IHCATuesday, December 9, 2014
MDS Case Mix Reporting
OMPP, via Myers & Stauffer, notified facilities last month of a change in the MDS Case Mix Reporting system. The notice (click here) provided instruction for each facility to provide M&S with contact and computer information for designated users for each facility. IHCA contacted M&S to inquire about the ability for corporations to have a login that would access all facilities within that corporation. To date, OMPP has replied that a third corporate designated user will be permitted, but had not clarified how that user is to sign up or whether that user will be able to access all corporate facilities via a single log-in. The deadline to submit this information to M&S has passed, but we will inform the membership asap on any changes via the Payment/Reimbursement Committee email list.
Indiana Medicaid Rate Update
The Indiana Office of Medicaid Policy and Planning (OMPP) has started issuing July 1, 2014 rate letters via its contractor Myers & Stauffer. The rate component medians have been released and can be found by clicking here. M&S is due to release the other LTC Information System reports on the 7/1/14 Rate Effective Date in the next week or so. This includes information on the second year of facility performance in the Value Based Purchasing add-on (i.e. the Total Quality Score add-on). IHCA is also hearing early rumblings that some facilities with Special Care Units (SCU) that have received 7/1/14 rate letters are seeing SCU add-ons in excess of what they expected. IHCA urges facilities to double check their submitted cost report information against their rate letter, and eventually the M&S SCU calculation file that will be posted on the M&S LTC website this month.
In other Indiana Medicaid rate news, IHCA is expecting a decision from OMPP concerning the transition to RUGs IV this month. There has been months and months of debate on whether such a transition should be to the 48 or 64 grouper, with IHCA and its members advocating for the 48 grouper. IHCA has continued meeting with agency officials and most recently proposed a cost-neutral solution to the agency to that any cost to the State for transitioning to a 48-grouper system would be absorbed by redistributing gains and losses more equitably. Beyond this issue are the issues of maintaining the SCU add-on, which two years ago was floated to be eliminated in order to in-part pay for the costs of moving to a 48-grouper, and whether or not to re-group Medicaid therapy residents at the end of therapy based on the reference MDS assessment already on file. IHCA has argued against elimination of the SCU add-on and has advocated for a common sense approach to the end of therapy re-grouper, which at this point is not to do it since it costs the State money to do and derives no policy objective.
To learn more on these issues, contact Zach Cattell at 317-616-9001 or zcattell@ihca.org or particulate in our monthly Payment/Reimbursement Committee conference calls (contact Zach for this as well).
In other Indiana Medicaid rate news, IHCA is expecting a decision from OMPP concerning the transition to RUGs IV this month. There has been months and months of debate on whether such a transition should be to the 48 or 64 grouper, with IHCA and its members advocating for the 48 grouper. IHCA has continued meeting with agency officials and most recently proposed a cost-neutral solution to the agency to that any cost to the State for transitioning to a 48-grouper system would be absorbed by redistributing gains and losses more equitably. Beyond this issue are the issues of maintaining the SCU add-on, which two years ago was floated to be eliminated in order to in-part pay for the costs of moving to a 48-grouper, and whether or not to re-group Medicaid therapy residents at the end of therapy based on the reference MDS assessment already on file. IHCA has argued against elimination of the SCU add-on and has advocated for a common sense approach to the end of therapy re-grouper, which at this point is not to do it since it costs the State money to do and derives no policy objective.
To learn more on these issues, contact Zach Cattell at 317-616-9001 or zcattell@ihca.org or particulate in our monthly Payment/Reimbursement Committee conference calls (contact Zach for this as well).
CMS Transmittal Related to Appendix PP
CMS issued transmittal 127 on November 26, 2014. This transmittal updates Appendix PP (Ftags and surveyor guidance) and contains no new information. All material included in this transmittal was issued as policy or as advance guidance between 2003 and May 2014. Except for information related to four tags (F155, F309, F322, F329) all of this material was issued as an advance copy on July 3, 2014. The additional language at the four tags not in the July advance copy and the original advance release information follows:
• F155 relates to Advance Directives (issued as an advance copy on September 27, 2012 and revised March 8, 2013);
• F309 relates to care and services for individuals with dementia (issued as an advance copy on May 24, 2013);
• F322 relates to Naso-Gastric Tubes (issued as a revised advance copy on March 8, 2013); and
• F329 relates to Unnecessary Drugs (issued as an advance copy on May 24, 2013).
