AANAC LTC Leader
Transcription
AANAC LTC Leader
w w w. a a n ac .o r g LTC june 26 2012 LEADER CMS Releases New Five-Star Rating System Judi Kulus, nha, rn, mat, c-ne, rac-mt As of this week, facilities are indicating that they have received a new Five-Star rating from the Casper on-line reporting system. It includes revised survey, staffing, and quality measure date using MDS 3.0 based information. Facilities have received advanced notice of their updated Five-Star ratings and their quality measure reports that will be posted on the Nursing Home Compare website for the public this July. The reports indicate that each facility’s most recent Survey and Certification Statement of Deficiencies (CMS 2567) used to calculate the base portion of the Five-Star rating will be posted directly on Nursing Home Compare. Each facility also received notice that the staffing component of the Five-Star rating is no longer based on RUG III data, but now includes RUG IV adjusted staffing ratios derived from MDS 3.0 case-mix data from assessments completed in 2011, as well as new national averages of reported staffing. continued on page 3 Antipsychotic Medication Use: QIS Forms Can Help, But No Cure-All Caralyn Davis, Staff Writer Six months. That’s how long facilities have to meet the national goal of a 15 percent reduction in antipsychotic drug use in nursing home residents by year-end 2012. The goal is not a federal mandate. However, it has broad-based support from the Partnership to Improve Dementia Care, a coalition that the Centers for Medicare and Medicaid Services (CMS) has established with other federal and state partners, nursing home associations, physician and pharmacy associations, and advocacy groups. Further, stakeholders such as the Willimantic, Conn.-based Center for Medicare Advocacy (CMA) are pushing for CMS to move beyond education and increase enforcement of antipsychotic drug deficiencies. “Although some drug deficiencies are cited each year, their significance is understated and undercoded,” said the CMA in a June 14 Alert. “State survey agencies typically cite continued on page 4 AANAC Expert Advisory Panel Discusses Issues with CMS Jennifer Pettis, RN, BS, WCC, RAC-MT, C-NE, Chair, Expert Advisory Panel The AANAC Expert Advisory Panel (EAP) discussed several outstanding issues with CMS during a call on May 29, 2012. As always, the EAP is very appreciative of the time that CMS takes to discuss issues impacting the membership of AANAC with the Panel. CMS is continuing to evaluate current practices and individual Fiscal Intermediaries/Medicare Administrative Contractors (FI/ MAC) guidance to providers related to patients transitioning from a Medicare Advantage Plan (MAP) to traditional Medicare Part A during a spell of illness. Issues raised included whether or not to restart the assessment schedule and, if the scheduled is not restarted, whether or not those assessments that were previously completed for the MAP are to be submitted. CMS stated that providers should contact their individual FI or MAC continued on page 9 1 Use your abilities to advance your association. Apply to be on the AANAC Board of Directors. What are the benefits of being on the AANAC Board of Directors? There are many. Joining this prestigious group of professionals is an excellent way to become (and remain) up-to-date on the latest issues, concerns and advancements in the regulatory environment that so dramatically affect the long-term care nursing profession. By being on the Board of Directors, you have an opportunity to personally grow as a healthcare professional and to have an impact on the professional growth of your peers as they take the journey with you and AANAC. On a more tangible basis, your attendance at all AANAC Conferences is covered, and upon completion of your Board service, you will become a lifetime member of AANAC. What’s the commitment? • Attend four board meetings per year, along with any called meetings (expect to spend twelve to fifteen days per year devoted to meetings and organizational activities) •R eview materials for board meetings and AANAC’s development. • Share responsibility for setting the strategic direction for AANAC. • Focus on high-level, goal-oriented decision-making. Help shape the future of AANAC. Apply today. Applications are being accepted until July 15, 2012. 2 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 New Five-Star Rating System, continued from page 1 Short-Stay Residents •Percentage of residents given influenza vaccination during the flu season •Percentage of residents who were assessed and given pneumococcal vaccination •Percentage of residents who had moderate to severe pain* •Percentage of residents with pressure ulcers that are new or worsened* •Percentage of residents who newly received an antipsychotic medication * Indicate QM’s used for the revised Five-Star Rating system. Finally, each facility has received a revised Five-Star rating using nine (listed below in bold) MDS 3.0 Quality Measures with data from the second, third and fourth quarters of 2011. The following new measures will be posted on the Nursing Home Compare website in July: Long Stay Quality Measures •Percentage of residents given influenza vaccination during the flu season •Percentage of residents who were assessed and given pneumococcal vaccination •Percentage of residents experiencing one or more falls with major injury* •Percentage of residents who have moderate to severe pain* •Percentage of high-risk residents who have pressure sores* •Percentage of residents who had a urinary tract infection* 3 •Percentage of low-risk residents who lose control of their bowels or bladder •Percentage of residents who have/had a catheter inserted and left in their bladder* •Percentage of residents who were physically restrained* •Percentage of residents whose need for help with daily activities has increased* CMS guidance related to how the current Casper reported information is calculated will be detailed in an update to the currently posted Technical User’s Guide. CMS plans on posting “a complete description of the new QM rating as well as changes to the staffing case-mix and rating thresholds by July 19, 2012.” In addition to the upcoming posting of a revised manual CMS is offering and extended Helpline timeframe for facilities. They indicate the following, “It will be available, Monday – Friday, from June 18, 2012 – August 3, 2012. Hours of operation will be from 9 am – 5 pm ET, 8 am – 4 pm CT, 7 am – 3 pm MT, and 6 am – 2 pm PT. The Helpline CMS plans on posting “a complete description of the new QM rating as well as changes to the staffing case-mix and rating thresholds by July 19, 2012.” In addition to the upcoming posting of a revised manual CMS is offering and extended Helpline timeframe for facilities. •Percentage of residents who lose too much weight •Percentage of residents who are more depressed or anxious •Percentage of residents who received an antipsychotic medication number is 1.800.839.9290. The Helpline will be available again August 13 – 17, 2012. During other times, direct inquiries to [email protected], as Helpline staff will respond to e-mail inquiries when the Helpline is not operational. CMS anticipates updating Nursing Home Compare to reflect these new ratings on July 19, 2012.” ● A A N AC LT C L E A D E R 6 . 