FSSA released a draft Aged, Blind and Disabled Managed Care report that is due to the General Assembly on December 15th (click here for the draft report). The report concludes that neither Risk Based Managed Care nor Managed Fee For Service would result in savings for the State if all ABD groups were enrolled in either program (see Table 31, page 73).
The report provides several scenarios of carve-outs (exclusions) to each program in order to realize a savings to the State, including carving-out nursing facilities. The report also indicates that Risk Based Managed Care and Managed Fee For Services provide high potential for improved care coordination and availability of enhanced services since those services would not be tied to the State Plan Amendment. The report specifically includes discussion of carving-out nursing facility (institutional) care, and details concerns with loss of UPL supplemental payments and QAF payments.
Once the final report is issued, IHCA will ensure it is distributed to members. Contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.
Monday, December 2, 2013
HHS OIG Releases Report Recommending a New QM for Rehospitalization Rates
The HHS Office of Inspector General (OIG) released a report last month (click here for the report) that recommends CMS develop a quality measure describing nursing home rehospitalization rates and instruct State Survey Agencies to review that quality measure as part of the survey process. In 2011, the OIG found that 25% of nursing home patients were transferred to hospitals for inpatient admissions, which cost $14.3 billion to the Medicare program. They also found that readmission rates varied widely across nursing homes. The OIG is concerned that readmissions increase risk of residents’ experiencing harm and negative care outcomes.
OSHA Revises Hazard Communication Standard
OSHA has revised its Hazard Communication Standard to align with the United Nations Globally Harmonized System of Classification and Labeling of Chemicals. All nursing centers and assisted living centers must train staff on this new standard by December 1, 2013. Click here for a summary of the training requirements and a brief power point presentation that can be used in the required training. These were prepared by Jackson Lewis LLP, AHCA’s OSHA consultant. A summary of the OSHA Final Rule related to these changes can be found here.
CMS Memo Concerning Full Sprinklering of Nursing Centers
This is the latest CMS memo concerning full sprinklering of nursing facilities and includes actions that a nursing center may take to substantially lower exposure to fire risks while a sprinkler system is being installed. As well, there is additional information related to enforcement actions that may be taken when a nursing center has not met the required deadline for full sprinklering, and an update Question and Answer document about full sprinklering. Indiana required full sprinklering for nursing facilities prior to the Federal requirement, so this memo is mostly for your general information and awareness.
ISDH Residential Survey Update
There were 62 offense and deficiency citations issues to residential care facilities in October, a high for 2013. 14 of the citations were offense and 48 were deficiency. The total number of citations was increased in part due to the federal government shutdown as surveyors completed more annual surveys of residential care facilities that would otherwise have occurred. Leading the way in October were Tags 241 and 273, each of which were cited 10 times. Tag 241 is issued for failures to have physician ordered medications administered by licensed nursing personnel or by QMAs, and Tag 273 is issued for failures maintaining food preparation and service areas in accordance with state/local sanitation and food handling standards. The next most frequent tag for October was Tag 144, cited 6 times, concerning maintenance of grounds in a clean and orderly manner.
Click here to view a summary of the October residential care facility offense and deficiency citations.
Click here to view a summary of the October residential care facility offense and deficiency citations.
ISDH IJ/SSQC Update
There were 2 events in the month of October that led to 1 citation that was SSQC only and 2 citations that were IJ and SSQC. Reaching back to a frequent issue in 2012, unsafe hot water temperatures were found in a facility and resulted in F323 being cited (SSQC only). The facility was aware of the water temperature issue due to a faulty water heater, that was replaced, and a newly-installed mixing valve. However, these remedies did not solve the hot water problem and several residents were aware of it and had reported it to staff. The Administrator knew the maintenance director was checking the water temperatures, but was not aware that a log was not being maintained to check for patterns. Temperatures exceeded the 120-degree limit, and at some faucets water more than 150, 160 and 180-degrees Fahrenheit.
The other October event concerned an allegation of abuse and the failure to ensure timely reporting of the allegation to the Administrator and the ISDH. This event led to two citations, F225 and F226, at the IJ and SSQC levels. There was an allegation that a CNA had tied a resident’s gown to the resident’s wheelchair on 10/1/13, but the incident was not reported to the DON until 10/2/13 and it also did not reach the Administrator until 10/4/13. The accused CNA was seen manipulating the resident’s gown on surveillance tape, and continued to work until the Administrator received the report. A second CNA appeared to be aware of the alleged abuse, did not report it, and also was still working until the Administrator received the report. The ISDH was notified via incident report the same day the Administrator was made aware of the issue, but this was 3 days after the alleged abuse was known to staff.
Click here to view a summary of 2013 IJ/SSQC citations and for the citations from October.
The other October event concerned an allegation of abuse and the failure to ensure timely reporting of the allegation to the Administrator and the ISDH. This event led to two citations, F225 and F226, at the IJ and SSQC levels. There was an allegation that a CNA had tied a resident’s gown to the resident’s wheelchair on 10/1/13, but the incident was not reported to the DON until 10/2/13 and it also did not reach the Administrator until 10/4/13. The accused CNA was seen manipulating the resident’s gown on surveillance tape, and continued to work until the Administrator received the report. A second CNA appeared to be aware of the alleged abuse, did not report it, and also was still working until the Administrator received the report. The ISDH was notified via incident report the same day the Administrator was made aware of the issue, but this was 3 days after the alleged abuse was known to staff.
Click here to view a summary of 2013 IJ/SSQC citations and for the citations from October.
Monday, November 4, 2013
Changes to the e450B Process – Recorded Webinar and Q&As
As reported by IHCA, and communicated by the Indiana Division of Aging, there have been 3 webinars conducted in the past 2 weeks and one in-person training session concerning the latest changes to the e450B process that became effective on Nov. 1, 2013. The webinars attracted outstanding attendance and due to this many people could not access the webinar due to space limitations.
The Division of Aging has added a recording of the e450B webinar to their e450B website at https://myweb.in.gov/FSSA/aging/form450b/. That website will also have a Q&A document for viewing once posted by the Division of Aging. That website also has the memo from the Division of Aging that describes the revisions that take effect Nov. 1, 2013, which include:
• Selecting the appropriate assessment type
• "Short" e450B form
• Updates to "Request for Continued Stay" or "PAS/PASRR not completed"
• Training, materials and resources to be found on the e450B webpage
• Who can complete the Resident Summary
The Division of Aging is committed to making this e450B process work for providers and patients, and is still willing to provide corporate trainings as requested. For additional assistance or to schedule a corporate training, please contact Becky Koors at Rebecca.Koors@fssa.in.gov or 317-232-4355.
The Division of Aging has added a recording of the e450B webinar to their e450B website at https://myweb.in.gov/FSSA/aging/form450b/. That website will also have a Q&A document for viewing once posted by the Division of Aging. That website also has the memo from the Division of Aging that describes the revisions that take effect Nov. 1, 2013, which include:
• Selecting the appropriate assessment type
• "Short" e450B form
• Updates to "Request for Continued Stay" or "PAS/PASRR not completed"
• Training, materials and resources to be found on the e450B webpage
• Who can complete the Resident Summary
The Division of Aging is committed to making this e450B process work for providers and patients, and is still willing to provide corporate trainings as requested. For additional assistance or to schedule a corporate training, please contact Becky Koors at Rebecca.Koors@fssa.in.gov or 317-232-4355.
Wednesday, October 30, 2013
CMS Issues Memorandum Concerning Treatment of Survey Activities Post-Federal Government Shutdown
CMS issued a memo to State Survey Agencies on Oct. 25th concerning survey activities during and following the Federal government shutdown. (Click here for the full memo.) Many of the questions and answers in the beginning of the memo deal with the funding of state activities during the shutdown. Beginning in section B several relevant sections address how IJs, CMPs, and DPNA are to be treated post-shutdown. Please note two questions and answers in particular:
• Item B3 about fixing IJs (posed on bottom of page 4 continuing on to page 5 is the one we received most frequently and submitted to CMS). The answer is the time for fixing IJs will be linked to the date the citation was issued not the date of inspection. Also IJs that were issued prior to the shutdown but a revisit was delayed will be considered abated if evidence of fixing the problem is well documented
• Item B5 about CMPs or DPNA (posed on page 5 and continuing onto page 6). If credible evidence is submitted to SSA during the shut-down or is found at revisit that problem was resolved, CMPs or DPNA will be discontinued as of that date (see detailed criteria on page 6 of the memo).
• Item B3 about fixing IJs (posed on bottom of page 4 continuing on to page 5 is the one we received most frequently and submitted to CMS). The answer is the time for fixing IJs will be linked to the date the citation was issued not the date of inspection. Also IJs that were issued prior to the shutdown but a revisit was delayed will be considered abated if evidence of fixing the problem is well documented
• Item B5 about CMPs or DPNA (posed on page 5 and continuing onto page 6). If credible evidence is submitted to SSA during the shut-down or is found at revisit that problem was resolved, CMPs or DPNA will be discontinued as of that date (see detailed criteria on page 6 of the memo).
CMS Issues Memorandum Concerning CPR in Nursing Homes
CMS has issued S&C Memo 14-01-NH (click here for the full memorandum), “Cardiopulmonary Resuscitation (CPR) in Nursing Homes,” making the following three key points:
• Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident’s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times.
• Facility CPR Policy –Some nursing homes have implemented facility-wide no CPR policies. Facilities must not establish and implement facility-wide no CPR policies.
• Surveyor Implications - Surveyors should ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not reflect instances where CPR was not initiated by staff even though the resident requested CPR or had not formulated advance directives.
The memorandum reiterates the resident’s right to formulate an advance directive, emphasizing the requirement that skilled nursing facilities provide written information to residents about this and other rights at the time of admission. While acknowledging that research shows that CPR is generally ineffective among elderly nursing facility residents, the memo also notes that trends in the nursing facility population including more younger residents, more individuals seeking short-term rehabilitation, and increasing ethnic and cultural diversity and underscores the need for effective, individualized, well-documented and consistently implemented policies and procedures for advance directives.
In this context, CMS clarifies that nursing facilities are not permitted to implement facility-wide no-CPR policies, stating:
“Facility policy should specifically direct staff to initiate CPR when cardiac arrest occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC). Additionally, facility policy should not limit staff to only calling 911 when cardiac arrest occurs. Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest in accordance with that resident’s advance directives or in the absence of advance directives or a DNR order. CPR-certified staff must be available at all times to provide CPR when needed. Facilities must not establish and implement facility-wide no CPR policies for their residents as this does not comply with the resident’s right to formulate an advance directive under F155. The right to formulate an advance directive applies to each and every individual resident and facilities must inform residents of their option to formulate advance directives. Therefore, a facility-wide no CPR policy violates the right of residents to formulate an advance directive.”
• Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident’s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times.
• Facility CPR Policy –Some nursing homes have implemented facility-wide no CPR policies. Facilities must not establish and implement facility-wide no CPR policies.
• Surveyor Implications - Surveyors should ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not reflect instances where CPR was not initiated by staff even though the resident requested CPR or had not formulated advance directives.
The memorandum reiterates the resident’s right to formulate an advance directive, emphasizing the requirement that skilled nursing facilities provide written information to residents about this and other rights at the time of admission. While acknowledging that research shows that CPR is generally ineffective among elderly nursing facility residents, the memo also notes that trends in the nursing facility population including more younger residents, more individuals seeking short-term rehabilitation, and increasing ethnic and cultural diversity and underscores the need for effective, individualized, well-documented and consistently implemented policies and procedures for advance directives.
In this context, CMS clarifies that nursing facilities are not permitted to implement facility-wide no-CPR policies, stating:
“Facility policy should specifically direct staff to initiate CPR when cardiac arrest occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC). Additionally, facility policy should not limit staff to only calling 911 when cardiac arrest occurs. Prior to the arrival of EMS, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest in accordance with that resident’s advance directives or in the absence of advance directives or a DNR order. CPR-certified staff must be available at all times to provide CPR when needed. Facilities must not establish and implement facility-wide no CPR policies for their residents as this does not comply with the resident’s right to formulate an advance directive under F155. The right to formulate an advance directive applies to each and every individual resident and facilities must inform residents of their option to formulate advance directives. Therefore, a facility-wide no CPR policy violates the right of residents to formulate an advance directive.”
Residential Care Facility – September Deficiency and Offense Citation Update
There were 32 deficiency citations and 3 offense citations issued to Residential Care Facilities in September (click here for a summary of the September deficiency and offense citations). A total of 8 citations were issued for Tag 217 concerning use of appropriately trained staff to complete resident evaluations and service plans, and review, revision and resident agreement with those evaluations and plans. All but one of the citations were due to residents, or their representatives, not signing the service plan. The ISDH interprets its regulation concerning service plans to require residents, or their representatives, to sign the service plan every time it is evaluated and whether or not changes are made to the service plan. Service plans must, at a minimum, be updated semiannually or upon a substantial change in condition. Tag 217 is now tied for 1st as the most often cited deficiency tag in 2013 (tied with Tag 273, concerning kitchen sanitation and food handling, which was cited 3 times in September; each have been cited 34 times in 2013).
