HCPro.com - LTC Educator's Corner

Newsletter update: Announcing The Center for Post Acute Excellence Update

Mon, 01 Mar 2010 20:51:00 GMT

Starting next month, you will notice a change in the name of this e-newsletter: LTC Educator’s Corner will become The Center for Post Acute Excellence Update to better reflect our evolving content and services.

In response to the ever-changing regulatory and payment landscape of the long-term care and homecare industries, HCPro, Inc. has redesigned this e-newsletter as a service of The Center for Post Acute Excellence (www.CenterforPostAcuteExcellence.com).

Regulatory experts from The Center for Post Acute Excellence provide solutions to foster discussion among staff members, ensure that your staff is current on the latest rules and guidelines, and help you gauge how new regulatory changes will impact your organization today and in the future.

The Center for Post Acute Excellence Update will ensure you stay informed. Each month, subscribers will receive a tip of the month, a featured article from one of our regulatory experts, and a tool from our Web site spotlight.

We look forward to providing you with helpful tips, tools, and insightful articles.

MDS 3.0 Training Timeline

Mon, 01 Mar 2010 20:46:00 GMT

Many providers are concerned about the various changes and education that must take place before MDS 3.0 implementation, but it is important that facility leaders do not take their anxiety out on their staff members. Nursing home leaders should motivate and coach their staff as best as they possibly can. Rather than punish staff when there is a problem or setback, facility leaders should reward accomplishments and progress. The road to MDS 3.0 implementation will not likely be a smooth one, but maintaining a positive environment and attitude among staff members will make navigating it a little easier.

There is a lot to be done between now and MDS 3.0 implementation. Providing staff members with the necessary training and addressing procedural and operational changes as soon as possible will be major factors in the success of a facility’s transition.

MDSCentral has an MDS 3.0 training timeline available for download.

Discharge Planning Under the MDS 3.0

Mon, 01 Mar 2010 19:49:00 GMT

As federal attention to preventable rehospitalizations increases, SNFs should ensure that their discharge planning processes include steps to provide residents with the equipment, education, and access to services they need to remain safe and healthy in the home environment.

“One of the biggest mistakes facilities make with discharge planning is that they do not make sure a resident and his or her home is adequately prepared prior to discharge,” says Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, HCPro Boot Camp instructor and clinical services consultant at LTC Systems, a long-term care clinical consulting firm in Conway, AR. “If the home is not prepared to meet the resident’s needs, the risk of rehospitalization can increase.”

The SNF’s responsibility to ensure that residents are safe and receive the necessary care does not stop at the facility doors. “Facilities should review their discharge planning process and make sure it is started early, involves the resident and/or family, and provides the resident with the education, community contacts, equipment, and other information he or she needs to remain independent in the home for as long as possible,” Rubertino says.

The discharge planning process
Including the resident and his or her significant family members in the MDS process is crucial for discharge planning because their expectations about the ultimate goals and outcomes will help the interdisciplinary team develop a care plan specific to the resident’s needs.

“It’s similar to building a house; before you go to the builder, you already have an idea of what you want the house to look like. You have a blueprint. You don’t just tell the builder to build you a house without showing him the blueprint,” Rubertino says. “If the resident and family members expect the resident to eventually return home, you can develop your care plan with that ultimate goal in mind. You have to focus on the outcome.”

Prior to discharge, the interdisciplinary team is responsible for providing the resident with a discharge summary and the post-discharge plan of care. The discharge summary should include a variety of information, such as the functional status of the resident upon admission, his or her progress, and his or her needs once the resident is back in the community setting or the next level of care.

“Every resident should receive a discharge summary, regardless of where they are being discharged to,” says Maureen McCarthy, president of Celtic Consulting in Goshen, CT. “The MDS coordinator, unit manager, member of the social service department, dietitian, therapist, and physician should be involved in developing the discharge summary.”

The post-discharge plan of care is similar to the discharge summary in terms of what the resident will need after being discharged from the SNF, but the post-discharge plan of care typically addresses these issues in more detail.

“Although some people think that the next level of care or home care provider should develop the post-discharge plan of care, I think this should be done prior to discharge from the SNF so there is enough time to make arrangements for the home care setting or other facility the resident is being discharged to,” Rubertino says. “The post-discharge care plan should address specific safety issues, assistive devices, equipment, and other items or services the resident will need.”

Facilities are also responsible for providing education to the resident regarding proper self-care. This education is usually provided throughout the resident’s SNF stay, but if not, it must occur prior to discharge.

Beyond the basics
Although the discharge summary, post-discharge plan of care, and self-care training are essential components to the discharge planning process, merely providing the resident with this information is not enough.

“Don’t just give them information, discuss it. Discuss the resident’s needs, requirements for the home, and service options with the resident and his or her family members,” Rubertino says. “They may not be aware of all the resources and services in the community, so you should walk them through what is available rather than just giving them a list.”

The key to a good discharge planning process and successful transitions between levels of care is to communicate with the resident and family members and check to make sure they have everything the resident needs prior to discharge.

“You really have to look at each discharge individually and make sure it is appropriate,” McCarthy says. “For example, if you have a resident that will be discharged on a Friday afternoon, there may not be a home health aide available on Saturday. So if the resident is going home, he or she may not have services during that first weekend. The interdisciplinary team must decide if the resident will be able to function without these services, and if not, the discharge should be delayed until Monday when the services would be available and it would be a better transition for the resident.”

MDS 3.0 changes
SNFs should ensure that residents and their homes are adequately prepared prior to discharge not only because it could reduce the risk of rehospitalization, but also because the MDS 3.0 will draw attention to this aspect of discharge planning.

The MDS 3.0 contains two new items related to discharge planning: Q0500, Return to Community, and Q0600, Referral. These items are intended to support a resident’s expressed interest to return to the community and ensure collaboration between the SNF and the local contact agency to facilitate this transition.

“The way things are now, for short-term stays, discharge planning is usually pretty thorough and generally progresses as it should, ending with a discharge back to a noninstitutional setting. When discharge back to the community does not appear to be feasible on admission, though, the possibility for discharge often is not reevaluated through the stay, even though a resident’s situation might change over time,” says Rena R. Shephard, MHA, RN, RAC-MT, C-NE, president of RRS Healthcare Consulting Services in San Diego. “Discharge might become feasible, and the resident might want to explore the possibilities. That’s where section Q [of the MDS 3.0] comes in.”