2 6 . 2 012 Antipsychotic Meds, continued from page 1 antipsychotic drug deficiencies at the no-harm level…As a consequence of the no-harm, no-penalty practice, FY2012 data show that most facilities cited with unnecessary drug deficiencies are unlikely to have had any financial penalty imposed.” According to the CMA, meaningful financial penalties are a necessary component “to bring about change in the facilities’ practices.” Despite the current educational focus, CMS likely will institute increased scrutiny through the survey process, anticipates Rena Shephard, mha, rn, rac-mt, c-ne, president/CEO of RRS Healthcare Consulting Services in San Diego and an AANAC master teacher. “Frankly, that is what tends to bring things to a head in facilities. When the surveyors are looking at an issue, then the facilities give more attention to it.” There is definitely work to be done. At some point in 2010, almost 40 percent of nursing home patients with signs of dementia received antipsychotic continued on page 5 Antipsychotic Meds: Change Staff Mindset to Cut Use Caralyn Davis, Staff Writer Unnecessary antipsychotic medications are a long-standing problem in nursing homes even though a wealth of studies support limiting the use of atypical antipsychotics in dementia patients. “Studies have shown that the off-label use of these drugs doesn’t provide a statistically significant benefit “Studies have shown that the off-label use of these drugs doesn’t provide a statistically significant benefit and is even adding risk to dementia patients,” notes Rena Shephard. and is even adding risk to dementia patients,” notes Rena Shephard, mha, rn, rac-mt, c-ne, president/CEO of RRS Healthcare Consulting Services in San Diego. “That includes an increased risk for death, and there has been a corresponding increase in black-box warnings.” For example, as far back as 2005, the Food and Drug Administration issued an Alert for Healthcare Professionals for risperidone (Risperdal), requiring a black-box warning because “patients with dementiarelated psychosis treated with atypical (second generation) antipsychotic medications are at an increased risk of death compared to placebo.” “It is probably accurate to say that atypical antipsychotics should almost never be used in dementia patients,” says Shephard. “No one seems to be advocating that these drugs should be forbidden as a blanket policy. But there are so many other things that need to be done first.” However, despite the mounting evidence and warnings, “in practice these medications remain a first-line treatment in many nursing homes,” says Shephard. “Facility staff, and perhaps attending physicians as well, may misunderstand the role of these medications. So before management hands them any tools to help them identify the unnecessary use of antipsychotic medications, staff needs to be tuned into the concept of what is unnecessary. Ever since OBRA ’87 was implemented, we are supposed to be using these drugs only when they don’t meet the definition of unnecessary. Until facility staff really understands the concept of what unnecessary medication means in terms of atypical antipsychotics, they are not going to be able to make much progress.” continued on page 5 4 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 Antipsychotic Meds, continued from page 4 Change Staff Mindset Sidebar, continued from page 4 drugs, “even though there was no diagnosis of psychosis,” according to a statement by Patrick Conway, M.D., CMS chief medical officer and director of clinical standards and quality. In addition, 2010 CMS data show that more than 17 percent of residents had daily doses of antipsychotic drugs exceeding recommended levels. Appendix PP, the “Guidance to Surveyors for Long-term Care Facilities” in the State Operations Manual, “tries to define unnecessary medication, but it needs to be refined even more,” says Shephard. In the meantime, the key takeaway for providers is that “the first line of treatment for behavior problems in dementia patients has to be nonpharmacological,” she states. “Providers need to develop the mindset of looking at behavior as a message: a message about a need or a want or a discomfort from someone who is not able to express it verbally.” Two tools used by state surveyors in the Quality Indicator Survey (QIS) can help providers manage and monitor antipsychotic drug use: Critical Elements for Unnecessary Medication Review and Critical Elements for Psychoactive Medications. Successful implementation of these Critical Element (CE) tools requires providers to lay some groundwork, says Shephard. (See “Antipsychotic meds” sidebar on pages 5 – 6.) However, once staff members have the right mindset, these QIS tools “provide some nice potential audit protocols for facilities to use,” notes Jennifer Pettis, rn, bs, wcc, rac-mt, c-ne, director of program development at Harmony Healthcare International in Topsfield, Mass., and chair of the AANAC Expert Advisory Panel. Still, facility managers should take steps to optimize the use of the CE tools, acknowledges Pettis. These steps include the following: Get protocols, policies, and procedures in line “Before leadership hands over the QIS tools and says, ‘Audit your charts,’ they need to ensure that facility protocols, policies, and procedures actually will lead to regulatory compliance if followed by the staff,” suggests Pettis. “The QIS tools are a great guide for leadership, but as part of that review, they also should take a close look at F-tag 329 (unnecessary drugs) and F-tag 222 (chemical restraints) in Appendix PP, the ‘Guidance to Surveyors for Long-term Care Facilities,’ in the State Operations Manual.” When Shephard presents this concept during workshops and consultations, providers often ask a key question, “How do we know what this dementia patient might be trying to tell us?” The answer