September also saw 4 citations for Tag 117 concerning sufficient staffing, qualifications, and training. This tag was cited 3 times in August as well, but only 4 other times in 2013 before the last two months. This appears to be the beginning of a trend and facilities should focus some attention to ensuring compliance. In addition, Tag 241 continues to be cited with regularity for alleged failure to dispense medications with only either licensed nurses or QMAs. Lastly, the following were cited for the first time in 2013 at the deficiency level: Tag 45 (resident notification regarding interfacility transfer); Tag 86 (compliance with all applicable laws); and Tag 118 (providing ADL assistance by unlicensed personnel that are not either a CNA or HHA).
Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk. It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement. Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.
September also saw 4 citations for Tag 117 concerning sufficient staffing, qualifications, and training. This tag was cited 3 times in August as well, but only 4 other times in 2013 before the last two months. This appears to be the beginning of a trend and facilities should focus some attention to ensuring compliance. In addition, Tag 241 continues to be cited with regularity for alleged failure to dispense medications with only either licensed nurses or QMAs. Lastly, the following were cited for the first time in 2013 at the deficiency level: Tag 45 (resident notification regarding interfacility transfer); Tag 86 (compliance with all applicable laws); and Tag 118 (providing ADL assistance by unlicensed personnel that are not either a CNA or HHA).
Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk. It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement. Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.
IJ/SSQC Update – August and September 2013
Due to delays in obtaining IJ/SSQC data from August, no update was provided last month. However, data has been obtained for August and September and can now report to catch up on the year to date. Through July of 2013, there had been 7 events leading to IJ tags, and 8 events leading to SSQC tags. August and September, combined, saw 5 events leading to IJ tags and 6 events leading to SSQC tags. There were a couple of IJ/SSQC citations issued that had not risen to that level in more than 3 years (F311, F333, F520). Click here for the August and September surveys, as well as the year to date summary.
• August Summary
In August a facility was cited for alleged failure to timely report allegations of abuse to the administrator and to timely investigate said allegations. The first issue appeared to stem from alleged rough care/physical abuse that was verbally reported to her by an Activity Aide, but that SSD did not report it to either the DON or Administrator and admitted that she had forgotten to do so. The SSD was approached about the alleged verbal abuse when the QA Consultant approached her about it after having received an allegation of abuse report. A second issue for this facility related to an incomplete and inconsistently documented abuse allegation investigation. Both F225 and F226 were cited.
Also in August, F309 was cited for a facility’s alleged failure to ensure availability of CPR certified staff on each shift for residents with full code status, and for residents that wish to have full resuscitation in the event of cardiopulmonary arrest. Based on the survey document, the facility has residents that were documented as full code for all hours of the day, however the facility also documented that did not have CPR certified staff 24 hours per day. The DON herself had let her CPR certification lapse and only 4 of 10 licensed staff were CPR certified at that time. A separate facility was cited for a violation of F329 related to PT/INR monitoring and PICC line complications. The issue here appeared to be related to confusion on when the PT/INRs were supposed to be conducted.
The last issue in August resulted in F333 and F520 being cited at the IJ level for first time in more than 3 years. According to the survey documentation, a resident was administered his roommates medications after the resident was not identified correctly by the LPN who administered the medications (F333 was cited). A citation as also issued for the alleged failure of the QA committee to implement plans of action for a number of concerns identified by the committee, nor was there evidence of a system being in place to monitor implementation of plans to address issues identified by the QA committee (F520 was cited).
• September Summary
A facility was cited for alleged violation of F225 and F226 for issues related to timely reporting of abuse allegations and failures to perform criminal history checks on employees. The reporting of abuse citation stemmed from an incomplete abuse investigation and failure to report the incident to the ISDH. In addition, a second issue was noted concerning another incomplete abuse investigation. Regarding criminal history checks, the surveyor noted that there were seven then-current employees for whom a completed criminal history check could not be found or produced by facility staff. It appeared there was a gap as to who was assigned responsibility for performing criminal history checks due to the absence of a business office managed that used to perform them, but was no longer employed. This facility was also cited F311 for alleged failure to ensure a resident received restorative services to prevent loss of ability to ambulate. It appeared that the facility’s therapy company had discontinued services at the facility due to a dispute with the facility, and adequate therapy staffing had not been found to provide services thereafter.
Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk. It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement. Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.
• August Summary
In August a facility was cited for alleged failure to timely report allegations of abuse to the administrator and to timely investigate said allegations. The first issue appeared to stem from alleged rough care/physical abuse that was verbally reported to her by an Activity Aide, but that SSD did not report it to either the DON or Administrator and admitted that she had forgotten to do so. The SSD was approached about the alleged verbal abuse when the QA Consultant approached her about it after having received an allegation of abuse report. A second issue for this facility related to an incomplete and inconsistently documented abuse allegation investigation. Both F225 and F226 were cited.
Also in August, F309 was cited for a facility’s alleged failure to ensure availability of CPR certified staff on each shift for residents with full code status, and for residents that wish to have full resuscitation in the event of cardiopulmonary arrest. Based on the survey document, the facility has residents that were documented as full code for all hours of the day, however the facility also documented that did not have CPR certified staff 24 hours per day. The DON herself had let her CPR certification lapse and only 4 of 10 licensed staff were CPR certified at that time. A separate facility was cited for a violation of F329 related to PT/INR monitoring and PICC line complications. The issue here appeared to be related to confusion on when the PT/INRs were supposed to be conducted.
The last issue in August resulted in F333 and F520 being cited at the IJ level for first time in more than 3 years. According to the survey documentation, a resident was administered his roommates medications after the resident was not identified correctly by the LPN who administered the medications (F333 was cited). A citation as also issued for the alleged failure of the QA committee to implement plans of action for a number of concerns identified by the committee, nor was there evidence of a system being in place to monitor implementation of plans to address issues identified by the QA committee (F520 was cited).
• September Summary
A facility was cited for alleged violation of F225 and F226 for issues related to timely reporting of abuse allegations and failures to perform criminal history checks on employees. The reporting of abuse citation stemmed from an incomplete abuse investigation and failure to report the incident to the ISDH. In addition, a second issue was noted concerning another incomplete abuse investigation. Regarding criminal history checks, the surveyor noted that there were seven then-current employees for whom a completed criminal history check could not be found or produced by facility staff. It appeared there was a gap as to who was assigned responsibility for performing criminal history checks due to the absence of a business office managed that used to perform them, but was no longer employed. This facility was also cited F311 for alleged failure to ensure a resident received restorative services to prevent loss of ability to ambulate. It appeared that the facility’s therapy company had discontinued services at the facility due to a dispute with the facility, and adequate therapy staffing had not been found to provide services thereafter.
Also in September, a facility was cited for F323 as past noncompliance due to the elopement of a resident with known elopement risk. It appeared that the facility did not have a consistent plan for monitoring residents deemed high risk for elopement. Lastly in September, a facility was cited F371 and F469 for failure to maintain a sanitary kitchen due to evidence of rodent activity.
Monday, September 30, 2013
Value Based Purchasing – CMS Issues Request for Additional Information
On August 14, 2013, CMS issued a Request for Additional Information to the Indiana Medicaid Office concerning the State Plan Amendment (SPA) to implement the Value Based Purchasing (VBP) program. Click here to read the CMS letter. The VBP program is the new methodology for an add-on to the Medicaid NF rate that is based on Report Card Scores, nursing hours per resident day, and staff retention and turnover. Click here for details on the VBP program. In the CMS letter, the agency suggested to Indiana Medicaid that the VBP program incorporate certain MDS Quality Measures, even though those Quality Measures were not part of the original submission. CMS also requested that additional detail be added to the SPA concerning calculation of the various VBP domains.
Indiana Medicaid responded to the CMS letter on September 9th. Click here to read Indiana Medicaid’s response. With the submission on September 9th, CMS has 90-days to respond, so we expect an approval or denial in early December of this year. Regarding the incorporation of Quality Measures, Indiana Medicaid agreed with CMS that Quality Measures should be incorporated into the VBP program at a future date. To that end, IHCA has been part of recent meetings with Indiana Medicaid and the Division of Aging to begin discussions on how Quality Measures could be incorporated in the future.
Lastly, as you are aware, Indiana Medicaid and its contractors conducted satisfaction surveys of residents, family and staff this summer. That data is not yet available for review or analysis, but will be in the coming month or so. Once IHCA has this data, we will report back to the membership.
If you have any questions, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
Indiana Medicaid responded to the CMS letter on September 9th. Click here to read Indiana Medicaid’s response. With the submission on September 9th, CMS has 90-days to respond, so we expect an approval or denial in early December of this year. Regarding the incorporation of Quality Measures, Indiana Medicaid agreed with CMS that Quality Measures should be incorporated into the VBP program at a future date. To that end, IHCA has been part of recent meetings with Indiana Medicaid and the Division of Aging to begin discussions on how Quality Measures could be incorporated in the future.
Lastly, as you are aware, Indiana Medicaid and its contractors conducted satisfaction surveys of residents, family and staff this summer. That data is not yet available for review or analysis, but will be in the coming month or so. Once IHCA has this data, we will report back to the membership.
If you have any questions, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
Indiana Medicaid Managed Care Report
The IHCA staff has engaged in multiple meetings and made presentations this summer concerning the study of managed care programming for the Aged, Blind and Disabled beneficiary group being conducted by the Family and Social Services Administration (FSSA). The FSSA study is being conducted pursuant to a law that was passed in 2013 mandating such a report be made to the legislature’s Health Finance Commission by December 15, 2103. For a summary of what the report must address, visit FSSA’s website on the topic at http://www.in.gov/fssa/4828.htm. IHCA submitted initial comments to FSSA concerning its report and approach to the issue in mid-July. Click here for IHCA’s responses. You can view IHCA’s presentation that was made to FSSA’s internal committee at http://www.in.gov/fssa/files/IHCA_ABD_Taskforce_Presentation.pdf and watch the presentation at http://www.in.gov/fssa/4830.htm (see Indiana Health Care Association under the August 16th, 2013 heading).
e450B Process
The e450B process continues to be slow, despite increase staff assigned to process the submissions. While the wait time for approval has decreased some, the Division of Aging is just now processing forms that were submitted in late July and early August. IHCA has learned that the Division of Aging is working on a contract to obtain more personnel to assist with the e450B process. In addition, the Division is working on a short-form e450B that should help move the process faster. They are not sure of a completion date for the short-form, but hope it will not be any later than January 1, 2014.
The State will be holding a webinar in late October to continue to educate facilities about the e450B process. Once that date is released, we will inform membership. Also, the Division is working on a revised Resident Summary description and guidance in order to help streamline that portion of the e450B process.
If you have any questions, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
The State will be holding a webinar in late October to continue to educate facilities about the e450B process. Once that date is released, we will inform membership. Also, the Division is working on a revised Resident Summary description and guidance in order to help streamline that portion of the e450B process.
If you have any questions, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
IGT/UPL Distribution Methodology is Changing
On September 10, 2013, CMS approved Indiana Medicaid’s State Plan Amendment to change the way supplemental payments are distributed to non-state government operated or owned nursing facilities (i.e. county or city hospital owned nursing facilities). The new methodology will calculate supplemental payments based on each facility’s Medicare Rate and adjusted Medicaid rate – in other words, it will be a facility-specific calculation. Prior to this new methodology, the supplemental payment was an average amount that was paid to all participating hospitals. This change results in some hospitals gaining and some losing supplemental payment funds. Click here to read CMS’s approval letter.
If you have any questions, or need specific calculation information on the new methodology, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
If you have any questions, or need specific calculation information on the new methodology, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
CMS Issues RAI Manual Updates Effective October 1, 2013
CMS recently posted the fall updates to the RAI User’s Manual, which take effect on October 1. Among the important changes providers need to be familiar with are new items in Section K (swallowing/nutritional status) and Section O (special treatments, procedures and programs). Additional clarification is also provided in Section G (activities of daily living) and on setting the assessment reference date (ARD) for Discharge assessments. These changes will impact classification of residents into RUGs for payment purposes and should be reviewed carefully by center staff involved in care documentation and MDS assessments and coding.
In Section K, a new item is added to capture information about caloric and fluid intake via parenteral feeding, tube feeding or intravenously.
In Section O, two new pieces of information are being captured. First, centers will be required to report co-treatment minutes by entering the total number of minutes each discipline of therapy was administered to the resident in co-treatment sessions in the last 7 days. Second, centers will now be required to report the number of distinct calendar days on which at least 15 minutes of therapy services were provided in the past 7 days.