Certain answers to Section Q items will trigger the need for a discharge planning evaluation, which will be done by a local contact agency in collaboration with the facility.

Shephard says the need for a discharge planning evaluation is triggered when:

The resident or family wants to speak to someone about return to the community (Q0500B = 1) and
There is no discharge plan in place for the residentto return to the community (Q0400A = 0) and
A determination was made that discharge to the community was feasible (Q0400B = 1)

(For information about how to code MDS 3.0 items Q0500 and Q0600, see “Coding the new Section Q items” on p. 4.)

In addition to the new items related to discharge planning, the MDS 3.0 will require facilities to complete a discharge assessment. This assessment must be completed within seven days of the Event Date (item A2000) and submitted within 14 days of the Event Date.

“When a resident is discharged by MDS definition, a discharge assessment is required [under the MDS 3.0] regardless of whether the discharge is return anticipated or return not anticipated,” Shephard says. “An assessment is not required with MDS 2.0, just a discharge tracking form with a few brief items on it.”

Although the discharge assessment required under the MDS 3.0 means more work for the interdisciplinary team, it could help improve care transitions and even the quality of care people receive.

“I think the discharge assessment may be the beginning of a process that will someday be able to track an individual’s progress across healthcare settings,” Shephard says.

CBO report notes increase in Medicare spending over next 10 years

Mon, 01 Feb 2010 12:33:00 GMT

A Congressional Budget Office (CBO) report released January 26 says if the 2009 payment rates are maintained throughout this decade, Medicare and Medicaid spending would increase by an average of 7% a year over that period, according to The Wall Street Journal.

The report also highlights the pending consequences of the aging Baby Boomer population. Social Security spending is expected to be growing at 6% a year by 2020, a 3% rise from this year. In addition, gross Medicare spending, which totals $528 billion in 2010, is projected to rise to more than $1 trillion by the end of the decade.

Understanding billing for blood glucose

Mon, 01 Feb 2010 12:20:00 GMT

Under the Centers for Medicare & Medicaid Services (CMS) regulations, any diagnostic test, including a clinical diagnostic laboratory test, to be considered reasonable and necessary, must be ordered by the physician, and the ordering physician must use the result in the management of the beneficiary’s specific medical problem.

Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary and should not be billed under Medicare Part B.

A physician’s standing order is not sufficient to order a series of blood glucose tests payable under the Clinical Laboratory Fee Schedule.

These requirements might make billing Medicare Part B for blood glucose fingersticks not worth the effort that goes into it. For example, with the added burden of physician certification for each fingerstick, a 120-bed facility will probably end up with 15−20 fingersticks that it can bill to Part B per month—for $6,000—and receive $9,000 in return for its efforts. Facilities should evaluate whether it’s worth the time and effort to meet CMS’ requirements.

Increased financial pressure
Skilled nursing facilities are under increasing financial pressure and Medicare accounts for a large portion of their revenue. HCPro's Medicare Boot Camp - Long-Term Care Version will give you the knowledge and confidence to:

Find the answers for your most troublesome Medicare questions
Determine the correct MDS-driven payment category and bill accurately
Improve interdepartmental communication to avoid compliance pitfalls
Prevent missing revenue and denials
Improve communication that will increase the productivity of your billing and MDS staff
Gain nursing and nursing home administrator CEUs

Avoid the common pitfalls of consolidated billing

Mon, 04 Jan 2010 19:49:00 GMT

The intricacies of consolidated billing continue to challenge even the most experienced billers. Often, the issues that cause the greatest uncertainty are shared across the industry.

For that reason, Elizabeth Malzahn, health and wellness finance manager at Covenant Retirement Communities in Skokie, IL, compiled a list of some of the most common pitfalls associated with SNF consolidated billing:

Distinguishing Major Category I items
Failing to establish a contract or agreement with outside vendors
Failing to create a process for paying outside invoices

Ron Orth, RN, NHA, CPC, RAC-MT, president of Clinical Reimbursement Solutions in Milwaukee, agrees that these three issues continually trouble many billers and offers an additional common pitfall:

Remembering the leave of absence rule and the midnight rule

All four issues are addressed by Malzahn and Orth in the hope of not only summarizing the relevance of each, but more importantly, offering valuable tips and solutions to help billers handle these common pitfalls of consolidated billing.

Major Category I items

Major Category I services that are not performed at a hospital will not be excluded from consolidated billing, requiring a SNF to cover the cost.

One of the reasons CMS encourages treatment at hospitals is because it feels that hospitals are the most appropriate setting for providing extensive services to geriatric residents, says Malzahn. If anything were to go wrong or if an emergency arose, the resident would already be in a hospital setting where equipment, staff members, and greater resources are typically available to handle any occurrences, she says.

The arrangement is win-win given that residents can receive the best care and SNFs can avoid additional expenses, Malzahn adds.

“I think that’s what CMS’ motivation was behind that, because that’s really where they wanted the services provided, and what better incentive?” she says.

However, some treatments can also be delivered outside of a hospital. When a resident is sent to one of those locations, a facility becomes liable for the costs.

Orth says three of the most common services performed outside of a hospital are CT scans, MRI, and radiation treatment.

“I think the best thing that a facility can do is when these tests are ordered—somebody orders a CT scan, somebody orders an MRI—they need to be asking the appropriate questions before the resident is sent,” he says. “And the No. 1 question you want to ask is: Where are they having this done?’

The problem occurs when this question is not addressed or when facility staff members do not communicate information regarding a resident’s service needs.

“A lot of times what happens is the individuals who are actually scheduling the appointments may be ward clerks or medical secretaries, who are actually working on the floor,” Malzahn says. “So there’s a disconnect between who’s scheduling it and who’s receiving the bill and possibly an assumption that the staff scheduling the appointments are aware of these place of service criteria.”

To address this issue, Malzahn recommends creating a resource guide for staff members who schedule resident appointments. The guide should list locations where services should be provided and indicate what the priority should be in selecting a location, making it clear that Major Category I items should be executed at a hospital whenever possible.

“Just have something quick at the nurses’ station or at the ward clerk desk so they understand to make every effort to schedule these specific services in a hospital,” Malzahn says.

Contracts with outside vendors

To avoid discrepancies later on, Malzahn and Orth recommend establishing contracts with outside vendors from the very beginning, thus forging a payment agreement regarding the service before it is actually provided.