• F155 relates to Advance Directives (issued as an advance copy on September 27, 2012 and revised March 8, 2013);
• F309 relates to care and services for individuals with dementia (issued as an advance copy on May 24, 2013);
• F322 relates to Naso-Gastric Tubes (issued as a revised advance copy on March 8, 2013); and
• F329 relates to Unnecessary Drugs (issued as an advance copy on May 24, 2013).
OSHA Reporting Requirements to Change January 1, 2015
Our national association AHCA/NCAL has provided this summary of the OHSA final rule concerning Occupational Injury and Illness Recording and Reporting Requirements. Effective January 1, 2015 employers must report an expanded list of injuries to OSHA and revises the requirements for when an employer must report work-related hospitalizations. Please review the above document for more details.
MSD Focused Surveys
CMS issued Survey & Certification Memo 15-06-NH (click here for the memo) on October 31st that announces an expansion of the 5-state pilot program that was focused on MDS coding practices. The pilot program found deficiencies in 24 of 25 facilities’ MDS coding practices that had a negative impact on the ability of surveyors to identify deficiencies in patient care. Findings included inaccurate staging and documentation of pressure ulcers, problems with classification of antipsychotic drugs, and poor coding concerning use of restraints. This pilot project followed a 2013 report from the OIG that indicated found issued with MDS information as the OIG reported on issues concerning NF care planning and discharge planning.
To be coupled with the MDS surveys will be a staffing surveys in order for CMS to validate what is now reported during the annual survey on the CMS-671. Staffing levels will be assessed during the expanded MDF “Focused Surveys”.
The Focused Surveys will begin in early FY2015, which is any time now. CMS will work with States to determine how many surveys will be conducted, and when, as well as whether specific facilities should be surveyed. IHCA understands that Indiana will have 12 facilities as part of this expanded program. A survey protocol and tool is also being developed. Record review and interviews will be utilized in the surveys.
To be coupled with the MDS surveys will be a staffing surveys in order for CMS to validate what is now reported during the annual survey on the CMS-671. Staffing levels will be assessed during the expanded MDF “Focused Surveys”.
The Focused Surveys will begin in early FY2015, which is any time now. CMS will work with States to determine how many surveys will be conducted, and when, as well as whether specific facilities should be surveyed. IHCA understands that Indiana will have 12 facilities as part of this expanded program. A survey protocol and tool is also being developed. Record review and interviews will be utilized in the surveys.
Residential Care Facility Citation Update
In October 2014 the ISDH issued 31 Deficiency tags and 8 Offense tags to Residential Care Facilities. The leading tag in October was Tag 241, an Offense tag, concerning the failure to have physician ordered medications administered by licensed nurses or QMAs. This citation is often cited by the ISDH, being cited in each month of 2014 except for February. Tag 247, a Deficiency, was cited three times in the month concerning the documentation of errors in mediation administration and notification to the physician of any such error when there is actual or potential harm to the resident. A usual high-frequency tag, Tag 273 concerning maintaining food preparation and service areas in accordance with state and local sanitation standards, was only cited 4 times in October. Lastly, hand washing appears to continue to be an issue as three facilities were cited Tag 414 for staff failure to wash hands after each resident contact.
Click here to review a summary of October’s Residential Care Facility Offense and Deficiency citations.
Click here to review a summary of October’s Residential Care Facility Offense and Deficiency citations.
