New Physician Certification for Long Term Care Services (450B) Policies

The Division of Aging has announced two new policies regarding the Physician Certification for Long Term Care Services (450B). Beginning January 1, 2013, the current 450B document will no longer be limited to only the physician's signature. The physician may now delegate, within his or her scope of practice, that responsibility to either a Physician Assistant (PA) or Nurse Practitioner (NP) for whom the physician has supervisory responsibilities. 

This change in policy and practice affects the following:
• Pre-Admission Screening (PAS)
• Pre-Admission Screen Resident Review (PASRR)
• Nursing facility requests for continued stays
• Nursing facility transfers
• New Medicaid pay status
• Clients transition from Medicaid Waiver program to nursing facility admissions
• Nursing facilities must develop a policy regarding their process for assuring compliance with the delegation of the Physicians authority to the PA and/or NP 

As a result of the expansion of 450B signatory responsibility, the State is requesting that completed documents be submitted to the AAA/PAS office within 14 days of the NF admission date for those that require AAA/PAS processing.

Also effective on January 1, the Division of Aging (DA) and the Office of Medicaid Policy and Planning (OMPP) is expanding statewide a piloted electronic 450B (e-450B) process. The new e-450B form utilizes an online "check-off" system that thoroughly describes the resident's condition. It is a summary of the MDS, the "old" 450B, and the eligibility screen used by the AAA/PAS team in determining nursing facility level of care. Required additional documents include the 4B, medication sheets, and the nurse's clinical summary, which includes a narrative of the resident's current condition. No more than 10 pages of documentation including the nurse's clinical summary will be accepted along with the submission of the e-450B. Please also be aware that e-450Bs submitted to the DA without all required documentation will be rejected, denied or returned to the NF for additional information.

With the new web-based process, NF staff completes the e-450B online, saves and prints it, obtains the approved signature (physician, PA, or NP) and then uploads the completed e-450B along with the required documentation. The DA receives the information electronically, reviews and processes it, data-enters Medicaid information as appropriate, and returns the reviewed e-450B electronically to the NF.

The Division will host e-450B trainings at the Indiana Government Center South Auditorium on the following dates and times:

Thursday, January 10, 10:00 am - 12:00 pm
Wednesday, January 16, 1:00 pm - 3:00 pm
Wednesday, January 23, 10:00 am - 12:00 pm
Thursday, January 24, 1:00 pm - 3:00 pm

Please note the above-listed trainings are repeats session. You may attend any training that fits in your schedule. Please bring a copy of the User Guide and the PowerPoint presentation slides to the training (Which may be accessed at https://myweb.in.gov/FSSA/aging/form450b/ as of December 10), as the DA will not have printed copies.

Full implementation will be effective February 1, 2013. After that date, the DA will no longer accept mailed documents.

The Division of Aging has clarified that the request for the completed 450B to be submitted to the PreAdmission Screening agency within 14 days does NOT replace the requirement in IAC 455 1-1-8 requiring that the signed application and Level 1 be submitted to the PAS agency within 5 working days of the date of admission.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions about these new policies.

CMS Survey & Cert Memo – Hand in Hand Training Series for Nursing Homes

CMS released an S&C memo regarding training materials that will be distributed to nursing facilities in December of 2012 regarding nurse aide training on how to care for residents with dementia and on preventing abuse. The training materials consist of an orientation guide and six one-hour video modules, each coming with a DVD and instructor guide.  Annual training is required for nurse aides on dementia care and abuse prevention, but the Hand in Hand Training Series is not mandated to be used and facilities can develop their own training program so long as it conforms to existing requirements. The memo can be accessed in the Members Only section of the IHCA website.

CMS Survey & Cert Memo– Guidance related to Medication Errors and Pharmacy Services

A recent CMS Survey & Cert Memo contains clarification on three specific topics related to medication errors and pharmacy services:  (1) Medication Errors:  Potential medication errors related to medication administration via feeding tube and administration timing for metered dose inhalers and proton pump inhibitors and survey implications; (2) Medication Administration Practices:  The practice of “borrowing” medications and issues related to diversion, control, reconciliation and disposal of medications, including fentanyl patches; (3) Medication Regimen Reviews for Stays under 30 days and/or Changes in Condition:  The need for pharmacist medication regimen reviews when a resident experiences a change in condition and/or for residents admitted for less than 30 days. The memo can be accessed in the Members Only section of the IHCA website.

ISDH Survey Area Changes

The ISDH will be moving to 10 survey areas beginning December 1. The new survey area map is available in the Members Only section of the website, as is a listing of the facilities in Marion County by survey area. Only Marion County is divided up into different areas, hence the listing so that facilities know what area they are in. IHCA will be obtaining a survey area staffing chart in the near future and will distribute it to members.

RUG IV

 In early October, the State proposed that the Nursing Facility reimbursement formula move from RUG III to RUG IV.  Two days after proposing the change, the State retracted the proposal due to questions from the IHCA and other nursing facility associations about the timing of the change (then proposed to be 7/1/13) and the overall impact to facilities (details of which were incomplete by the State’s own data).  Detailed discussions on future implementation of RUG IV into the Nursing Facility reimbursement formula have not yet continued, but quick reference has been made to a potential implementation date of July 1, 2014.  At the request of IHCA, the State has provided the Draft RUG IV 48-Group Calculation Guide for review by the associations and facilities.  IHCA will keep its members update on any additional discussion regarding a transition to RUG IV.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.