“If you don’t do that and you send [the resident], they have every right to basically bill you whatever their usual and customary charge is,” Orth says. “And now you might have this dispute about what they’re billing you and what you want to pay, and it’s best to have that beforehand.”

This may seem like an easy issue to avoid. Still, most facilities do not establish agreements from the get-go, says Malzahn, who attributes this to a lack of communication. “Again, I think it’s that disconnect,” she says. “Who do we have contracts with? Who do we not have contracts with? I think there are a lot of assumptions made.”

Orth says it is especially important to enter into contractual agreements with outside vendors that are routinely used.

“I also understand that there are times when a doctor may order something and there is only one place that does it, and maybe you don’t have a standing contract with that particular provider,” Orth says. If that’s the case, the facility should make every effort to come to a financial agreement before the service is provided, he says.

Malzahn points to the best practices insight offered by CMS, which details why an early agreement is so important.

“At this point, CMS hasn’t made it mandatory, but they’ve made as many suggestions and put as much emphasis on it that they can,” she says.

Although print documentation is always best, the contract doesn’t necessarily have to be written, Malzahn says. “It can be verbal and it also can just be something that we’re sending with the resident out to their appointment that says, ‘This person is Medicare Part A. We expect you to bill us for any included services and we’ll pay you at the fee schedule.’ Because if we don’t have an agreement, then that vendor is not required to accept the Medicare fee schedule as payment,” she says.

Still, it is best to draft a contract with an outside vendor as early as possible to avoid any last-minute agreement concerns and potentially ensuing discrepancies.

A simple way to manage this issue is to compile an easily accessible binder that contains all information regarding outside vendors, explains Malzahn. It should include the contracts that have been established and ones that need to be drafted. Anyone who needs to identify this information should have access to the binder, which could prove to be a resource capable of saving a facility many unnecessary costs and headaches. Paying outside invoices

With the high numbers and varieties of outside invoices received, it is critical that SNFs stay on top of finances and keep organized. Creating an invoice payment process will do just that, Malzahn says.

Facilities need to scrutinize each invoice and ask themselves three questions:

Was the billed resident on Part A?
Are we sure we have to pay for this item or service?
Do we have an already established agreement with this vendor and, if so, are we paying the correct fee schedule amount?

Going through such a step-by-step process will help eliminate potential payment mistakes, Malzahn says.

“For a bill to come into the business office for $1,500 for an MRI, a lot of places aren’t even sending that to the director of nursing for approval,” she says. “They’re coding it and paying it.”

Facilities also need to make sure they are only paying for the technical component of services, says Orth. The technical component is the actual test performed, such as an MRI, and the professional component is the physician’s time and interpretation.

“There are certain tests and procedures that are performed that have both a professional component and a technical component, so there’s really two fees associated with that particular test or procedure,” Orth says. “The SNF is only responsible for the technical component.”

Orth adds that it is important to remember the leave of absence rule and the midnight rule when addressing outside invoices.

“If a resident departs your facility and does not return before midnight, then any charges that are assumed while that resident is gone from your facility are not part of consolidated billing and are not the SNFs responsibility,” he says.

A sleep study is a prime example, Orth says. If a facility pays for a resident taking part in a sleep study off-site, the SNF should not be billing for that day under Medicare because of the midnight rule—if a resident is not in the facility at midnight, that day is nonbillable.

“For consolidated billing purposes, the resident ceases to be a resident of the facility if they’re not in your building at midnight,”Orth adds.

Malzahn and Orth agree that efficient communication is critical in dealing with each of these consolidated billing common pitfalls. Staff members need to share pertinent information. Doing so not only helps ensure that everyone is on the same page, it also serves as a reminder that resources are readily available to answer any questions or uncertainties involving consolidated billing.

“It comes down to a basic principle: Know what services your residents are getting, where they are getting them, and how much you’re going to pay for them,” Orth says.

“It’s so simple, but it’s so overlooked,” Malzahn says.

Source: Billing Alert for Long-Term Care, November 1, 2009

For more information on consolidated billing visit HCPro's Medicare Boot Camp® - Long-Term Care Version.

Ostomy, urological, and tracheostomy supplies: An easier approach to Part B billing

Mon, 07 Dec 2009 18:29:00 GMT

Similar to Part A services, facilities can bill Part B ostomy, urological, and tracheostomy supplies directly to their Fiscal Intermediary/Medicare Administrative Contractor (FI/MAC).

Since SNF business offices are familiar with this process, billing for these supplies is not as labor-intensive and time-consuming as billing for other Part B items. Ultimately, billing Part B ostomy, urological, and tracheostomy supplies can generate revenue for a SNF without the problems that can accompany other supply billing procedures.

Familiar billing process

Although a facility can bill Part B ostomy, urological, and tracheostomy supplies directly to their FI/MAC using the UB-04, the Part B billing requirements differ from those of Part A.

Part B requires line-item date-of-service billing. This means each supply, accompanied by the corresponding HCPCS code and service date, must have its own line on the bill.

Since ostomy, urological, and tracheostomy supplies are considered prosthetic or orthotic devices, revenue code 274 must be included for each item on the claim.

Medical necessity and coverage requirements

Billing for ostomy, urological, and tracheostomy supplies involves a wide variety of items. For example, covered ostomy supplies typically include:

Ostomy faceplates
Pouches
Adhesives
Barriers

Part B–billable urological supplies include:

Insertion trays
Catheters
Collection devices

Since Medicare only covers certain items associated with tracheostomy care provided to SNF residents, facilities should only bill for a limited number of tracheostomy supplies, such as care kits.

But before submitting Part B claims for these supplies, SNF billers must ensure that the criteria for medical necessity and coverage requirements are met.

Medicare Part B covers:

Ostomy supplies provided to a SNF resident with a surgically created opening to remove waste, such as urine or fecal matter, from the body.
Urological supplies provided to a resident with permanent urinary incontinence or permanent urinary retention.
Tracheostomy care kits provided to a SNF resident after a surgical tracheostomy. The tracheostomy must be expected to remain open for a minimum of three months.

Supplies not essential to these processes are considered medically unnecessary and, therefore, not covered by Medicare.

Although CMS’ NCDs establish basic coverage criteria for services and supplies, many FIs and MACs have created more detailed requirements. These LCDs can be found on contractors’ Web sites and often require additional documentation to support the medical necessity of a service or supply. If a biller is aware of this requirement, he or she can inform the clinical staff about what is needed and, ultimately, avoid problems before they occur.