ISDH IJ/SSQC Update
The ISDH cited one tag in October that was at the IJ and SSQC level. That tag, F329, was cited for failure to ensure an anticoagulant that had been discontinued per the physicians order was actually discontinued, and that accurate documentation of MARs and Physician Order Sheets were accurately reflecting physician orders. The resident had been placed on Coumadin therapy, with corresponding orders for P/INR tests, to manage deep vein thrombosis as of April 21, 2014. The physician discontinued the medication regimen on May 12, 2014 and the medication was not administered in May thereafter. In June the Physician Order Sheet included an order for Coumadin for the resident, however the RN in charge of checking orders caught the error and crossed it off per the physician’s order. In July, August and September the Physician Order Sheet contained the same order for Coumadin, but in each of these months the nurse did not catch the error and according to the MARs the Coumadin was administered. The error was caught in September when the DON was reviewing lab results, at which time the resident was experiencing critically high PN/INR values resulting in administration of Vitamin K and ongoing monitoring for bleeding issues. Investigation at the facility found that Coumadin flow sheets were not being maintained in July and August, and the pharmacy indicated that they reported no discontinuation orders for this medication. The IJ was lifted when new staff was assigned to review Physician Order Sheets, random audits were performed for the sheets, and all staff were in-serviced concerning Physician Orders Sheets and monitoring for effects of medication.
Please click here to access the October 2567 and the IJ/SSQC 2014 Summary.
Please click here to access the October 2567 and the IJ/SSQC 2014 Summary.
Wednesday, November 12, 2014
Division of Aging Holds Listening Session on HCBS Transition Plan
On November 10th, IHCA/INCAL staff attended the second of six listening session that have been scheduled by the Indiana Family and Social Services Administration’s Division of Aging (DA). (Click here for a copy of the listening session presentation.) The listening session included the DA’s broad overview of the CMS HCBS Final Rule and the work that the DA has done so far to help Indiana come into compliance with those CMS Rules through the FSSA’s draft HCBS transition plan. Click here for the schedule of the remaining listening sessions that all occur in the next week! Comments to the DA on the transition plan are due December 1.
The DA staff mainly addressed two types of waiver settings and providers at the November 10th meeting – Adult Family Care and Assisted Living waiver providers. The DA recently published the draft statewide transition plan, which is posted at www.in.gov/fssa/4917.htm, and it addresses the issues that the DA has identified with current provider operations and the CMS rules. The transition plan also includes other divisions of FSSA and HCBS service categories. The transition plan also sets out timing for providers to meet the new requirements, but leaves a lot of detail out that still needs to be determined.
To develop that detail, the DA is reviewing existing state law and regulation, as well as internal policies, to determine what must be changed to conform with the CMS rule. Part of the DA’s work has also been a survey of waiver providers. As you know, the DA surveyed 87 existing AL waiver providers and 62 responded. These responses were used to develop the transition plan for the AL waiver section. The DA noted the following areas with AL providers that must be addressed in the years to come through law, rule and policy changes to ensure compliance with the CMS rule:
• Hours of visitation will need to become more resident friendly and broader
• Permitting Secured Units for Alzheimer/Dementia patients will be subject to “heightened scrutiny”
o A provider, and the DA, must show why secured units for AL are different than secured units for skilled nursing with a focus on patient integration with others in the residential care facility and the greater community.
• 24-hour resident access to food and drink need to be defined and improved
• Putting in place enforceable leases that conform to landlord tenant laws for each resident
• Clarifying roommate choice
• Ensuring medical services are provided in private areas only
• Improving transportation to areas outside of the facility
Many of these issues will require in-depth review of current DA and ISDH regulations to ensure residents receive appropriate services and that providers are not place in a legal/regulatory catch-22. IHCA/INCAL will continue to participate in the development of the state’s HCBS transition planning and implementation.
For additional information, contact Katie Niehoff at kniehoff@ihca.org or Zach Cattell at zcattell@ihca.org.
The DA staff mainly addressed two types of waiver settings and providers at the November 10th meeting – Adult Family Care and Assisted Living waiver providers. The DA recently published the draft statewide transition plan, which is posted at www.in.gov/fssa/4917.htm, and it addresses the issues that the DA has identified with current provider operations and the CMS rules. The transition plan also includes other divisions of FSSA and HCBS service categories. The transition plan also sets out timing for providers to meet the new requirements, but leaves a lot of detail out that still needs to be determined.
To develop that detail, the DA is reviewing existing state law and regulation, as well as internal policies, to determine what must be changed to conform with the CMS rule. Part of the DA’s work has also been a survey of waiver providers. As you know, the DA surveyed 87 existing AL waiver providers and 62 responded. These responses were used to develop the transition plan for the AL waiver section. The DA noted the following areas with AL providers that must be addressed in the years to come through law, rule and policy changes to ensure compliance with the CMS rule:
• Hours of visitation will need to become more resident friendly and broader
• Permitting Secured Units for Alzheimer/Dementia patients will be subject to “heightened scrutiny”
o A provider, and the DA, must show why secured units for AL are different than secured units for skilled nursing with a focus on patient integration with others in the residential care facility and the greater community.