is straightforward: “The only way that providers can interpret behaviors is by conducting a process of investigation to try to find out,” she points out. “That has to be the first line.” Matthew S. Wayne, md, cmd, president of the Columbia, MD-based American Medical Directors Association, defined the crux of the issue in a recent article in the Journal of the American Medical Association. “We must not jump from symptoms to treatment,” he stated. “Dementia-related behavior is not a diagnosis. It is a symptom.” “Don’t just consider what the behavior is and how you are going to take care of it. Consider why it is happening,” Pettis advises. “What is going on with that resident that they have the need to move or to shout or to strike out?” Unfortunately, many facilities do make that jump from the symptom (i.e., the behavior) to the treatment (i.e., the medication) “instead of actually figuring out what is going on with the resident,” says Shephard. Often, the behavior is an indication of pain, she notes. “Several studies have shown that routine pain medications such as Tylenol can relieve agitation in demented patients.” Conducting a root-cause analysis prior to care-planning the management of any behavior problems is essential, agrees Jennifer Pettis, rn, bs, wcc, rac-mt, c-ne, director of program development at Harmony Healthcare International in Topsfield, Mass., and chair of the AANAC Expert Advisory Panel. “Don’t just consider what the behavior is and how you are going to take care of it. Consider why it is happening,” she advises. “What is going on with that resident that they have the need to move or to shout or to strike out? You have to ask the questions of why. We’re not taking care of symptoms. We’re taking care of people who are exhibiting those symptoms, and we need to try to figure out what is going on with them.” Conducting this investigative process to interpret behaviors opens up the potential for improved comfort and quality of life for dementia patients, says Shephard. “In addition, on the facility side, it can make everyone’s job easier and more satisfying too.” The information in the “Guidance to Surveyors” has become “more helpful continued on page 6 5 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 Antipsychotic Meds, continued from page 5 evidence of monitoring is, etc.,” she suggests. “More detailed information will allow you to do a deeper analysis.” Many of the questions on the Unnecessary Medication Review CE are addressed in the care area assessment (CAA) for psychotropic medication use in Appendix C of the RAI User’s Manual for the MDS 3.0, notes Pettis. “This CE could be used nicely in conjunction with that care area assessment. Facility leadership has an awesome opportunity to take that CAA and this tool used by QIS surveyors and demonstrate how strong the link is between robust use of the RAI process and compliance with regulations.” than it ever was before,” points out Shephard. “CMS previously didn’t include a lot of clinical information, and if they did, it wasn’t necessarily current. However, in the last few years, the ‘Guidance to Surveyors’ has become much more educational and instructional for staff training.” Unnecessary Medication Critical Element: Go a step further The Unnecessary Medication Review CE applies to all medications, not just antipsychotics. “But clearly, that’s a really good place for facilities to start,” says Pettis. The key to turning the Unnecessary Medication Review CE into a strong auditing tool is to expand the six critical elements (e.g., adequate indication for use) beyond the basic “yes” or “no” answers the CE is looking for, she recommends. “Instead, ask for a notation of what the indication for the medication is, what the appropriate duration is, where your The Unnecessary Medication Review CE also can help “leadership demonstrate to the interdisciplinary team just how critical comprehensive assessment is,” says Pettis. “All of the QIS tools take surveyors—and providers—through a defined process of assessment leading to the development of the plan of care, that plan of care being implemented, and then the plan of care being changed if it doesn’t So the staff needs to determine, “What does that question mean?” You may be missing opportunities for needed interventions because the staff has the philosophy that a specific behavior is usual for a resident and therefore can’t be distressing,” she explains. “If staff members say, for example, ‘the resident always does that,’ that’s a pretty good indication that the staff is disregarding the behavior as usual and not needing intervention. A key point for staff to remember is that usual doesn’t mean normal. Usual behavior doesn’t mean that it is not distressing to that resident or distressing to other people, and that it is not negatively impacting the functional life of that resident.” The Psychoactive Medications CE also gives management a useful tool for focusing on the interdisciplinary management of behavior. “Facility leadership should consider having a roundtable discussion with the entire interdisciplinary team, including nurses and nurses aides, physicians, “Facility leadership should consider having a roundtable discussion with the entire interdisciplinary team, including nurses and nurses aides, physicians, rehabilitation therapy, social work, activities, recreational therapy, and dietary. Discuss, as a facility, every strategy that the facility has to offer to manage behaviors,” suggests Pettis. work. So the Unnecessary Medication Review CE sends a strong message that the interdisciplinary team should go back to that basic clinical process.” Psychoactive Medication Critical Element: Get on the same page To use the Psychoactive Medications CE effectively, “it is critical that leadership bring the staff together and talk about what the elements in the tool mean,” says Pettis. For example, one question that the surveyors will be asked to respond to is, “Are the staff monitoring for behaviors that cause the resident or others distress?” rehabilitation therapy, social work, activities, recreational therapy, and dietary. Discuss, as a facility, every strategy that the facility has to offer to manage behaviors,” suggests Pettis. Often facilities fall into the trap of using canned approaches to try to meet the needs of residents, she notes. “So really brainstorm and identify: What is your whole bag of tricks—the full array of interdisciplinary, non-medication approaches you can use before you give antipsychotic medications to patients?” The Psychoactive Medications CE lists some options