Detailed documentation

All ostomy, urological, and tracheostomy supplies require a physician’s order, which should be as specific as possible. The physician’s order must specify the type and quantity of supplies. Any change in supply type or increase in supplies requires a new order. You must have clinical supporting documentation for each supply.

Before submitting a claim, check that all diagnosis codes are appropriate for the services being billed. If you have any questions about diagnosis codes, documentation, or the physician’s orders, seek assistance from the clinical staff.

Given the detailed documentation and facilitywide cooperation needed, billing your FI/MAC for Part B ostomy, urological, and tracheostomy supplies is truly a team effort.

Additional education
HCPro, Inc. offers many educational tools to help master the billing for Medicare Part B including HCPro’s Medicare Boot Camp – Long-Term Care Version which covers the Medicare rules and regulations applicable to skilled nursing facilities. The objective of this four-day course is to provide course participants with a detailed understanding of the Medicare "rules" with a particular emphasis on the operational application of those rules. Billing for ancillary services under Medicare Part B is just one agenda item covered during the four-day course. Make sure your facility isn’t leaving money on the table. At the end of the course, you’ll be able to:

Identify services billable by a SNF to Medicare Part B
Identify the component parts of a NCD
Identify billing requirements for Pneumoccoccal pneumonia, Influenza, and Hepatitis vaccinations
Define a DME MAC
Identify coverage of DMEPOS in a nursing facility
Describe the difference between claims that are submitted to the DME MAC vs. the FI

CMS posts chapters of the RAI User's Manual

Mon, 07 Dec 2009 15:33:00 GMT

The Centers for Medicare & Medicaid Services (CMS) released chapters 1, 3, and 5 of the new RAI User’s Manual for the MDS 3.0 late November. Appendices A through G, and H were also released. Chapters 2, 4, and 6, and Appendix C are scheduled to be posted on the CMS Web site in December.

To view chapters 1, 3, and 5 of the RAI User’s Manual for the MDS 3.0, visit the CMS Web site.

Visit MDSCentral for continued analysis on the MDS 3.0.

Observations from the field: Proper hand washing techniques

Mon, 07 Dec 2009 15:23:00 GMT

By: Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, Boot Camp Instructor

As we discussed in a previous issue of LTC Educator’s Corner, the Centers for Medicare & Medicaid Services has revised F441, Infection Control by combining it with F442, Isolation and Preventing the Spread of Infections, F443, Employee Communicable Diseases, F444, Hand washing, and F445, Linen Handling.

Hand hygiene continues to be the primary means of preventing the transmission of infection in long-term care. F441 stresses the importance of consistent proper hand washing techniques.

The recommended technique for hand washing using soap and water is as follows:

Wet hands with clean, warm water.
Apply cleaning product according to manufacturer instructions.
Rub hands together vigorously for a minimum of 15 seconds, remembering to cover all surfaces of the hands and fingers.
Rinse with water.
Dry thoroughly with disposable paper towel.
Turn off faucet with disposable paper towel.

The recommended technique for hand washing using alcohol-based hand rubs (not appropriate for use in a food service setting) is as follows:

Apply the product according to manufacturer instructions to the palm of one hand.
Rub hands together, covering all surfaces of the hands and the fingers until the hands and fingers are dry.

Situations which require hand washing include, but are not limited to, the following:

Before and after eating or handling food
Before and after assisting a resident with meals
Before and after coming in contact with a resident’s intact skin (pulse, blood pressure, lifting, etc.)
Before and after assisting a resident with toileting
After removing gloves or aprons

CMS releases final MDS 3.0

Mon, 02 Nov 2009 18:12:00 GMT

The Centers for Medicare & Medicaid Services (CMS) released the much anticipated final MDS 3.0 item set on October 29, giving long-term care providers approximately one year to prepare for implementation of this new assessment tool.

“The release of the final MDS 3.0 item set is very exciting news for the long-term care industry,” says Diane Brown, a regulatory specialist, consultant, and Boot Camp instructor at HCPro. “Although the previous drafts gave us a good idea of what to expect, facilities could not do much in terms of preparation without the final version. Now, we can start preparing for the October 2010 implementation, which will be here before we know it.”

In addition to the various item subsets for each MDS 3.0 assessment (e.g. admission, quarterly, annual, etc.), CMS released the following files:

MDS 3.0 Item Matrix – This document identifies the items required for each type of assessment along with how the item is used.
Data Technical Files – This file contains the following MDS 3.0 technical specification information:

o MDS 3.0 Data Submission Specifications – Detailed data submission specifications for MDS 3.0.
o RUG-IV SAS Package – Thoroughly tested SAS code for RUG-IV classification with documentation and test data.
o RUG-III MDS 3.0 Mapping Specifications – This document presents logic that can be used to produce RUG-III classifications using assessment items contained on MDS 3.0.
o MDS 3.0 Care Area Trigger (CAT) Specifications – For each Care Area, this document provides CAT specifications for the MDS 3.0 items used in triggering the Care Area, the conditions for triggering, and Visual Basic code for triggering. The CATs are replacing the MDS 2.0 Resident Assessment Protocols (RAP).

The release of the MDS 3.0 RAI User’s Manual, however, has been delayed. Rather than release the manual in its entirety, CMS is planning to release it in sections and anticipates that Chapters 1, 2, 3, 5, and 6 will be published in November, while Chapter 4 (Care Area Assessments (CAA)) and Appendix C (CAA resources) will be released in December.

According to CMS, the manual, once published, will include “description and instructions for types of assessments and tracking documents, each MDS 3.0 item, the CAA, submission and correction of MDS 3.0 records, SNF and Swing Bed Prospective Payment System (PPS) policy for the MDS 3.0, and the RUG-IV classification system.”

“Once the RAI User’s Manual is released, we will have a better understanding of how to code the MDS 3.0,” Brown says.

To view the final MDS 3.0 item set, visit the Resources page on MDSCentral.

For additional files, visit the CMS Web site.

Check MDSCentral next week for additional analysis of the MDS 3.0

A strong MDS team leads to a more accurate, efficient MDS process

Mon, 05 Oct 2009 17:44:00 GMT

The role of MDS coordinator is vital to the viability and operating efficiency of nursing homes. Although job descriptions for this position tend to be similar throughout the long-term care industry, approaches to the job run the gamut from solo operator to ultimate team coordinator. The insight gained from examining diverse approaches can yield better processes with less reliance on a single person and greater reliance on a functional, diverse team.