In Section G, item G0110, Activities of Daily Living (ADL), the manual updates relate to the “rule of three” and the use of the ADL Self-Performance Algorithm. Over the past several months, CMS has commented in a number of different venues regarding the intended application of the rule of three described in the RAI manual. In these new updates, CMS clarifies the instruction that as the first step to determining the appropriate coding for this section, “When an activity occurs three or more times at any one level, code that level.” If this step applies to the situation, providers are instructed not to go on to apply the algorithm. New examples are included in this section to illustrate correct coding.
Finally, with regard to discharge assessments, CMS clarifies that the ARD for a discharge assessment is always the date of discharge.
CMS also released a separate memorandum describing the transition process for implementation of these new items, effective October 1. The transition policies will apply to determination of RUGs for individuals with assessment reference dates between October 1 and October 13.
In Section K, a new item is added to capture information about caloric and fluid intake via parenteral feeding, tube feeding or intravenously.
In Section O, two new pieces of information are being captured. First, centers will be required to report co-treatment minutes by entering the total number of minutes each discipline of therapy was administered to the resident in co-treatment sessions in the last 7 days. Second, centers will now be required to report the number of distinct calendar days on which at least 15 minutes of therapy services were provided in the past 7 days.
In Section G, item G0110, Activities of Daily Living (ADL), the manual updates relate to the “rule of three” and the use of the ADL Self-Performance Algorithm. Over the past several months, CMS has commented in a number of different venues regarding the intended application of the rule of three described in the RAI manual. In these new updates, CMS clarifies the instruction that as the first step to determining the appropriate coding for this section, “When an activity occurs three or more times at any one level, code that level.” If this step applies to the situation, providers are instructed not to go on to apply the algorithm. New examples are included in this section to illustrate correct coding.
Finally, with regard to discharge assessments, CMS clarifies that the ARD for a discharge assessment is always the date of discharge.
CMS also released a separate memorandum describing the transition process for implementation of these new items, effective October 1. The transition policies will apply to determination of RUGs for individuals with assessment reference dates between October 1 and October 13.
Antipsychotic Drug Use is Declining
On August 27, CMS released data regarding antipsychotic drug use in nursing homes. Click here for the data and the CMS press release. Use has decreased across the country by 9.1 percent comparing first quarter of 2013 with last quarter of 2011. At least eleven States have hit or exceeded a 15 percent target reduction, and Indiana saw nearly a 10% reduction (9.79%).
Affordable Care Act Communication Directory
The State of Indiana has published a communication directory for use when fielding questions from clients, patients, families, and even your friends related to the Affordable Care Act. Click here to access the directory. It is organized by General Topic with Subtopics, then provides referral information. Although much of the ACA’s health care expansion and insurance provisions do not directly impact long term care, you may find this directory useful.
ISDH Health Facility Plan Review
As many are aware, the ISDH is behind in reviewing health facility plans for construction with 27 pending plans to be reviewed. The ISDH Division of Long Term Care has re-arranged the plan review process so that Kim Rhoades will be directly involved with the plan review process rather than it being directed by ISDH engineers. Mrs. Rhoades plans to contact the facility’s representative and architect to arrange for an in-person meeting at which time the facility and the architect will be required to walk through the submitted plans to explain how the plans comply with regulatory requirements and then sign an affidavit attesting to such compliance. The ISDH hopes that this process will speed up plan review with the goal of clearing the existing 27 plans by December 31, 2013.
Friday, September 27, 2013
Residential Facility Survey Update
There were 37 Residential Care citations issued by the ISDH in June, 33 of which were deficiency tags and 4 were offense tags. Tag 273, Food & Nutritional Services, continues to be cited frequently with 4 citations in August for alleged failure to maintain food preparation and service areas in accordance with local sanitation and food handling standards. Tag 273 is the most often cited tag in 2013. Right behind this tag in terms of frequency is Tag 241 concerning administration of medication by licensed personnel or by a QMA. Three facilities were cited for alleged failure to comply with Tag 241 in August.
For only the second and third time this year, Tag 41 was issued to two facilities for alleged failure to investigate and respond to complaints or grievances. The low incidence of this tag is testament to the good work facilities do in responding to complaints when filed. Click here to see the summary of the August Residential Care Citations.
For only the second and third time this year, Tag 41 was issued to two facilities for alleged failure to investigate and respond to complaints or grievances. The low incidence of this tag is testament to the good work facilities do in responding to complaints when filed. Click here to see the summary of the August Residential Care Citations.
Incident Reporting – Changes Ahead
The IHCA was given a preview of an online Incident Reporting System that is being developed by the Indiana State Department of Health. The online system will be housed in the same area as the existing online Survey System. The online Incident Reporting System mimics the existing Incident Report Form in terms of content and work flow. Accessing the online Incident Report Form will be limited to those with a log-in and password to the Survey System, and facilities may have more than one person with such access.
The online form will allow a user to begin completing an incident report and save that progress without having to complete it in one sitting so that the user can return to the form to later complete it and submit the form. In order to submit the form, the user will have to complete all fields except the ‘Follow-up’ field. Once submitted, the user will be able to track all submitted incidents reported. In addition, once an incident is submitted, the user will receive an email reminder to submit the required follow-up report 3-days after the incident is submitted, thereby helping the user comply with the 5-day follow-up requirement. The online Incident Reporting System will not include or cover applicable Crimes Reporting requirements under the Elder Justice Act. Reports of reasonable suspicions of crimes will still have to be reported separately, but the ISDH is working on a web-form for that process as well that will be housed on a publically accessible portion of the ISDH website.
The ISDH expects that it will test the online Incident Reporting System in October, with a live release in November, and then require mandatory use of the online system as of January 2014.
The online form will allow a user to begin completing an incident report and save that progress without having to complete it in one sitting so that the user can return to the form to later complete it and submit the form. In order to submit the form, the user will have to complete all fields except the ‘Follow-up’ field. Once submitted, the user will be able to track all submitted incidents reported. In addition, once an incident is submitted, the user will receive an email reminder to submit the required follow-up report 3-days after the incident is submitted, thereby helping the user comply with the 5-day follow-up requirement. The online Incident Reporting System will not include or cover applicable Crimes Reporting requirements under the Elder Justice Act. Reports of reasonable suspicions of crimes will still have to be reported separately, but the ISDH is working on a web-form for that process as well that will be housed on a publically accessible portion of the ISDH website.
The ISDH expects that it will test the online Incident Reporting System in October, with a live release in November, and then require mandatory use of the online system as of January 2014.
Tuesday, July 9, 2013
AHCA Submits Comments on the CMS SNF PPS Proposed Rule
On July 1, 2013, AHCA President and CEO Mark Parkinson submitted comments to CMS concerning the SNF PPS Proposed Rule. Click here to read AHCA’s comments. AHCA addressed key components of the proposed rule including SNF market basket weights, CMS cost category weight methodology, price proxies, the forecast error adjustment, and the reporting of distinct days of therapy. If you have any questions, please contact Peter Gruhn (pgruhn@ahca.org, 202-898-2819) or Elise Smith (esmith@ahca.org, 202-898-6305).
Indiana Medicaid Publishes Proposed NF Rates Due to Continued and Reduced Rate Cuts
As reported in June, Indiana Medicaid announced that the existing 5% NF reimbursement rate cut would continue until December 31, 2013. However, beginning January 1, 2014, the rate cut would be reduced from 5% to 3%. This reduction in the rate cut is directly attributable to the advocacy efforts of the IHCA. While Indiana Medicaid has not yet released official 7/1/13 NF rates, they did publish an estimate of the 7/1/13 rates with the 5% reduction and also the projected rates as of 1/1/14 with the 3% reduction. Click here for the proposed rates.
Please contact Zach Cattell, zcattell@ihca.org, with any questions.
Please contact Zach Cattell, zcattell@ihca.org, with any questions.
Indiana Medicaid Publishes Final Rule Concerning Value Based Purchasing
OnJune 26th, 2013, the final rule to implement the long-awaited Indiana Medicaid Value Based Purchasing program (VBP) was published in the Indiana Register. Click here to read the rule. The VBP program is now the legal standard for NF reimbursement, however it still must be approved by CMS prior to implementation. Indiana Medicaid submitted a State Plan Amendment to CMS on May 18, 2013, and approval should take place yet this year. To read more details about the VBP program, click here.
The final rule also makes other changes to the Indiana NF reimbursement regulation, including changes to field audit procedures, administrative reconsideration and appeal processes, and the addition of new allowable costs in the direct care, in-direct care, and administrative components of the NF reimbursement rate.
Please contact Zach Cattell, zcattell@ihca.org, with any questions.
The final rule also makes other changes to the Indiana NF reimbursement regulation, including changes to field audit procedures, administrative reconsideration and appeal processes, and the addition of new allowable costs in the direct care, in-direct care, and administrative components of the NF reimbursement rate.
Please contact Zach Cattell, zcattell@ihca.org, with any questions.
CMS Reminds Nursing Facilities of Resident’s Access and Visitation Rights
CMS issued S&C 13-42-NH to remind SNFs and NFs of the access and visitation rights held by nursing facility residents. This reminder emphasizes that residents must be notified of their rights to have visitors on a 24-hour basis, who could include, but are not limited to, spouses (including same-sex spouses), domestic partners (including same-sex domestic partners), other family members, or friends. Click here to read the memo.
CMS Releases Five-Star Quality Rating System Three-year Report
CMS issued S&C 13-44-NH containing the three-year review of the Five Star Rating System. Click here to read the report. The report contains the results of an analysis that examined trends in the first three years of the Five-Star Quality Rating System. (2009-2011). The report states: “Since implementation of the Five-Star Quality Rating System, there have been improvements in nursing facility performance in all three domains of quality that the system utilizes: health inspection surveys, quality measures (QMs) and staffing levels.”
Monday, July 8, 2013
CMS Publishes LTC Hospice Requirements Final Rule
On June 27th, 2013, CMS published the final rule establishing new requirements for the provision of hospice care in SNFs/NFs, and specifically focuses on certain information that must be in an agreement between a hospice and a nursing center. The Final Rule is effective August 26th, 2013. Please click here to access a copy. The CMS summary of the rule is below:
We are adopting the provisions of this final rule as proposed, with the following changes:
• We originally proposed the standard regarding LTC facility/Hospice cooperation at §483.75(r); however, during the process of finalizing this rule, CMS published a separate interim final rule, Requirements for Long- Term Care (LTC) Facilities; Notice of Facility Closure (76 FR 9503). The interim final rule added standards §483.75(r) and (s). Since the standards at §483.75(r) and (s) are now in use, we are finalizing this standard at §483.75(t).
• In consideration of public comments, we are making three substantive changes in this final rule. We have made a revision at 483.75(t)(3) to clarify that the LTC representative must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. We have also made a revision to the requirement at §483.75(t)(3)(iii) removing the phrase “other physicians” and replacing it with “other practitioners.” Lastly, we have made a revision to the requirement at §483.75(t)(2)(ii)(E)(3) by removing the phrase “that is not related to the terminal condition.”
Technical Correction
• We are finalizing the proposed technical correction which would fix an incorrect citation at §483.10(n). In §483.10(n), we are revising the reference “§483.20(d)(2)(ii)” to read “§483.20(k)(2)(ii).”
• We are also finalizing the proposed technical correction which would fix an incorrect citation at proposed §483.75(r)(4). In §483.75(t)(4), we are revising the reference “483.20(k)” to read “483.25.”
We are adopting the provisions of this final rule as proposed, with the following changes:
• We originally proposed the standard regarding LTC facility/Hospice cooperation at §483.75(r); however, during the process of finalizing this rule, CMS published a separate interim final rule, Requirements for Long- Term Care (LTC) Facilities; Notice of Facility Closure (76 FR 9503). The interim final rule added standards §483.75(r) and (s). Since the standards at §483.75(r) and (s) are now in use, we are finalizing this standard at §483.75(t).
• In consideration of public comments, we are making three substantive changes in this final rule. We have made a revision at 483.75(t)(3) to clarify that the LTC representative must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. We have also made a revision to the requirement at §483.75(t)(3)(iii) removing the phrase “other physicians” and replacing it with “other practitioners.” Lastly, we have made a revision to the requirement at §483.75(t)(2)(ii)(E)(3) by removing the phrase “that is not related to the terminal condition.”
Technical Correction
• We are finalizing the proposed technical correction which would fix an incorrect citation at §483.10(n). In §483.10(n), we are revising the reference “§483.20(d)(2)(ii)” to read “§483.20(k)(2)(ii).”
• We are also finalizing the proposed technical correction which would fix an incorrect citation at proposed §483.75(r)(4). In §483.75(t)(4), we are revising the reference “483.20(k)” to read “483.25.”
Indiana Division of Aging Issues Memo Concerning Delays with e450B Processing
As has been reported to the IHCA, the Indiana Division of Aging (Division) has experienced some delays in processing the new electronic 450B, or e450B, that became effective statewide February 1, 2013. The IHCA contacted the Division in June to discuss what the reasons for the delays were and how we could help resolve the issues. The Division has responded with a memo. Click here to read the Division’s response.
