HCPro.com - PPS Alert for Long-Term Care

OSHA targets high-risk workplaces for possible inspections

Sat, 01 Jun 2013 04:00:00 GMT

OSHA targets high-risk workplaces for possible inspections

In letters sent out to 9,400 facilities with high worker injury and illness rates, the agency encourages employers to address safety and health

In March, the Occupational Safety and Health Administration (OSHA) sent letters to 9,400 employers covered by federal OSHA based on high injury and illness rates. The agency focused specifically on facilities that had reported "days away from work, restricted work, or job transfer injury and illness" (DART) rates that were higher than the average rate for their industry.

In the letter, OSHA expressed concern for the high injury and illness rates among employees and advised employers to hire an outside consultant or speak with an insurance carrier or state workers' compensation agency in order to identify unique workplace hazards and implement solutions and prevention measures.

OSHA also indicated that it may target up to 2,500 high-rate general industry workplaces for inspection within the next year.

LTC providers were among the nearly 10,000 employers to receive this letter. In September 2012, in response to high rates of illnesses and injuries at nursing and residential care facilities, OSHA released a notice that it would be reviving its National Emphasis Program (NEP) for Programmed Inspections of Nursing and Residential Care Facilities in which it would be addressing the following specific hazards:

Ergonomic stressors in patient lifting
Bloodborne pathogens
Tuberculosis
Workplace violence
Slips, trips, and falls

Although issues such as exposure to multidrug-resistant organisms and hazardous chemicals are not targeted specifically in this NEP, if those hazards become known during an inspection, OSHA will investigate, says Libby Chinnes, RN, BSN, CIC, infection prevention and control consultant and owner of IC Solutions, LLC, in Mount Pleasant, S.C. Hazardous chemicals in the form of drugs, disinfectants, or sanitizers may be commonplace in LTC facilities. The Hazard Communication standard requires employers to have a written plan along with employee training and access to material safety data sheets.

According to data from the Bureau of Labor Statistics (BLS), the national DART rate in 2010 was 1.8 in the private industry. Nursing and residential care facilities were as high as 5.6.

"Facilities that have read that notice will have a better understanding of what to expect because that's how they're training their surveyors to do the inspection," Chinnes says. "It basically says, if you have a very high injury and illness rate, you can expect an OSHA inspection. That doesn't mean everyone will get one, but if you have high rates, you can probably expect one."

Whether or not you were one of the 9,400 letter recipients, given the clear attempt to focus on employee safety within the industry, all LTC providers should take the time to look at the safety risks within their own facility and initiate action plans to reduce employee injury and illnesses where high injury rates persist.

Focus areas

One of the reasons LTC providers have fallen behind in maintaining employee safety is because tighter CMS regulations have forced them to direct much of their focus toward patient safety or face the risk of lower reimbursement rates, says Peggy Prinz Luebbert, MS, MT(ASCP), CIC, CHSP, founder of Healthcare Interventions, Inc., in Omaha, Neb. Fortunately, OSHA has outlined the areas it is particularly concerned with in long-term care so providers can begin looking at those specific risks in their facility.

Bloodborne pathogens. According to OSHA, from October 2011 to September 2012, the Bloodborne Pathogens standard was the most-cited standard among SNFs, totaling 39 citations and more than $30,000 in fines.

Every nursing home should have a copy of that standard available to employees and, more importantly, they should develop their own written exposure control plan that dictates exactly how the facility plans to limit exposures, implement engineering and work practice controls, and train employees on personal protective equipment (PPE) and regulated waste, Chinnes says. Some common areas where LTC providers fall short with this standard include the following:

Improper placement of sharps containers. Sharps containers need to be placed in rooms where sharps are being used routinely. "If you have it placed inappropriately so that you have to go through a door to reach the sharps container, you're going to get a citation," Chinnes says.
Evaluating safety devices. Employers are required to evaluate safety sharps annually and test safety syringes that are on the market. A multidisciplinary group of employees ranging from nurses to managers should all have input in evaluating safety devices and replace non-safety sharps whenever possible.
Appropriate use of PPE. Employees should receive training on what PPE they should be wearing when there is the potential for exposure to blood or bodily fluids. "For some procedures you should have on not only gloves and a gown to protect your hands and your body, but also face protection, which is more than just your eyeglasses, but goggles that go all the way around the side of your face or a mask and face shield," Chinnes says. Employees need to receive this training free of charge during normal work hours.
Keeping a sharps injury log. Employers typically track bloodborne exposures in a body fluid exposure log, which includes sharps injuries as well as other exposures. Injuries are also reported through the OSHA 300 form so that data can be retrospectively evaluated to spot patterns or trends. OSHA inspectors will ask to see this log if they come to inspect your facility.
Developing an exposure control plan. This should be a written plan that is available to all employees and utilized during training so that employees know the facility's specific protocol on what to do and who to contact if an exposure does occur. "It needs to be a 24/7 protocol," Chinnes says. "It can't be that no one is there on the weekend to cover that. Who is going to cover that nurse or aide if they get stuck on Saturday night at midnight and they need to be taken care of right then?"

Ergonomics. This is one area that is particularly applicable to SNFs and LTC providers given the elderly patient population that may be less mobile, coupled with a bariatric population that is steadily increasing, Luebbert says. "They need to have all the lifts and spend more time and money on ergonomics than the average healthcare facility for prevention of back injuries," she says.

Providers need to build a written ergonomics plan and incorporate safety lifting and use of mechanical lifts into their annual training.

Tuberculosis precautions. The elderly patient population puts LTC employees at greater risk for TB, Chinnes says. "Some of the older patients could have had TB years ago and reacted today because they have lost some of their immunity from steroids or chemotherapy, and it may have masked that they were developing TB again," she says.

LTC providers need to develop a written plan for managing patients with suspected or confirmed TB. Because most LTC facilities do not have airborne isolation rooms with the appropriate air exchanges to prevent the spread of TB, most providers have a transfer agreement in place to move that resident to an acute care facility. However, providers also need to develop an action plan for those few hours while the patient is waiting to be transferred that includes patient segregation and respiratory protection for employees.

Using N-95 respirators requires annual fit-testing for employees who may be exposed to respiratory illnesses. Chinnes recommends fit-testing a designated core group of employees who can care for the resident so that the entire staff doesn't need to be fit-tested, or use powered air-purifying respirators, which don't require annual fit-testing. Employees should also be tested for TB upon hire and annually thereafter if their risk assessment so indicates.

"They have to demonstrate, in a written plan, how are they going to handle TB in a resident and even how they would handle it in an employee, which is that the employee will not be allowed to work until deemed noninfectious," Chinnes says.

Workplace violence. OSHA has focused on workplace violence in all healthcare settings. In 2011, it released new enforcement procedures for investigating or inspecting workplace violence, which provided general enforcement policies for field officers to use when conducting inspections. "They want to see that you have addressed workplace violence and making sure you've done a risk assessment," Luebbert says.

This risk assessment needs to be formally documented and must identify areas in which workplace violence may occur and plans to eliminate or mitigate those risks.

Slips, trips, and falls. Healthcare is one of the top industries for slips, trips, and fall injuries. According to the latest data from the BLS, in 2009 the rate of lost workdays due to slips, trips, and falls in hospitals was 38.2 per 10,000 employees, which was 90% greater than the average rate for private industries. However, studies have shown that implementing slip, trip, and fall prevention programs can drastically reduce those rates.

The CDC offers comprehensive guidance in its resource paper Slip, Trip, and Fall Prevention for Healthcare Workers, Luebbert says. LTC facilities should consider addressing issues such as hazard assessment, changes to environmental cleaning procedures and products, general awareness campaigns, and facility design, including flooring changes.

Managing an inspection

Keeping up with all of these OSHA standards can be difficult, especially if the person responsible for employee safety has multiple job responsibilities. But with the imminent threat of OSHA inspections and fines-not to mention the workers' compensation costs associated with employee injuries and illnesses-it's imperative that LTC providers take a comprehensive look at the safety risks in their facility.

Each facility will face unique risks, but a risk assessment along with a comprehensive evaluation of injury and illness rates will help determine exactly what areas are considered high risk.

"One long-term care provider may look and say, 'We really have bloodborne pathogens down because we have been working on that for years, but workplace violence and ergonomics are another story,' " Chinnes says. "Or they can look at their injuries and see that injuries weren't from needlesticks, they were from slips, trips, and falls and not lifting properly, so we really need to build up that area."

It's no longer the case that OSHA inspections are initiated by employee complaints, Luebbert says. In fact, she was recently working with a facility that was replacing the flooring in the entryway. The facility had done an infection control risk assessment and found the chemicals it was using to put down the flooring had potential for minor eye irritation, but proper ventilation was considered an acceptable intervention. However, the receptionist ended up in the emergency room with asthmatic symptoms. A few weeks later a surveyor showed up based on the workers' compensation data.

The surveyor wanted to see an after action report and the risk assessment. Ultimately the facility was not fined since it had taken the appropriate steps, but it was a lesson in how OSHA is becoming more stringent.

"What I recommended to people is that with each workers' comp case, you should sit down with your risk assessment people or whoever is appropriate for that event, evaluate it, and come up with a documented action plan to prevent that injury from reoccurring," Luebbert says.

Frequently, even if a facility does have high rates of a particular injury, if there is clear documentation that the issue has been discussed and an action plan has been put into place and acted upon, an inspector may be less likely to cite the facility.

"You always want to be able to speak to what you're getting ready to implement," Chinnes says. "That plan of action based on the risk assessment is not only developing the written policy, but will always include educating their staff because that's who they are trying to protect."

MedPAC reiterates recommendations to restructure Medicare payment system

Sat, 01 Jun 2013 04:00:00 GMT

MedPAC reiterates recommendations to restructure Medicare payment system

For the second straight year, MedPAC makes recommendations to Congress to revise PPS and begin rebasing payments in 2014

On March 15, the Medicare Payment Advisory Commission (MedPAC) issued its annual report to Congress, which evaluates deficiencies in the Medicare payment system and makes recommendations to Congress regarding necessary improvements. Its evaluation of SNFs in Chapter 8 of the report included some interesting new data on services provided in 2011; however, its recommendations were a carbon copy of last year's report.

SNFs provided care to 1.7 million fee-for-service (FFS) beneficiaries during 2.4 million stays in 2011, according to the report. All told, Medicare spent $31 billion on SNF care that year. MedPAC issued the following findings based on its assessment of providers:

The number of SNFs participating in the Medicare program increased slightly between 2010 and 2011. Bed days available did not change between 2009 and 2010, and the median occupancy rate was 88%, indicating some excess capacity for admissions. Days and admissions on a per FFS beneficiary basis were essentially unchanged between 2010 and 2011.
SNF quality of care, as measured by risk-adjusted rates of community discharge and rates of rehospitalization for patients with five potentially avoidable conditions, has changed little over the past decade. This year, MedPAC reports a third measure-rehospitalizations within 30 days of discharge from the SNF. The three measures show considerable variation across the industry.
Increases in payments between 2010 and 2011 outpaced increases in providers' costs, reflecting the continued concentration of days in the highest payment case-mix groups. In addition, payments in 2011 were unusually high because of overpayments resulting from an adjustment made with implementation of the new case-mix groups. Because no 2011 cost report data were available, MedPAC estimated a range for the 2011 margins of 22%-24%, making it the 11th year in a row with Medicare margins above 10%. It projects that the 2013 margin will range from 12% to 14%.

On a positive note, MedPAC notes that approximately 900 SNFs have been able to sustain consistently below-average costs while also maintaining high margins, a sign that providing quality care while keeping costs down is a viable option. Still, MedPAC reiterated last year's recommendations to revise the SNF PPS to improve the accuracy of payments, including the following three specific revisions:

Payments for therapy services should be based on patient characteristics (not services provided).
Payments for non-therapy ancillary services (such as drugs) need to be removed from the nursing component and made through a separate component established specifically to adjust for differences in patients' needs for these services.
An outlier policy would be added to the PPS. After the PPS is revised, in the following year, CMS would begin a process of rebasing payments, starting with a 4% reduction in payments.

Although Congress does not need to follow through with MedPAC's recommendations, repeated calls to reorganize the PPS may become hard to ignore, says David Bufford, a healthcare attorney with Hall, Render, Killian, Heath & Lyman, PSC, in Louisville, Ky. The recommendations illustrate a system that would focus more on individualized payments based on resident needs, meaning in future payment systems, SNFs may be forced to continue providing high-quality care on slimmer margins.

"What the future looks like is your reimbursement will be based on the quality of care you provide," Bufford says. "We're seeing this in some states already in their Medicaid plans with value-based purchasing programs where they receive payment based on their comparative quality throughout the state. So I think that we're probably going to have a few programs like that that are state-based and have a few years of experimentation to see what works."

What to expect

In the recommendations, MedPAC notes that approximately 900 SNFs have been able to successfully provide comprehensive quality care with consistently lower costs. Although it sounds good on paper, Bufford notes that statistic only represents a very small percentage of SNFs.

"It almost seems like they are basing their recommendations on a sample size that is too small," he says. "They talk about how 900 SNFs are able to provide quality care and have their margins relatively high, and if you look at 900 SNFs, that's like 5%-6% of SNF providers. That's almost just looking at the outliers, and I'm not certain it was adjusted for regional differences. So those 5%-6% of top performers might just be benefiting from an overall healthier resident base."