• 24-hour resident access to food and drink need to be defined and improved
• Putting in place enforceable leases that conform to landlord tenant laws for each resident
• Clarifying roommate choice
• Ensuring medical services are provided in private areas only
• Improving transportation to areas outside of the facility
Many of these issues will require in-depth review of current DA and ISDH regulations to ensure residents receive appropriate services and that providers are not place in a legal/regulatory catch-22. IHCA/INCAL will continue to participate in the development of the state’s HCBS transition planning and implementation.
For additional information, contact Katie Niehoff at kniehoff@ihca.org or Zach Cattell at zcattell@ihca.org.
Tuesday, November 11, 2014
Ebola Virus Resources
Although news of the Ebola outbreak has dissipated a bit in the last week or so and that long term care centers are not regarded as “first receivers” for patient care, we wanted to ensure that our members were aware of the vast resources and guidance available on the CDC’s website concerning the Ebola virus. Many public health departments and local hospitals have been working tirelessly to gear up for any potential signs of Ebola in Indiana, and long term care has been tacitly aware of those preparations but not necessarily directly involved.
• CDC
The CDC’s Ebola Virus Disease website is at http://www.cdc.gov/vhf/ebola/index.html and contains a number of helpful topics and infographics that can be printed and used with your staff. Specific guidance for healthcare workers, which focuses on Emergency Departments, Ambulatory Care, Hospitals, Medical Transports and Labs can be found at http://www.cdc.gov/vhf/ebola/hcp/index.html. While the focus are on those acute care settings, the infographics and treatment algorithms may be helpful for you to review. At the bottom of the healthcare worker’s guidance page are a series of PDFs discussing preparedness in healthcare settings.
In particular, documents that discuss Ebola Basics, a infographic on the differences between Ebola and Flu, and information about the West Africa breakout are particularly helpful in answering questions from residents, families or the general public.
• ISDH
In addition, the Indiana State Department of Health (ISDH) has re-posted CDC resources on its website, but also has opened a call center to handle question from the public and providers concerning the outbreak. The call center number is 877-826-0011 (hearing impaired 888-561-0044). Health representatives are available to answer questions regarding symptoms, screening and diagnosis of Ebola. It is open 24 hours. The ISDH just updated it’s quick factsheet on Ebola on Nov. 10, 2014.
For the ISDH website click here: http://www.in.gov/isdh/26447.htm.
• Individual Legal Counsel
Several concerns have been raised about staff or visitor restrictions due to travel to West Africa or contact with persons that have traveled to West Africa. It is important to remember that Ebola is only spread through close contact with those that are infected via blood or bodily fluids. Neither the CDC nor the ISDH are recommending avoidance of contact with people that have recently traveled to West Africa unless they have symptoms of the disease, in which case that person should be referred to their personal health care provider or a hospital emergency room.
There are a host of laws that must be considered in the employment context that govern how employers can, or more accurately cannot, screen employees. For example, an employer would not be correct to refuse to hire or prohibit an employee from coming to work just because they recently traveled to West Africa or is of West African decent as this could be a discriminatory practice banned by Title VII of the Civil Rights Act of 1964. Laws governing medical examinations of employees, such as the Americans with Disabilities Act should also be considered if medical examinations of employees are desired. Also, if your facility is covered by FMLA, how a facility handles any mandatory leave requires specific analysis to minimize risk to the employer. Visitor restrictions also need to be carefully considered in the context of resident rights both the resident being visited and the protection of all other residents in the facility. Special consideration for the patients within nursing facilities and regulatory requirements for nursing facilities do make some of these challenges more straight forward to handle, but individual legal counsel should be sought to determine your facility’s compliance with applicable law.