The Division indicates that the sheer volume of e450Bs has slowed their processing, but also that a number of e450Bs are having to be returned to the provider due to incorrect or missing information that must be completed in order to process the e450B. The most common issues appear to be missing resident Medicaid identification number, facility provider number, missing admission date, and missing documentation. A complete list of all issues is included in the memo.
The Division has re-assigned staff to help clear the backlog and hope that with additional staff, and additional attention from providers, that delays in processing e450Bs can be avoided in the future. The Division understands that with any change some process issues will come up and they do appreciate the hard work all have put into making this system change.
The Division indicates that the sheer volume of e450Bs has slowed their processing, but also that a number of e450Bs are having to be returned to the provider due to incorrect or missing information that must be completed in order to process the e450B. The most common issues appear to be missing resident Medicaid identification number, facility provider number, missing admission date, and missing documentation. A complete list of all issues is included in the memo.
The Division has re-assigned staff to help clear the backlog and hope that with additional staff, and additional attention from providers, that delays in processing e450Bs can be avoided in the future. The Division understands that with any change some process issues will come up and they do appreciate the hard work all have put into making this system change.
Wednesday, June 26, 2013
CMS Releases Guidance on Medicaid Funding for LTC Ombudsman Functions
On May 18, 2013, CMS released guidance to State Medicaid Agencies and State Units on Aging on the availability of federal Medicaid administrative matching funds for the LTC Ombudsman program. In prior years, CMS has indicated the Medicaid matching funds were not available for the LTC Ombudsman program.
The guidance lists the following activities that may be eligible for Medicaid administrative matching (50% match rate):
• Information provided to potential enrollees regarding Medicaid eligibility and facilitation of the enrollment process;
• Identifying and referring individuals who may be eligible for and in need of Medicaid services;
• Tracking and reporting to the Medicaid agency consumer requests for assistance in obtaining medical, dental, mental health, or long-term care (including home and community based) services that are covered by Medicaid;
• Providing ombudsman services to assist beneficiaries in transitioning from Medicare Part A coverage into the Medicaid nursing facility benefit or from private pay status into Medicaid funded nursing facility, home and community based services, or other Medicaid service categories;
• Consultation and direct case advocacy to assist individuals participating in home and community-based waiver programs;
• Identifying Medicaid-eligible residents who want to transition out of nursing home facilities and then connecting them with the appropriate local contact agency or other services to assist them in returning to the community.
Identifying and reporting suspected instances of Medicaid fraud to federal and state agencies for investigation and action; and
• Other LTCO activities which are determined by the Secretary of DHHS to be necessary for proper and efficient administration of the Medicaid state plan.
• State Medicaid Agencies will submit State Plan Amendments to begin to draw down such funding. And, the CMS Regional Offices will lead in working with interested states as well as Administration for Community Living regional offices.
In order to draw down the federal Medicaid matching funds, States must meet a number of complex requirements, including documentation of direct benefits to the Medicaid program and consistency with federal cost allocation principles. It is unclear at this time if Indiana will utilize this new guidance, and IHCA has contacted the Indiana Division of Aging and Office of Medicaid Policy and Planning to inquire about their potential use of the potential funding. Increased funding to the LTC Ombudsman program may help consumers and facilities in a number of ways, including better support with discharges and transfers and assisting with resident access to specialty services.
The guidance lists the following activities that may be eligible for Medicaid administrative matching (50% match rate):
• Information provided to potential enrollees regarding Medicaid eligibility and facilitation of the enrollment process;
• Identifying and referring individuals who may be eligible for and in need of Medicaid services;
• Tracking and reporting to the Medicaid agency consumer requests for assistance in obtaining medical, dental, mental health, or long-term care (including home and community based) services that are covered by Medicaid;
• Providing ombudsman services to assist beneficiaries in transitioning from Medicare Part A coverage into the Medicaid nursing facility benefit or from private pay status into Medicaid funded nursing facility, home and community based services, or other Medicaid service categories;
• Consultation and direct case advocacy to assist individuals participating in home and community-based waiver programs;
• Identifying Medicaid-eligible residents who want to transition out of nursing home facilities and then connecting them with the appropriate local contact agency or other services to assist them in returning to the community.
Identifying and reporting suspected instances of Medicaid fraud to federal and state agencies for investigation and action; and
• Other LTCO activities which are determined by the Secretary of DHHS to be necessary for proper and efficient administration of the Medicaid state plan.
• State Medicaid Agencies will submit State Plan Amendments to begin to draw down such funding. And, the CMS Regional Offices will lead in working with interested states as well as Administration for Community Living regional offices.
In order to draw down the federal Medicaid matching funds, States must meet a number of complex requirements, including documentation of direct benefits to the Medicaid program and consistency with federal cost allocation principles. It is unclear at this time if Indiana will utilize this new guidance, and IHCA has contacted the Indiana Division of Aging and Office of Medicaid Policy and Planning to inquire about their potential use of the potential funding. Increased funding to the LTC Ombudsman program may help consumers and facilities in a number of ways, including better support with discharges and transfers and assisting with resident access to specialty services.
CMS Alters SNF/NF Medication Pass Survey Protocol
IHCA members may have seen that CMS released a memorandum changing the survey protocol for Medication Pass. This change only impacts the Traditional Survey process. The change will now make the Traditional Survey procedure for Medication Pass the same as the QIS Medication Administration Observation protocol. If you’d like to read more, click here.
CMS Releases Introductory QAPI Materials
CMS announced the release of several QAPI tools for providers to use, and a new webpage to hold these resources. S&C 13-37-NH, accessible in the Members Only section of the IHCA website briefly discusses the following introductory materials:
o QAPI at a Glance – a guide for understanding and implementing QAPI in nursing homes
o QAPI Tools – process tools, within QAPI at a Glance, to help providers establish a foundation in QAPI
o QAPI News Brief – newsletter describing basic principles of QAPI
o Video – Nursing Home QAPI – What’s in it for you? - introduces QAPI, its value to residents, their families and caregivers, and what is in it for nursing homes that embrace QAPI
Moving forward, CMs plans to expand its QAPI efforts by developing resources for consumers. Visit the QAPI website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html.
o QAPI at a Glance – a guide for understanding and implementing QAPI in nursing homes
o QAPI Tools – process tools, within QAPI at a Glance, to help providers establish a foundation in QAPI
o QAPI News Brief – newsletter describing basic principles of QAPI
o Video – Nursing Home QAPI – What’s in it for you? - introduces QAPI, its value to residents, their families and caregivers, and what is in it for nursing homes that embrace QAPI
Moving forward, CMs plans to expand its QAPI efforts by developing resources for consumers. Visit the QAPI website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html.
ISDH Updates Advance Directives Brochure and Creates an Advance Directives Resource Center
The Indiana State Department of Health (ISDH) has released an updated version of their Advance Directives – Your Right to Decide brochure. You may access at the following link: http://www.in.gov/isdh/files/advanceddirectives.pdf. The updated version revises guidance concerning Out of Hospital Do Not Resuscitate Orders, and includes a description of the new Physician Orders for Scope of Treatment (POST) form, which is due out on or around July 1, 2013 (for a summary of the POST form and law, see http://blog.ihca.org/2013/06/indiana-physician-orders-for-scope-of.html).
In addition, the ISDH has created a new Advance Directives Resource Center website with links to the several advance directives authorized under Indiana law. See http://www.in.gov/isdh/25880.htm for more information.
In addition, the ISDH has created a new Advance Directives Resource Center website with links to the several advance directives authorized under Indiana law. See http://www.in.gov/isdh/25880.htm for more information.
Nursing Home Resident Satisfaction Surveys to Begin in July
A friendly reminder that contractors from the Office of Medicaid Policy and Planning, GoResource Link and Knowledge Services, will begin performing satisfaction surveys of residents in Indiana Nursing Facilities during the month of July. These interviews are part of the Indiana Medicaid Value Based Purchasing (VBP) program. For more on the VBP program, click here.
IHCA was invited to observe one of the training sessions conducted for the persons that will be interviewing the residents in your facilities. IHCA passed along the following observations and recommendations:
• The training sessions were thorough and discussed the nursing home environment, the need to be neutral during the surveys, HIPAA training and confidentiality of resident information
• The interviewers had a range of backgrounds, including some that have had prior long term care experience. Others were retired individuals or home-makers working part time.
• There will likely be 2 to 4 interviewers in each facility and they may have questions or need assistance with locating residents. IHCA recommends you assign a point-person to that interview team during their visit to your facility in order to field questions and assists as necessary.
• Interviewers are aware of the need to immediately report to the Administrator any specific information that could be an allegation of abuse, neglect, or misappropriation of resident property.
IHCA recommends you discuss this procedure with the interview team when they arrive at the facility.
IHCA was invited to observe one of the training sessions conducted for the persons that will be interviewing the residents in your facilities. IHCA passed along the following observations and recommendations:
• The training sessions were thorough and discussed the nursing home environment, the need to be neutral during the surveys, HIPAA training and confidentiality of resident information
• The interviewers had a range of backgrounds, including some that have had prior long term care experience. Others were retired individuals or home-makers working part time.
• There will likely be 2 to 4 interviewers in each facility and they may have questions or need assistance with locating residents. IHCA recommends you assign a point-person to that interview team during their visit to your facility in order to field questions and assists as necessary.
• Interviewers are aware of the need to immediately report to the Administrator any specific information that could be an allegation of abuse, neglect, or misappropriation of resident property.
IHCA recommends you discuss this procedure with the interview team when they arrive at the facility.
Timeframe to Report Incidents to the ISDH
State and federal regulations require health care facilities to report certain “incidents” to the Indiana State Department of Health (“ISDH”). Both the ISDH and the Centers for Medicare & Medicaid Services (“CMS”) have expectations of the timing in which a facility must report an incident. The current expectations and rules for both the ISDH and CMS are below; please note, however, that the standards may change once CMS issues the long-awaited memorandum concerning reporting allegations of abuse and neglect. Furthermore, it is likely that the ISDH will alter its guidance to align with CMS once the memo is issued.
According to the ISDH Division of Long Term Care, current CMS regulation concerning incident reporting takes precedent over that of the ISDH policy, and any facility must ensure that incidents are reported to the Administrator and ISDH immediately. The federal regulation, 42 C.F.R. §483.13(c)(2), states the following concerning timeliness of reporting incidents:
The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
The ISDH Division of Long Term Care has indicated that CMS interprets the regulation so that the term “immediately” applies both to reporting to the Administrator and reporting to “other officials in accordance with State law through established procedures.” Id. Furthermore, CMS has maintained that “immediately” means “as soon as possible, but ought not exceed 24 hours after discovery of the incident.”
Guidance from the ISDH Reportable Incidents Policy, accessible in the Members Only section of the IHCA website, is the main source of confusion on whether the Indiana standard for reporting is immediately or within 24 hours. The first sentence of the Indiana guidance states, “Facilities are required by law to report unusual occurrences within 24 hours of occurrence to the Long Term Care Division.” Through discussions with the ISDH Division of Long Term Care, this sentence is not accurate and needs to be revised. However, the language in the Reportable Incidents Policy will not likely change until CMS issues the memo regarding F 223.
CMS surveyors are beginning to cite facilities for alleged failures to report incidents immediately through look-behind surveys. Because of the increased CMS oversight, the ISDH may be changing its approach and begin to more aggressively cite facilities for not reporting incidents immediately. An example of a citation concerning incident reporting in which a facility was cited for failing to report immediately is also available in the Members Only section. Please note that the facility in this example reported 24 hours after the incident occurred, and referenced the ISDH guidance on the 24 hour reporting requirement. This incident should have been reported sooner.
Below are best practices and key points regarding the current legislation and requirements to comply with ISDH and CMS guidelines for incident reporting.
• “Immediately” does not mean a 24 hour grace period exists to report an incident.
• “Immediately” means as soon as possible once the resident is safe and protected.
o An example of the immediacy required: If an allegation of abuse has been made and the resident is bleeding, stop the bleeding and then immediately notify the ISDH. You do not stop the bleeding, suspend the employee(s), take witness statements, draw conclusions, and then finally notify the ISDH.
• Use best judgment and report as soon as possible when dealing with “degrees” of incidents, including the time of day in which incidents take place. A common concern is immediate reporting in the middle of the night when the alleged incident is not especially grave or injurious (for example: a bruise of unknown origin discovered at 2a.m.). Immediate in this circumstance may not require an ISDH report by 2:30 a.m.. However, if an allegation of an employee hitting a resident is made at 2 a.m., a report to the ISDH as soon as possible once the resident is safe and protected (which may also require the removal and suspension of the employee) is required. A reasonable time to do this may be an hour, or perhaps a bit more.