In addition to recommendations in Chapter 8, SNFs can glean valuable information about any prospective changes in Chapter 7, which addresses payment for postacute care providers, says Diane L. Brown, BA, CPRA, director of postacute education at HCPro, Inc., in Danvers, Mass. This chapter focused on four broad reforms for SNFs, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals:

Bundled payments and Accountable Care Organizations (ACO). This approach would pay for an array of services over a defined period, with one bundled payment covering all postacute care services. This would incentivize providers to focus on maintaining quality in order to operate under the highest margins. CMS is currently working on a bundling initiative, the results of which should be released later this year.
A common assessment instrument. CMS completed a common assessment tool in 2011 and it supports the potential for a single-payment system that would hold various institutional settings jointly responsible for quality care.
New quality measures. MedPAC has developed measures for risk-adjusted rates of discharge to the community and has determined that rehospitalization rates are a good gauge of the care furnished by postacute care providers.
Expanded readmission policies. MedPAC has examined readmission policies to align the incentives of postacute care providers and hospitals, and would hold both jointly responsible for safe transitions from one facility to the next.

"They are looking at various ways to manage costs and revenues with incentives to provide efficient care with the lowest-cost settings and the best outcomes," Brown says. "That's not new, but it reiterated that this is the direction we are heading in. There are issues and boundaries towards getting there, but we need to start working towards that."

Since its inception, the current PPS system has been criticized for facilitating unnecessary therapy, since payments are based in part on the amount of services provided to the resident. Furthermore, the system provides no real quality incentives for postacute care providers, but a revamped payment system as described by MedPAC would force SNFs to focus on those quality metrics. However, the time frame on its recommendations doesn't provide a very lengthy adjustment period for nursing facilities. Many trade organizations argue that SNFs are already operating under low margins and a 4% cut would make it next to impossible to operate.

"They are saying the first year we want the pot to remain the same, but distribute it differently, and that difference is how it's going to be distributed," Brown says. "One year is not a long learning curve when you're playing with reduced systems. It's also not a lot of ramp-up time to adjust and look at how it's going to impact your facility. Without the detail in the rules, I don't think it's easy to make those decisions, but certainly the likelihood is there."

Another possible consideration for MDS coordinators is that if reimbursement is focused more on precisely how residents are utilizing postacute care, an already lengthy MDS 3.0 document may get even larger and more comprehensive, Bufford says. SNFs are currently required to complete the MDS in five days, but doubling the size may yield less meaningful answers from the resident at all service levels.

"I think that's something that may be better overcome as technology advances to the point where the MDS doesn't have to be so personal interaction intensive," Bufford says. "Maybe just a more efficient assessment process is what is needed."

What facilities can do now

There are no forthcoming changes unless Congress takes action on these recommendations; however, SNFs don't need to wait to work on improving their operating margin and efficiency, with a greater focus on quality care metrics, Bufford says. There are two specific areas that SNFs can focus on now to get the most out of their Medicare dollars:

Involve billing in the quality assessment and performance improvement (QAPI) program. In December, CMS release updated guidance on implementing a QAPI program (see the February issue of PPS Alert). Although this program focuses largely on improving clinical quality of care, the billing and financial departments can help dictate how the SNF should financially approach those objectives.

"You have to start with assessing quality of care, but part of that is ensuring you have the financial capacity to provide that quality of care," Bufford says. "I think your costs and profitably should be included in a QAPI program so that you are ensuring you are providing quality of care efficiently."

Improve claim accuracy. SNF billing departments and MDS coordinators have to be very diligent in submitting accurate claims, Bufford says. MedPAC reports the increase of therapy RUG usage, which is most likely a result of SNFs trying to maximize their therapy services and the fact that MDS 3.0 has a lot more factors to properly assess a resident's need for therapy. The accuracy of a claim involving ultra-high RUG rates needs to be built into the triple-check process so that clinicians and therapists are communicating their assessments with billers.

"The billing department really needs to coordinate with the MDS assessment coordinator and the director of nursing to ensure the financial MDS and the nursing documentation are able to properly reflect that appropriate level of therapy services they are going to bill for, because you don't want to submit an unsupported claim," Bufford says.

Ongoing monitoring and periodic audits key to continued success

Sat, 01 Jun 2013 04:00:00 GMT

Ongoing monitoring and periodic audits key to continued success

Readmissions are a moving target, requiring continuous diligence to track data and identify trends

Editor's note: This is the fifth and final installment of a series of articles focusing on how SNFs can help reduce hospital readmissions. See our series wrap-up on p. 9 for a summary and key takeaways.

Readmissions are a constantly moving target. Each patient requires a unique assessment, and two residents may require two completely different interventions based on their health risks and comorbidities. Reducing readmissions requires a multidimensional approach, with many different parts working in conjunction to identify and intervene with patients who present risks for rehospitalization.

"People are not widgets," says Maureen McCarthy, RN, BS, vice president of clinical reimbursement for National Healthcare Associates and president of Celtic Associates, LLC, in Goshen, Conn. "People have different diagnoses and different medication interactions. There are so many things that can happen, you always have to be vigilant about the current status of your patient."

For that reason, ongoing monitoring and periodic audits that evaluate hospital readmissions data and trends is the crucial final step in maintaining an effective program. Identifying both success and failure will help build a stronger program over time.

"You have to be continually looking at your numbers and seeing where you are to make sure you're continuing to see improvement, where you see a change, where your reshospitalizations are starting to increase, and maybe going back and delving into the information again to see if there was a system problem," McCarthy says. "It may be a new staff member on a certain unit and they need to be educated, or a new physician on board that may not be aware of your initiatives."

Implementing a process for ongoing monitoring

An administrator or DON should be charged with monitoring readmissions on an ongoing basis. They should have a formal process for continually evaluating readmissions data and then relaying that information to nursing staff and attending physicians.

Although an administrator should be responsible for this formal process, systems should also be in place for staff members to discuss interventions on a daily basis in the form of nursing huddles or stand-up meetings, says Barbara Frank, MPA, cofounder of B&F Consulting in Warren, R.I.

"If your existing systems are working well, you're looking prospectively at situations that are coming up, potential risks and how to address them, and retrospectively, without blame, to look at what we can learn from what just happened," Frank says.

SNFs should also implement periodic audits at least quarterly, McCarthy says. Setting benchmarks will help determine whether you need to take a deeper dive into quarterly data. For example, if readmissions for your first quarter remain below 10%, but there is a sharp increase in the second quarter, a more detailed look at the month-to-month data to determine what caused the increase may be required. Periodic audits will also help categorize readmissions that were avoidable and which were unavoidable.

"Determining what is unavoidable versus avoidable is going to take SNFs a little while to understand," McCarthy says. "If the hospital is sending the resident to you with a certain condition, and you turn around and within a week you're sending that patient back to the hospital with the same condition, they are eventually going to turn around and say, 'Why are we sending them that person when they can't take care of them in the first place?' "

Using your QAPI program

One vehicle for ongoing monitoring of readmissions is through the quality assessment and performance improvement (QAPI) program. In December, CMS released a draft version of "QAPI at a Glance" as a preliminary guideline to setting up a QAPI program.

"If your hospitalization rates are 10% or below, it might not be something you focus on in QAPI because you're probably doing a pretty good job, but if your hospitalization rates are 35% or 40%, you probably want to add that to your QAPI plan where you have other members of your team , not just management, looking at the issues," McCarthy says.

Monitoring readmissions fits perfectly in the QAPI program because it allows a multidisciplinary team, including clinical staff, therapists, and the billing department, to take a closer look at what is working and where additional interventions, such as staff education, need to be implemented.

"An audit is a retrospective QA process to find out what you did, while an analysis for performance improvement is a continuous way of being able to look ahead and say, 'How can we apply what we learn from what we did?' " Frank says.

For a full analysis of setting up your QAPI program, see "As more information comes forth, SNFs look to implement compliant QAPI programs" in the February issue of PPS Alert.

Documentation is key

Part of what contributes to successful ongoing monitoring and periodic audits comes back to thorough documentation. When an audit reveals an increase in readmissions, nursing documentation provides a more comprehensive story of what led to that readmission.

"What I see a lot of times is that documentation can either help or hurt you," McCarthy says. "If you don't have enough of a story about that resident and their symptoms, reactions, and response to care, there may be something that you're missing. But if the nurses are documenting appropriately for what they see and what they are treating, you may be able to pick up on those subtle changes."

Communicate with hospitals

In some situations, readmission trends may indicate problems that are out of the SNF's control. For example, readmissions may spike one quarter simply because of more complex admissions.

Although SNFs are intently focused on what they can do in their own facility to reduce readmissions, there needs to be more collaboration between quality assessment departments in the hospital and the nursing facility, Frank says. She suggests meeting with a hospital representative once a month or once per quarter to review readmissions data and identify opportunities for collaborative interventions.

"So many times hospitals don't recognize that nursing facilities don't have an in-house pharmacy or a supply store, and admitting a patient on a Friday night is not the optimal time if you want the person to have the best transition. So there has to be a way between the hospital and the nursing home to establish a QA process to look at on a case-by-case basis."

Hospital QA committees do their own trend tracking and may have additional input on improving patient transitions to reduce readmissions, says McCarthy.

"I'd start the conversation with that referring entity," she says. "Is there anything we can be doing or anything we can work on together, because x amount of residents have been coming back in y amount of days and we want to be able to get a handle on that."

Your comprehensive guide to reducing readmissions

Beginning in the February issue, PPS Alert began a series of articles that looked closely at each specific step of the readmissions process and where facilities can make improvements in an effort to reduce rehospitalizations. The June issue completes that series and SNFs are left with a comprehensive guide to reducing readmissions. The summary below takes a look at key takeaways from each step of the process:

Mastering the admissions process (February): This first step dictates the course of the resident's stay at your facility. SNFs should focus on documenting a comprehensive overview of the resident's history in order to establish a baseline for that individual.

Additionally, nurses need the training and education to appropriately identify health issues that may pose a risk of readmission later in order to identify any complications early in the stay.

Using root cause analysis to expose readmission weaknesses (March): SNFs can break readmissions data into specific categories including payer source, high-risk diagnosis, days of the week, specific shifts, or specific clinicians or physicians. This root cause analysis will help identify particular weaknesses in your care processes.

During the root cause analysis it's particularly important to eliminate any preconceived notions (e.g., readmissions only occur on weekends) and focus on what that data is describing about your facility.

Improving nursing practices and systems (April): INTERACT is the primary system available to nursing homes for improving communication among clinicians and helping CNAs identify potential health problems early on. However, this approach will only work if the facility provides a supportive environment to understand and implement those tools.

This requires ongoing training to establish any interventions that can take place in-house, and relies heavily on the CNAs to identify small changes that may lead to readmissions.

Refining systems and tools (May): This article focuses specifically on care planning, discharge planning, and admission processes, as well as common pitfalls and solutions to each process. These systematic changes will eventually give way to a culture change in which early recognition of possible readmissions becomes second nature for clinicians and there is an organized and defined process for taking action.

This article also takes a look at a new approach to long-term care established through the Green House Project, which includes a radical redesign of LTC facilities in which residents have their own bedroom and bathroom, and CNAs are provided with additional training to take on more responsibility with fewer patients.

Ongoing monitoring and periodic audits (June 2013): This last step is imperative to maintaining an effective program by continuously tracking readmissions data and taking a deeper dive through your facility's QAPI program when necessary. SNFs should perform quarterly audits and communicate with admitting hospitals to identify areas for additional staff training or process improvements.

MDS professor

Sat, 01 Jun 2013 04:00:00 GMT

MDS professor

Test your knowledge of the MDS and long-term care by answering the following questions. Answers are on p. 12.

1.Under the basic rules of coverage for Medicare outpatient therapy services, which of the following is not covered under Medicare Part B?

a.Occupational therapy

b.Respiratory therapy

c.Physical therapy

d.Speech and language therapy

2.Mr. Cain has recently had pneumonia and been in bed for the past 10 days on bed rest. He was normally ambulatory on his own prior to the pneumonia. Mr. Cain's physician asked therapy to see him to determine appropriateness of therapy. Which of the following statements is false?

a.Since the physician asked therapy to see Mr. Cain but did not provide an order to evaluate and treat him, therapy can only provide a screening

b.Because of the length of time he was in bed, Mr. Cain may benefit from both physical and occupational therapy

c.Only speech and language therapy would be appropriate for Mr. Cain

d.The therapist will need to provide a detailed plan of care, which will need to be signed by Mr. Cain's physician

3.Which of the following are the correct revenue codes used for PT, OT, and ST when completing a UB-04 form?

a.320, 330, 340

b.520, 530, 540

c.220, 230, 240

d.420, 430, 440

4.Which of the following are the correct modifiers to be used when submitting therapy claims for PT, OT, and ST for Medicare Part B claims?

a.GN, GO, GP

b.NG, OG, PG

c.TN, TO, TP

d.ST, OT, PT

5.Medicare Part B outpatient therapy has certain specific rules. Which of the statements listed below identifies some of these rules?

a.The Medicare Physician Fee Schedule (MPFS) is the method of payment that applies to Medicare Part B outpatient therapy claims

b.Medicare Part B outpatient therapy claims are paid at 80% of cost

c.The claim submitted for outpatient therapy must be in a line-item format

d.Medicare Part B outpatient therapy claims do not require a specific ICD-9-CM code

6.Outpatient therapy recertifications are required at what minimum time interval?

a.30 days

b.45 days

c.90 days

d.60 days

7.Which of the following is not currently a Medicare requirement related to therapy documentation?

a.Progress report every 10 treatment days at minimum

b.Evaluation

c.Plan of care

d.Daily therapy narrative note

e.Daily treatment log

MDS professor answer key

Below are the answers to the MDS professor on p. 10:

1.b. Respiratory therapy is not provided for as an outpatient covered service payable under Medicare Part B. See Medicare Benefit Policy Manual, Chapter 15. The five-day assessment covers payment for the first 14 days of a covered stay.