• CDC
The CDC’s Ebola Virus Disease website is at http://www.cdc.gov/vhf/ebola/index.html and contains a number of helpful topics and infographics that can be printed and used with your staff. Specific guidance for healthcare workers, which focuses on Emergency Departments, Ambulatory Care, Hospitals, Medical Transports and Labs can be found at http://www.cdc.gov/vhf/ebola/hcp/index.html. While the focus are on those acute care settings, the infographics and treatment algorithms may be helpful for you to review. At the bottom of the healthcare worker’s guidance page are a series of PDFs discussing preparedness in healthcare settings.
In particular, documents that discuss Ebola Basics, a infographic on the differences between Ebola and Flu, and information about the West Africa breakout are particularly helpful in answering questions from residents, families or the general public.
• ISDH
In addition, the Indiana State Department of Health (ISDH) has re-posted CDC resources on its website, but also has opened a call center to handle question from the public and providers concerning the outbreak. The call center number is 877-826-0011 (hearing impaired 888-561-0044). Health representatives are available to answer questions regarding symptoms, screening and diagnosis of Ebola. It is open 24 hours. The ISDH just updated it’s quick factsheet on Ebola on Nov. 10, 2014.
For the ISDH website click here: http://www.in.gov/isdh/26447.htm.
• Individual Legal Counsel
Several concerns have been raised about staff or visitor restrictions due to travel to West Africa or contact with persons that have traveled to West Africa. It is important to remember that Ebola is only spread through close contact with those that are infected via blood or bodily fluids. Neither the CDC nor the ISDH are recommending avoidance of contact with people that have recently traveled to West Africa unless they have symptoms of the disease, in which case that person should be referred to their personal health care provider or a hospital emergency room.
There are a host of laws that must be considered in the employment context that govern how employers can, or more accurately cannot, screen employees. For example, an employer would not be correct to refuse to hire or prohibit an employee from coming to work just because they recently traveled to West Africa or is of West African decent as this could be a discriminatory practice banned by Title VII of the Civil Rights Act of 1964. Laws governing medical examinations of employees, such as the Americans with Disabilities Act should also be considered if medical examinations of employees are desired. Also, if your facility is covered by FMLA, how a facility handles any mandatory leave requires specific analysis to minimize risk to the employer. Visitor restrictions also need to be carefully considered in the context of resident rights both the resident being visited and the protection of all other residents in the facility. Special consideration for the patients within nursing facilities and regulatory requirements for nursing facilities do make some of these challenges more straight forward to handle, but individual legal counsel should be sought to determine your facility’s compliance with applicable law.
Monday, November 3, 2014
FSSA Releases Draft HCBS Transition Plan
The Indiana Family and Social Services Administration (FSSA) has released a draft statewide transition plan regarding its Home and Community Based Services (HCBS) programs. Following a new regulation from CMS in January 2014 that redefined what settings can qualify for reimbursement for HCBS, Indiana is reviewing all of FSSA’s HCBS programs to ensure compliance with the new CMS regulations. FSSA has developed a website at www.in.gov/fssa/4917.htm that includes information on the CMS final rule and the Indiana draft transition plan.
The transition plan assesses all of FSSA’s HCBS program to identify where Indiana’s programs are already in-line with the new CMS regulations and where changes and improvements are needed to meet the new CMS regulations. The plan sets out strategies and timelines for Indiana’s compliance with the CMS regulations, which must be no later than March 2019.
Indiana FSSA is seeking public comment on the transition plan, and will hold the comment period open from November 1st to December 1st. The above FSSA website includes instructions on how to submit comment, including attending one of the scheduled stakeholder forums and listening sessions.
The transition plan assesses all of FSSA’s HCBS program to identify where Indiana’s programs are already in-line with the new CMS regulations and where changes and improvements are needed to meet the new CMS regulations. The plan sets out strategies and timelines for Indiana’s compliance with the CMS regulations, which must be no later than March 2019.
Indiana FSSA is seeking public comment on the transition plan, and will hold the comment period open from November 1st to December 1st. The above FSSA website includes instructions on how to submit comment, including attending one of the scheduled stakeholder forums and listening sessions.
Indiana Medicaid Rate Update
The Indiana Office of Medicaid Policy and Planning (OMPP) indicates that the July 1, 2014 rate letters will be released in early December. Updated median data will not be released before the rate letters are released.