An MDS team could include the director of nursing, members of the interdisciplinary team, unit managers, and certified nursing assistants (CNA). Direct line and ancillary staff members should also be involved in the MDS process since these staff members have the most relevant and nuanced knowledge of residents and patients. These include, but are not limited to line staff members, housekeeping staff members, volunteers, hairdressers, and activities professionals. The wealth of information that can be gleaned from these staff members promotes quality care and can lead the clinical and MDS team to uncover root causes and develop appropriate and focused interventions.

For example, if a diabetic patient who recently lost weight suddenly experiences high blood sugar spikes every afternoon, it might lead to increasing medication to lower the blood sugar. But if a CNA or a housekeeping staff member observes family members providing the patient with high-sugar snacks so the patient can regain weight and reports it to the clinical and MDS team, a more appropriate educational intervention could be developed in addition to treating the short-term problem.

Recent studies and literature confirm the benefits of a team approach. Teams foster automatic patterns of communication regarding resident needs and identification of subtle changes that could lead to adverse outcomes.

Ads seeking MDS coordinators frequently mention teamwork. Using team-gathered information to complete an MDS improves accuracy. If the data captured in the MDS are accurate, resource utilization group (RUG) scores will be compliant and optimal.
The question is, do we practice what we know is the best model? Anecdotal evidence gathered from years of listening to and interviewing MDS coordinators suggests reality does not always match best practice.

Attitude affects teamwork
Multiple factors, including attitudes and clashing personalities, can impede teamwork. Working in such a setting forces MDS coordinators to act as solo operators to get the job done.

Expectations need to be set high. If administration enforces respect and courtesy among coworkers, petty differences can be set aside for the benefit of resident care. Encouraging an open-minded environment fosters contributions from all staff members. The administrative and corporate team needs to buy into, or be convinced to buy into, teamwork.

The effect of training and communication
A facility experiencing high staff turnover or that has recently introduced new staff members will face challenges working as a team. The introduction of new team members requires patience and effort to develop the trusting relationships that make teamwork effective.

Teaching teamwork and communication skills for new staff members and as a refresher for existing staff members should be a part of staff development. Relating education to residents and peer situations will enhance the results.

Changing old habits
The RAI was introduced in 1990 to emphasize tasks rather than process and methods. Usually, MDS tasks were completed by the MDS coordinator in a vacuum. Since 1998, the industry has used MDS information to calculate payment for Medicare and, in many states, Medicaid.

Although most facilities realized that an MDS team would produce better reimbursement, they found it difficult (and continue to find it difficult) to overcome ingrained habits and make the fundamental changes necessary to build a strong MDS team.

Good business practices
Have you ever heard MDS coordinators express how unappreciated they feel by their peers and bosses? Upper-level management should recognize and monitor this situation and be prepared to intervene before it escalates from “I’m not appreciated” to “I’m irreplaceable and nobody really knows or cares what I do (or should do).” Quick investigation and prompt intervention is required, as this type of invincibility never has a good long-term outcome and defies good team process.

There are many aspects of the MDS process requiring precise adherence to technical details with the goal of 100% accuracy. The responsibility can be inundating. Upper management should not assume the MDS coordinator has it all under control.

Offering support and checking frequently to make sure MDS coordinators are not feeling overwhelmed is a simple and effective way of alleviating this common condition.
Although MDS coordinators may feel overwhelmed, some choose to complete the MDS process on their own because it is faster or easier than working with a team. Working with an MDS team can provide MDS coordinators with the support they need to thrive and lessen the burden of completing the entire MDS. Transitioning from a solo operator to a team member may initially be challenging for some coordinators, but many will welcome the opportunity to take vacations or leave work for the evening feeling comfortable that the MDS process is under control.

HCPro, Inc. offers many educational tools to help prepare for the MDS 3.0, including bringing a customized MDS 3.0 version of the popular HCPro Boot Camps to your facility and train all your staff at once.

Hosting an HCPro Boot Camp at your facility:

Keeps employees in one convenient location and eliminates travel cost
Allows instructors to focus on the issues that affect your facility; no wasted time reviewing issues that may or may not apply
Empowers staff members with knowledge to avoid situations that lead to survey deficiencies or monetary losses
Boosts employee confidence and retention by providing a valuable professional development opportunity

For more information on bringing a boot camp to your facility, contact client relations manager Adrienne Trivers at atrivers@hcpro.com or 781-639-1872 ext 3207.

Observations from the field: It's time to update your infection control policy and procedures

Mon, 05 Oct 2009 15:50:00 GMT

By: Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, Boot Camp Instructor

Hey there, what’s new? The answer is “a lot.” As of September 30, 2009, the revisions to the Interpretive Guidelines for Long-Term Care Facilities F-tag 441 is effective. If your infection control coordinator, now referred to in the regulation as the Infection Preventionist (IP), has not yet implemented any changes with your infection control program, now is the time to review it and ensure you are compliant. A scope and severity of A, B, or C will not apply with this tag since non-compliance has the potential to cause harm. A copy of the Transmittal 51 is available on The Centers for Medicare & Medicaid Services Web site.

F-tags 442, 443, 444, and 445 have all been combined and incorporated into F-tag441, Infection Control. The regulatory language is the same. It states “The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.”

No longer acceptable is a simple log of everyone on antibiotics with an end-of-the-month list of type of infections and where the infections were. The facility’s infection control program should emphasize the prevention of the onset of infections, recognizing infections, management of infections until resolved, and control of the spread of infections. Ongoing surveillance by the IP is crucial to maintain compliance. This is accomplished through monitoring staff compliance (process surveillance) and reviewing information to detect trends and outcomes (outcome surveillance). Use of a standard list of infection criteria is common. Most facilities use the McGeer’s list of infections that can be found in the article entitled, Definitions of Infection for Surveillance in Long-Term Care Facilities.

The expectations are extensive but clear, and it’s in the best interest of the resident and the facility to ensure adequate documentation of compliance and educate staff on the facility’s updated infection control policy and procedures.

Next month we’ll focus on hand-hygiene, types of transmission-based precautions, and linen handling from the F-tag 441 interpretive guidance.

Hot shot pop quiz

Mon, 07 Sep 2009 19:38:00 GMT

TAKE THE QUIZ AND WIN!

Do you know the answer to the question below? If so, submit your name and answer to Managing Editor Adrienne Trivers at atrivers@hcpro.com . Each correct answer will be entered into a drawing with a chance to win a complimentary copy of Satisfied Customers Seldom Sue: A Guide to Exceptional Customer Service in Long-Term Care.