2.c. According to the information presented, both physical and occupational therapy may be appropriate for Mr. Cain. Speech therapy would seem highly unlikely given the information presented.

3.d. The correct revenue codes to be used on a Part B therapy claim are 420 for PT, 430 for OT, and 440 for ST. See Medicare Claims Processing Manual, Chapter 25 § 60.B.

4.a. The correct modifiers to be used with Medicare Part B outpatient therapy claims are GN for ST, GO for OT, and GP for PT. It is important to note that without these modifiers, Medicare will deny the claims and return them to the provider. See Medicare Claims Processing Manual, Chapter 5 § 10.2(E).B.

5.a & c. All Medicare Part B outpatient therapy claims are paid utilizing the MPFS. All claims must be submitted in a line-item format, meaning that therapy provided on any given day must be listed out by an individual line item.

6.c.

7.d. There is no requirement to complete daily narrative notes.

PPS Q&A

Sat, 01 Jun 2013 04:00:00 GMT

PPS Q&A

Editor's note: This month's PPS Q&A was modified from the HCPro book Finance, Budgeting & Quantitative Analysis: A Primer for Nursing Home Administrators, by Brian Garavaglia, PhD, FACHCA. For more information about this book or to order, call customer service at 800-650-6787 or visit www.hcmarketplace.com/prod-11118.

To submit a question for upcoming issues, email Editor Casey Pickering at cpickering@hcpro.com.

Q. What is the role of the administrator in billing processes?

A. The healthcare administrator usually does not involve him- or herself in the total Medicare billing process. Because it is so complex, administrators at most long-term care facilities have their accountants or professional billing personnel submit billing information to a CMS designated national repository. Nevertheless, administrators do have to be aware of a few major elements.

First, the administrator should be somewhat familiar with the MDS process. Although a nurse is usually in charge of the MDS process, the administrator has to make sure MDS personnel are fully capturing everything that can be billed for and are not shortchanging the facility because they are not capturing the true complexity of the resident evaluation process, possibly leading to a lower RUG score and, consequently, less revenue.

This means the evaluation process, through the use of the MDS, is a driving force for Medicare billing, and often it may not capture everything that could be coded for in the MDS process, leading to a potentially lower reimbursement level. This is not to say that the administrator should encourage MDS personnel to code for things that are nonexistent. However, the administrator should be able to help choose well-informed personnel to oversee this area, as well as to address, in an informed manner with MDS personnel, whether the facility is capturing the true RUGs.

The administrator also must be able to calculate revenue from Medicare, especially Medicare Part A. The administrator may be directly involved in this or may oversee someone else who handles this. Revenue for Medicare services is calculated at the end of the month. Often, before the revenue is sent to the accountant or billing personnel to be submitted to the national repository, the administrator or MDS personnel (or both) review the month's productivity, review the RUG levels and days of Medicare for the month, and calculate the appropriate RUG billing amount for the number of days associated with each RUG category.

Physical or occupational therapy personnel also can play an active role in this process. This helps to provide for a greater level of internal control. After the MDS coordinator compiles this data, it is further reviewed by the administrator and possibly calculated by either the administrator or the MDS personnel and finally reviewed together before the information is sent to billing personnel.

One final element the administrator should understand has to do with the day-to-day rules the long-term care facility must incorporate into its internal accounting process. The administrator must remember that not everyone qualifies for the full 100 days of Medicare and must be able to explain this information to residents and family members.

Furthermore, the administrator must understand the concept of Medicare technical denials. This happens when the resident has not had the appropriate number of qualifying hospital days or the resident no longer qualifies for Medicare because he or she has exhausted his or her Medicare days in a relevant benefit period.

Q. When a resident is discharged from a hospital to a SNF, is the resident entitled to the full 100 days of Medicare reimbursement?

A. This is a common misconception. Often the resident or his or her family thinks the resident is entitled to the full 100 days of Medicare reimbursement.

First, the first 20 days are covered in full, but days 21-100 have a copay attached to them. Second, although the person may be transferred from the hospital and may qualify for skilled coverage under Medicare Part A, he or she still has to meet stringent requirements to continue being covered under Medicare. The resident is evaluated on days five, 14, 30, 60, and 90, and during any one of these evaluations, if the multidisciplinary team feels the resident no longer requires skilled services, billing under Medicare must be discontinued.

To continue to maintain a person under Medicare when the person is not benefiting from skilled care on any level would be fraud. Thus, the facility's interdisciplinary team should meet regularly to protect against this egregious error.

PPS Alert for Long-Term Care, June 2013

Sat, 01 Jun 2013 04:00:00 GMT

OSHA targets high-risk workplaces for possible inspections

In letters sent out to 9,400 facilities with high worker injury and illness rates, the agency encourages employers to address safety and health

OSHA also indicated that it may target up to 2,500 high-rate general industry workplaces for inspection within the next year.

Ergonomic stressors in patient lifting
Bloodborne pathogens
Tuberculosis
Workplace violence
Slips, trips, and falls

According to data from the Bureau of Labor Statistics (BLS), the national DART rate in 2010 was 1.8 in the private industry. Nursing and residential care facilities were as high as 5.6.

Focus areas

Improper placement of sharps containers. Sharps containers need to be placed in rooms where sharps are being used routinely. "If you have it placed inappropriately so that you have to go through a door to reach the sharps container, you're going to get a citation," Chinnes says.
Evaluating safety devices. Employers are required to evaluate safety sharps annually and test safety syringes that are on the market. A multidisciplinary group of employees ranging from nurses to managers should all have input in evaluating safety devices and replace non-safety sharps whenever possible.
Appropriate use of PPE. Employees should receive training on what PPE they should be wearing when there is the potential for exposure to blood or bodily fluids. "For some procedures you should have on not only gloves and a gown to protect your hands and your body, but also face protection, which is more than just your eyeglasses, but goggles that go all the way around the side of your face or a mask and face shield," Chinnes says. Employees need to receive this training free of charge during normal work hours.
Keeping a sharps injury log. Employers typically track bloodborne exposures in a body fluid exposure log, which includes sharps injuries as well as other exposures. Injuries are also reported through the OSHA 300 form so that data can be retrospectively evaluated to spot patterns or trends. OSHA inspectors will ask to see this log if they come to inspect your facility.
Developing an exposure control plan. This should be a written plan that is available to all employees and utilized during training so that employees know the facility's specific protocol on what to do and who to contact if an exposure does occur. "It needs to be a 24/7 protocol," Chinnes says. "It can't be that no one is there on the weekend to cover that. Who is going to cover that nurse or aide if they get stuck on Saturday night at midnight and they need to be taken care of right then?"

Providers need to build a written ergonomics plan and incorporate safety lifting and use of mechanical lifts into their annual training.

This risk assessment needs to be formally documented and must identify areas in which workplace violence may occur and plans to eliminate or mitigate those risks.

Managing an inspection

Each facility will face unique risks, but a risk assessment along with a comprehensive evaluation of injury and illness rates will help determine exactly what areas are considered high risk.

MedPAC reiterates recommendations to restructure Medicare payment system

For the second straight year, MedPAC makes recommendations to Congress to revise PPS and begin rebasing payments in 2014

The number of SNFs participating in the Medicare program increased slightly between 2010 and 2011. Bed days available did not change between 2009 and 2010, and the median occupancy rate was 88%, indicating some excess capacity for admissions. Days and admissions on a per FFS beneficiary basis were essentially unchanged between 2010 and 2011.
SNF quality of care, as measured by risk-adjusted rates of community discharge and rates of rehospitalization for patients with five potentially avoidable conditions, has changed little over the past decade. This year, MedPAC reports a third measure-rehospitalizations within 30 days of discharge from the SNF. The three measures show considerable variation across the industry.
Increases in payments between 2010 and 2011 outpaced increases in providers' costs, reflecting the continued concentration of days in the highest payment case-mix groups. In addition, payments in 2011 were unusually high because of overpayments resulting from an adjustment made with implementation of the new case-mix groups. Because no 2011 cost report data were available, MedPAC estimated a range for the 2011 margins of 22%-24%, making it the 11th year in a row with Medicare margins above 10%. It projects that the 2013 margin will range from 12% to 14%.

Payments for therapy services should be based on patient characteristics (not services provided).
Payments for non-therapy ancillary services (such as drugs) need to be removed from the nursing component and made through a separate component established specifically to adjust for differences in patients' needs for these services.
An outlier policy would be added to the PPS. After the PPS is revised, in the following year, CMS would begin a process of rebasing payments, starting with a 4% reduction in payments.

What to expect

Bundled payments and Accountable Care Organizations (ACO). This approach would pay for an array of services over a defined period, with one bundled payment covering all postacute care services. This would incentivize providers to focus on maintaining quality in order to operate under the highest margins. CMS is currently working on a bundling initiative, the results of which should be released later this year.
A common assessment instrument. CMS completed a common assessment tool in 2011 and it supports the potential for a single-payment system that would hold various institutional settings jointly responsible for quality care.
New quality measures. MedPAC has developed measures for risk-adjusted rates of discharge to the community and has determined that rehospitalization rates are a good gauge of the care furnished by postacute care providers.
Expanded readmission policies. MedPAC has examined readmission policies to align the incentives of postacute care providers and hospitals, and would hold both jointly responsible for safe transitions from one facility to the next.

What facilities can do now

Ongoing monitoring and periodic audits key to continued success

Readmissions are a moving target, requiring continuous diligence to track data and identify trends

Implementing a process for ongoing monitoring

Using your QAPI program

For a full analysis of setting up your QAPI program, see "As more information comes forth, SNFs look to implement compliant QAPI programs" in the February issue of PPS Alert.

Documentation is key

Communicate with hospitals

OIG report highlights quality-of-care shortcomings

Wed, 01 May 2013 04:00:00 GMT

OIG report highlights quality-of-care shortcomings

The newest report from OIG indicates that SNFs fail to meet care planning and discharge planning requirements, calling for more CMS oversight

If you were starting to wonder whether the Office of Inspector General (OIG) has a bone to pick with SNFs, add its most recent report to the pile of mounting evidence.

The report, published in February, reveals that many nursing facilities fail to meet quality-of-care standards, and furthermore, Medicare is footing the bill despite these shortcomings. Based on a medical review of a random sample of 190 Medicare Part A stays in 2009, the OIG found the following:

In 37% of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with the care plan
In 31% of stays, SNFs did not meet discharge planning requirements
Medicare paid approximately $5.1 billion for stays in which SNFs didn't meet these quality-of-care requirements
OIG also found examples of poor-quality care specifically with wound care, medication management, and therapy

As a result, the OIG made the following recommendations, all of which were accepted by CMS:

Strengthen the regulations on care planning and discharge planning
Provide guidance to SNFs to improve care planning and discharge planning
Increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and hold these SNFs accountable
Link payments to meeting quality-of-care requirements
Follow up on the SNFs that failed to meet care planning and discharge planning requirements or that provided poor-quality care

"The way Medicare pays nursing facilities right now offers few incentives to provide high-quality care," Judy Kellis, team leader for the Office of Evaluations and Inspections in New York, said in an audio podcast shortly after the report's release. "Medicare should use its purchasing power to ensure that facilities provide good care and transitions for patients. That said, CMS needs to link payment to quality. CMS should pay for good performance and better outcomes as opposed to the volume of services provided. That way, patients get better care and overall healthcare costs can go down."

Some might argue the monetary figures were slightly sensational given the small sample size, but the takeaway from this report is that reimbursement is pretty clearly heading down a path in which payment is closely tied with quality of care, says Diane Brown, BA, CPRA, director of postacute education at HCPro, Inc., in Danvers, Mass.

"This is the direction that we're all heading in, so we need to pay attention to these elements and incorporate some of this into compliance programs because that's absolutely a recommendation pervasive in this report," she says. "I think that we can debate the suggestion that there are billions of dollars in error, what we can't debate is the fact that we're going to see that focus come down on quality-of-care and billing compliance, so I think it's an opportunity for individual facilities to examine their own practices."

Evaluating care plans

Specifically, the OIG identified problematic stays, which yielded the following issues in the care plan:

It did not address one or more resident assessment protocols and provided no explanation in the medical record
The care plan lacked measurable objectives and detailed time frames
It was not completed by an interdisciplinary team

OIG evaluated care plans to see whether they included the following measurable objectives:

Scheduled toileting plans or bladder retraining programs
Parenteral IV or feeding tubes
Skin treatments
Speech therapy
Occupational therapy
Physical therapy
Respiratory therapy
Restorative nursing services

In 26% of stays, SNF care plans did not meet at least one of the following: addressing problem areas identified in the beneficiaries' assessments, including measurable objectives and detailed time frames, and completion by an interdisciplinary team. In 15% of stays, SNFs failed to provide at least one service according to the frequency or duration that was described in the care plan.

These statistics weren't as surprising as the correlation the OIG made between these care planning deficiencies and the associated Medicare dollars spend on these inadequate services, says Kathleen McDermott, a partner at Morgan Lewis in Washington, D.C., who has also served as an Assistant U.S. Attorney and a Healthcare Fraud Coordinator at the Department of Justice.

"These are issues that are generally not separately reimbursable or line item reimbursed events, so it's difficult to tag them with a monetary value," she says. "In that sense, it was a surprise that the OIG issued a value to the deficiencies they perceived in their survey."

Care plans have always been one of the top 10 CMS citations and it's clear that SNFs are going to have to invest more time into creating individualized care plans for each patient and educating staff members to closely follow those plans, Brown says.