as a jumping-off point, “but the interdisciplinary team will be able to think of many more,” continued on page 7 6 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 Antipsychotic Medication, continued from page 6 Make a difference with music Debbie Lee, otr /l, rac- ct Regional Consultant, Harmony Healthcare International (HHI) Therapy professionals are often an underutilized resource when interdisciplinary teams (IDTs) are brainstorming nonpharmacological interventions to help nursing home residents manage behaviors. Not only can therapists suggest more obvious approaches such as occupational therapy programs looking at environmental modifications and physical therapy looking at ambulation/exercise, but they also can spur the IDT to think outside the box. Two examples of nontraditional interventions that therapists can use to help patients meet functional goals involve music. My personal experience using music for residents with dementia or behavior issues has been quite positive. The first idea is a Therapeutic Listening program (i.e., an evidence-based auditory intervention for people with sensory/communication challenges). Mary Jean Hughes, edd, ma, otr /l, the director of rehab at HHI client Carleton-Willard Village in Bedford, Mass., initially used the program with children. She designed the program to assess the effects of Therapeutic Listening on a nursing home resident’s balance as measured by the Berg balance test (quantitative measure) and improvements in energy level, mood, communication, sleeping, behaviors, etc. (qualitative measures) after the residents participated in Therapeutic Listening while doing an exercise program on the Nu-step for six weeks. For additional information about Therapeutic Listening, visit the Vital Links website and review this study from the March/April 2007 issue of the American Journal of Occupational Therapy. The second idea is to incorporate interventions included in the May 17, 2012, “The New Old Age” column in the New York Times. This article depicts several nursing home residents and the effects that a personalized playlist has on them. Check out the short video clip and you can see the transformation with these residents. OT or speech therapy, as well as activities, could pursue this type of intervention if it was linked to functional goals. says Pettis. Many providers focus on nursing, activities, and social work as the three key disciplines for managing behaviors. However, “I want to stress the importance of therapy intervention, which can feed into restorative nursing, functional maintenance, and activities,” she says. For example, one of Pettis’ therapy colleagues recommended that providers adopt “get up and move” programs that encourage staff to get patients out of their chairs and active periodically during the day. (Therapists often develop creative solutions, such as music-based interventions. See “Make a difference with music” sidebar at left.) Involve the medical staff and pharmacist Effective use of both medication CEs requires the participation of the medical staff, says Pettis. “It’s never going to work in your facility if the medical staff isn’t involved. The physician is driving the team here. Even the very best longterm care nurses are not prescribers of continued on page 8 Music-based interventions may not be the answer for every resident. However, as these ideas demonstrate, therapists can be a valuable resource for fresh ideas when IDTs need to look beyond pharmacological interventions. 7 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 Antipsychotic Medication, continued from page 7 medications. Facility leadership needs to ensure that the medical staff bring that extra piece to the table.” To ensure medical staff participation, “the medical director needs to be involved in every stop along the way of using these tools,” she suggests. “His or her input is going to be vital to ensure that the process of staff auditing is beneficial. The medical director is certainly a great resource for educating the medical staff about the regulatory requirements, and also that medical director needs to be involved in the development and implementation of any protocols, policies, or audit tools based on those policies to ensure compliance with the unnecessary medication tag, F329.” In addition to bringing the physicians on board, facility leadership “definitely needs to be talking with their consultant pharmacist about the elements of these tools,” says Pettis. “Management should make sure that those expert eyes of the pharmacist are evaluating compliance with these issues.” Assign a nurse expert With the increased emphasis on antipsychotic medications, facilities should assign a nurse to be the staff expert, much like many facilities have a wound care expert, suggests Shephard. “This is another area that needs that level of attention.” This nurse should receive all available training on the unnecessary use of antipsychotic medications and conduct the facility’s overview monitoring from a quality improvement perspective. “Obviously, the staff working with the patient needs to handle day-to-day monitoring,” says Shephard. “However, an RN, for example, assigned to oversee staff activities and review accuracy provides for the kind of continuous quality improvement that is necessary.” 8 Make sure monitoring is up to par Once a decision is reached to use an antipsychotic medication, federal regulations require providers to monitor the medication’s effectiveness. However, many facilities need to beef up their monitoring skills, says Shephard. “In chart reviews, I often find that the episodes of the identified behavior coded in Section E of the MDS may not always agree with what is written in the nurse’s notes and documentation by other disciplines. Education on how to monitor for effectiveness accurately needs to be enhanced.” Emphasize documentation of functional benefits “Everything we do in the nursing home should be aimed at the overarching need to help our residents attain or maintain the highest practical level of functioning,” says Pettis. “So when staff members are documenting about antipsychotic drug use, we want to focus on the overall functional well-being of that resident, not just on the fact that we have controlled or managed a behavior.” more than the behavior. Certainly there needs to be a medical symptom to justify the use of the drug, but then how is that medical symptom negatively impacting that resident’s life? Sometimes antipsychotic drugs are appropriate for residents, but using them shouldn’t be just to manage a behavior for the