosis & Include ALL appropriate Medical Diagnosis Codes and Treatment Codes Communication of skilled vs. non-skilled levels of care

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QUALITY MEASURES: DATA AND OUTCOMES THE NEW CURRENCY $$$

PAYMENT REFORM: MUST SHOW VALUE VIA OUTCOMES (E.G. QUALITY MEASURES)

ALTERNATIVE PAYMENT MODELS (Bundling, ACOs, MA, Capitation, Episodic Payments) SNF-QRP VALUE-BASED PURCHASING ANPRM (RCS-1) – Heavy on Patient’s Conditions, Characteristics & Diagnosis Codes

QUALITY MEASURES

• 1. MDS-BASED QM’S: Designed to assess residents’

physical and clinical conditions, abilities, preferences & life care wishes

• 2. CLAIMS-BASED QM’s: Developed to provide another

source of information for the consumer & the provider related to quality of care. “Data obtained from claims submitted to Medicare A & B for services rendered to beneficiaries” Unique Info from UB-04: Hospital Information, Prior SNF Stays, Treatment History, Routine Charges/Costs, NTA Costs, Physician Information, Managed Care Levels, Benchmarking data (RUG levels, Per diem rate, Episodic Cost, LOS, Types of Assessments, Discharge Status/destinations)

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QUALITY MEASURES

For PUBLIC REPORTING For 5-STAR RATING For SURVEYORS For SNF-QRP’s For VALUE-BASED PURCHASING PURGING PREVIEW REPORTS FROM QIES*

MDS 3.0 Facility & Resident QM Preview Reports

• Available to nursing home-based SNFs only
• Effective November 1, 2016, the retention time

period for these reports will change from 230 days to 90 days  MDS 3.0 Nursing Home QM Five Star-Rating Preview Reports

• Available to nursing home-based SNFs only
• Deleted after 90 days

CLAIMS-BASED QUALITY MEASURES: 5-STAR RATING

 % RESIDENTS WHO WERE RE- HOSPITALIZED AFTER A NURSING HOME ADMISSION  % RESIDENTS WHO HAVE HAD AN OUTPATIENT EMERGENCY DEPARTMENT VISIT  % RESIDENTS WHO WERE SUCCESSFULLY DISCHARGED TO THE COMMUNITY

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• Medicare Spending per

Beneficiary

MEDICARE SPENDING

• Successful Discharge to

Community

COMMUNITY DISCHARGE

• Potentially Preventable 30-Day

Post-Discharge Readmission Measure (SNF QRP)

30-DAY READMISSION

CLAIMS-BASED QM’S FOR SNF-QRP REPORTING OCTOBER 2017 MEDICARE SPENDING PER BENEFICIARY – SNF-QRP

 Used for benchmarking provider to “expected spending”  Not just a simple sum of costs – some exclusions apply  Begins upon admission to SNF  Ends 30 days after SNF discharge (includes associated services)  Mirrors hospital Medicare Spending Per Beneficiary measure

DISCHARGE TO COMMUNITY – POST-ACUTE CARE SNF-QRP

 Assesses successful discharge to the community  Successful community discharge has achieved significant savings where capitated payments are in place  Ability to care for long-term disability patients in the community vs. institution creates significant savings  “Community”: Defined by codes on bill  * Discharge status codes

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DISCHARGE TO COMMUNITY – POST-ACUTE CARE SNF-QRP

 Successful community discharge:

• No unplanned hospitalizations (Acute of LTCH)
• No death
• From any cause… Within 31 days of discharge

 Exclusions:

• Hospice, other adjustments similar to previous

claims-based measures

• Discharge to psych hospital
• Discharge to law enforcement/court
• Medicare benefit exhausts

POTENTIALLY PREVENTABLE 30-DAY POST- D/C READMISSION MEASURE (SNF-QRP)

 No simple numerator/denominator  Numerator is risk adjusted estimate of the number of unplanned hospital readmissions that occurred within 30 days of PAC discharge

• Risk adjusted for patient/resident characteristics
• ICD-10 codes from hospital claims

 Potentially preventable:

• Management of infections (i.e. Pneumonia, UTI, C-Diff,

Cellulitis)

• Management of chronic conditions (i.e. CHF, COPD, DM)
• Inadequate prevention of other events (i.e. accidents,

injury)

POTENTIALLY PREVENTABLE 30-DAY POST- D/C READMISSION MEASURE (SNF-QRP)

Exclusions:

 Under 18 years  Discharge AMA (status code on UB-04)  Not continuously enrolled in Part A 12 months prior to SNF stay or 30 days after  Prior hospitalization for non-surgical treatment of cancer  Transferred to federal hospital (DOD, VA, Prison)  Problematic data

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SNF VALUE-BASED PURCHASING PROGRAM (SBF-VBP): SNFRM

SNF VBP Re-hospitalization Measure – FY 2019

• 30 day all cause all condition Readmission

Measure (SNFRM, unplanned hospital readmissions of SNF Medicare beneficiaries within 30 days of discharge from their prior proximal acute hospitalization

• Medicare Fee for Service claims based measure
• Readmissions within 30-day window are counted

regardless of whether the beneficiary is readmitted directly from SNF or had been discharged from SNF

• -----------------------------------------Benchmark- average of all top
• ----------------------------------------performing SNFs in 2015

(16.40) __________________________2017 your SNF (?)

• -----‘Achievement’ Rating--------25% threshold: minimum

improvement expected (20.41) __________________________2015 ALL SNFs If your SNF meets the benchmark, then your rating is 100. If your SNF doesn’t meet at least the 25th percentile, then your rating is 0. Remainder will be disbursed, 0-99.

SNF VBP RE-HOSPITALIZATION MEASURE RM

_____________________________ 2017 your SNF  ‘Improvement’ Rating up to 90 POINTS _____________________________ 2015 your SNF Better of the two, Improvement Rating Achievement Rating

SNF VBP RE-HOSPITALIZATION MEASURE RM

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SNF-VBP: SNFRM

Results in achievement rating score based on

percentage of residents that were not readmitted during the window

Compares value rating scores between providers How did you do in 2017 compared to all SNFs

nationwide in 2015?

• If you did better than benchmarks (100 points)
• If you did worse than achievement threshold (0 points)
• All facilities in between points assigned based on

“Achievement Score”

Second score “Improvement Score” based on how well

your facility did in 2017 compared to your 2015 data

• Above benchmark (90 points)
• If worse than 2015 (0 points)

PERFORMANCE SCORES

 The lower the readmission rate, the better.  Since a lower readmission rate is better, CMS

has inverted every SNF’s readmission rate using (1 –readmission rate) for the purposes of the performance standards (i.e., benchmark and achievement threshold) and performance scoring. Standard 2015 25th Percentile 20.41% Achievement Threshold 79.59% Mean of the Best Decile 16.40% Benchmark 83.60% OTHER PROGRAMS TO ENCOURAGE VALUE

Payments to nursing homes are now tied to Value CJR Bundling Shared savings & ACO partnerships

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OPERATIONAL STRATEGIES MANAGING QUALITY MEASURES

Know your Data

 Monitor your data on an ongoing basis

• Quality Measure Reports – CASPER
• Key Operational Performance Measures
• Hospitalization/Re-hospitalization Data
• Discharge Data

 Assess your data for accuracy

• Focus on the key data elements that trigger the

Quality Measures

• MDS data
• Claims data

 “Your success in life isn't based on your ability to simply change. It is based on your ability to change faster than your competition, customers, and business”. - Mark Sanborn QUESTIONS???

THANK YOU!!!

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