"You want to actually set up an audit and look at your own risk factors and look at where you're doing things well and where you need improvements and focus on those areas of improvement," she says.

Similar concerns were raised regarding discharge planning:

16% of stays did not have summaries of the beneficiaries' stay or status at discharge
In 25% of stays, SNFs did not have post-discharge plans of care

However, many of these issues surrounding discharge planning are byproducts of reduced resources in the community, says Bonnie Foster, RN, BSN, MEd, owner and president at Foster Consulting, Inc., in Columbia, S.C.

"We don't have Meals on Wheels anymore in many states across the United States, and we don't have the resources that we used to have," she says. "You can do all the discharge planning you want, but you can't just put them on the front step and say goodbye."

Increased surveyor scrutiny

The immediate impact that most SNFs will need to consider is the increased scrutiny expected from surveyors following this report.

"I think it's a signal that the bar in quality-of-care and adequate services is high and the government is looking," McDermott says.

The report is part of a larger body of work in which the OIG has focused on SNFs and how Medicare dollars are used to pay for beneficiaries. In 2010, the OIG published a report on questionable billing practices in SNFs, and then followed that up in November 2012 with a report that indicated 25% of SNFs billed claims in error, resulting in $1.5 billion in inappropriate Medicare payments. In a forthcoming report, OIG looks at adverse events in postacute care, specifically in SNFs.

As a result, SNFs are going to be under more scrutiny from surveyors on any number of quality-of-care issues. The regulations haven't changed, but strict adherence to those regulations is going to be more of a focus, Brown says.

Identifying steps toward improving care planning and discharge planning

Wed, 01 May 2013 04:00:00 GMT

Identifying steps toward improving care planning and discharge planning

In light of a recent OIG report, SNFs need to place more emphasis on developing and following through with care plans and discharge planning

The numbers featured in an OIG report released in February should tell SNF providers all they need to know about the emphasis that regulators are going to put on care planning, discharge planning, and quality of care moving forward. With more than a third of SNF stays encountering problems with developing and following through with care planning, and 31% of stays failing to meet minimum discharge planning requirements, CMS will be monitoring quality-of-care issues more closely, especially as it relates to reimbursement.

Previous OIG reports have revealed deficiencies in how SNF services are billed, but this most recent report brings quality to the forefront. OIG recommended that CMS increase surveyor efforts in identifying SNFs that don't meet minimum care planning and discharge planning requirements, and hold facilities accountable by linking payments to quality-of-care measures.

"SNFs will probably want to assess that their quality assurance activities are functioning as well as they want them to be," says Kathleen McDermott, a partner at Morgan Lewis in Washington, D.C., who has also served as an Assistant U.S Attorney and a Healthcare Fraud Coordinator at the Department of Justice. "And then identifying these issues in a timely fashion and not relying on old data, but having real-time quality data to act upon when there may be a trend in your particular facility."

SNFs should take a closer look at their care planning and discharge planning process to ensure they are involving the entire interdisciplinary team, providing appropriate documentation, and identifying problem areas within their own system.

Start with an audit

As with most quality concerns, SNFs should perform an audit of their care planning processes at least once a year in order to identify unique risk factors and improvement strategies, says Diane Brown, BA, CPRA, director of postacute education at HCPro, Inc., in Danvers, Mass.

There is no such thing as a typical deficiency when it comes to care planning, Brown says. The report identifies a variety of issues surrounding care plans that didn't address issues raised during the resident's assessment or a lack of measurable objectives within the care plans. An audit helps identify those gaps in your care planning process.

Many of the issues identified are not necessarily complex problems, Brown says.

For example, a common deficiency identified in the OIG report is that SNFs failed to document why they chose not to include a particular issue in the care plan, even though it was identified in the resident assessment.

"Sometimes that is difficult because it requires cross-training across a broad spectrum of staff," Brown says. "There are a lot of staff that document in the medical records and that documentation may be feeding some of your MDS and care plans, and if that isn't done correctly, it could result in an inaccurate care plan."

SNFs should include a review of past citations as part of their review, and then develop a strong and detailed action plan to fix any outstanding issues.

"If you have strong action plan that says you're going to do this in a certain time frame, you adhere to it," Brown says. "If you don't have an action plan after you've done your assessment and figured out your issues, how are you going to show improvement?"

Transforming your care plan

Although an audit will reveal some of the unique deficiencies with your care planning process, there are some universal approaches that will strengthen care plans and withstand surveyor scrutiny.

These approaches include:

Customize your plan.

The biggest mistake that SNFs make during the care planning process is attempting to utilize canned care plans.

This has only become more common as SNFs rely more on electronic forms, says Bonnie Foster, RN, BSN, MEd, owner and president at Foster Consulting, Inc., in Columbia, S.C.

An effective care plan starts from scratch with each resident and addresses all of the issues identified in the assessment.

"It needs to be very individualized," Foster says. "You're supposed to be able to put your hand over the resident's name and know who the resident is based on the care plan."

Document in first person.

Another trick that helps support the care planning process is encouraging staff members to document in first person, Foster says.

"You need to be focusing on 'I' care plans where you're putting yourself into the resident's shoes so you are writing it from their perspective," she says.

This approach is consistent with the push to provide more resident-centered care by documenting specific needs or complaints from the perspective of the patient, and then addressing those needs in the care plan.

Utilize CNAs.

Although only 2% of SNF stays in the OIG report failed to utilize an interdisciplinary team, SNFs need to focus more on involving CNAs in the care planning process, Foster says.

CMS surveyors want to see that the doctor, the RN, and any other discipline that is involved with the resident's care is included in the care planning process. Although they don't explicitly require CNAs to be a part of that process, their input helps create a more thorough care plan and ensures that certain measures are met.

"We should have been doing it all along, it's just that no one ever said the interpretation is that the CNA needs to be there," Foster says.

Is it complete, are you following through?

Finally, those involved with the care planning want to ask two questions as they are implementing the plan:

Are all of the resident's problems addressed? And if not, why not?
Do we have measurable objectives along with a detailed time frame?

These problems were specifically identified in the OIG report and will likely be heavily scrutinized by surveyors.

"Those seem to be the two areas where you could attach a good process to and evaluate it and find out where you stand," Brown says.

Review your discharge planning

Although care planning requirements simply require measures for the resident to maintain or improve their health status, discharge planning requirements are slightly more comprehensive.

SNFs need to be thinking about educating the resident on all aspects of their post-discharge care, including where they can go to get medication, where they can get food, and how they will care for themselves if they are going home.

The problem that many providers run into is that the community resources that used to be available, such as Meals on Wheels, are no longer there.

"What I'm finding across the country is that you can put that in your plan, but if the resources aren't there, you're damned if you do and damned if you don't," Foster says. "You can put it in the care plan, but then when it's not available [surveyors] get you on that."

During the discharge planning process, staff members need to do their homework to determine which resources are available to the resident and which are not, which is going to vary by state.

To combat this issue, Foster recommends placing more focus on restorative care to help residents become more self-sufficient before they leave the facility so they don't need as many outside resources.

Despite the deficiencies revealed in the report, Brown notes that the OIG looked at data from 2009, before SNFs transitioned to MDS 3.0, which placed more emphasis on discharge planning.

"I think if they repeated that study even now, they would see major improvements in the discharge planning because there are better tools available and more direction available," she says.

Refining systems and tools to improve early recognition and care

Wed, 01 May 2013 04:00:00 GMT

Refining systems and tools to improve early recognition and care

Editor's note: This is the fourth installment of a series of articles focusing on how SNFs can help reduce hospital readmissions. By the end of the series, readers will have a comprehensive guide that walks them through the entire resident stay.

The tools and systems that SNFs utilize become ingrained in everyday care processes, and ultimately serve as the backbone for reducing readmissions. These elements dictate the way in which CNAs and nurses identify early indications of possible complications, and further strengthen the trust that physicians have to make accurate decisions.

"The biggest part of that is the communication with the physicians," says Maureen McCarthy, RN, BS, vice president of clinical reimbursement for National Healthcare Associates and president of Celtic Associates, LLC, in Goshen, Conn. "If he or she doesn't trust the information coming from the facility, then they are not as likely to risk their malpractice insurance to keep the patient in the building if they're not sure the staff can take care of that person."

In order to foster efficient paths of communication, SNFs need to correctly identify vulnerable areas of their healthcare system, and effectively utilize care planning tools to improve care.

Identifying trends

Tracking trends in your facility is the best way to identify specific areas of your facility that need more attention.

The key is to identify the root cause of any problems or trends associated with readmissions, says Frosini Rubertino, RN, CDONA/LTC, C-NE, CPRA, founder and executive director of TrainingInMotion.org in Bella Vista, Ark.

She recommends using the following resources as a baseline for root cause analysis:

CASPER reports
Incident and accident logs
Grievances
Documentation for rehospitalizations
Shift to shift reports

SNFs should also rely heavily on input from staff members, which can be an invaluable resource in identifying potential issues.

"Make sure that any correction to any practice is followed up on to ensure it is still successful in correcting the problem," Rubertino says. "QAPI will move us in this direction. Sometimes software has these bells and whistles to help with retrospective activities, but software does not take the place of your own eyes and ears, so don't rely solely on data from events that have already happened."

McCarthy notes that although many facilities are focusing their efforts to track rehospitalizations among Medicare patients, it's important to track Medicaid patients as well, since those hospital readmissions will be covered under Medicare.

"Every person, if they don't fall under managed care, and they go to the hospital, they are Medicare," McCarthy says. "So you can say, 'We're doing a great job and only readmitted 10% of our Medicare populations back into hospital.' But the hospital has a different number; they have 30%. They have that Medicaid person that came and went three times in a month, and you may not be including them, but the hospital is."

Utilizing INTERACT tools

In terms of tools dedicated to reducing readmissions, INTERACT tools are the primary driver utilized in long-term care facilities right now. However, these tools are only as good as the information that goes in, McCarthy says.

"It's like a computer: If you put garbage in, you get garbage out," McCarthy says. "But it at least sets up the tools and gives you a guideline and you can utilize it to get the thorough information you need."

Arguably the most popular tool in the INTERACT system is the "Stop and Watch" tool used by members of the care team as well as family members to detect subtle changes. The "Change in Condition" cards and "Care Paths" tool provide subsequent steps built on established standards of evidence-based practices.

"As far as additional tools, follow-up is our biggest problem after we address an issue," Rubertino says. "I suggest the facility create a format for documentation that includes the problem, the intervention, and the outcome to guide the caregiver down a critical thinking path to managing a change in condition. Then, when reporting off to the next shift, include the same format when communicating the problem shift to shift."

Refining care planning, discharge planning, and admissions

SNFs can make huge strides toward improving their readmission rates simply by focusing on three processes within their healthcare system:

Admissions. This initial process either sets the resident up for failure, or provides the appropriate information for the care team to easily identify vulnerabilities in the resident's health. Early identification of possible negative outcomes establishes a baseline for CNAs and nurses to reference when caring for the patient on a daily basis. This initial evaluation will help identify those subtle changes that often result in rehospitalization.

"It's not enough to only investigate what will yield you a skilled service," Rubertino says. "We need to also look for comorbidities that may impact the outcome of the skilled services."

Providers should supplement the admissions process by providing ongoing skills improvement opportunities for nursing staff so they are viewed as skilled postacute care providers.

Care planning. Once the admissions process has been successfully executed, it's imperative that the care team implements the appropriate care plan based on the specific needs of the resident. A recent report from the Office of Inspector General identified ongoing issues among SNFs regarding care planning and discharge planning, an accurate reflection of some of the problems that plague the industry, McCarthy says.

Ultimately, this boils down to case management and how well the facility is coordinating care so that it is more organized. The facility should identify one person to do daily rounding, but those rounds should be communicated to other members of the disciplinary team.

"Historically, the MDS coordinator has been the only one completing care plans," Rubertino says. "Those that are still using this old method will continue to experience negative outcomes. The care plan must be developed with an interdisciplinary approach. Only then will it impact care outcomes in a positive way."

Discharge planning. An individualized discharge plan is the last step in preventing rehospitalizations after the resident leaves the building. SNFs need to consider issues such as how the resident will be transported to post-discharge appointments and what specific education they have received regarding their care going forward as well as any medications they may be taking.

"We document where they are headed in terms of the discharge destination, but not who is transporting them," McCarthy says. "We need to be coordinating that care that comes afterward."

Following through with culture change

All of these systems come together to form a rather ambiguous term known as "culture change." This term is used liberally in healthcare, but grasping how to initiate that change that will positively impact readmission rates is less concrete.

Time is the most important element of culture change, Rubertino says. Consistent implementation of tools and education will eventually transform the efficiency of your system, but that process also hinges on the unique factors present in each facility.

"Just as each family has a different dynamic, so do nursing facilities," Rubertino says. "We should be working at it every day and eventually it will become the culture of the facility. It will not happen overnight. Just like anything that is resilient, it takes time to make the culture a strong environment."

The main goal for instituting culture change should be to make the LTC environment more resident centered, while also focusing on quality care. Reducing your readmission rate will improve the overall attitude in your facility because, ultimately, fewer readmissions make for happier families and residents.

"Transferring residents from care setting to care setting is upsetting for them," McCarthy says. "It's really bad for patients with dementia, but it's upsetting even if you don't have cognitive issues. Just getting used to new faces and new places, and how do I get this when I need it, it's upsetting for patients."

The Green House effect

Although small system changes that focus on properly using INTERACT tools and redefining the care planning and discharge processes can be an effective method of gradually implementing widespread system changes, some institutions are taking a much more radical approach to postacute care.