convenience of the staff. It is to improve the overall function and life of that resident, and documentation needs to show that.” Resources Free CMS webcast on its initiative to reduce antipsychotic medication use AANAC on-demand webinar, “Interventions That Matter: Antipsychotic Use in Dementia Care” American Society of Consultant Pharmacists information and resources Advancing Excellence in America’s Nursing Homes resource list ● Unfortunately, facility documentation often focuses exclusively on the behavior. For example, the documentation might state something like this: “Resident X had a problematic behavior; Resident X was started on an antipsychotic medication; the problematic behavior is gone; Resident X hasn’t experienced any side effects.” But what if Resident X’s problematic behavior prevented her from being able to sit and engage in a meal and conversation with her peers, and taking the antipsychotic medication allowed Resident X to feed herself and be engaged during mealtime? “That is a functional benefit that the resident has been able to realize,” points out Pettis. “In our documentation, we need to focus on that as much as if not A A N AC LT C L E A D E R 6 . 2 6 . 2 012 AANAC Expert Advisory Panel, continued from page 1 for guidance as to how to handle these issues when a patient converts from a MAP to traditional Medicare Part A. providers are encouraged to acknowledge this issue and strategically set the ARD to avoid default payment. As many providers are aware, when a 5-day PPS Assessment or Return/ Readmission Assessment is combined with a Significant Change in Status The final issue that was discussed was the inability to modify the Reason for Assessments (RFAs) and to resubmit the same assessment instead requiring the to discussion related to provider compliance with completion of discharge assessments. CMS reminds providers that discharge assessments are required in the following circumstance, regardless of facility policies regarding opening and closing clinical records and bed holds: The AANAC Expert Advisory Panel will continue to monitor for guidance and/or policy changes and alert members of any new developments. •Resident is discharged from the facility to a private residence (as opposed to going on an LOA); Assessment (SCSA) that has an ARD of day 1 – 5 default payment results for those days prior to the Assessment Reference Date (ARD) and then the correct RUG takes effect on the ARD of the SCSA. Regarding this issue, CMS acknowledged that the RAI User’s Manual does apply in the relatively rare instances that a 5-day combined with a SCSA is completed with an ARD of day 1 – 5. CMS is considering a potential clarification in the RAI User’s Manual related to this issue. Meanwhile, •Resident is admitted to a hospital or other care setting (regardless of whether the nursing home discharges or formally closes the record); and provider to inactivate the assessment and then complete a new assessment with the current date as the ARD. CMS is continuing to evaluate the current policy, including adherence to the policy. At this time, there are not changes in guidance and/or policy forthcoming. The Expert Advisory Panel encourages robust use of the Encoding Period to ensure correctness of those items that cannot be modified. One of the particular items that cannot be modified is the discharge date. Discussions of this issue lead •Resident has a hospital observation stay greater than 24 hours, regardless of whether the hospital admits the resident. The AANAC Expert Advisory Panel will continue to monitor for guidance and/or policy changes and alert members of any new developments. ● Worried about Readmissions? DID yoU kNoW? yOUR RAC-CT® CERTIFICATION EXPIRES AFTER TWO yEARS. Refresh your RAI/MDS 3.0 knowledge and maintain your mark as an expert in assessment by recertifying today. We’ve compiled the most recent information into two easy-to-complete courses available online or in hard copy manual formats: MDS 3.0 Common Coding Errors MDS 3.0 Updates don’T Lose THis vaLuaBLe CredenTiaL. Readmission Watch from eHDS helps you remain a provider of choice. > Track the rate of readmissions > Identify residents at risk > Monitor diagnostic trends www.ehds.biz Click here before your designation expires. 9 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 Q+A How a DON can provide support to the MDS Coordinator Because I am not familiar with details of the MDS, I am not sure how to provide support or oversight for the MDS Coordinator. Do you have some suggestions on how I can be successful as her supervisor? In order to succeed at supervising your MDS Coordinator, there are several things you can do. Administrators and nurse leaders who set MDS accuracy as a top priority tend to be most successful in this area. Educating yourself and your Coordinator about the MDS process is critical. It is highly recommended that your MDS Coordinator receive continuous training on MDS coding to keep their knowledge current as things change often. While it is not necessary that you personally know all of the MDS details, a general understanding of the process is important. As their supervisor, seek out quality courses geared toward increasing your knowledge on how to oversee the RAI/MDS Process. This will enhance your foundational understanding of the MDS 3.0 and its key components, the role of the MDS Coordinator, scheduling, auditing for and improving accuracy, and much more. You do not mention if you are a nurse leader or a non-clinical administrator, but either way, taking courses yourself will provide you with valuable insight. Although administrators and nurse leaders often develop a high level of confidence in their MDS staff, the only way you can be sure that coding and scheduling are accurate is by equipping yourself with enough knowledge to ask the right questions. In addition to educating yourself, you can bring in an outside consultant to work with your MDS Coordinator and the rest of the Interdisciplinary Team, and to conduct audits. Ensure your staff is using the most current MDS 3.0 manuals and updates. These combined actions will prepare you to successfully supervise your MDS Coordinator and to assure MDS accuracy for your facility. Betty Frandsen, rn, nha, mha, c-ne ([email protected]) Timing of Resident Interviews Where exactly can I find in the RAI manual that resident interviews are to be done on or before the ARD? The RAI Manual, page 2-13, under the definition of the observation period, says that only occurrences that happened during the look-back period can be captured on the MDS. The