Discussions with OMPP and Indiana Division of Aging concerning changes to Indiana’s Medicaid rate setting methodology, particularly concerning RUGs IV, the Special Care Unit add-on, and end of therapy RUG re-categorization will pick back up in November. IHCA staff have had informal discussions with agency officials on these subjects in the month of October, however the next formal meeting to discuss and ascertain the direction of these issues is set for the middle of November. Click here to review past months’ Indiana Medicaid Rate Updates.
Discussions with OMPP and Indiana Division of Aging concerning changes to Indiana’s Medicaid rate setting methodology, particularly concerning RUGs IV, the Special Care Unit add-on, and end of therapy RUG re-categorization will pick back up in November. IHCA staff have had informal discussions with agency officials on these subjects in the month of October, however the next formal meeting to discuss and ascertain the direction of these issues is set for the middle of November. Click here to review past months’ Indiana Medicaid Rate Updates.
President Obama Signs the IMPACT Act of 2014
The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 was signed into law in October 2014. The act will standardize assessments for critical care issues across post-acute care providers. AHCA has assembled a summary of the 5 parts to the IMPACT Act and a timeline. Click here for the AHCA summary.
ISDH Updating Provider Change of Ownership Packets
The ISDH has announced that it is in the process of updating all of the packets on the ISDH website for provider changes. The goal is to have all of the packets for both comprehensive care and residential care facilities reviewed and updated by the end of the year. The first packet that has been updated and is currently available on the website is the CHOW packet for Medicare or Medicare/Medicaid facilities. The link for the updated packet is http://www.in.gov/isdh/files/Change_of_Ownership_Medicare_or_Medicare_-_Medicaid.pdf
In the future, please check the below websites for packet updates.
The comprehensive care facility packets can be found under the forms section on the comprehensive care facility website at http://www.in.gov/isdh/20511.htm
The residential care facility packets can be found under the forms section on the residential care facility website at http://www.in.gov/isdh/20227.htm
Contact Miriam Buffington at the ISDH for any questions.
In the future, please check the below websites for packet updates.
The comprehensive care facility packets can be found under the forms section on the comprehensive care facility website at http://www.in.gov/isdh/20511.htm
The residential care facility packets can be found under the forms section on the residential care facility website at http://www.in.gov/isdh/20227.htm
Contact Miriam Buffington at the ISDH for any questions.
ACIP Recommends Pneumococcal Conjugate Vaccine for Adults 65 Years and Older
As reported by the ISDH Long Term Care Newsletter, The Advisory Committee on Immunization Practices (ACIP) now recommends a dose of PCV13 (Prevnar 13®) in addition to the currently recommended PPSV23 (Pneumovax®) in persons 65 years and older.
Those who have not previously received pneumococcal vaccine or whose vaccination history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23 6-12 months later. The two vaccines should not be co-administered. The minimum acceptable interval between PCV13 and PPSV23 is 8 weeks.
Adults aged 65 years who have previously received 1 dose of PPSV23 and who have not yet received PCV13 should receive a dose of PCV13 at least 1 year after receipt of their most recent PPSV23 dose. When an additional dose of PPSV23 is indicated, it should be given 6 -12 months after PCV13 and 5 years after the most recent dose of PPSV23.
ACIP recommendations remain unchanged for the routine use of PCV13 in adults aged 19 years with high risk conditions including:
• immunocompromising conditions
• functional or anatomic asplenia
• cerebrospinal fluid leak
• cochlear implants
Those who have not previously received pneumococcal vaccine or whose vaccination history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23 6-12 months later. The two vaccines should not be co-administered. The minimum acceptable interval between PCV13 and PPSV23 is 8 weeks.
Adults aged 65 years who have previously received 1 dose of PPSV23 and who have not yet received PCV13 should receive a dose of PCV13 at least 1 year after receipt of their most recent PPSV23 dose. When an additional dose of PPSV23 is indicated, it should be given 6 -12 months after PCV13 and 5 years after the most recent dose of PPSV23.