The Green House Project is at the center of that systematic transformation. Developed by geriatrician William Thomas, MD, the Green House theory is described as "the next generation of the Eden Alternative," according to David Farrell, MSW, LNHA, director of The Green House Project in Arlington, Va. In 2005, the Robert Wood Johnson Foundation awarded a five-year, $10 million grant to NCB Capital Impact to replicate the Green House concept, and the company continues to help facilities administer the program today.

The concept is a radical redesign of the traditional nursing home structure, Farrell says. Green House facilities consist of homes that house up to 12 elders, each with their own private bedroom and bathroom. At the center of the house is the kitchen and dining area.

The other significant change to this model is that CNAs received 128 additional hours of training to become what the model calls a "Shahbazim," essentially adopting the responsibilities of housekeepers, laundry aids, dietary aids, and cooks. In turn, they have a much lower patient ratio, caring for only two residents at a time. The responsibility of nurses is strictly clinical with a focus on communication and resident assessment.

"Smaller is better and these residents get more care and attention as measured by hours per patient per day, by a group of staff members who used to be strictly CNAs, but now they are trained in the Green House model and principles," Farrell says.

In terms of reducing readmissions, this model gives CNAs the ability to make a greater impact, allowing them the opportunity to identify subtle health changes quicker and communicate them more effectively. Green House facilities still rely heavily on INTERACT's "Stop and Watch" tool, but the model gives CNAs a stronger voice.

"In a lot of organizations, that tool can't be implemented because the CNAs either have high turnover or absenteeism, or they have no voice," Farrell says. "So as a former administrator I'm here to say if 'Stop and Watch' is alive and well, it's only alive and well in an organization where the CNAs are empowered and respected."

Farrell says that the costs of having a smaller facility and CNA-to-patient ratio are offset because CNAs serve as a utility employee, covering responsibilities traditionally held by multiple staff members.

Additionally, the structural environment of Green House facilities helps reduce rehospitalizations. In traditional LTC models, as many as six residents may share two bedrooms and one bathroom, which spreads infection that leads to readmissions. Green House facilities are also smaller, eliminating the need for wheelchairs and allowing residents to be more mobile, which has a direct impact on improving their health. Traditional facilities typically have long corridors to accommodate many rooms, forcing elders into wheelchairs in order to be transported via wheelchair from one part of the facility to another.

Short-term rehabilitation facilities that adopt the Green House model eliminate medication carts and include small locked medical cabinets in each room, which allows nurses to provide continuous medication education throughout the patient's stay.

"In this scenario the nurse has the opportunity to privately administer meds in a nice quite environment," Farrell says. "And for those short-term folks that stay for 12 days and then go home, one of the leading causes of rehospitalization is they mess up their meds after discharge because in the traditional setting, they don't really spend any time at all educating the elder about their medication regime until the day of discharge."

Recent statistics support the radical approach. In an unpublished working paper entitled, "Cost of Care In Green House Home Compared to Traditional Nursing Home Residents," researchers found the rate of hospitalization per resident over a 12-month period was seven percentage points higher in traditional nursing home models compared to the Green House model. The difference in total Medicare and Medicaid costs per resident over that same time frame was approximately $1,300-$2,300 less in Green House facilities.

Admittedly, this change is too radical for some administrators and it's often difficult to understand the return on investment in creating a smaller facility that accommodates less patients, but Farrell insists the model relies on cost shifting more than increased expenditure.

Although many view the Green House model as the pinnacle of a radical redesign, those that don't want to make such drastic changes can still adopt some of the basic principles in order to reduce readmissions, such as adopting consistent assignments, reducing CNA turnover, and giving CNAs a stronger voice in the care process. Still, Farrell believes that in time, this radical change will become commonplace.

MDS professor

Wed, 01 May 2013 04:00:00 GMT

MDS professor

Test your knowledge of the MDS and long-term care by answering the following questions. To review the correct answers, see the answer key on p. 12.

1.Mrs. Jacobs is admitted to the SNF on April 1. She has a new PEG and is debilitated by a long hospital stay. She requires both physical and speech therapy. What date range for the assessment reference date (ARD) could be used for her five-day MDS?

2.Which days are paid with this MDS?

3.What assessment reference dates could the MDS coordinator use to complete her 14-day MDS?

4.Which days are paid by the 14-day MDS?

5.Which type of case-mix classification system is the Medicare SNF PPS?

6.A resident qualifies for each of the following RUG categories (with corresponding CMI). Which category will be assigned to the resident for reimbursement purposes?

7.Which of the following is not considered a purpose of an OMRA assessment?

MDS professor answer key

Below are the answers to the MDS professor on p. 10:

1.b. While the ARD for the five-day assessment may be any day between day 1 and day 5, there are also three grace days that may be used, thus allowing for the date range for the five-day MDS to be anywhere between day 1 and day 8.

2.c. The five-day assessment covers payment for the first 14 days of a covered stay.

3.c. The 14-day MDS may have an ARD range from day 13 through day 18, allowing for the use of the five-day grace period. Therefore, the assessment for Mrs. Jacobs could be completed anytime between April 13 and April 18.

4.b. The 14-day MDS covers payment for days 15-30.

5.b. Index maximizing.

6.a. HD2 has the highest CMI value, thus would equate to the highest reimbursement.

7.b. An OMRA is not required for completion of Medicare coverage.

PPS Q&A

Wed, 01 May 2013 04:00:00 GMT

PPS Q&A

Editor's note: This month's "PPS Q&A" was modified from the HCPro book Evidence-Based Practice in Long-Term Care, by Suzanne C. Beyea, RN, PhD, FAAN, and Mary Jo Slattery, RN, MS. For more information about this book or to order, call customer service at 800-650-6787 or visit www.hcmarketplace.com/prod-10441. To submit a question for upcoming issues, email Editor Casey Pickering at cpickering@hcpro.com.

Q. How can we encourage our leadership team to use evidence-based answers to everyday problems?

A. The leadership team must be willing and able to pursue evidence-based answers to everyday problems. In the example of rotating shifts, the management team should conduct a literature search and obtain evidence about best practices for scheduling nurses. If no specific evidence exists, the management team could collect information from organizations with the lowest turnover rates. The leadership team also could collect specific data from staff nurses about their preferred work hours. This information could be included in an analysis of the unit's daily census, rates of admissions and discharges, or other indicators of department activity.

From when it begins, the entire initiative must be visible to the frontline caregivers who will administer the vaccines. First, clinicians need to know that giving eligible patients these vaccines is best practice and why. Next, by including staff nurses in the critique of the research and other findings, they are able to contribute to developing a strategy that will result in success. Keeping the process visible in this way makes it apparent that nurses are integral to ensuring continuous improvement.

Imagine working in a clinical environment where the nurse leaders simply send a memo that states, "Starting tomorrow, nurses will administer flu vaccine to all residents by the specified date."

It is hard to believe that nurses would comply with this dictate 100% of the time. Nurses might well ask questions:

Who is going to write the order?
Why is this the charge nurse's responsibility and not the infection control nurse's responsibility?
How am I going to find time to do this?

One might wonder whether a professional practice environment exists when decisions are made from the top down, which is not how evidence-based practice (EBP) occurs. Creating the right environment requires nurses and leaders to use evidence in their efforts to achieve the highest possible outcomes.

The merit of making EBP visible is making it a core value within an organization. EBP should never be seen as the latest fad or as something that leadership values only for the purpose of seeking designation. If an organization does not fully commit to EBP, it will not work-not to mention the fact that an organization limits its chances of attaining or maintaining designation.

Q. What are some strategies for documenting evidence-based practice efforts?

A. To help an organization document evidence-based efforts, take advantage of internal publications, whether print or electronic. Featuring stories about evidence-based efforts and nurses' contributions helps inform the public and staff of what you're doing. In this way, patients and families learn about efforts to improve care, and staff members not involved in the projects learn about how evidence can be used. Likewise, nursing newsletters or nursing annual reports can help disseminate information between various clinical units and get additional staff interested in projects.

When organizations embark on evidence-based projects, goals should include possible publication. Do not underestimate the helpfulness of sharing work. Each day on electronic nursing listservs, for example, someone asks how another organization implemented a change or managed certain issues. Therefore, when a group undertakes a systematic process to solve a clinical problem, information about that effort can help guide others. Sharing that work may update others about the latest research findings and provide insight into which strategies were helpful. Further, publications provide documentation that an organization has participated and does participate in EBP.

Collecting data related to nurse-sensitive quality indicators and benchmarks is another way to document evidence-based projects. A nursing organization may decide to focus evidence-based efforts on improving performance related to these indicators.

Efforts related to various nurse-sensitive outcomes and the use of evidence could be documented in meeting minutes, care protocols, posters, and presentations. For example, a facility may want to reduce the occurrence of facility-acquired pressure ulcers. Meeting minutes may include information about how evidence related to prevention was reviewed, critiqued, and integrated into the skin care protocol. That guideline could include references to the latest research findings about treating pressure areas. The team could develop a poster to disseminate information about practice changes for staff nurses throughout the organization.

PPS Alert for Long-Term Care, May 2013

Wed, 01 May 2013 04:00:00 GMT

OIG report highlights quality-of-care shortcomings

The newest report from OIG indicates that SNFs fail to meet care planning and discharge planning requirements, calling for more CMS oversight

If you were starting to wonder whether the Office of Inspector General (OIG) has a bone to pick with SNFs, add its most recent report to the pile of mounting evidence.

In 37% of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with the care plan
In 31% of stays, SNFs did not meet discharge planning requirements
Medicare paid approximately $5.1 billion for stays in which SNFs didn't meet these quality-of-care requirements
OIG also found examples of poor-quality care specifically with wound care, medication management, and therapy

As a result, the OIG made the following recommendations, all of which were accepted by CMS:

Strengthen the regulations on care planning and discharge planning
Provide guidance to SNFs to improve care planning and discharge planning
Increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and hold these SNFs accountable
Link payments to meeting quality-of-care requirements
Follow up on the SNFs that failed to meet care planning and discharge planning requirements or that provided poor-quality care

Evaluating care plans

Specifically, the OIG identified problematic stays, which yielded the following issues in the care plan:

It did not address one or more resident assessment protocols and provided no explanation in the medical record
The care plan lacked measurable objectives and detailed time frames
It was not completed by an interdisciplinary team

OIG evaluated care plans to see whether they included the following measurable objectives:

Scheduled toileting plans or bladder retraining programs
Parenteral IV or feeding tubes
Skin treatments
Speech therapy
Occupational therapy
Physical therapy
Respiratory therapy
Restorative nursing services

"You want to actually set up an audit and look at your own risk factors and look at where you're doing things well and where you need improvements and focus on those areas of improvement," she says.

Similar concerns were raised regarding discharge planning:

16% of stays did not have summaries of the beneficiaries' stay or status at discharge
In 25% of stays, SNFs did not have post-discharge plans of care

Increased surveyor scrutiny

The immediate impact that most SNFs will need to consider is the increased scrutiny expected from surveyors following this report.

"I think it's a signal that the bar in quality-of-care and adequate services is high and the government is looking," McDermott says.

Identifying steps toward improving care planning and discharge planning

In light of a recent OIG report, SNFs need to place more emphasis on developing and following through with care plans and discharge planning

Start with an audit

Many of the issues identified are not necessarily complex problems, Brown says.

SNFs should include a review of past citations as part of their review, and then develop a strong and detailed action plan to fix any outstanding issues.

Transforming your care plan

Although an audit will reveal some of the unique deficiencies with your care planning process, there are some universal approaches that will strengthen care plans and withstand surveyor scrutiny.

These approaches include:

Customize your plan.

The biggest mistake that SNFs make during the care planning process is attempting to utilize canned care plans.

This has only become more common as SNFs rely more on electronic forms, says Bonnie Foster, RN, BSN, MEd, owner and president at Foster Consulting, Inc., in Columbia, S.C.

An effective care plan starts from scratch with each resident and addresses all of the issues identified in the assessment.

"It needs to be very individualized," Foster says. "You're supposed to be able to put your hand over the resident's name and know who the resident is based on the care plan."

Document in first person.

Another trick that helps support the care planning process is encouraging staff members to document in first person, Foster says.

"You need to be focusing on 'I' care plans where you're putting yourself into the resident's shoes so you are writing it from their perspective," she says.

Utilize CNAs.

Although only 2% of SNF stays in the OIG report failed to utilize an interdisciplinary team, SNFs need to focus more on involving CNAs in the care planning process, Foster says.

"We should have been doing it all along, it's just that no one ever said the interpretation is that the CNA needs to be there," Foster says.

Is it complete, are you following through?

Finally, those involved with the care planning want to ask two questions as they are implementing the plan:

Are all of the resident's problems addressed? And if not, why not?
Do we have measurable objectives along with a detailed time frame?

These problems were specifically identified in the OIG report and will likely be heavily scrutinized by surveyors.

"Those seem to be the two areas where you could attach a good process to and evaluate it and find out where you stand," Brown says.

Review your discharge planning

Although care planning requirements simply require measures for the resident to maintain or improve their health status, discharge planning requirements are slightly more comprehensive.

The problem that many providers run into is that the community resources that used to be available, such as Meals on Wheels, are no longer there.

During the discharge planning process, staff members need to do their homework to determine which resources are available to the resident and which are not, which is going to vary by state.

Despite the deficiencies revealed in the report, Brown notes that the OIG looked at data from 2009, before SNFs transitioned to MDS 3.0, which placed more emphasis on discharge planning.