• Educate facility staff. The 24 hour window that most believe exists before an incident report must be submitted does not likely exist at all.
If you have questions or would like more information about this, contact Zach Cattell at (317) 616-9001.
According to the ISDH Division of Long Term Care, current CMS regulation concerning incident reporting takes precedent over that of the ISDH policy, and any facility must ensure that incidents are reported to the Administrator and ISDH immediately. The federal regulation, 42 C.F.R. §483.13(c)(2), states the following concerning timeliness of reporting incidents:
The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
The ISDH Division of Long Term Care has indicated that CMS interprets the regulation so that the term “immediately” applies both to reporting to the Administrator and reporting to “other officials in accordance with State law through established procedures.” Id. Furthermore, CMS has maintained that “immediately” means “as soon as possible, but ought not exceed 24 hours after discovery of the incident.”
Guidance from the ISDH Reportable Incidents Policy, accessible in the Members Only section of the IHCA website, is the main source of confusion on whether the Indiana standard for reporting is immediately or within 24 hours. The first sentence of the Indiana guidance states, “Facilities are required by law to report unusual occurrences within 24 hours of occurrence to the Long Term Care Division.” Through discussions with the ISDH Division of Long Term Care, this sentence is not accurate and needs to be revised. However, the language in the Reportable Incidents Policy will not likely change until CMS issues the memo regarding F 223.
CMS surveyors are beginning to cite facilities for alleged failures to report incidents immediately through look-behind surveys. Because of the increased CMS oversight, the ISDH may be changing its approach and begin to more aggressively cite facilities for not reporting incidents immediately. An example of a citation concerning incident reporting in which a facility was cited for failing to report immediately is also available in the Members Only section. Please note that the facility in this example reported 24 hours after the incident occurred, and referenced the ISDH guidance on the 24 hour reporting requirement. This incident should have been reported sooner.
Below are best practices and key points regarding the current legislation and requirements to comply with ISDH and CMS guidelines for incident reporting.
• “Immediately” does not mean a 24 hour grace period exists to report an incident.
• “Immediately” means as soon as possible once the resident is safe and protected.
o An example of the immediacy required: If an allegation of abuse has been made and the resident is bleeding, stop the bleeding and then immediately notify the ISDH. You do not stop the bleeding, suspend the employee(s), take witness statements, draw conclusions, and then finally notify the ISDH.
• Use best judgment and report as soon as possible when dealing with “degrees” of incidents, including the time of day in which incidents take place. A common concern is immediate reporting in the middle of the night when the alleged incident is not especially grave or injurious (for example: a bruise of unknown origin discovered at 2a.m.). Immediate in this circumstance may not require an ISDH report by 2:30 a.m.. However, if an allegation of an employee hitting a resident is made at 2 a.m., a report to the ISDH as soon as possible once the resident is safe and protected (which may also require the removal and suspension of the employee) is required. A reasonable time to do this may be an hour, or perhaps a bit more.
• Educate facility staff. The 24 hour window that most believe exists before an incident report must be submitted does not likely exist at all.
If you have questions or would like more information about this, contact Zach Cattell at (317) 616-9001.
Wednesday, June 19, 2013
Indiana Physician Orders for Scope of Treatment (POST)
During the 2013 session of the Indiana General Assembly, House Enrolled Act 1328 was passed by the legislature and signed into law by Governor Pence. The bill establishes the framework for use of the Physician Orders for Scope of Treatment (POST) form and requires the Indiana State Department of Health to develop the official form and place it on the department's website. The law becomes effective July 1, 2013, and it is expected that the ISDH will have a form available on its website that day.
The initiative to adopt the POST form in Indiana was born from a national effort, started in Oregon, to develop a new and more effective approach to end of life care planning. The form captures a patient's treatment preferences in specific medical orders that health care providers can act upon. A POST form "is built upon conversations between patients, loved ones, and health care professionals, during which patients can determine the extent of care they wish to receive." A patient may elect to execute a POST form as a result of the conversations and guidance concerning end of life care, and those care preferences then become medical orders that are carried out by health care providers.
A POST form, once properly executed, results in the creation of medical orders that by law are actionable across all medical settings. As with any new health care treatment tool, it will take time and communication for health care providers to implement use of POST within their own facilities and amongst health care settings.
For your information, IHCA has developed the following summary of the POST law along with some practical and operational considerations. IHCA will continue to update its members on the implementation of POST as information becomes available. Read More.
The remainder of this article is located in the Members Only section of the IHCA website. To request access to that section, click here. If you have already assigned yourself a password but have difficulty logging in to the Members Only section, please contact Kate Vaulter at kvaulter@ihca.org.
Friday, May 31, 2013
Indiana Health Coverage Program Change in Medicare Replacement Claim Processing
The Office of Medicaid Policy and Planning (OMPP) published notice on May 31, 2013 that a change will be made on Medicare replacement claim processing. For claims received on or after June 27, 2013, the Indiana Health Coverage Programs (IHCP) will require a claim filing indicator of "16" when providers file Medicare replacement plan claims through an 837 electronic data interchange (EDI) transaction and Web interChange. Previously, providers were instructed to use a claim filing indicator of "MA" or "MB" when filing Medicare replacement claims. The IHCP will begin to validate Medicare replacement plan payer IDs based on the contract number published by the Centers for Medicare & Medicaid Services (CMS). To view the posting, see http://provider.indianamedicaid.com/news,-bulletins,-and-banners/news-summary/the-ihcp-to-implement-change-in-medicare-replacement-claim-processing-.aspx.
Indiana Medicaid Nursing Facility Rate Cuts to be Partially Restored
The Office of Medicaid Policy and Planning (OMPP) published notice on May 29, 2013 that it will reduce the existing nursing facility rate cut from 5% to 3% on January 1, 2014. The notice can be accessed in the Members Only section of the IHCA website. Once implemented, the reduction in the rate cut will be in effect at least until June 30, 2015. This partial restoration of the rate cut is a direct result of the intense lobbying effort that IHCA led during the 2013 session of the Indiana General Assembly where IHCA staff and lobbyists contacted key legislative leaders and personnel within Governor Pence’s administration.
The reduction of the rate cut results in approximately $68M being restored to the Indiana Medicaid nursing facility rate. Prior to the announcement of the partial rate restoration, the estimated impact of a 5% cut for State Fiscal Years 2014 and 2015 was $160M in Federal and State funds. The reduction of the rate cut to 3% will result in an estimated impact of $92M in Federal and State funds during the same period, a restoration of approximately $68M.
More details will be forthcoming from OMPP on exactly which components of the rate will be impacted by the cut, but the general, and positive, financial impact noted above is welcomed good news. Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.
The reduction of the rate cut results in approximately $68M being restored to the Indiana Medicaid nursing facility rate. Prior to the announcement of the partial rate restoration, the estimated impact of a 5% cut for State Fiscal Years 2014 and 2015 was $160M in Federal and State funds. The reduction of the rate cut to 3% will result in an estimated impact of $92M in Federal and State funds during the same period, a restoration of approximately $68M.
More details will be forthcoming from OMPP on exactly which components of the rate will be impacted by the cut, but the general, and positive, financial impact noted above is welcomed good news. Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.
Value Based Purchasing State Plan Amendment Notice
The Office of Medicaid Policy and Planning (OMPP) published notice on May 29, 2013 to amend the Indiana Medicaid State Plan to implement the Value Based Purchasing (VBP) add-on to the nursing facility Medicaid rate. The notice can be accessed in the Members Only section of the IHCA website. The VBP add-on will replace the current Report Card Score add-on as of July 1, 2013. Due to how the State Plan Amendment approval process works with CMS, IHCA expects retroactive adjustment of claims once the amendment is approved. For more on the VBP add-on, click here to read more detail about the VBP program, including how to earn points under the new system, or contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
Tuesday, May 28, 2013
Medicare Signature Requirements
Transmittal 465, CMS Manual System Pub 100-08 Medicare Program Integrity was released on May 17, 2013 (see http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R465PI.pdf). It clarifies the use of a rubber stamp for signature for medical review purposes. For those purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable. There are four exceptions; Exception 4 has been added in the recent transmittal. The four exceptions are:
EXCEPTION 1: Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
EXCEPTION 2: There are some circumstances for which an order does not need to be signed. For example, orders for some clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and Pub.100-02 chapter 15, §80.6.1 state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation (e.g., a progress note) by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.
EXCEPTION 3: Other regulations and the CMS’ instructions regarding conditions of payment related to signatures (such as timeliness standards for particular benefits) take precedence. For medical review purposes, if the relevant regulation, NCD, LCD and CMS manuals are silent on whether the signature needs to be legible or present and the signature is illegible/missing, the reviewer shall follow the guidelines listed below to discern the identity and credentials (e.g., MD, RN, etc.) of the signator. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.
EXCEPTION 4: CMS would permit use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.
EXCEPTION 1: Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
EXCEPTION 2: There are some circumstances for which an order does not need to be signed. For example, orders for some clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and Pub.100-02 chapter 15, §80.6.1 state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation (e.g., a progress note) by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.
EXCEPTION 3: Other regulations and the CMS’ instructions regarding conditions of payment related to signatures (such as timeliness standards for particular benefits) take precedence. For medical review purposes, if the relevant regulation, NCD, LCD and CMS manuals are silent on whether the signature needs to be legible or present and the signature is illegible/missing, the reviewer shall follow the guidelines listed below to discern the identity and credentials (e.g., MD, RN, etc.) of the signator. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.
EXCEPTION 4: CMS would permit use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.
CMS Survey & Certification Memorandum 13-34-ALL – Mandatory Surveyor Training on Care of Persons with Dementia
CMS released S&C: 13-34-ALL that provides information about the third and final training video in the three-part series of mandatory surveyor trainings CMS has prepared on this topic. The first two modules of the training program were released earlier this year. This third installment of the training addresses how to cite severity level and other aspects of deficiency citations in more detail, based on the new guidance at F309, Care of Residents with Dementia, and revised guidance at F329 referenced in S&C: 13-35-NH. This training module is 35 minutes in length and will be available after May 31. The memorandum provides instructions for accessing this content.
To access the memorandum, go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-34.pdf.
To access the memorandum, go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-34.pdf.
CMS Survey & Certification Memorandum 13-35-NH – Dementia Care and Reduction of Antipsychotic Drug Use
CMS released S&C 13-35-NH that clarifies Appendix P and Appendix PP of the State Operations Manual. These revisions are to the surveyor guidance and re-emphasize key principles in nursing facility regulations. Updates to Appendix P include changes to the resident sampling process for the traditional survey (changes to QIS were included in the recent 10.1.3 release), intended to ensure that the survey sample includes an adequate number of residents with dementia who are receiving an antipsychotic medication.
Updates to Appendix PP include:
• A new section of interpretive guidance at F309 related to the review of care and services for a resident with dementia;
• Revisions to the antipsychotic medication section of Table 1 at F329;
• New severity example at the end of the interpretive guidance at F329 (Unnecessary drugs);
A surveyor checklist that may be used in either the traditional or QIS process (modeled after the Critical Element pathways) is also provided in the memorandum. This checklist is not part of the State Operations Manual. To access the memorandum, go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-35.html?DLPage=1&DLSort=2&DLSortDir=descending (as of May 28, 2013, the advance copy of the memo has not been posted, but when it is it will be at this link).
Updates to Appendix PP include:
• A new section of interpretive guidance at F309 related to the review of care and services for a resident with dementia;
• Revisions to the antipsychotic medication section of Table 1 at F329;
• New severity example at the end of the interpretive guidance at F329 (Unnecessary drugs);
A surveyor checklist that may be used in either the traditional or QIS process (modeled after the Critical Element pathways) is also provided in the memorandum. This checklist is not part of the State Operations Manual. To access the memorandum, go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-35.html?DLPage=1&DLSort=2&DLSortDir=descending (as of May 28, 2013, the advance copy of the memo has not been posted, but when it is it will be at this link).
Survey Schedule
The subcontractors have released a schedule for the resident, family/friend, and employee surveys, which is provided below:
• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September
• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013
• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013
The State has communicated that if any of the onsite interviews of residents conflict with a survey conducted by the Indiana State Department of Health, that the satisfaction surveys of residents will be rescheduled.
If you have any questions about the satisfaction survey process, or about the VBP program, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September
• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013
• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013
The State has communicated that if any of the onsite interviews of residents conflict with a survey conducted by the Indiana State Department of Health, that the satisfaction surveys of residents will be rescheduled.
If you have any questions about the satisfaction survey process, or about the VBP program, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
Nursing Facility Data Requests
The two subcontractors, GoResource Link and Knowledge Services, have already begun contacting Nursing Facilities across the state to obtain the names and addresses of employees and the family/friend of a resident so that they can be contacted to complete a survey. The State will be providing the subcontractors each facility’s MDS file from the prior month (June MDS file for surveys conducted in July, and so on) in order for the subcontractors to perform the in-person surveys of residents. Each Nursing Facility Administrator will be contacted via letter and email concerning the survey process and the request for data submission. Residents of Assisted or Independent Living are to be excluded from the surveys, and employees who are 100% dedicated to Assisted or Independent Living units are also to be excluded.