Can you describe the five different audits that can have significant financial and compliance implications for facilities?

Hot shot pop quiz

Mon, 07 Sep 2009 17:55:00 GMT

TAKE THE QUIZ AND WIN!
Do you know the answer to the question below? If so, submit your name and answer to Managing Editor Adrienne Trivers at atrivers@hcpro.com. Each correct answer will be entered into a drawing with a chance to win a complimentary copy of Satisfied Customers Seldom Sue: A Guide to Exceptional Customer Service in Long-Term Care.

Can you describe the five different audits that can have significant financial and compliance implications for facilities?

Your Medicare Program: Communication is the key

Mon, 07 Sep 2009 17:53:00 GMT

By: Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, Boot Camp Instructor

Medicare admissions usually happen like this: The hospital faxes information to one individual at the facility. That individual decides if they can meet the resident's needs and reports during the daily management meeting that the facility is getting an admission at 11 a.m. that day. The nursing assistants come to the desk at 1:30 p.m. and tell the nurse they didn’t know there was a new resident and that the resident is hungry. Therapy complains about nursing, and nursing complains about therapy. No one attends the weekly Medicare meeting except the MDS coordinator and a therapist. Doesn't sound like much of an interdisciplinary process, does it? If this doesn't sound familiar, then stop reading and take a break. If it sounds all too familiar, then keep reading.

Since meeting a resident's needs involves staff from all departments, it is best practice to include key individuals in the admission process. Everyone has a role in making the transition from the hospital to a nursing home a positive experience for the resident; the customer we are supposed to case manage. Whether a formal or an informal format, the following collaborative efforts should take place:

Business office will need to verify benefits in the common working file
Both nursing and therapy will need to determine if there is a specific skilled need that is reasonable and necessary
Nursing will need to determine if they can meet the residents needs with medication, equipment (i.e. specialty bed, dressings), or staff competency (i.e. IV training)
Therapy will need to determine if they have adequate staff to provide the treatment since many facilities do not employ dedicated full-time therapists from all disciplines
Social services and activities will be involved in the process as well to identify any special needs and confer with the MDS coordinator on the resident’s preferences, history, and customary routines
The decision to admit takes place with all in agreement as to the resident’s specific needs
All departments are alerted regarding the admission
Housekeeping will ensure the room is ready for the new admission from linens in good condition to a properly hanging curtain
Dietary will ensure the first meal is scheduled timely with the appropriate diet
Maintenance will ensure that all the equipment is in working order from the bed adjustments to the call light devices
Nursing has all necessary equipment available and staff is trained on any special needs (i.e. negative pressure wound therapy device, continuous passive motion devices)
A collaborative initial care plan meeting with the resident/family to discuss treatment and goals for treatment

The Medicare admission process, like any admission, is an interdisciplinary process. Communication between departments and the resident/family not only ensures successful case management for the resident in your Medicare program, it can move your facility one step closer to a person-centered culture change and build a stronger team. It's a win-win situation for everyone. A solid Medicare program can become reality if the facility's key individuals commit to the process.

Master the Medicare appeals process

Mon, 07 Sep 2009 17:47:00 GMT

At one point or another, many SNFs will disagree with their fiscal intermediary’s (FI), Medicare administrative contractor’s (MAC), or carrier’s decision to deny a claim. When this occurs, a facility should not hesitate to file an appeal.

Appealing a denial must be a team effort, involving all facility staff members who participated in billing or providing the service in question. Although the individual staff members involved may vary depending on the service or reason for denial, a facility’s MDS coordinator, administrator, billers, therapists, and members of the clinical and medical records staff all typically play a role in the appeals process.

Nursing home billers are critical to preventing and identifying denials and gathering information for an appeal. Since the appeals process can be confusing and time-consuming, SNF billers must have a clear understanding of the system and the important role they play.

Understand the process

FIs, MACs, and carriers deny claims for several reasons, such as insufficient documentation or the diagnosis code not supporting the medical necessity of the service. In some situations, the person reviewing the claim could have overlooked important information and mistakenly denied it. Regardless of the reason for denial, providers have the right to appeal.

The following are the five levels of the Medicare appeals process:

1. Redetermination. The first level of appeal, known as redetermination, must be filed with the FI, MAC, or carrier responsible for the initial determination. Facilities must submit a written request for redetermination within 120 days of receiving the notice of initial determination. Although not required, a request for redetermination can be filed using Form CMS-20027, which can be found on the CMS Web site at www.cms.hhs.gov/CMSForms/CMSForms. The FI, MAC, or carrier has 60 days from receipt of the redetermination request to issue its decision.

2. Reconsideration. If it is unsatisfied with the result of the redetermination, a facility can move on to the second level of appeal, known as reconsideration, in which a qualified independent contractor (QIC) reviews the claim.

A facility must file a written reconsideration request with the appropriate QIC within 180 days of receiving the redetermination. The Medicare Redetermination Notice will identify the QIC to which a facility should submit the request. Although not required, a reconsideration request can be filed using Form CMS-20033, which will be mailed with the Medicare Redetermination Notice. The QIC has 60 days from receipt of the reconsideration request to issue its decision.

3. Administrative law judge (ALJ) hearing. The ALJ hearing is the third level of appeal. A written request for an ALJ hearing must be filed within 60 days of receiving the QIC decision. Although not required, an ALJ request can be filed using Form CMS-20034.

To request an ALJ hearing, the amount that remains in controversy must meet the minimum amount requirement, which is adjusted annually ($120 this year). The ALJ has 90 days to issue a decision. However, if it is unable to do so, the facility can request that the appeal be escalated to the next level of review.

4. Medicare Appeals Council. If it is unsatisfied with the result of the ALJ hearing, a facility can request a review by the Medicare Appeals Council, which is part of the Departmental Appeals Board. The request for a review by the appeals council must be filed within 60 days of receiving the ALJ decision.

The ALJ will provide instructions on how and where to submit a request for an appeals council review. The appeals council has 90 days to issue a decision, and if it fails to do so, the facility may request the council to escalate the appeal to the judicial review level.

5. Judicial review. The final stage of the appeal process is judicial review in a U.S. District Court. To request a judicial review, the amount that remains in controversy must meet the minimum amount requirement, which is adjusted annually ($1,220 this year). A facility must file a request for a judicial review within 60 days of receiving the Medicare Appeals Council’s decision.