"I think if they repeated that study even now, they would see major improvements in the discharge planning because there are better tools available and more direction available," she says.

Refining systems and tools to improve early recognition and care

In order to foster efficient paths of communication, SNFs need to correctly identify vulnerable areas of their healthcare system, and effectively utilize care planning tools to improve care.

Identifying trends

Tracking trends in your facility is the best way to identify specific areas of your facility that need more attention.

She recommends using the following resources as a baseline for root cause analysis:

CASPER reports
Incident and accident logs
Grievances
Documentation for rehospitalizations
Shift to shift reports

SNFs should also rely heavily on input from staff members, which can be an invaluable resource in identifying potential issues.

Utilizing INTERACT tools

Refining care planning, discharge planning, and admissions

SNFs can make huge strides toward improving their readmission rates simply by focusing on three processes within their healthcare system:

Admissions. This initial process either sets the resident up for failure, or provides the appropriate information for the care team to easily identify vulnerabilities in the resident's health. Early identification of possible negative outcomes establishes a baseline for CNAs and nurses to reference when caring for the patient on a daily basis. This initial evaluation will help identify those subtle changes that often result in rehospitalization.

"It's not enough to only investigate what will yield you a skilled service," Rubertino says. "We need to also look for comorbidities that may impact the outcome of the skilled services."

Providers should supplement the admissions process by providing ongoing skills improvement opportunities for nursing staff so they are viewed as skilled postacute care providers.

Care planning. Once the admissions process has been successfully executed, it's imperative that the care team implements the appropriate care plan based on the specific needs of the resident. A recent report from the Office of Inspector General identified ongoing issues among SNFs regarding care planning and discharge planning, an accurate reflection of some of the problems that plague the industry, McCarthy says.

Discharge planning. An individualized discharge plan is the last step in preventing rehospitalizations after the resident leaves the building. SNFs need to consider issues such as how the resident will be transported to post-discharge appointments and what specific education they have received regarding their care going forward as well as any medications they may be taking.

"We document where they are headed in terms of the discharge destination, but not who is transporting them," McCarthy says. "We need to be coordinating that care that comes afterward."

Following through with culture change

The Green House effect

Short-term reha

HIPAA finalizes omnibus rule, increases security for health data

Mon, 01 Apr 2013 04:00:00 GMT

HIPAA finalizes omnibus rule, increases security for health data

The comprehensive revisions to HIPAA laws require SNFs to review their contracts to avoid increased fines

On January 17, the U.S. Department of Health and Human Services (HHS) announced its biggest set of modifications to the HIPAA privacy and security rules. The final rule includes significant enhancements to patient privacy protections and strengthens the government's enforcement abilities.

"Much has changed in health care since HIPAA was enacted over fifteen years ago," HHS Secretary Kathleen Sebelius said in a press release. "The new rule will help protect patient privacy and safeguard patients' health information in an ever expanding digital age."

The final rule is effective March 26, 2013, but there is a 180-day grace period, meaning covered entities and business associates must comply with the final rule by September 23.

The rule applies to any facility that is treating patients and providing healthcare (versus an assisted living facility that may not actually be providing care), and sending electronic patient transactions to a health plan directly or billing service. Under these parameters, all SNFs and most LTC facilities are subject to the requirements of the rule.

"What that basically means is if you're providing nursing services and you have a medical director that is signing off on care plans or dealing with any payment transactions and you don't have any kind of HIPAA compliance program, that is probably going to be seen by the Office for Civil Rights [OCR] as willful neglect," says Kelly Hagan, an attorney at Schwabe, Williamson, and Wyatt in Portland, Ore. "You're looking at a minimum penalty of $10,000 per violation, and if it's not corrected within 30 days its $50,000."

One of the major changes associated with the omnibus rule is the additional requirements holding third-party contractors responsible for protected health information (PHI). HHS plans to offer additional guidance in the near future, but SNFs should devote time over the next several months reviewing their contracts and their privacy and security risk analysis in preparation for the final September deadline.

"I think the takeaway is that HIPAA has been through its teething period and now the teeth are in, and if you're taking the position that you're not a covered entity, you better be real clear about that," Hagan says.

Review your contracts

The first and perhaps most important step for SNFs will be to review all their contracts with their party business associates. According to the HHS press release, some of the largest reported breaches have involved business associates. From an LTC perspective, facilities need to review those contracts and ensure there is language that holds business associates accountable for privacy protections.

"If they have a contract in place and that contract isn't up until February of next year, they have until September 22, 2014 to comply-to actually get all those contracts rolled out," says Chris Apgar, CISSP, CEO and president of Apgar & Associates, LLC, of Portland, Ore. "They don't need to drop everything and roll out contracts right now, they just need to make sure the contract they have in place is compliant with the old rule, and if that's the case then they need to update it the sooner of the next time it expires or September 22 of next year."

The updated contract should include expectations of the business associate, including steps to take to prevent a breach of patient information. Facilities may also want to build in the ability to periodically audit those business associates to ensure their protections are effective. If there is a breach, the facility will have documentation that it performed due diligence.

More facilities are also looking at cyber liability coverage in case there is a breach.

"Every other contract I see asks for the business associate to carry that coverage because they don't want to do business with a small company that can't afford the cost of meeting their indemnity obligations," Hagan says.

Apgar also recommends sending a checklist to all business entities to complete along with the updated contract that looks at what is being done to protect electronic information. This can serve as documentation that you worked with the vendor to ensure that information was not at risk.

For facilities that utilize information storage services or cloud storage, those entities are now considered business associates, Hagan says.

"If someone maintains information for you and stores it on a server farm or somewhere in a cloud that's backing up your records, if it wasn't clear before, it's clear now: You are going to need a business associate contract with them," he says.

Risk assessment

If a breach does occur in your facility that attracts a visit from the OCR, the first document the organization will ask for is your risk assessment. For example, in January the Hospice of Northern Idaho was forced to pay HHS $50,000 to settle HIPAA violations stemming from a 2010 incident. The OCR conducted an investigation of the facility after a company laptop was stolen containing the information of 441 patients and determined that the facility had not conducted an adequate risk analysis to safeguard patient information.

Over the next few months, providers should take the time to review their policies and procedures, including their documented risk assessment.

"This is really a propitious moment to do a top-to-bottom review of your compliance program," Hagan says. "Something that should be built in already is periodic review of those provisions."

A comprehensive risk assessment evaluates what the provider owns in terms of hardware, software, clinics, beds, etc., and then identifies threats and vulnerabilities related to patient information. A simple identification system using low, medium, and high risks will help categorize your threats and the controls that you need to implement.

"Let's say my network could be infected with a virus, or my building could burn down," Apgar says. "You need to look at what are the security protocols I have in place. I have antivirus software, and it's up to date, and as far as the building is concerned I have the appropriate fire suppression devices and an alternative place to move the residents in the event something happens to the building. Those would be good controls."

Eliminating the harm threshold

Although the new HIPAA requirements aren't necessarily more onerous, they are certainly more stringent. Part of the update includes lifting the harm threshold, which had previously allowed providers to determine whether a breach caused significant harm to the affected individual. The rule calls for covered entities to conduct a risk assessment of the breach to determine the probability that the PHI has been compromised based on the following four factors:

The nature and extent of PHI involved, including the types of identifiers and the likelihood of re-identification
The unauthorized person who used the PHI or to whom the disclosure was made
Whether the PHI was actually acquired or viewed
The extent to which the risk to the PHI has been mitigated

"It's making the assumption up front that you will need to notify, and then go through the risk assessment to determine reasonably if it rises to that level," Apgar says.

Additionally, the price of noncompliance has increased significantly. Penalties are assessed based on the level of negligence, with a maximum penalty of $50 thousand per violation to a maximum of $1.5 million for the same type of violation per calendar year. A typical breach will involve violation of multiple standards.

"If they are just waking up to this, it gets into the enforcement side of willful neglect," Apgar says. "The breaches that have occurred and the fines from the OCR-at least some part of it-were because the provider hadn't done a risk analysis."

Individual rights expanded

There are a few nuanced rules surrounding marketing that SNFs should be aware of, Apgar says. In general, the rules around marketing and communication with patients haven't changed much from the old rule, with a few additional caveats. For example, providers are no longer allowed to market via mail or phone.

"I can have a conversation about glucose meters if you're sitting in front of me, but I can't have the same conversation over the phone," Apgar says. "As soon as it's not face-to-face it becomes marketing."

Additionally, if a provider is sending out information about a prescription refill, that provider can only be paid for the cost of mailing.

If a patient that has insurance pays for a procedure out of pocket and requests that his or her records be kept from the insurance company, the provider has to honor that request, Hagan says. Many providers are going to have to work out a system to ensure they are able to comply with those requests. "It becomes a workflow nightmare because that's easy to do when it comes up the first time, but how did you flag those chart notes or records so that in six months, when there is another request for health files, that information doesn't get sent along inadvertently," Hagan says.

Finally, there are some nuanced changes regarding deceased patients, which may apply to long-term care. Previously after a patient died, only the personal representative had access to that patient's PHI. The new rule grants access to friends and family members that were involved with the patient's care or payment for it. The rule also puts a 50-year cap on the HIPAA protections for patient information (formerly, the records were protected indefinitely).

"It was a real pain for people that were not 'personal representatives' or appointed as the administrator of the estate," Hagan says. "That's one person and one person only, and suddenly everyone else who had been kept in the loop was kind of shut out."

Improving nursing practices and systems to recognize the first signs of readmission

Mon, 01 Apr 2013 04:00:00 GMT

Improving nursing practices and systems to recognize the first signs of readmission

Recognition and communication are key elements to help nurses identify high-risk residents and take early action

Editor's note: This is the third installment of a series of articles focusing on how SNFs can help reduce hospital readmissions. By the end of the series, readers will have a comprehensive guide that walks them through the entire resident stay.

There are myriad factors that contribute to hospital readmissions, but undoubtedly one of the main drivers in their identification and prevention is the nursing staff and the policies and procedures put in place to help them pinpoint high-risk residents.

Typically, the resident's first interactions after an admission are with a nurse or CNA, and CNAs usually spend the most one-on-one time with the resident in the following days and weeks. CNAs who identify and communicate changes (e.g., behavior, appetite, or demeanor) that might be symptomatic of a greater health issue play a huge role in early identification of a potential readmission.

But nurses and CNAs will only be successful with this approach if the facility provides them the tools and training to build relationships with residents and use critical thinking to evaluate subtle changes.

"If you want to know how you're doing, ask the people you're doing it for and ask the people that are doing it with them," says Barbara Frank, MPA, cofounder of B&F Consulting in Warren, R.I. "In long-term care, it's the staff that is closest to the resident. The quality of your care is dependent on the quality of the working relationships among the staff, which is dependent on the quality of your systems to foster those working relationships."

Many facilities have found the Interventions to Reduce Acute Care Transfers (INTERACT) program, which combines clinical and educational tools and strategies, depends on good staff relationships. In recent years the INTERACT program has gained popularity among SNFs because of its proven success in identifying and reducing potentially avoidable readmissions.

A study published in the April 2011 issue of the Journal of the American Geriatrics Society observed the INTERACT II collaborative in 25 community-based nursing homes in Florida, Massachusetts, and New York. It found a 17% reduction in self-reported hospital admissions over a six-month period with a projected savings of around $125,000 in Medicare costs.

INTERACT revolves around two main steps: early recognition of a resident's change in condition, and appropriate communication of that change to the care team, which can then make a decision on how to adjust the resident's care, says Laurie Herndon, MSN, GNP-BC, senior project coordinator for INTERACT, a gerontological nurse practitioner at Reliant Medical Group in Worcester, Mass., and director of clinical quality at the Massachusetts Senior Care Foundation.

"[The INTERACT program] prompts critical thinking, it prompts the assessment, and it also provides documentation around that whole process of identification," Herndon says. "So the nurse really goes through that process around the change of condition and gets a comprehensive history, does a focused exam, and then comes up with her assessment and works with the collaborating team on the plan."

Regardless of what tools or policies you use to approach the nursing aspect of readmissions, a successful program revolves around early recognition and identification of potential issues and effective communication with physicians.

Getting to know the resident

The key to this whole process is instituting a system where your nurses are able to recognize subtle changes in a resident's behavior. Even small triggers, such as loss of appetite or bouts of insomnia, can be clues to a larger issue. "You need a system where you have a deep close knowledge to the resident right away, particularly if you're talking about people who are newly admitted because 30% of rehospitalizations occur in the first seven days," Frank says.

One way to facilitate that process is by utilizing your CNAs, says Maureen McCarthy, RN, BS, vice president of clinical reimbursement for National Healthcare Associates and president of Celtic Associates, LLC, in Goshen, Conn. Implementing consistent assignments and including CNAs in huddles and care planning facilitates more open communication with the nurse or nurse supervisor. "The CNA is the eyes and ears of what happens on the unit," McCarthy says. "They spend more time with the resident than any other staff member in the entire facility."

Doing a functional assessment also allows staff members to categorize residents based on high or low risk for rehospitalization, McCarthy says. For example, having a history of readmissions or multiple comorbidities may categorize a resident as high risk, meaning the nursing staff needs to be more aware of potential warning signs. "You should be assessing the patient and looking at who is high risk and who is low risk and what types of assessments would be appropriate to make sure one of the underlying conditions doesn't force them back into the hospital," McCarthy says.

Once the functional assessment is complete, Frank recommends including specific risks for each resident on the CNA assignment sheet.