VBP Update

The IHCA Board met on November 5 to discuss the State’s proposal to alter the VBP Add-on methodology by removing the Satisfaction Surveys and allocating those points to the Report Card Score (RCS) portion of the add-on.  In agreement with the IHCA Payment Committee’s recommendation, the IHCA Board agreed that the State should implement the VBP Add-on without the Satisfaction Surveys included, resulting in a VBP Add-on where 58% of the add-on is based on the RCS, 10% is based on Nursing Hours Per Resident Day, and 30% is based on retention and turnover of RN/LPNs, CNAs, Administrators, DONs,  and 2% is based upon contracting with an AMDA Certified Medical Director (for more detail on the VBP domains, see http://www.nxtbook.com/nxtbooks/naylor/INHB0112/index.php?startid=6#/6).

However, the Board also directed IHCA staff to continue work on changing the VBP Add-on methodology so that therapy hours are counted in the Nursing Hours Per Resident Day domain, and so that Administrator and DON promotion within a company does not count as turnover.  IHCA has been on record with both of these issues in the past and has communicated again with the State on these points. IHCA Staff is preparing to take additional steps to secure changes in these areas.

Faith Laird, Director of the Division of Aging, emailed IHCA a revised model of the impact that the revised VBP Add-on would have to nursing facilities.  The revisions include the 80th and 20th percentile values for measures where applicable.  In addition, the State indicated that it reviewed CNA turnover rates between urban and rural facilities to test the assertion that urban facilities have higher turnover rates than rural facilities, therefore supporting the need for a probationary period during which turnover would not negatively impact performance in the turnover domain.  Based on the State’s data from nursing facility cost reports, CNA turnover in urban areas measured 1.58 Quality Points and rural areas measure 1.57 Quality Points.

IHCA has requested additional information from the State regarding the data behind the Nursing Hours Per Resident Day calculation, modeling on how the revised methodology would impact the Profit Incentive Add-ons, and detail on actual performance of facilities in each of the domains rather than how many Quality Points were earned by each facility.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.

UPL Program

On November 5, the State held a meeting with the executives of the Non-State Government Owned (NGSO) Nursing Facilities regarding the UPL program.  The three nursing home trade associations were also present at the meeting.  Two issues were addressed.

How the UPL is Calculated
The State had previously discussed the possibility of moving the UPL payment to a facility specific payment versus the current average, pooled amount effective October 1, 2012.  Due to some pushback by certain providers, it was thought that the implementation date would be delayed.  However, the State informed everyone that they will implement this change effective October 1, 2012.  Three documents that discuss and describe the UPL calculation change are available in the Member's Only section of the IHCA website.

To accomplish the calculation change, a State Plan Amendment (SPA) will be filed soon.  If the SPA is not approved by CMS by February 15, 2013, the State will pay the October 1, 2012 – December 31, 2012 interim UPL payment based on the current pooled methodology.  The State would then settle up on the Final June 30, 2013 payment.  The State will calculate quarterly facility-specific UPL payment amounts for all Providers in the UPL program, even for interim payments effective with the October 1, 2012 – December 31, 2012 quarter.  One provider is pushing for a delay to  the January 1, 2012 rate effective date, but it is unclear if a delay will be granted.

How the UPL Money is Distributed
The State is concerned that the growth of the UPL program will cause CMS to investigate the Program and potentially eliminate it.  The State also said that it is concerned that the growth of the UPL program has not had quality care in mind.  To be in front of this, the State initially proposed the following to be effective July 1, 2013:

• 50% of the UPL payments will be distributed as they are today to County Hospitals
• 49.5% of the UPL payments will be put into a Quality Pool and be paid to all Medicaid certified nursing facilities (Not just Providers in the UPL program) based performance within the proposed Phase III – Value Based Purchasing Add-on.
     o When asked, the State did not know how much money this would add to the VBP Add-on.
• .5% of the UPL payments will go to the State to pay for the administration of the UPL Program.

The proposal was met with a number of questions from hospital representatives regarding the fairness of the proposal, where non-participating UPL facilities would have access to UPL funds through a quality payment.  IHCA voiced concern about plowing a potentially vast sum of funds into the VBP Add-on as it is currently designed due to concerns already voiced by IHCA regarding the methodology and the fact that many initiatives that could improve quality would be missed if only the VBP add-on was utilized.

Based on the robust discussion, the State said that the proposal would probably not be effective July 1, 2013, that the split of funds above is not set in stone, and that providers should forward comments and questions to the State.  Those that IHCA has talked to since that meeting agree that the proposal was the opening salvo in a longer discussion on a quality metric program paid for by UPL funds.
IHCA staff has already informed the Board of Directors of this proposal and will be taking further direction from the Board on next steps.  IHCA is also coordinating with the Indiana Hospital Association to ensure that both organizations are on the same page.

Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.