Letters will be sent to the designated family/friend and to each nursing facility employee along with the respective survey. Drafts of those letters and the surveys for residents, family/friend, and employees may be accessed in the Members Only section of the IHCA website.
The State has indicated willingness to set up a central point of contact for multi-facility entities for purposes of coordinating data submissions company-wide. To set up that single point of contact, please contact Division of Aging Deputy Director Karen Filler at 317-232-4651 or Karen.Filler@fssa.in.gov.
Letters will be sent to the designated family/friend and to each nursing facility employee along with the respective survey. Drafts of those letters and the surveys for residents, family/friend, and employees may be accessed in the Members Only section of the IHCA website.
The State has indicated willingness to set up a central point of contact for multi-facility entities for purposes of coordinating data submissions company-wide. To set up that single point of contact, please contact Division of Aging Deputy Director Karen Filler at 317-232-4651 or Karen.Filler@fssa.in.gov.
Indiana Medicaid to Perform Satisfaction Surveys of Nursing Home Residents, Families/Friends, and Employees
As part of the effort led by the Indiana Division of Aging and the Office of Medicaid Policy and Planning (collectively, the “State”) to incorporate performance measures into Indiana Nursing Facility reimbursement rates, the State has contracted with Press Ganey Associates of South Bend, IN to conduct satisfaction surveys of nursing home residents, family/friends, and employees. The satisfaction surveys are to be conducted this summer, during July, August, and September. Surveys of residents will be in-person at the facility, and surveys of family/friend and employees will be done via mail.
While the data collected this summer will not immediately impact Nursing Facility reimbursement rates, it will set the stage for a discussion between the State and Nursing Facility representatives on how the data can be incorporated into the State’s Value Based Purchasing program (“VBP”). The VBP program permits up to $14.30 per patient day to be paid as an add-on to the Medicaid reimbursement rate based on Nursing Facility performance on annual ISDH surveys, the number of nursing hours per resident day, and nursing and administrator retention and turnover metrics.
Webinars to Explain the Satisfaction Survey Process
Press Ganey Associates has subcontracted with GoResource Link and Knowledge Services to conduct the satisfaction surveys. Nursing Facility residents will be interviewed in-person, as long as they are deemed interview-able based on a cognitive test. Friends/Family of Nursing Facility residents and employees of Nursing Facilities will receive letters from one of the subcontractors that will contain a survey to be returned to the subcontractor. The State has held two webinars for Nursing Facilities that provide an overview of the interview process – one was held on May 10th, and the second on May 17th. For a copy of the webinar, click here.
Nursing Facility Data Requests
The two subcontractors, GoResource Link and Knowledge Services, have already begun contacting Nursing Facilities across the state to obtain the names and addresses of employees and the family/friend of a resident so that they can be contacted to complete a survey. The State will be providing the subcontractors each facility’s MDS file from the prior month (June MDS file for surveys conducted in July, and so on) in order for the subcontractors to perform the in-person surveys of residents. Each Nursing Facility Administrator will be contacted via letter and email concerning the survey process and the request for data submission. Residents of Assisted or Independent Living are to be excluded from the surveys, and employees who are 100% dedicated to Assisted or Independent Living units are also to be excluded.
Letters will be sent to the designated family/friend and to each nursing facility employee along with the respective survey. Drafts of those letters and the surveys for residents, family/friend, and employees may be accessed in the Members Only section of the IHCA website.
The State has indicated willingness to set up a central point of contact for multi-facility entities for purposes of coordinating data submissions company-wide. To set up that single point of contact, please contact Division of Aging Deputy Director Karen Filler at 317-232-4651 or Karen.Filler@fssa.in.gov.
Subcontractor Training
Press Ganey, the main contractor, will be holding training sessions for the subcontractor’s employees that will perform the in-person resident satisfaction surveys. Training sessions will be held on June 24, 25, and 26 at the Knowledge Services’ Carmel, IN location. The training will include a Project Overview, discussion of the nursing home environment, HIPAA training, overall project logistics, and how to conduct an interview.
Survey Schedule
The subcontractors have released a schedule for the resident, family/friend, and employee surveys, which is provided below.
• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September
• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013
• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013
The State has communicated that if any of the onsite interviews of residents conflict with a survey conducted by the Indiana State Department of Health, that the satisfaction surveys of residents will be rescheduled.
If you have any questions about the satisfaction survey process, or about the VBP program, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
While the data collected this summer will not immediately impact Nursing Facility reimbursement rates, it will set the stage for a discussion between the State and Nursing Facility representatives on how the data can be incorporated into the State’s Value Based Purchasing program (“VBP”). The VBP program permits up to $14.30 per patient day to be paid as an add-on to the Medicaid reimbursement rate based on Nursing Facility performance on annual ISDH surveys, the number of nursing hours per resident day, and nursing and administrator retention and turnover metrics.
Webinars to Explain the Satisfaction Survey Process
Press Ganey Associates has subcontracted with GoResource Link and Knowledge Services to conduct the satisfaction surveys. Nursing Facility residents will be interviewed in-person, as long as they are deemed interview-able based on a cognitive test. Friends/Family of Nursing Facility residents and employees of Nursing Facilities will receive letters from one of the subcontractors that will contain a survey to be returned to the subcontractor. The State has held two webinars for Nursing Facilities that provide an overview of the interview process – one was held on May 10th, and the second on May 17th. For a copy of the webinar, click here.
Nursing Facility Data Requests
The two subcontractors, GoResource Link and Knowledge Services, have already begun contacting Nursing Facilities across the state to obtain the names and addresses of employees and the family/friend of a resident so that they can be contacted to complete a survey. The State will be providing the subcontractors each facility’s MDS file from the prior month (June MDS file for surveys conducted in July, and so on) in order for the subcontractors to perform the in-person surveys of residents. Each Nursing Facility Administrator will be contacted via letter and email concerning the survey process and the request for data submission. Residents of Assisted or Independent Living are to be excluded from the surveys, and employees who are 100% dedicated to Assisted or Independent Living units are also to be excluded.
Letters will be sent to the designated family/friend and to each nursing facility employee along with the respective survey. Drafts of those letters and the surveys for residents, family/friend, and employees may be accessed in the Members Only section of the IHCA website.
The State has indicated willingness to set up a central point of contact for multi-facility entities for purposes of coordinating data submissions company-wide. To set up that single point of contact, please contact Division of Aging Deputy Director Karen Filler at 317-232-4651 or Karen.Filler@fssa.in.gov.
Subcontractor Training
Press Ganey, the main contractor, will be holding training sessions for the subcontractor’s employees that will perform the in-person resident satisfaction surveys. Training sessions will be held on June 24, 25, and 26 at the Knowledge Services’ Carmel, IN location. The training will include a Project Overview, discussion of the nursing home environment, HIPAA training, overall project logistics, and how to conduct an interview.
Survey Schedule
The subcontractors have released a schedule for the resident, family/friend, and employee surveys, which is provided below.
• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September
• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013
• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013
The State has communicated that if any of the onsite interviews of residents conflict with a survey conducted by the Indiana State Department of Health, that the satisfaction surveys of residents will be rescheduled.
If you have any questions about the satisfaction survey process, or about the VBP program, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
Residential Survey Update
Thirty-three (33) tags were cited in surveys of residential care facilities in April, 28 of which were Deficiency tags and the remaining 5 were Offense tags. The top citation for April was Tag 217, cited 5 times, concerning identification and documentation of services to be provided to residents following completion of a resident evaluation. Documentation of the scope, frequency, need, and preference for services is necessary, and it also must be signed and dated by the resident. If administration of medications or provision of residential nursing services are needed, a licensed nurse must be involved with identification and documentation of the services to be provided. In addition, 3 citations were issued for Tag 214, another resident evaluation tag concerning initiation of an evaluation prior to admission and upon a change of condition after admission. A licensed nurse must also be involved to evaluate the nursing needs of the resident.
Several tags were issued in April regarding medication administration, labeling, and storage. Tag 241 was cited 3 times due to failure to have medication administered either by licensed personnel or by a QMA. Tag 246 was cited 2 times for failure to ensure that each PRN medication administered by a QMA is authorized by either a nurse or physician. Tag 301 was cited once due to failure to properly label prescription drugs with the resident’s full name, physician’s name, prescription number, name and strength of drug, directions for use, date of issue and expiration (when applicable), and the name and address of the pharmacy that filled the prescription. Tag 304 was also cited once for failure to ensure medication storage areas/cabinets are locked at all times unless authorized personnel are present.
Citations were also issued in April in the Sanitation & Safety Standards area, for a total of 11 of the month’s 33 tags. Citations ranged from failure to keep grounds and facilities clean and good state of repair to failure to have an effective waste disposal program in place. Tag 90 was also cited three times in April for failure to ensure that the Administrator inform the ISDH within 24 hours of an unusual occurrence that threatens the health or safety of a resident.
A summary of the April Residential Care Facility Tags can be found in the Members Only section of the IHCA website.
Several tags were issued in April regarding medication administration, labeling, and storage. Tag 241 was cited 3 times due to failure to have medication administered either by licensed personnel or by a QMA. Tag 246 was cited 2 times for failure to ensure that each PRN medication administered by a QMA is authorized by either a nurse or physician. Tag 301 was cited once due to failure to properly label prescription drugs with the resident’s full name, physician’s name, prescription number, name and strength of drug, directions for use, date of issue and expiration (when applicable), and the name and address of the pharmacy that filled the prescription. Tag 304 was also cited once for failure to ensure medication storage areas/cabinets are locked at all times unless authorized personnel are present.
Citations were also issued in April in the Sanitation & Safety Standards area, for a total of 11 of the month’s 33 tags. Citations ranged from failure to keep grounds and facilities clean and good state of repair to failure to have an effective waste disposal program in place. Tag 90 was also cited three times in April for failure to ensure that the Administrator inform the ISDH within 24 hours of an unusual occurrence that threatens the health or safety of a resident.
A summary of the April Residential Care Facility Tags can be found in the Members Only section of the IHCA website.
April ISDH IJ/SSQC Report
There were two events in April that led to 2 IJ citations, one of which was also SSQC. The 2567s of April’s IJ/SSQC citations can be found in the Members Only section of the IHCA website, as is a summary chart for 2013.
The first, an F323 tag that was cited by Federal surveyors after a complaint, related to a physically and verbally aggressive male resident, and the 5 other residents that were impacted by his behaviors. The residents, a child in a children’s facility, was extremely aggressive towards staff and other residents that could not defend themselves. Since his admission 2/18/13 and through March, the facility had logged 79 aggression incidents, 121 cussing incidents, and 15 resistant to care incidents. The resident was prescribed Seroquel and diagnosed bipolar, in addition to other diagnoses, but the mother refused the medication and the diagnosis. The physician’s services were discontinued at that time by the mother. The IJ was removed when the facility issued 30-day notice of discharge along with continuous one-on-one and/or two-on-one supervision until discharge, provided psyhocsocial assessments on the other 5 impacted residents, reviewed and updated care plans, initiated staff education on behavior recognition that may affect other residents, and daily review of behavior reports and nursing notes.
The second, an F441 tag was cited due to surveyor observation of improper disinfection practices on a blood glucometer. During one observation, an RN used a blood glucometer without having cleaned it first, then after the use the RN did clean it with a Clorox wipe. The facility policy called for the blood glucometer to be cleaned with a Clorox wipe prior to and after each use. The surveyor noted that Clorox wipes are not effective in disinfecting blood borne pathogens, which was confirmed in a discussion with a Clorox representative. In a second observation, an LPN used the blood glucometer and returned it to the cart without cleaning it. During interview with the DON, the DON indicated there had not been any in-services regarding blood glucometer disinfection practices.
Through April of 2013 there have been 5 IJ citations issued and 6 SSQC citations, which is about half of the 2012 totals for the same period (13 IJs and 10 SSQCs), IJs are down more than half as compared to the same period in 2012. F323 continues to be the most cited tag during IJ/SSQC events with 3 so far in 2013 (4 tags through April of 2012, and 3 in 2011). The downturn in IJ/SSQC citations so far this year continues a downward trend that began in 2012 as compared to 2011.
The first, an F323 tag that was cited by Federal surveyors after a complaint, related to a physically and verbally aggressive male resident, and the 5 other residents that were impacted by his behaviors. The residents, a child in a children’s facility, was extremely aggressive towards staff and other residents that could not defend themselves. Since his admission 2/18/13 and through March, the facility had logged 79 aggression incidents, 121 cussing incidents, and 15 resistant to care incidents. The resident was prescribed Seroquel and diagnosed bipolar, in addition to other diagnoses, but the mother refused the medication and the diagnosis. The physician’s services were discontinued at that time by the mother. The IJ was removed when the facility issued 30-day notice of discharge along with continuous one-on-one and/or two-on-one supervision until discharge, provided psyhocsocial assessments on the other 5 impacted residents, reviewed and updated care plans, initiated staff education on behavior recognition that may affect other residents, and daily review of behavior reports and nursing notes.