look-back period ends at 11:59 p.m. on the ARD (p. 2-8). The exception for COT OMRAs is that the interviews may be conducted no more than 2 days after the ARD (ARD + 2 days). But, according to CMS, “We do not expect this will be necessary in all cases, as providers should be continually monitoring the progress of residents toward meeting the requirements of the RUG-IV therapy category to which they have been assigned” (Nov. 3, 2011, clarification memo). In doing so, it may be predictable that a COT OMRA is going to be needed and the interviews, in that case, should be completed before the end of the ARD. The instructions for the resident mood and pain interviews in chapter 3, section D, page 4 and section J, page 7, specify that the interviews should be conducted on the day of or the day before the ARD. The Cognition and Preferences interviews may be completed any day in the 7-day look-back period, since they do not ask the resident or the staff to look back in time. Rena R. Shephard, mha, rn, rac-mt, c-ne ([email protected]) Facility Billed for Hospital Therapy My biller has asked me to post these two scenarios: We have a private pay resident (she also has Medicare) who went out to the hospital in February for greater than 24 hour observation stay. While she was there, she was evaluated by PT/OT and given 2 units of PT and 1 unit of OT. The hospital is billing us, the SNF where she lives, as these charges were denied by Medicare when billed by them. When billing called Medicare they said they were “File 4 charges” and referred her to the Carrier file explanation. We interpret this to mean if we had a part B bill out on her for therapy, and she received therapy at the hospital that we would be responsible. But she had no part B bill out at that time. We have a second scenario where a LTC Medicaid resident (she also has Medicare) when out for video swallow as an outpatient in April. The hospital is billing us, the SNF for the video swallow, ST treatment, and X-ray. Again, she had no part B bill out or continued on page 14 10 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 AANAC 2012 Upcoming Workshops TRAINING PARTNER MASTER TEACHER DATES CITY/STATE MDS 3.0 RAC-CT Certification Workshops | 3-day Harmony Healthcare International Jennifer Pettis July 10 – 12 Coatesville, PA Aging Services of Michigan Amy Franklin July 10 – 12 Gaylord, MI Duran Consulting Services Sarah Riggin July 16 – 18 Brooklyn, NY Maine Health Care Association Andrea Otis-Higgins July 17 – 19 Augusta, ME Harmony Healthcare International Renay Corrigan July 17 – 19 Greer, SC Pathway Health Services, Inc. Judi Kulus July 17 – 19 Westmont, IL LeaderStat Lisa Hohlbein July 24 – 26 Charleston, WV Harmony Healthcare International Renay Corrigan July 24 – 26 Hagerstown, MD Harmony Healthcare International Jennifer Pettis July 31 – Aug 2 Napa, CA Pathway Health Services, Inc. Cynthia Perrault July 31 – Aug 2 Nashville, TN LeadingAge Kansas Ron Orth Aug 1 – 3 Wichita, KS Harmony Healthcare International Jennifer Pettis Aug 7 – 9 Glendale, AZ Colorado Health Care Association Rena Shephard Aug 7 – 9 Denver, CO Ohio Health Care Association Robin Hillier Aug 7 – 9 Columbus, OH Pathway Health Services, Inc. Judi Kulus Aug 7 – 9 Brookfield, WI MDS 3.0 RAC-CT re-Certification Workshops | 1-day Maine Health Care Association Andrea Otis-Higgins July 12 Augusta, ME Pathway Health Services Cynthia Perrault July 20 Orland Park, IL LeadingAge Iowa Deb Myhre July 24 West Des Moines, IA Life Services Network Ron Orth July 25 Springfield, IL Life Services Network Ron Orth July 26 Woodridge, IL Harmony Healthcare International Jennifer Pettis July 30 Napa Valley, CA Life Services Network Ron Orth Aug 7 Rockford, IL LeadingAge NY Sandy Biggi Aug 10 Latham, NY Harmony Healthcare International Jennifer Pettis Aug 7 – 9 Muncy, PA Life Services Network Judy Wilhide Aug 15 – 17 Springfield, IL Medicare University Workshops The workshop schedule is subject to change and is updated regularly. To see a full AANAC Training Partner workshop schedule, visit aanac.org/workshops 11 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 date the e sav n sa onio t n a 29 – A pril , 2 013 3 M ay t o share pertise o n at x e e v u ha o y presentati Do 0 13 2 P yo ur F /C .o rg S ubmit . aanac www 12 ? What’s new in Thousands of “peer-shared” LTC resources at your fingertips Active Discussions this week on AANAConnect: What are resource libraries? Resource libraries are where documents and files uploaded by members are kept. Each community has one, and each library is searchable. You can also search across all of the libraries on AANAConnect. Files and documents can get into the library in one of two ways: 1. Each time an attachment is shared in a discussion group it is automatically uploaded into the group’s library. 2. Files can be uploaded directly to the library of your choice. You can access a community’s resource library in several ways: •Click on the link/paper clip icon in an email you receive from a discussion group. •Click on the link named “Files” for the community you wish to access on the “View Community Discussions” page. •Go to “Communities” in the top navigation, and choose “View Libraries.” From there, select “All Libraries” to browse or “Search Library” to look for specific files. •From the “Communities” page, locate the community you want and click on the number located to the right of the “Book” icon. Save and store the resources that you need Library entries can contain several files. To view and download an attachment, click on its name under “Attachment(s)”. If you want all of the files, click on the library entry name and then the “Download all” link found at the bottom of the “Attachment(s)” section. Help point out the “good stuff” to others Each library entry has a five-star rating system, similar to amazon.com and other sites where you can flag things you like. By rating a document, you can help others judge the quality of the information contained in the file(s). Commenting allows you to add additional information— if a document was helpful and why, if it contains incorrect information, etc. ● 13 LTC Network: Thread Subject: BM in dementia residents Posted by: Tonya Weih We have a resident wh o is independent in toi leting. The problem is she ha s dementia and can’t remember anything for more tha n 2 minutes. She is co nsistently showing up on our BM alerts because she ca nnot remember if she has had a BM. We have trie d posting signs in her bathroom instructing her to pull her call light after she goes, we have talked to her abou t the need to know