The biller’s role
SNF billers can help their facility avoid denials through accurate coding and ensuring that the documentation supports the services on the claim. However, avoiding denials altogether would be nearly impossible, and SNF billers should be prepared to identify and respond to denied claims.

FIs, MACs, and carriers communicate claim determinations to providers using a notice called remittance advice. Remittance advice notices are issued daily and are usually sent to a SNF’s business office.

Once a biller identifies a denial, he or she should communicate with other staff members involved in billing or delivering the denied service to determine whether the documentation supports a case against the contractor’s decision. If so, these staff members should begin to compile the documentation and information needed to request a redetermination.

Prove your point
If a facility chooses not to use Form CMS-20027 to request a redetermination, the written request must include the following information:

Beneficiary’s name
Medicare health insurance claim number
Specific services and/or items being appealed
Specific dates of service
Name and signature of the beneficiary or representative of the beneficiary

In addition to the basic information included in the request, facilities should send documentation related to the denial reason and any other information that supports the need for the skilled service during the period in question. Examples of the additional documentation that may support a claim are:

Physician orders
Progress notes
Therapy evaluations
MDS assessments
Documentation to support the codes on each MDS
Medication and treatment records
Discharge summary

HCPro, Inc. offers many educational tools to help master the Medicare appeals process including HCPro’s Medicare Boot Camp – Long-Term Care Version which covers the Medicare rules and regulations applicable to skilled nursing facilities. The objective of this four-day course is to provide course participants with a detailed understanding of the Medicare "rules" with a particular emphasis on the operational application of those rules. The Medicare appeals process is one agenda item covered during the four-day course. Be able to identify correct level of appeals process. At the end of the course, you’ll be able to:

· Identify the correct level of appeals process

· Identify the difference between reopening versus an appeal

· Identify the requirements for Medicare claims appeals

· Identify the CMS forms used during the appeals process

Hot shot pop quiz

Mon, 03 Aug 2009 13:30:00 GMT

What is the Five-Star Quality Rating System?

Observations from the field: Staging pressure uclers

Mon, 03 Aug 2009 13:22:00 GMT

By: Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, Boot Camp Instructor

As we mentioned in last month’s issue, the National Pressure Ulcer Advisory Panel (NPUAP) defines pressure ulcers as a "localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction." A pressure ulcer is considered to be "unavoidable" when it develops despite an evaluation of risk factors with implemented and monitored interventions. A pressure ulcer is considered to be "avoidable" when one or more of the following did not occur:
               • Evaluation of clinical condition and risk factors
               • Implementing interventions
               • Monitoring and evaluating the interventions
               • Revising when appropriate

Evaluation of a pressure ulcer includes assessment of the pressure ulcer stage, drainage, infection, and condition of the wound bed. Without this assessment, a realistic goal and an appropriate dressing cannot be determined. The key concept is to assess them right, then treat them right.

NPUAP descriptions of pressure ulcer stages are as follows:

Suspected Deep Tissue Injury:
"Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue." In individuals with darker skin tones, this may be difficult to detect.

Stage I:
"Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area." A Stage I may be firm, soft, warm, cool, or painful compared to surrounding tissue.

Stage II:
"Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." A Stage II may appear as a shiny or dry shallow ulcer, and should not be used to describe skin tears, maceration, or excoriation. It presents without slough or bruising (bruising indicates a suspected deep tissue injury).

Stage III:
"Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling." The depth may vary by anatomical location,
so the nose, ear, occiput, and malleous Stage III’s may be shallow in appearance. In those individuals with a significant amount of adipose tissue, a Stage III may not visibly reveal bone or tendon.

Stage IV:
"Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling." As with Stage III’s, the depth may vary by anatomical location. However, Stage IV’s may extend deep into muscle and/or supporting structures such as fascia or tendons. The bone/tendon is visible or directly palpable.

Unstageable:
"Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed." Slough and/or eschar must be removed to expose the base of the wound to obtain a true depth, therefore the wound is considered unstageable until then. Any eschar on the heels that is stable (dry, adherent, intact without redness or fluctuance) serves as the body’s biological cover and should not be removed.

Assessing pain in the elderly

Mon, 03 Aug 2009 13:15:00 GMT

As a group, elderly individuals are frequently undermedicated. This is ironic because they often suffer from acute and chronic painful diseases and have multiple medical conditions that are capable of causing pain. The problem is complicated by existing delirium, dementia, and cognitive impairment in some residents. The well-published results of one study revealed that 71% of residents in long-term care facilities said they experience pain¹ Most were unhappy with the quality of nursing pain management.

Being in pain causes residents to be dissatisfied with the overall quality of facility care and promotes behavior problems. Unrelieved pain has the potential for causing delirium in otherwise stable individuals. In another informal study, nurses administered acetaminophen three times a day to 10 cognitively impaired residents with difficult behavior, who were also receiving psychotropic medication. This study showed a 63% reduction in behavioral symptoms over the course of a month. Seventy-five percent of the psychotropic drugs were discontinued.²

In a 1998 study, researchers found that 47% of the alert residents had a routine pain medication order. Only 25% of the cognitively impaired residents had analgesic orders. Additionally, cognitively impaired residents were given less pain medication compared with those who were alert.³ When residents with recent postoperative hip fractures were studied, 12 cognitively impaired persons received less opioid analgesia than did alert individuals during the first 48 hours postoperatively. After the initial 48-hour postoperative period, persons with cognitive impairment received significantly less acetaminophen than the alert persons in the study.⁴

In another study, 14 cancer patients over age 85 were less likely to receive narcotic analgesics than were patients 65 to 74 years of age. Of those who experienced daily pain, 26% received no analgesia. Cognitively impaired persons received significantly less pain medication, either PRN (as needed) or routine, compared with patients who were alert.⁵ Another study found that 60% of the residents in one long-term care facility with at least one painful diagnosis received no pain medication during the previous month.⁶

Some residents believe that pain is part of normal aging. Evaluating cognitively impaired residents may be especially difficult. Care for residents in long-term care is designed to assist residents to achieve optimal function, independence, and quality of life. Obviously, pain decreases quality of life and can have a devastating effect on the resident’s ability to achieve the highest level of function. Monitoring for, developing, and implementing a pain-relieving plan of care is essential.