Unfortunately, circumstances don't always allow for a full assessment by the nurse. For example, if a resident is admitted late in the day on a Friday, the activities director may not be available to do the customary routine assessment until Monday. As a result, staff may not be aware of the resident's daily routine, so they won't be able to follow that routine from day one. This can lead to sleep deprivation or loss of appetite that contribute to changes in mood, behavior, or functional status in those first days of settling in. In these instances, Frank recommends relying on the CNA to gather some basic information about when the resident likes to go to sleep, when he or she wakes up, what the resident's morning routine is, etc.

"A short-term rehab facility in NYC that had the CNA ask those questions within the first couple of hours," Frank says. "They cut back on rehospitalizations, they cut back on lost rehab appointments, and they cut back on family complaints because they weren't waiting for that formal protocol of some department head to ask it: The person closest to the resident was getting the information right away to establish that person's routine."

CNAs can also observe a resident's balance, mobility, and ability to transfer to bed, wheelchair, or toilet, and important information about the resident's strength. Although they cannot technically do an assessment, these observations will help ensure the resident makes it through the first night without any falls before therapy can do a full evaluation the following day.

The INTERACT program includes a "Stop and Watch Early Interaction" tool for instances in which a nurse or CNA notices a behavior change. This is considered the foundation of the program, used to document small changes and catch any potential issues early.

Communication between nurses and doctors

Once you have done a comprehensive assessment and the nursing staff has identified and documented risk factors for the resident, the next step in preventing readmissions is providing an avenue for effective communication.

Communication works on two levels. First, the CNA, social worker, therapist, or anyone that notices a change in the resident passes on the information to the nurse or the nurse manager. From there, the nurse can do a full evaluation on the resident to determine the next steps.

The INTERACT program uses the "SBAR Communication Form and Progress Note." This form is essentially designed as a standard recipe for nurses to record the appropriate information that will allow the doctors to make an informed decision, Herndon says.

Poor communication often contributes to readmissions, and that breakdown usually occurs between the nurse and the physician. Typically a nurse will notice a change in the resident, do a partial assessment, and then call the physician, who typically is dealing with many calls at once. If the nurse doesn't have the right information, or enough of it, the physician's reaction is usually either to watch the resident until his or her condition becomes more serious, but with no interventions put in place in the meantime, or to give orders for the resident to be sent to the hospital for tests

"By far the SBAR tool is one of the most popular and well received tools in the program," Herndon says. "The nurses really like it. It's quite a departure from what they usually do, but once they get over the initial shock and awe and actually put it into practice, they report unanimously that it doesn't take more time and it actually elevates their level of professionalism, and it really equips them to be on the phone with that physician."

Long-term care facilities also need to train nurses to communicate effectively over the phone. Because the physicians are not on-site to assess the resident, he or she is only making decisions based on the nurse's information. Nurses also need to be confident in their assessment and the signs that the resident is presenting.

"Unless the nurse says, 'I'm just calling to inform you about this,' the doctor believes the nurse is asking for action to be taken," Frank says. "And the two actions are to order them to the hospital or to order medications. So what really has to happen is the nurse needs to feel confident enough in what she sees and what she's doing to be able to say to the doctor, 'Here's what I see and here's what I'm doing. I don't think we need to do anything further, but I'll keep you posted.' "

Expanding internal procedures

As LTC facilities begin adding more clinical services to their repertoire, the responsibility of the nursing staff will evolve. McCarthy envisions nursing homes providing more comprehensive care for residents, similar to what medical-surgical units were doing in the hospital 20 years ago, while hospitals focus on a more intense level of care provided in the OR, ER, and ICU. That means nursing education is going to have to keep pace with the advancements in long-term care.

"We need to make sure we build up that skill set for the nurses: things like basic assessments, cardiac assessments, pulmonary functional assessments, cognitive assessments, and looking at baseline mental status," she says. "We need to help build those skills up for the patient that normally would have gone to the hospital five years ago."

Some SNFs provide this education through vendors, who have respiratory therapists on staff that can come in and conduct short in-services for nurses. Other SNFs have physician contracts that stipulate a certain number of in-services each month, year, or quarter. Additionally, many facilities are hiring nurse practitioners or physician assistants to provide support for the nursing staff.

"If a nurse isn't comfortable with their findings on the assessment, get them to do it side-by-side with a PA or utilize them for education," McCarthy says. "They spend a little more time in the facilities than the physicians are allowed to."

AHCA Quality Report shows progress within the LTC industry

Mon, 01 Apr 2013 04:00:00 GMT

AHCA Quality Report shows progress within the LTC industry

The annual report highlights improvements over the last year, including fewer deficiencies, more four- and five-star ratings, and a more stable workforce

In November, the American Health Care Association (AHCA) released its annual Quality Report, based on quality statistics from more than 11,000 member facilities. The statistics indicated that there has been progress in many areas of long-term care, including customer satisfaction, staffing turnover, and four- and five-star ratings, as well as a reduction in deficiencies.

The report also highlights some changes to the type of care that is offered in SNFs, transitioning from long-term residents to short-term rehabilitation stays.

"What we've seen in recent years with the patient mix are skilled nursing centers treating more patients in need of rehabilitation or to complete their course of care following an acute illness, rather than long term stays," said AHCA Senior Vice President of Quality & Regulatory Services David Gifford, MD, MPH, in a press release. "To continue to call them 'nursing homes' misses this important function and can sometimes be, frankly, misleading. What's encouraging is that, as these centers evolve to meet new patient demands, more individuals are happy with the care they received."

Some significant statistical takeaways from the report include:

Of the 3.7 million individuals who received care in a nursing facility in 2009, only 23% resided in the facility for at least a year. Of the remaining residents, 80% were admitted for short-term rehabilitation covered by Medicare.
Clinical quality measures tracked quarterly by CMS and publicly reported on the Nursing Home Compare website show that the average facility has improved in 12 of the 15 quality measures over the last five years. Specifically, there was a 29% improvement in the proportion of individuals with pressure ulcers and a 12% improvement in those with pain.
Direct care nursing per resident has improved significantly for all nursing levels. Direct care nursing hours per resident day improved from 3.38 in 2007 to 3.67 in 2012. Additionally, nursing turnover saw a significant decrease from 2008 to 2010, dropping from 48.7% to 39.5%.
The Five-Star Rating System was implemented in 2008, and since then the percentage of long-term care facilities receiving four- or five-star ratings has increased to 43%. Customer satisfaction remains stable at 89% from residents and 87% from family members.
Facilities still saw room for improvement among employee satisfaction from nurses and nursing assistants, with only 67% satisfaction in 2011.

These statistics support the measurable targets that AHCA has developed as part of its own Quality Initiative:

By March 2015, reduce the number of hospital readmissions within 30 days during a skilled nursing facility (SNF) stay by 15%
By March 2015, reduce turnover among nursing staff (RN, LPN/LVN, and CNA) by 15%
By March 2015, increase the number of customers who would recommend the facility to others to 90%
By December 2012, reduce the off label use of antipsychotic drugs by 15%

Overall, these statistics reaffirm the industry's direction in terms of caring for short-stay patients and placing more emphasis on quality measures, says Diane Brown, BA, CPRA, director of postacute education at HCPro, Inc., in Danvers, Mass. Although there are still some areas for improvement, Brown notes the report is positive and supports the efforts that have been made over the past few years.

"There's been a general focus on quality, a huge amount of public awareness, and you've got the 'Advancing Excellence' campaign," Brown says. "I think the collaborative efforts are very important and the fact that you have stakeholders collaborating with the federal government, I think all the pieces are just starting to come together."

The long-term care industry has also made strides toward expanding services that are provided to residents, says Marilyn Mines, RN, BC, RAC-CT, senior manager of clinical services at Frost, Ruttenbert, and Rothblatt, PC, in Deerfield, Ill. "The SNF environment has become mini-hospitals," she says. "The acuity of the residents has increased over the years, and many people view us as more than a place for mom or dad to live out their time. We have had to improve to remain open and have good relationships with our communities."

Takeaways from the report

The quality improvement statistics published in the report go hand-in-hand with stable staffing. In the past, long-term care relied heavily on outsourced nursing, and the nursing shortage had a direct impact on patient care because residents rarely had consistent nurse assignments.

"The reliance on outsourced nurses has steadily declined," Brown says. "It wasn't good for quality of care. There wasn't an investment in the patient, they didn't know the rules and regulations if you came from a pool of nurses, and it put facilities at risk."

The report notes that studies have shown a clear association between staff stability and lower turnover, as well as quality of care. There is also a direct correlation between a stable workforce and customer satisfaction, Brown says. Despite the drop in turnover, the industry still has work to do in building a more stable workforce through staff satisfaction or maintaining low turnover rates, she says-namely "working on the individual areas doing that root-cause analysis to find out what is important to your staff and what is not as important."

Staff satisfaction will likely vary depending on your geographical location and the unique characteristics of your facility. A nurse in an inner-city facility may have different incentives compared to someone working in a rural community.

Employee satisfaction surveys can help determine what staff members value in their work environment; however, Mines suggests using personalized face-to-face surveys instead of pen and paper.

"When a staff member leaves, is there an exit conference to find out the real reasons?" she says. "We may not be able to fix or correct all the reasons why someone may leave our employ, but we must attempt to fix those that we can."

Moving forward

It's clear from the AHCA report that the long-term care industry is headed toward a system in which quality dictates financial sustainability.

"Pay-for-performance and value-based purchasing is coming, whether we like it or not," Mines says. "If the facility is not prepared to deal with managed care organizations, the future will be very difficult. It is important to embrace this change and educate our staff regarding both Medicare and Medicaid managed care."

Additionally, SNFs are beginning to offer more comprehensive services in order to compete with neighboring SNFs as well as reduce readmissions. Going forward, SNFs need to be more efficient in order to remain profitable.

"Our processes have to be streamlined in order to accomplish more with potentially less dollars and less resources," Mines says. "Managing our residents in the most cost-effective and efficient manner, while providing them with the necessary care and services, is essential."

MDS professor

Mon, 01 Apr 2013 04:00:00 GMT

MDS professor

Test your knowledge of the MDS and long-term care by answering the following questions. To review the correct answers, see the answer key on p. 12.

1.Medicare medical review can occur either prepayment or post-payment.

2.A facility has only 30 days to respond to an ADR or an automatic denial will occur.

3.A claim is reviewed with an RUC HIPPS code. The A/B Medicare Administrative Contractor (MAC) determined that the therapy services were reasonable and necessary but not at the level billed. Which of the following will occur?

4.Imagine the same scenario as question 3, but this time the MAC has determined that none of the rehab services were reasonable and necessary; however, the resident did still qualify for skilled nursing care. What RUG level will the claim be adjusted to?

5.Which of the following is not a type of medical review conducted by a fiscal intermediary?

6. ADR stands for which of the following?

7.In order to stop recoupment of an original determination from the A/B MAC, a facility must submit its first level of appeal within _______ days.

8.Willow View Nursing Center submits a third-level appeal to the Administrative Law Judge (ALJ) since the facility was in disagreement with the qualified independent contractor's (QIC) decision at the second level of appeal. With the submission, Willow View appends additional documentation to support the services reported. Per the appeals revision process, must the additional documentation be considered during the ALJ hearing?

9.Which of the following identify information that the intermediaries/carriers are required to provide with the notice of an initial determination? Select all that apply.

MDS professor answer key

Below are the answers to the MDS professor on p. 10:

1.a. Either can occur depending on type of medical review.

2.b. If documentation is not received in 45 days, a medical review determination will be made on the information available, which could include a full denial.

3.b. The A/B MAC medical reviewer will adjust the claim based on the new RUG established using the QC tool.

4.c. The claim will be paid at the appropriate clinical RUG category as long as the resident remained at a skilled level of care.

5.d. An expedited review is conducted by the Quality Improvement Organization.

6.a or b. The term is more commonly referred to as Additional Development Request, but it is sometimes written as Additional Documentation Request in older literature/documents.

7.c.

8.b. The provisions under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provide that information NOT submitted at the level of a QIC redetermination cannot be submitted at a higher level of appeal.

9.a, b, and d. The A/B MAC is required to include the reason for the determination, including whether an LMRP, LCD, or NCD was used. The notice must also include any applicable appeal information.

PPS Q&A

Mon, 01 Apr 2013 04:00:00 GMT

PPS Q&A

Editor's note: This month's "PPS Q&A" was modified from the HCPro book ICD-10 Essentials for Long Term Care, by Karen L. Fabrizio, RHIA, CPRA. For more information about this book or to order, call customer service at 800-650-6787 or visit www.hcmarketplace.com/prod-10188. To submit a question for upcoming issues, email Editor Casey Pickering at cpickering@hcpro.com.

Q. Our facility continues to push off our ICD-10 training since the implementation deadline was changed. We are planning to begin our implementation and training efforts soon. What should our first steps be?

A. The transition to ICD-10 is the biggest transition for medical coding in over 30 years. The transition from ICD-9-CM to ICD-10-CM impacts all departments throughout the organization-including providers of healthcare as well as payers and vendors.

SNFs need to begin planning now for a smooth changeover. Other countries that have implemented ICD-10 have learned that the transition is a two- to three-year process that will involve the review of current systems using ICD-9-CM, education of a variety of staff, and meeting the implementation deadline of October 1, 2014.

The first key component to a successful plan will be convening a steering committee to oversee the implementation process. The steering committee (core team) must include leadership/directors from the major departments impacted by the change to ICD-10. The chair of the committee (or project leader) needs to be someone who is familiar with the impact ICD-10 will have on the industry. Choose either the chief information officer, the compliance officer, or the health information management (HIM) specialist; alternatively, consider hiring a consultant to lead the group.