The second, an F441 tag was cited due to surveyor observation of improper disinfection practices on a blood glucometer. During one observation, an RN used a blood glucometer without having cleaned it first, then after the use the RN did clean it with a Clorox wipe. The facility policy called for the blood glucometer to be cleaned with a Clorox wipe prior to and after each use. The surveyor noted that Clorox wipes are not effective in disinfecting blood borne pathogens, which was confirmed in a discussion with a Clorox representative. In a second observation, an LPN used the blood glucometer and returned it to the cart without cleaning it. During interview with the DON, the DON indicated there had not been any in-services regarding blood glucometer disinfection practices.
Through April of 2013 there have been 5 IJ citations issued and 6 SSQC citations, which is about half of the 2012 totals for the same period (13 IJs and 10 SSQCs), IJs are down more than half as compared to the same period in 2012. F323 continues to be the most cited tag during IJ/SSQC events with 3 so far in 2013 (4 tags through April of 2012, and 3 in 2011). The downturn in IJ/SSQC citations so far this year continues a downward trend that began in 2012 as compared to 2011.
Tuesday, May 7, 2013
Summary of the CMS SNF PPS Proposed Rule
Courtesy of Peter Gruhn of the American Health Care Association, a summary of the CMS SNF PPS Proposed Rule and the full proposed rule can be located in the Members Only section of the IHCA website. The proposed rule provides for a net market basket increase for SNFs of 1.4% beginning October 1, 2013. The 1.4% market basket update reflects a full market basket increase of 2.3 percentage points, less a 0.4 percentage point multifactor productivity adjustment required by Section 3401(b) of the Affordable Care Act (ACA), and a 0.5 percentage point reduction to correct for an error in forecasting the market basket in FY 2012. CMS estimates that the net market basket update would increase Medicare SNF payments by approximately $500 million in FY 2014 (a little over $7 per Medicare patient day).
Managed Care and Indiana Medicaid – A Summary from the 2013 Legislative Session
Though the utilization of managed care for Medicaid programs is certainly not new across the country, or in Indiana, IHCA did not expect to be dealing with a specific effort to include the Medicaid Aged, Blind and Disabled population (ABD) into managed care during this session of the Indiana General Assembly. The first sign of an effort to require enrollment of the Medicaid ABD population into managed care was seen in an amendment to HB 1591, authored by the House Public Health Committee Chairman, Rep. Ed Clere (R-New Albany). The language would have required the state to apply for a waiver to move the Medicaid ABD population into risk based managed care by October 1, 2013. Oddly, the language also called for state to study such a program at the same time it was supposed to design and submit a plan to actually implement a program IHCA testified and shared its concerns about including long term care into any ABD managed care program, and especially doing so without considering key factors such as the potential impact on resident services, access to care, provider networks, the Quality Assessment Fee, and the IGT/UPL program with county hospitals, as well as the expedited timeframe that was essentially impossible to meet.
While the language in HB 1591 did not continue on in the process, the very next week the Chairman of the House Ways and Means Committee, Rep. Tim Brown, M.D. (R-Crawfordsville) inserted language in the House Budget Bill that would have required the state to study the issue and move the ABD population to risk based managed care by July 1, 2014. IHCA met with Rep. Brown and expressed our concerns with the approach and implementation timeline. The significant strategic concern was that managed care language was now in the House Budget Bill, which is a bill that must be passed and does not die. This meant that the debate surrounding Medicaid ABD managed care was not going to go away.
A more reasonable approach to this issue was started in Senate Bill 551, authored by Sen. Patricia Miller (R-Indianapolis), that would have required a general study of the issue without an implementation mandate or deadline. Similar to the fate of the initial House bill (HB 1591), SB 551 did not move out of the House after having passed through the Senate. However, during this time IHCA, along with other provider organizations, was able to convince the Senate to remove the ABD managed care language from the Budget Bill during the Senate’s consideration of that bill. This was a significant undertaking, which was led by IHCA. The association’s staff and lobbyists provided legislators and the Governor’s office with information about what other states are doing in this space, and that a rushed implementation was not the right way to go for patients or providers.
In the end, IHCA and several provider groups worked with all of the relevant authors, budget conferees, and FSSA to reach a compromise on a written report concerning Medicaid ABD managed care that must be completed by December 15, 2013. The report must include careful consideration of what cost savings may be achieved, how a program would impact beneficiary choice of providers, how provider rates would be set, how care would be coordinated for dual-eligible patients, whether certain beneficiaries should be excluded from a managed care program, and whether a managed care program would affect the Quality Assessment Fee and Upper Payment Limit supplemental payments. We believe that this will be a more productive process that will allow us to provide critical information about what Medicaid ABD managed care means for the long term care industry and ensure that all important factors are being taken into consideration before any implementation of a Medicaid ABD managed care program.
While the language in HB 1591 did not continue on in the process, the very next week the Chairman of the House Ways and Means Committee, Rep. Tim Brown, M.D. (R-Crawfordsville) inserted language in the House Budget Bill that would have required the state to study the issue and move the ABD population to risk based managed care by July 1, 2014. IHCA met with Rep. Brown and expressed our concerns with the approach and implementation timeline. The significant strategic concern was that managed care language was now in the House Budget Bill, which is a bill that must be passed and does not die. This meant that the debate surrounding Medicaid ABD managed care was not going to go away.
A more reasonable approach to this issue was started in Senate Bill 551, authored by Sen. Patricia Miller (R-Indianapolis), that would have required a general study of the issue without an implementation mandate or deadline. Similar to the fate of the initial House bill (HB 1591), SB 551 did not move out of the House after having passed through the Senate. However, during this time IHCA, along with other provider organizations, was able to convince the Senate to remove the ABD managed care language from the Budget Bill during the Senate’s consideration of that bill. This was a significant undertaking, which was led by IHCA. The association’s staff and lobbyists provided legislators and the Governor’s office with information about what other states are doing in this space, and that a rushed implementation was not the right way to go for patients or providers.
In the end, IHCA and several provider groups worked with all of the relevant authors, budget conferees, and FSSA to reach a compromise on a written report concerning Medicaid ABD managed care that must be completed by December 15, 2013. The report must include careful consideration of what cost savings may be achieved, how a program would impact beneficiary choice of providers, how provider rates would be set, how care would be coordinated for dual-eligible patients, whether certain beneficiaries should be excluded from a managed care program, and whether a managed care program would affect the Quality Assessment Fee and Upper Payment Limit supplemental payments. We believe that this will be a more productive process that will allow us to provide critical information about what Medicaid ABD managed care means for the long term care industry and ensure that all important factors are being taken into consideration before any implementation of a Medicaid ABD managed care program.
CNA/QMA/Home Health Aide Registry and Criminal Background Checks
The ISDH alerted the IHCA that there have been a few persons that have cheated the CNA/QMA/Home Health Aide Registry in the past couple of months by using a former or married name to be re-listed on the registry after having been excluded for improper conduct. The ISDH encourages all facilities to use a Criminal Background Check and all names listed on that background check to compare against the Registry to see if the person appears under a different name. The ISDH cannot run Social Security numbers over the internet, but can confirm with a Social Security number if the facility calls the ISDH. To contact the Aide Registry Program, call Darlene Jones at 317-233-7351.
Indiana Medicaid Satisfaction Surveys
Several IHCA members have been contacted by either GoResource Link or Knowledge Services concerning the Indiana Medicaid satisfaction survey process that is part of the Value Based Purchasing program. Over the past few of weeks letters have been sent to facility administrators providing notice and a broad overview of the survey process. Since this letter went out, GoResource Link and Knowledge Services (contractors for the State) have begun calling facilities and sending emails containing instructions to report data on residents, family/friends, and employees to the contractors by May 13th (or May 17th depending on what material you received) in order that the contractors have information necessary to conduct surveys of these individuals.
Data Request
It has come to our attention that some administrators are receiving emails from the contractors without having been called first. After discussion with the State, it appears that the contractors are calling first and obtaining the administrator’s email from whomever answers the phone. In some cases, administrators are speaking with the contractors, but in other cases the administrator has not talked with the contractor and the first contact the administrator has is the receipt of the email with instructions on data submission. The requests from the contractors are legitimate requests. Though it would seem that some of the data will be stale by the time July, August and September roll around, the State is asking for facilities to cooperate with the submission of data this month to the contractors.
Residents/Employees of Residential or Unlicensed AL/IL – Excluded from Survey Process
The State has also indicated that residents of licensed residential units/beds and unlicensed AL/IL are not to be included in the survey process. In addition, if you have employees that are 100% dedicated to licensed residential units/beds and/or unlicensed AL/IL these employees are not to be included in the survey process. I have requested that the State communicate this to the contractors so the contractors can in turn communicate to providers.
Survey Schedule
The contractors indicate that they intend to perform resident, family/friend, and employee surveys according to the below schedule:
• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September
• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013
• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013
A sample of the letter to facility administrators and a presentation about the satisfaction survey process that was provided to the IHCA, and other trade associations, may be accessed in the Members Only section of the IHCA website.
If you have any questions or concerns about the survey process, or about the Medicaid VBP program generally, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
Data Request
It has come to our attention that some administrators are receiving emails from the contractors without having been called first. After discussion with the State, it appears that the contractors are calling first and obtaining the administrator’s email from whomever answers the phone. In some cases, administrators are speaking with the contractors, but in other cases the administrator has not talked with the contractor and the first contact the administrator has is the receipt of the email with instructions on data submission. The requests from the contractors are legitimate requests. Though it would seem that some of the data will be stale by the time July, August and September roll around, the State is asking for facilities to cooperate with the submission of data this month to the contractors.
Residents/Employees of Residential or Unlicensed AL/IL – Excluded from Survey Process
The State has also indicated that residents of licensed residential units/beds and unlicensed AL/IL are not to be included in the survey process. In addition, if you have employees that are 100% dedicated to licensed residential units/beds and/or unlicensed AL/IL these employees are not to be included in the survey process. I have requested that the State communicate this to the contractors so the contractors can in turn communicate to providers.
Survey Schedule
The contractors indicate that they intend to perform resident, family/friend, and employee surveys according to the below schedule:
• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September
• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013
• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013
A sample of the letter to facility administrators and a presentation about the satisfaction survey process that was provided to the IHCA, and other trade associations, may be accessed in the Members Only section of the IHCA website.
If you have any questions or concerns about the survey process, or about the Medicaid VBP program generally, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
Wednesday, April 3, 2013
Nasogastric Tube Surveyor Guidance Revised Again by CMS
CMS has issued S&C Memorandum 13-17-NF regarding nasogastric tubes. Additional revisions have been made to guidance on F 322 in Appendix PP of the State Operations Manual (SOM) and the associated training slides since the release of S&C 12-46 on September 27, 2012. The revisions include:
o Revision of the Regulatory Language format.
o Additional clarification regarding the Centers for Medicare and Medicaid Services (CMS) expanded definition of "Naso-Gastric tubes."
o Updating the Power Point training slides.
To read the memo, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-17.pdf.
o Revision of the Regulatory Language format.
o Additional clarification regarding the Centers for Medicare and Medicaid Services (CMS) expanded definition of "Naso-Gastric tubes."
o Updating the Power Point training slides.
To read the memo, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-17.pdf.
CMS Revises Surveyor Guidance on Advance Directives – F 155
CMS has issued S&C Memorandum 13-16-NF regarding advance directives. Revisions have been made to guidance on F 155 in Appendix PP of the State Operations Manual and the associated training slides since the release of S&C 12-47 on September 27, 2012. The revisions include:
o Removal of the term "right to accept" when referring to medical and surgical treatment.
o Addition of guidance specific to experimental research.
o Clarification that §483.10(b)(8) applies only to adult residents and not all residents regardless of age.
o Addition of definition for "Investigational or experimental drugs."
o Updating the Investigative Protocol.
o Updating the Power Point training slides/
To read the memo, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-16.pdf.
o Removal of the term "right to accept" when referring to medical and surgical treatment.
o Addition of guidance specific to experimental research.
o Clarification that §483.10(b)(8) applies only to adult residents and not all residents regardless of age.
o Addition of definition for "Investigational or experimental drugs."
o Updating the Investigative Protocol.
o Updating the Power Point training slides/
To read the memo, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-16.pdf.