The undertreatment of pain has the potential for numerous harmful effects. The maxim "no pain, no gain" has proven to be dangerously wrong. Research has shown that unrelieved pain can inhibit the immune system and enhances tumor growth. Pain causes increased oxygen demand, respiratory dysfunction, decreased gastrointestinal (GI) motility, and confusion. Severe acute pain is a major risk factor for chronic neuropathic pain.⁷

Nurses must consider pain the fifth vital sign and assess all residents regularly. Assessing residents for pain once each quarter when the MDS is completed is not adequate in this population.

Pain is a major preventable public health issue that slows recovery and increases healthcare costs.8 The most common nursing diagnoses for residents with pain are:

Activity intolerance (related to decreased muscle tone and strength from inactivity
Disturbed sleep pattern and sleep deprivation (related to pain and anxiety)
Ineffective coping (related to persistent pain)
Risk for disuse syndrome
Impaired physical mobility
Impaired comfort
Acute pain
Chronic pain (although "persistent pain" is the preferred terminology, the nursing diagnosis has not been updated)

Types of pain

Pain is never normal. It is always sign of something wrong. Unrelieved pain is a serious problem, with many significant physical and psychological consequences. It interferes with the resident’s optimal level of function and self-care. It contributes to immobility, increasing the risk of pneumonia, skin breakdown, contractures, behavior problems, depression, and many other complications. There are four basic types of pain:

Acute pain: Occurs suddenly and without warning but usually dissipates over time. This type of pain commonly occurs because of an injury or surgical procedure.
Persistent pain (this is a newer term that replaces “chronic” pain): This type of pain persists for more than six months. It may be constant or intermittent. It is often caused by chronic disease, residual from an old injury, or multiple medical problems. Unrelieved, it decreases quality of life, causes hopelessness, and may cause anxiety, depression, and a feeling of helplessnes.
Phantom pain: Develops as a result of an amputation. The pain is real and not imaginary.

Radiating pain: This pain moves from the site of origin to another area of the body.

The following article is an excerpt from The Long-Term Care Nursing Desk Reference, Second Edition by Barbara Acello, MS, RN.

References

"Long-Term Care Survey Monitor," www.hin.com. (accessed January 16, 2003).
Douzjian, M., Wilson, C., Shultz, M., et al. "A Program to Use Pain Control Medication to Reduce Psychotropic Drug Use in Residents With Difficult Behavior." Annals of Long-Term Care 6(5) (1998): 174–179.
Kaasalainen, S., Middleton, J., Knezacek, S., Hartley, T., Stewart, N., Ife, C., Robinson, L., "Pain and Cognitive Status in the Institutionalized Elderly," J Gerontol Nurs, 24 (1998):24–31.
Feldt, K., Ryden, M., Miles, S. "Treatment of Pain in Cognitively Impaired Compared With Cognitively Intact Older Adults With Hip-Fracture," J Am Geriatr Soc 1079–1085 46(1998).
Bernabei, R., Gambassi, G., Lapane, K., Landi, F., Gatsonis, C., Dunlop, R., Lipsitz, L., Steel, K., Mor, V., "Management of Pain in Elderly Patients With Cancer," JAMA: 1877–1882 279 (1998).
Feldt, K., Warne, M., Ryden, M., „Examining Pain in Aggressive Cognitively Impaired Older Adults," J Gerontol Nurs, 24 (1998):14–22.
Pasero, C., Paice, J.A., McCaffery, M., "Basic Mechanisms Underlying the Causes and Effects of Pain," Pain: Clinical Manual, Second Edition (St. Louis: Mosby, Inc., 1999), 15-34.

Staff education a key to reducing the risk of eye injuries

Wed, 01 Jul 2009 20:04:00 GMT

Did you know that eye injuries occur at a rate of more than 2,000 per day, with 1,000 of those daily injuries happening on the job? Since July is Eye Injury Prevention Month, it’s only fitting to focus on eye protection. One of the best ways for staff to protect their eyes is to wear appropriate eye protection. The Bureau of Labor Statistics has found that roughly three out of five work-related eye injuries was caused by staff not wearing eye protection or wearing the wrong type of eye protection.

Though the risk of objects falling into one’s eye are high, the risk catching an infectious disease is even higher. The Centers for Disease Control and Prevention (CDC) recommends that nursing home staff wear eye protection when there is the potential exposure to infectious diseases. Keep in mind that regular glasses and contacts are not considered eye protection.

The CDC defines infectious diseases as those that can be transmitted through various mechanisms, including infections that can be introduced through the mucous membranes of the eye (conjunctiva). These include viruses and bacteria than can cause conjunctivitis (e.g., adenovirus, herpes simplex, Staphylococcus aureus) and viruses that can cause systemic infections, including bloodborne viruses (e.g. hepatitis B and C viruses, human immunodeficiency virus), herpes viruses, and rhinoviruses. Infectious agents are introduced to the eye either directly (e.g., blood splashes, respiratory droplets generated during coughing or suctioning) or from touching the eyes with contaminated fingers or other objects.

Eye protection provides a barrier to infectious materials entering the eye and is often used in conjunction with other personal protective equipment (PPE) such as gloves, gowns, and masks or respirators.

Personal protective equipment
Protective barriers reduce the risk of your skin or mucous membranes from being exposed to potentially infected blood and body fluids. You should wear the appropriate barriers for the work you are doing. Employers must provide suitable personal protective equipment (PPE) in the right sizes.

Wear personal protective equipment (PPE) when the nature of the anticipated resident interaction indicates that contact with blood or body fluids may occur. During care delivery, avoid touching surfaces in close proximity to the resident. Prevent contamination of clothing and skin during the process of removing PPE. Before leaving the resident’s room or cubicle, remove and discard gowns and gloves.

There is a variety of types of protective eyewear available. When selecting appropriate eye protection, the CDC suggests asking the following:
• Is the eyewear comfortable?
• Does it allow for sufficient peripheral vision?
• Is it adjustable to ensure a secure fit?

Common eye protection devices are as follows:
• Goggles
• Face shields
• Safety glasses
• Full-face respirators

What combination of eye protection and other PPE should be used?
The CDC suggests that staff should select their eye protection in context with other PPE use requirements. For instance, some safety goggles don’t fit properly when used with half-face respirators. Some face shields may not fit properly over certain types of respirators. When removing eye protection, only handle the area that secures the device to the head. Do not touch the front and sides of the goggles, face shield, etc. Place non-disposable eye protection in a designated receptacle for disinfection. It’s best for each staff member to have his or her own eye protection equipment.