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. ●
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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
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sa onio
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n
a
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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
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13
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does not constitute
direct permission
legal or regulatory
advice.
© 2011 AANAC.
No part of
this publication
may beand
reproduced
without written
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The information presented is informative and does not constitute direct legal or regulatory advice.