if she’s had a BM, etc. Does an yone out there have any su ggestions on how to tra ck this sor t of thing? There have already be en a few creative ideas presented to help Tonya out with her quandar y. Contribu te to the conversation and subm it an idea or best practi ce that has proven effective in your facility by clicking on the thread subject. n: MDS Connectio of stay : Death on day 5 Thread Subject ia Preston Posted by: Anton ay. I had set r Medicare st die on day 5 of he iews as they I had a resident A - on the interv d ke ar m ve ha I I put ARD for day 8. question but do is may be a silly 2400) (A ay st e were not done. Th of her Medicar d en e th as h at O? Therapy the date of de ended in section y ap er th te da e ink I should and also as th had not died. I th e sh if d ue in nt ning myself would have co but I am questio so al e er th te da put the death rred. Thanks. time this has occu as this is the first ng that we must , death is somethi rk wo of w does e lin r ou In ular basis. But ho with on a semi-reg rogress -p in an of unfortunately deal to the coding e lat rre co t en sid tonia the death of a re r situation? Help An perienced a simila t. ec bj su MDS? Have you ex e thread by clicking on th with her question Q + A, continued from page 10 What You Need to Know Check out these latest updates from the “Need to Know” section of the AANAC homepage and find the information you need to get the job done right. July 19 Nursing Home Compare Redesign: CMS S&C Letter Gives Details CMS Releases New Five-Star Rating System MDS 3.0 Public Reports—CMS Website MDS Tip Last month, CMS announced that for all MDS questions providers should contact their RAI Coordinator instead of going directly to CMS. For payment issues, providers should contact their Fiscal Intermediary or Medicare Administrative Contractor. Please share the responses you get back from them with other AANAC members by emailing them to [email protected]. Judi Kulus, nha, rn, mat, c-ne, rac-mt Vice President of Curriculum Development, AANAC Treatment of Members Policy Our biller explained to Medicare that these are LTC residents, not Part A residents that we are receiving any consolidated billing for. Can you help, please? We are a privately owned facility that has no corporate to look to for support. For scenario one, any Medicare beneficiary who resides in a Medicare certified bed, Part B therapies fall under consolidated billing. Any Part B therapies received outside the facility are to be billed to the SNF. The SNF then must submit a Part B bill to Medicare to get reimbursed. For scenario two, the resident’s swallow study the x-ray would be billed directly to Medicare by the hospital, the SNF should not be paying for that. Part B therapy services for residents of a SNF (residing in a Medicare Certified Bed) are the only Part B services that do fall under consolidated billing, even if not under a Part A stay. Ronald A. Orth, rn, nha, cpc, rac-mt ([email protected]) Missed Readmission/Return Assessment On 5/7/12, Med A resident went to the hospital, was admitted overnight & returned on 5/8/12. A Discharge Return Anticipated & Entry Record was completed. ARD was set for 5/9/12 and EOT completed and transmitted rather than a Readmission/Return Assessment. (Therapy was stopped and skilled nursing continued x 10 days.) Unfortunately, this wasn’t caught until triple check. I’m thinking we are unable to bill, due to not having a valid assessment present and being on Medicare > 7 days? (From missed assessment, RAI Manual ch 6.) Any other options since the assessment is present but coded incorrectly? Can Medicaid be billed? Thanks. You are correct. This would be billed at “provider liability” which means you would get no payment. Definitely do NOT bill Medicaid. That would be seen as attempting to get double payment for those days. They were valid Medicare days and come out of the beneficiary’s benefit period for Medicare A. You won’t get paid for them, but the days were used under the Part A benefit. AANAC has posted the Treatment of Members Policy on the website. If you need to access it, please click here. I want to caution everyone here that “provider liability” means: valid benefit period days, facility unable to collect from Medicare A because we did not follow the rules. It NEVER means “bill default” or “bill Medicaid.” And, many, many state Medicaid agencies are beginning to audit just this issue to recoup money the state paid that should have been paid by Medicare or provider liability. Get Answers Now Judy Wilhide Brandt, rn, c-ne, rac-mt ([email protected]) When you need answers fast, the best place to start is AANAConnect. We have thousands of member questions that have already been answered by our experts who moderate the communities 24/7. Just type your topic into the search box to see the discussions, tools and peer-submitted resources that may be just what you’re looking for. 14 pending. The hospital says Medicare denied and we are responsible under consolidated billing. This File 4 carrier file says “File 4 is only to be used for services rendered to beneficiaries in a part B non-covered stay. It includes the therapy codes that are subject to SNF consolidated billing for beneficiaries in a Part B non-covered SNF stay. The physician, non-physician practitioner, or supplier must look to the SNF for payment of these services. The Medicare carrier will not pay these services.” Incorrect Entry Date I have an Entry Tracking Record and a PPS 5-day MDS that both have incorrect entry dates and have been submitted to the QIES ASAP system. Do I inactivate them or modify them? Here are the manual references that I have found regarding this question. continued on page 15 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 Q + A, continued from page 14 AANAC Board of Directors Carol Siem msn, rn, bc, gnp Chair Ruth Minnema rn, ma, c-ne, rac-ct Vice Chair Carol Maher rn-bc, rac- ct Secretary Peter Arbuthnot aa, ba, rac- ct Treasurer Susan Duong, rn, bsn, nha, rac- ct, c-ne Patrice E Macken, mba, rhia, lnha, rac- ct Gail Harris, rn, bsn, rac- ct, c-ne Joanne Powell nha, rhia Diana Sturdevant ms, gcns-bc AANAC Expert Panel AANAC is pleased to introduce you to our panel of volunteer reviewers who represent the best and the brightest in our field: Jennifer Pettis rn, wcc, rac-mt, c-ne Chair, Harmony Healthcare International Topsfield, MA Betty Frandsen rn, nha, mha, c-ne Nichols, NY Robin L. Hillier cpa, stna, lnha, rac-mt President, RLH Consulting Becky LaBarge rn, rac-mt Vice President, Clinical Reimbursement The Tutera Group Deb Myhre