It is critical for the steering committee to spend adequate time at the beginning of the project to discuss, brainstorm, and analyze the undertaking. A useful tool for the steering committee would be to develop a Gantt chart-a horizontal bar chart that graphically displays the time relationship in a project. Project tasks are listed along with the time required for each step. This is a helpful tool to chart actual progress of the project.

Because this is a new venture for everyone, the steering committee should receive education right away on the ICD-10 code structure as well as the differences between ICD-9 and ICD-10. This education will serve as a basis for understanding the challenges of the transition and future decision-making concerning education and any capital expenditures. Remember, the change to ICD-10 is not a simple substitution of one code set for another; rather, it is an entirely new classification system that will have a learning curve for both clinicians and administrative staff.

Q. Once we get our ICD-10 training under way, what big elements should we consider when it comes to the transition?

A. The three major considerations regarding the ICD-10 transition project are quality of information and data, cost of conversion, and time and education. Your facility may want to consider developing subgroups to focus on these elements. If a Gantt chart is used to track the identified steps, the use of color will help differentiate the tasks assigned to each subgroup.

Quality of information is the fundamental component of the project because it affects patient safety, communication, and reimbursement. This subcommittee should be in charge of testing the 5010 conversion, testing the data, and auditing the documentation for sufficient detail. Also consider contingency plans in the event of critical systems failure during the ICD-10 transition.

Cost allocation is essential in the planning process so that the expenditures can be submitted and entered into the correct budget year. Because this is a two- to three-year project, costs can be spread across 24-36 months. The budget subcommittee will estimate the costs for education, additional staffing, new equipment, and IT or HIM consultants. Plan, prepare, and budget for outside education, coding certification, and staff turnover.

The third subcommittee should focus on education. This group will assess the different needs for education: who, how, what, and when. Because education is a key component of the conversion to ICD-10, look at the resources available to the organization such as in-house experts, local experts, or national resources such as webinars, training seminars, or written resources.

The successful conversion from ICD-9-CM to ICD-10-CM will depend on open and honest communication, planning, and education both within a given department as well as between departments. It is important for everyone to accurately report their abilities and status on any gap analysis. Holding regularly scheduled meetings on a consistent day and time will promote open communication and improved attendance. Core team members who are unable to attend team meetings must be represented by subcommittee members.

Develop a plan for the identification of issues and a process to assign responsibilities, task completion, and progress toward goals. Include agenda items on communication to ensure open discussion of issues, changes, upgrades, and ongoing updates. Encourage collaboration so that people feel free to bring up issues that impact other departments or staff members.

Each director within the core team should evaluate the current departmental processes and procedures. Understanding how information is collected, who collects it, the process the information goes through in each department, and the impact of that information on other departments is critical. Consider using a flow chart-a graphical representation of a process with its various inputs and outputs-to aid in understanding. This evaluation will assist in planning as it relates to budgeting, education, and staffing needs.

The policy manual and standard operating procedures will also need to be assessed for any necessary changes under ICD-10. Each core team member is responsible for seeing that the required departmental policies are in place and support law, regulation, and practice. Additionally, interdepartmental collaboration is recommended as processes flow to other areas.

Determining who will have responsibility for specific tasks should be done as early as possible so they may participate in the scheduling of tasks and identify needed financial resources. Establishing "buy-in" from all parties involved will be essential for a smooth transition. Benefits from the preparation and planning process can be realized right away, such as the improvement in detailed documentation and the education of staff.

PPS Alert for Long-Term Care, April 2013

Mon, 01 Apr 2013 04:00:00 GMT

HIPAA finalizes omnibus rule, increases security for health data

The comprehensive revisions to HIPAA laws require SNFs to review their contracts to avoid increased fines

The final rule is effective March 26, 2013, but there is a 180-day grace period, meaning covered entities and business associates must comply with the final rule by September 23.

Review your contracts

More facilities are also looking at cyber liability coverage in case there is a breach.

For facilities that utilize information storage services or cloud storage, those entities are now considered business associates, Hagan says.

Risk assessment

Over the next few months, providers should take the time to review their policies and procedures, including their documented risk assessment.

"This is really a propitious moment to do a top-to-bottom review of your compliance program," Hagan says. "Something that should be built in already is periodic review of those provisions."

Eliminating the harm threshold

The nature and extent of PHI involved, including the types of identifiers and the likelihood of re-identification
The unauthorized person who used the PHI or to whom the disclosure was made
Whether the PHI was actually acquired or viewed
The extent to which the risk to the PHI has been mitigated

"It's making the assumption up front that you will need to notify, and then go through the risk assessment to determine reasonably if it rises to that level," Apgar says.

Individual rights expanded

Additionally, if a provider is sending out information about a prescription refill, that provider can only be paid for the cost of mailing.

Improving nursing practices and systems to recognize the first signs of readmission

Recognition and communication are key elements to help nurses identify high-risk residents and take early action

Getting to know the resident

Once the functional assessment is complete, Frank recommends including specific risks for each resident on the CNA assignment sheet.

Communication between nurses and doctors

Expanding internal procedures

AHCA Quality Report shows progress within the LTC industry

The annual report highlights improvements over the last year, including fewer deficiencies, more four- and five-star ratings, and a more stable workforce

The report also highlights some changes to the type of care that is offered in SNFs, transitioning from long-term residents to short-term rehabilitation stays.

Some significant statistical takeaways from the report include:

Of the 3.7 million individuals who received care in a nursing facility in 2009, only 23% resided in the facility for at least a year. Of the remaining residents, 80% were admitted for short-term rehabilitation covered by Medicare.
Clinical quality measures tracked quarterly by CMS and publicly reported on the Nursing Home Compare website show that the average facility has improved in 12 of the 15 quality measures over the last five years. Specifically, there was a 29% improvement in the proportion of individuals with pressure ulcers and a 12% improvement in those with pain.
Direct care nursing per resident has improved significantly for all nursing levels. Direct care nursing hours per resident day improved from 3.38 in 2007 to 3.67 in 2012. Additionally, nursing turnover saw a significant decrease from 2008 to 2010, dropping from 48.7% to 39.5%.
The Five-Star Rating System was implemented in 2008, and since then the percentage of long-term care facilities receiving four- or five-star ratings has increased to 43%. Customer satisfaction remains stable at 89% from residents and 87% from family members.
Facilities still saw room for improvement among employee satisfaction from nurses and nursing assistants, with only 67% satisfaction in 2011.

These statistics support the measurable targets that AHCA has developed as part of its own Quality Initiative:

By March 2015, reduce the number of hospital readmissions within 30 days during a skilled nursing facility (SNF) stay by 15%
By March 2015, reduce turnover among nursing staff (RN, LPN/LVN, and CNA) by 15%
By March 2015, increase the number of customers who would recommend the facility to others to 90%
By December 2012, reduce the off label use of antipsychotic drugs by 15%

Takeaways from the report

Employee satisfaction surveys can help determine what staff members value in their work environment; however, Mines suggests using personalized face-to-face surveys instead of pen and paper.

Moving forward

It's clear from the AHCA report that the long-term care industry is headed toward a system in which quality dictates financial sustainability.

PPS Q&A

Fri, 01 Mar 2013 13:31:00 GMT

This month's PPSA Q&A discusses documentation and survey success tips.

New claims-based data collection codes put additional pressure on therapists

Fri, 01 Mar 2013 04:00:00 GMT

New claims-based data collection codes put additional pressure on therapists

CMS initiates its testing period of claims of 42 new nonpayable G-codes and seven new modifiers on therapy claims

The testing period has begun for the claims-based data collection requirement for outpatient therapy services, and SNFs would be wise to start familiarizing themselves with the new codes now so that implementation is easier when the testing period ends in June.

According to a CMS transmittal released on December 21, 2012, the new codes are being implemented as part of a requirement outlined in section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act of 2012. According to the act:

The Secretary of Health and Human Services shall implement, beginning on January 1, 2013, a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)). Such strategy shall be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes.

A testing period for the 42 nonpayable G-codes and seven severity/complexity modifiers related to physical therapy (PT), occupational therapy (OT), and speech-language therapy (SLP) is currently under way and will continue through July 1. After the testing period is complete, claims for therapy services that do not contain the required G-code and modifier information will be returned or rejected.

This new requirement aims to provide more information about the beneficiary's functional status, along with projected goals at specified points during treatment. This will affect all claims for services under Medicare Part B outpatient therapy, and PT, OT, and SLP services under the comprehensive outpatient rehabilitation facility benefit. According to the CMS transmittal, the functional G-codes and severity modifiers should be included on the following claims:

At the outset of a therapy episode of care (i.e., on the claim for the date of service of the initial therapy service)
At least once every 10 treatment days, which corresponds with the progress reporting period
When an evaluative procedure, including a reevaluative one, is furnished and billed
At the time of discharge from the therapy episode of care
At the time reporting of a particular functional limitation is ended in cases where there is a need for further therapy
At the time reporting is begun for a new or different functional limitation within the same episode of care

This will be a significant change for most SNFs, with therapists taking the brunt of the responsibility to meet those requirements, says Kate Brewer, PT, MBA, GCS, RAC-CT, president of Greenfield Rehabilitation Agency, Inc., in Milwaukee.

"The previous requirements were very vague and encouraged the use of an objective system which most providers did," Brewer says. "This new change forces providers to conform to CMS' program."

Although the new coding requirements shouldn't change how therapists treat patients, there will likely be a transition period in which therapists develop a new routine for recording these new codes and modifiers, says Janet Potter, CPA, MAS, manager of healthcare research at FR&R Healthcare Consulting, Inc., in Deerfield, Ill.

"The therapy will still be provided in the same way where the therapist who is familiar with the patient will be able to determine the appropriate codes," Potter says. "It will just be a matter of implementing the new process of selecting and reporting the codes for every Part B therapy patient."

SNFs should begin preparing now by familiarizing therapists with the codes and requirements, and providing effective training to get therapists up to speed.

Another layer of regulation

These new requirements add another dimension of coding for therapists who are already burdened with additional challenges such as the therapy cap, and the automatic and manual exceptions process, Brewer says. These additional G-codes and modifiers will ultimately take attention away from the patient and force therapists to conform to a very rigid process.

"Therapy professionals strive to provide excellent care every day to facilitate progress toward goals for their patients," Brewer says. "This is just another regulatory barrier to attempt to trigger medical review if progress is not demonstrated in a timely manner."

Essentially, CMS is looking to recover money in areas where therapy is provided unnecessarily. Because of that, Brewer recommends that therapists place increased focus on documenting and justifying progress that is being made and noting any barriers that have affected progress so that the documentation stands up to CMS scrutiny.

"[This is] just one more thing to learn and incorporate," Brewer says. "I believe there is always pressure on the therapist in the current state of regulation to document impeccably-this just puts increased pressure on them as they are able to see how progress or lack thereof can trigger review and need to make sure their documentation can stand up."

Additionally, this new regulation will affect the billing department, Potter says.

"The therapists will provide the G-codes as well as the necessary modifiers to the billers, either electronically or on the therapy logs," she says. "The primary responsibility of the biller should be to simply ensure that the necessary codes are on the claims and contact the therapists if they are missing."

What to do now

During this six-month testing period, SNFs and therapists should familiarize themselves with the required G-codes and modifiers and determine how they will impact current residents. Additionally, software vendors and billers will need to incorporate these new codes into their system by the time the trial period ends.

SNFs should look at implementing a process so that required coding and documentation is not missed at specified intervals. It may also be advisable to implement a training program to help therapists understand the categories of coding, and ensure that coding is done consistently with every patient and across multiple therapists.

"Facilities need to spend time helping their team members understand the definitions and how to apply them correctly," Brewer says. "Then develop an internal monitoring system to identify outliers and a system to ensure documentation is supporting the need for continued therapy services. Ensure your department has a comprehensive chart audit and quality improvement plan in place to make sure documentation is always being done defensively."

Therapy managers should be working with therapists now so they understand and can confidently choose the correct G-codes and modifiers, Potter says. Therapists should already know how to set appropriate goals and measure the patient's progress toward those goals, but this transition may be difficult as they will need to translate that information to the appropriate G-code. Facilities should begin implementing a standard method for conversion so that all therapists are completing G-codes and modifiers based on the same criteria.

"What they will need is an in-service or other training session in order to review the G-codes and modifiers and to determine the proper use of each," Potter says. "The hardest part will be converting the results that they receive on the existing assessment tools to a severity rating."

Facilities that contract therapy services need to discuss an implementation process and ensure the correct communication of codes to the billing department.

Finally, the most important part of building a smooth transition process is ensuring clinical documentation always supports therapy coding, Potter says. For example, if a G-code indicates the resident has met a specific functional goal, but the clinical documentation does not reflect that improvement, there will be a discrepancy in the reported claim.

"It is essential that communication between therapy and the direct care staff be ongoing; that there is communication with therapy and the care plan team; that care plans are updated; and direct care staff is following updated interventions," Potter says.

Categories of G-codes

The new G-codes being tested by CMS can be divided into the following categories:

Physical therapy (PT)/occupational therapy (OT):
- Mobility (three codes)
- Changing and maintaining body position (three codes)
- Carrying, moving, and handling objects (three codes)
- Self-care (three codes)
- Other PT/OT primary codes (three codes)
- Other PT/OT subsequent codes (two codes)
Speech-language therapy:
- Swallowing (three codes)
- Motor speech (three codes)
- Spoken language comprehension (three codes)
- Spoken language expressive (three codes)
- Attention (three codes)
- Memory (three codes)
- Voice (three codes
- Other (three codes)

Source: CMS Manual System Transmittal 2622.