CMS Clarifies Delegation of Physician Tasks in SNFs and NFs
S&C Memorandum 13-15-NF replaced a 2003 guidance memo concerning physician delegation of certain tasks in SNFs and NF to non-physician practitioners (NPP) such as nurse practitioners, physician assistants, or clinical nurse specialists. Due to federal regulation, there is a difference between SNFs and NFs in terms of what a physician can delegate to NPPs. The first part of the analysis is to determine (1) which setting, SNF or NF, are the physician services being provided, (2) whether the task must be personally performed by the physician, and (3) whet her the NPP is employed by the facility. Certain tasks, such as conducting physician visits, writing orders, signing certifications and re-certifications should be analyzed to ensure proper personal action by the physician or proper delegation to an NPP.
The S&C Memorandum discusses the distinctions between SNFs and NFs for physician required visits and proper delegation to NPPs and provides a helpful chart to depict the various elements at play. To read the memo, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-15-.pdf.
The S&C Memorandum discusses the distinctions between SNFs and NFs for physician required visits and proper delegation to NPPs and provides a helpful chart to depict the various elements at play. To read the memo, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-15-.pdf.
Tuesday, April 2, 2013
Luer Misconnections Leading to Adverse Events Identified by CMS
CMS issued Survey & Certification Memorandum, S&C: 13-14-ALL, highlighting the continuing risk of Luer misconnections in health care settings, suggesting actions providers can take to reduce the likelihood of these events; and actions surveyors should take when investigating these events. To read the memo, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-14.pdf.
Summary:
• Luer Misconnections continue to result in adverse events and deaths – Luer connectors easily link many medical components, accessories, and delivery systems. Clinicians, in any type of provider or supplier setting, can mistakenly connect the wrong devices and deliver substances through the wrong route. Despite numerous alerts and warnings, a patient’s blood pressure tubing was recently misconnected to an intravenous (IV) line in an ambulatory surgery center (ASC) resulting in a patient death.
• Adverse Event Complaint Investigation: During a complaint investigation for an adverse event involving delivery of an incorrect substance or utilization of an incorrect delivery route, surveyors must be alert to whether the event involved misconnection of a Luer device. If so, surveyors must determine whether the facility has taken actions to ensure systems are in place to prevent recurrence of this type of adverse event.
• Facility Reporting to Food & Drug Administration (FDA): Surveyors should encourage health care facilities to report problems with Luer misconnections to the FDA, even if no adverse event occurred.
Examples of actions providers and suppliers can take to reduce the likelihood of Luer misconnections include, but are not limited to (1) changing to devices already on the market with alternative connector designs which reduce the likelihood of misconnections of incompatible lines; (2) tracing lines back to their origins when reconnecting devices; (3) positioning catheters and tubes that have different purposes on different sides of the patient’s body or in unique and standardized directions; and (4) implementing a multidisciplinary facility approach to address Luer misconnections.
Summary:
• Luer Misconnections continue to result in adverse events and deaths – Luer connectors easily link many medical components, accessories, and delivery systems. Clinicians, in any type of provider or supplier setting, can mistakenly connect the wrong devices and deliver substances through the wrong route. Despite numerous alerts and warnings, a patient’s blood pressure tubing was recently misconnected to an intravenous (IV) line in an ambulatory surgery center (ASC) resulting in a patient death.
• Adverse Event Complaint Investigation: During a complaint investigation for an adverse event involving delivery of an incorrect substance or utilization of an incorrect delivery route, surveyors must be alert to whether the event involved misconnection of a Luer device. If so, surveyors must determine whether the facility has taken actions to ensure systems are in place to prevent recurrence of this type of adverse event.
• Facility Reporting to Food & Drug Administration (FDA): Surveyors should encourage health care facilities to report problems with Luer misconnections to the FDA, even if no adverse event occurred.
Examples of actions providers and suppliers can take to reduce the likelihood of Luer misconnections include, but are not limited to (1) changing to devices already on the market with alternative connector designs which reduce the likelihood of misconnections of incompatible lines; (2) tracing lines back to their origins when reconnecting devices; (3) positioning catheters and tubes that have different purposes on different sides of the patient’s body or in unique and standardized directions; and (4) implementing a multidisciplinary facility approach to address Luer misconnections.
Expanded Time Period for Postings of 2576s on Nursing Home Compare
On March 22, CMS issued S&C Memo 13-21-ALL that highlighting changes to public reporting of survey findings/statements of deficiencies on the web. CMS has been posting 2567s to Nursing Home Compare since July of 2012, and starting this month CMS will expand 2567 postings from a single survey cycle to a 3 year period of standard and complaint surveys. CMS will also be adding indicators for the scope and severity of each deficiency cited on the forms. To read the memo, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-21.pdf.
CMS Releases New Civil Money Penalty Analytic Tool
AHCA recently obtained an CMS Administrative Information Memo concerning a new process for calculating CMPs when it is determined they should be imposed. The memo and accompanying instructions direct CMS Regional Offices to apply a new methodology and process for determining CMPs when such an enforcement remedy is appropriate. The new policy guidance has been issued to promote more consistent application of enforcement remedies, and all CMS Regional Offices will use the guidance to choose, impose, and calculate CMPs. CMS also included guidance for the Regional Office to consider when determining whether to impose a CMP or an alternate remedy regardless of whether or not the State Survey Agency recommended a CMP.
The memo states that failure of a State to recommend a CMP or other remedy, or a State policy of not recommending CMPs, are not acceptable reasons for not imposing such remedies. In such a case, the RO must on its own review the survey findings and impose the appropriate remedy.
CMS describes this effort as a six-month pilot, to be evaluated for the usefulness and overall effectiveness of the Analytic Tool and guidance. At the end of six months, they will assess whether or not the tool and guidance have provided greater consistency in the use and application of CMPs and assess whether or not the imposition of CMPs had an effect on a facility’s ability to achieve and sustain compliance with Federal requirements. At that point, CMS will make any needed revisions to the tool and guidance as applicable.
The CMS Administrative Memo and Instructions are accessible in the Members Only section of the IHCA website. IHCA also has a copy of an Excel spreadsheet that Regional Offices will use to calculate the dollar amount of CMPs and if you would like a copy, please contact Zach Cattell at zcattell@ihca.org.
The memo states that failure of a State to recommend a CMP or other remedy, or a State policy of not recommending CMPs, are not acceptable reasons for not imposing such remedies. In such a case, the RO must on its own review the survey findings and impose the appropriate remedy.
CMS describes this effort as a six-month pilot, to be evaluated for the usefulness and overall effectiveness of the Analytic Tool and guidance. At the end of six months, they will assess whether or not the tool and guidance have provided greater consistency in the use and application of CMPs and assess whether or not the imposition of CMPs had an effect on a facility’s ability to achieve and sustain compliance with Federal requirements. At that point, CMS will make any needed revisions to the tool and guidance as applicable.
The CMS Administrative Memo and Instructions are accessible in the Members Only section of the IHCA website. IHCA also has a copy of an Excel spreadsheet that Regional Offices will use to calculate the dollar amount of CMPs and if you would like a copy, please contact Zach Cattell at zcattell@ihca.org.
Notice of Involuntary Transfer and Discharge – Change of Procedure
The ISDH announced on Monday, April 1 that it is requesting facilities to send completed involuntary transfer and discharge notices to the ISDH in order to speed up the transfer/discharge hearing process. Completed forms can be faxed to either 317-233-7143 or 317-234-6278, and can also be emailed to incidents@isdh.in.gov.
Tuesday, March 12, 2013
Manual Medical Prepayment Review
AHCA has been heavily engaged with CMS on behalf of its members regarding CMS direction to Medicare Administrative Contractors (MACs) regarding prepayment review of therapy claims. Below is an update on recent CMS direction to the MACs on the issue and attached is a letter from AHCA to CMS with recommendations on the approach for implementing a better, more reasonable post-payment review process.
On February 21, CMS updated its Manual Medical Review web site (See posting below) and directed the Medicare Administrative Contractors (MACs) to conduct prepayment review on the claims reaching the $3700 threshold. CMS requested that MACs conduct these manual medical reviews within 10 days. CMS also indicated that this prepayment review was an interim measure and that it is developing a long term strategy to deal with manual medical review. The MACs were in essence floundering, and CMS had been considering:
1. A prior approval process similar to that used in 2012;
2. A strictly pre-payment review process for all claims above $3,700 without a prior approval process; and
3. A post-payment review process for some or all claims over $3,700.
AHCA had recommended to CMS that it choose the third option with additional safeguards to ensure whatever process is adopted operates in as efficient manner as possible. AHCA does not believe that CMS prepayment directive will alleviate the process problems and may even exacerbate them. We continue to communicate with CMS on this issue.
CMS.gov -- Therapy Cap Medical Review and Education
http://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/therapycap.html
The American Taxpayer Relief Act of 2012 (ATRA) was signed into law by President Obama on January 2, 2013. This law extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013. Section 603 of this Act contains a number of Medicare provisions affecting the outpatient therapy caps and manual medical review (MR) threshold.
The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,900 for 2013, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,900 for 2013. This is an annual per beneficiary therapy cap amount determined for each calendar year. Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. Per beneficiary, services above $3,700 for PT and SLP services combined and/or $3,700 for OT services are subject to manual medical review. CMS is not precluded from reviewing therapy services below these thresholds.
The therapy cap applies to all Part B outpatient therapy settings and providers including:
• Therapists’ private practices
• Offices of physicians and certain nonphysician practitioners
• Part B skilled nursing facilities (Type of Bill (TOB) 42X, 43X,44X)
• Home health agencies (TOB 34X)
• Rehabilitation agencies (also known as Outpatient Rehabilitation Facilities-ORFs)
• Comprehensive Outpatient Rehabilitation Facilities (CORFs)
• Hospital outpatient departments (HOPDs) (TOB 12X or 13X)
CMS is developing a long term strategy to deal with manual medical review. However, in the interim, Medicare Administrative Contractors (MACs) will conduct prepayment review on the claims reaching the $3700 threshold. CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process. Additional information will be provided on the MAC websites.
Section 603 (b) of the American Tax Relief Act counts outpatient therapy services furnished in a Critical Access Hospital (CAH) toward a beneficiary’s annual cap and threshold amount using the Medicare Physician Fee Schedule rate. CAHs are not subject to the therapy cap, the manual medical review process, or the use of the KX modifier.
You can contact CMS with questions about the therapy cap and new threshold via a designated e-mail box at therapycapreview@cms.hhs.gov. (http://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/therapycap.html)
On February 21, CMS updated its Manual Medical Review web site (See posting below) and directed the Medicare Administrative Contractors (MACs) to conduct prepayment review on the claims reaching the $3700 threshold. CMS requested that MACs conduct these manual medical reviews within 10 days. CMS also indicated that this prepayment review was an interim measure and that it is developing a long term strategy to deal with manual medical review. The MACs were in essence floundering, and CMS had been considering:
1. A prior approval process similar to that used in 2012;
2. A strictly pre-payment review process for all claims above $3,700 without a prior approval process; and
3. A post-payment review process for some or all claims over $3,700.
AHCA had recommended to CMS that it choose the third option with additional safeguards to ensure whatever process is adopted operates in as efficient manner as possible. AHCA does not believe that CMS prepayment directive will alleviate the process problems and may even exacerbate them. We continue to communicate with CMS on this issue.
CMS.gov -- Therapy Cap Medical Review and Education
http://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/therapycap.html
The American Taxpayer Relief Act of 2012 (ATRA) was signed into law by President Obama on January 2, 2013. This law extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013. Section 603 of this Act contains a number of Medicare provisions affecting the outpatient therapy caps and manual medical review (MR) threshold.
The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,900 for 2013, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,900 for 2013. This is an annual per beneficiary therapy cap amount determined for each calendar year. Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. Per beneficiary, services above $3,700 for PT and SLP services combined and/or $3,700 for OT services are subject to manual medical review. CMS is not precluded from reviewing therapy services below these thresholds.
The therapy cap applies to all Part B outpatient therapy settings and providers including:
• Therapists’ private practices
• Offices of physicians and certain nonphysician practitioners
• Part B skilled nursing facilities (Type of Bill (TOB) 42X, 43X,44X)
• Home health agencies (TOB 34X)
• Rehabilitation agencies (also known as Outpatient Rehabilitation Facilities-ORFs)
• Comprehensive Outpatient Rehabilitation Facilities (CORFs)
• Hospital outpatient departments (HOPDs) (TOB 12X or 13X)
CMS is developing a long term strategy to deal with manual medical review. However, in the interim, Medicare Administrative Contractors (MACs) will conduct prepayment review on the claims reaching the $3700 threshold. CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process. Additional information will be provided on the MAC websites.
Section 603 (b) of the American Tax Relief Act counts outpatient therapy services furnished in a Critical Access Hospital (CAH) toward a beneficiary’s annual cap and threshold amount using the Medicare Physician Fee Schedule rate. CAHs are not subject to the therapy cap, the manual medical review process, or the use of the KX modifier.
You can contact CMS with questions about the therapy cap and new threshold via a designated e-mail box at therapycapreview@cms.hhs.gov. (http://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/therapycap.html)
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