rn, c-ne, rac-mt Nurse Consultant, Continuum Health Care Services Ron Orth rn, nha, rac-mt Clinical Reimbursement Solutions, LLC, Milwaukee, WI Andrea Otis-Higgins rn, mlnha , cdona , clnc, rac-mt CEO, Administrator, St. Andre Healthcare Biddeford, ME Rena R. Shephard mha, rn, rac-mt, c-ne AANAC Executive Editor President, RRS Healthcare, Consulting Services, San Diego, CA Judy Wilhide Brandt rn, rac-mt, c-ne Regional MDS/Medicare Consultant President, Judy Wilhide MDS Consulting, Inc. In the 4/1/2012 errata (v1.08) on page 50, paragraph #1, it states that you inactivate the entry tracking form when the admission date is incorrect. But in paragraph #3 is where the confusion comes in. I understand that they are referring to the items identified in paragraph #1 as the reasons to inactive but it could be taken to mean you have to inactive the assessment also. In the MDS 3.0 Manual’s latest version with effective items for 4/1/12, page 5-10 in the Modification Request section under ‘exceptions’ which goes on to page 5-11, at the bottom of 5-11 is the date April, 2012, in the first paragraph of 5-12 INACTIVATION REQUESTS. I understand it to mean if there is an error in entry date, do a modification on the assessment but only inactivation on the entry tracking form. On the SNF PPS Clarification Memo from CMS of March 29, 2012—page #8 under item #8 regarding inactivation of assessments, in the middle of the page, it lists those subset of items that may not be modified, again listing Entry Date (A1600) on an entry tracking record as one you must inactive. No mention that you have to inactive an assessment with this. After reading these documents, I’m still not sure what to do. Thanks for the help. If the entry date on an ENTRY TRACKING record is incorrect, the ENTRY TRACKING form must be INACTIVATED. A new entry tracking form must then be completed with the correct entry date and transmitted. IF the ENTRY DATE on any MDS ASSESSMENT is incorrect, a modification of field A1600 is allowable. An incorrect entry date on an ASSESSMENT does not require inactivation. Carol Maher, rn-bc, rac-mt ([email protected]) Reducing Hospital Readmissions Our QA Committee wants to begin an effort to reduce hospital readmissions. Our medical director does not agree, mainly because he says residents are sent to the emergency room to legally protect the doctor and facility when there is a question that cannot be answered in the nursing home. Should we proceed with this project? Hospital readmissions are a growing concern, both due to the financial impact and the disruption they cause to the resident. According to data released by Robert Wood Johnson Foundation, 25% of Medicare beneficiaries discharged to SNF’s are readmitted to the hospital within 30 days. Information from the Commonwealth Fund supports the belief that 40% of those transfers could be avoided. Plans are in place to begin penalizing hospitals in October 2012 if they are in the highest 25% of the readmission category. The Advancing Excellence in America’s Nursing Homes Campaign and the AHCA/NCAL Quality Initiative both include safely reducing hospital readmissions as a goal for participating facilities. The most commonly used materials for this effort are from Interact and can be obtained free of charge. If your Medical Director has not seen the Interact materials, schedule time to review the content with him. Even if your facility is not able to significantly reduce your readmission rate, the education and Interact tools you incorporate as your protocols will better-prepare your nurses clinically and guide them through an assessment and evaluation process when a resident experiences a change in condition. Quality of care will be positively impacted as changes are identified sooner and interventions implemented more timely. The associated improvements are likely to provide you with better DOH Survey outcomes. Your QA Committee is wise to work on this effort. Betty Frandsen, rn, nha, mha, c-ne ([email protected]) ● 15 A A N AC LT C L E A D E R 6 . 2 6 . 2 012 Business pARtNERS & Professional buSINESS & Development Partners CoRpoRAtE SpoNSoRS Diamond Business Partners Diamond Business Partners Platinum Business Partners Platinum Business Cerner Partners Dementia Care Forest Specialists Pharmaceuticals, Inc. eHealth Data PointClickCare Gold Harmony Healthcare Business Partners International accu-Med MED-PASS Services, Inc. Purdue Pharma aIS Systems answers on Demand golden living Centers Accu-Med leaderStat Technology Solutions MDI achieve AIS Inc. PointClickCare AOD Software PointRight LeaderStat SunDance MDI Achieve Rehabilitation Additional PointRight Inc. Partners Solutions Inc. MeD-PaSS, Golden Living Gold Business Partners keane Care, Inc. 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Hattiesburg kingston Medical Healthcare Company Park Corporation kissito Health Healthcare Dimensions Group lexington Healthcare Care Management nHS Management llC NHS Management LLC Paramount Health Care Company Paramount Health Care Company Pinon Management Pinon Management Plantation Management Plantation Company Management Company Preferred Care Plott Partners Healthcare Management Preferred group Care Partners Prestige Management Healthcare Group Regent Care Center Prestige Healthcare Riverside Regent Care Center Health Care Rockport Rockport Healthcare Healthcare Services Services SavaSeniorCare SavaSeniorCare Senior Care Senior CentersCare Centers Skilled Health Care Skilled Health Care St. Francis St. Francis Health Services Health Services Ten Broeck Ten Broeck Commons Commons Trinity Senior Trinity Living Senior living Communities Communities TRISUN TRISun Healthcare Healthcare Vanguard Vanguard Healthcare Healthcare Services, LLC ● Services, llC ● WE’RE WITH YOU EVERY STEP OF THE WAY. GROW Find out more at aanac.org LEARN SHARE JOIN At every step in your long-term care journey, AANAC has the resources you need to succeed. AANAC | 400 S. Colorado Blvd., Suite 600 | Denver, Colorado 80246 | Phone 800.768.1880 | Fax 303.758.3588 | 400 S.No Colorado Blvd., Suite 600 |may Denver, Colorado 80246 | Phone 800.768.1880 | Faxfrom 303.758.3588 © AANAC 2012 AANAC. part of this publication be reproduced without written permission AANAC. 16 13 The information presented is informative does not constitute direct permission legal or regulatory advice. © 2011 AANAC. No part of this publication may beand reproduced without written from AANAC. The information presented is informative and does not constitute direct legal or regulatory advice.
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