ACIP recommendations remain unchanged for the routine use of PCV13 in adults aged 19 years with high risk conditions including:
• immunocompromising conditions
• functional or anatomic asplenia
• cerebrospinal fluid leak
• cochlear implants
New Indiana QIO Ramps-Up Work
The Atom Alliance, which is an umbrella organization that encompasses the new Indiana QIO, QSource, is ramping up it’s activities in Indiana. They have provided a fact sheet concerning the Atom Alliance as well as a fact sheet concerning their work on reducing Health Care Acquired Conditions in Nursing Homes. CMS has issued a letter concerning the next QIO scope of work and the focus on the National Nursing Home Quality Care Collaborative that has already begun in Indiana. The effort is aimed at bringing together nursing homes to “instill quality and performance improvement practices”. QSource will be asking nursing homes from all across the state to participate in the NNHQCC and specifically ask for the facility to sign a Participation Agreement. The goal is to recruit 75% of all nursing homes in Indiana to participate with an oversampling of 1-Star facilities. The focus of the NHCQCC will be on reduction of anti-psychotic medications, improvement of mobility and reduction in falls, reduction in readmissions, HAIs and HACs.
Residential Care Facility Citation Update
In September 2014 the ISDH issued 17 Deficiency tags and 4 Offense tags to Residential Care Facilities. Leading the way in September is the most often cited Deficiency tag – Tag 273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation standards. The tag was cited 6 times in September. Two facilities were cited Tag 241 for failing to administer physician ordered medications by licensed nurses or by a QMA and one facility was cited Tag 242 for failing to observe, document, and immediately notify the physician of any undesirable medication effects.
Click here for a summary of the September tags.
Click here for a summary of the September tags.
ISDH IJ/SSQC Update
There were four events in September leading to four IJ citations, three of which were also SSQC. The first issue involved the failure of a facility to put in place appropriate interventions to prevent non-consensual sexual contact between two residents with diagnoses of dementia, and known wanderers, amongst other issues. F323 was cited when the male resident was transferred to a psychiatric unit for evaluation and the female resident was placed on 1:1 care with 15 minute checks. The male resident was found undressed in his room (which according to his care plan is normal for when he was sleeping) and the female resident wandered into the male resident’s room. The male resident was reported to have his hand up the female resident’s gown. A staff investigation occurred, including medical examinations of the female resident, and the staff did not find any abuse, however there was uncertainty concerning the consensual or non-consensual nature of the contact. Due to cognitive status surveyors determined this to be non-consensual sexual contact.
A second F323 citation was issued for failure of a facility to provide supervision and interventions to reduce risk of harm to other residents to a resident who was a known wanderer and that had a history of physical and verbal abuse. Several residents reported that they were afraid of the resident in question. The surveyors noted that the resident had been in a dementia unit before and the resident’s daughter was aware of the behavior, however the SSD indicated that the family member had not been contacted prior to survey about placing the resident on a secured dementia unit.
A citation was also issued for F414 for the facility’s failure to ensure proper sanitation procedures for the cleaning of reusable glucometers. The staff mistakenly used non-manufacturer approved, or non-bleach based, wipes for cleaning the glucometers. Also in September, F314 was issued concerning failure to prevent development of a State 4 pressure ulcer (this tag was reported last month as well as it was included in the August report even though it occurred on September 2).
Click here for a summary of the 2014 IJ/SSQCs and for the September 2567s.
A second F323 citation was issued for failure of a facility to provide supervision and interventions to reduce risk of harm to other residents to a resident who was a known wanderer and that had a history of physical and verbal abuse. Several residents reported that they were afraid of the resident in question. The surveyors noted that the resident had been in a dementia unit before and the resident’s daughter was aware of the behavior, however the SSD indicated that the family member had not been contacted prior to survey about placing the resident on a secured dementia unit.
A citation was also issued for F414 for the facility’s failure to ensure proper sanitation procedures for the cleaning of reusable glucometers. The staff mistakenly used non-manufacturer approved, or non-bleach based, wipes for cleaning the glucometers. Also in September, F314 was issued concerning failure to prevent development of a State 4 pressure ulcer (this tag was reported last month as well as it was included in the August report even though it occurred on September 2).
Click here for a summary of the 2014 IJ/SSQCs and for the September 2567s.
Monday, October 6, 2014
Indiana to Launch the State’s First PACE Program
Beginning on November 1, 2014 Indiana will begin enrollment for the State’s first PACE program. The Program for All-inclusive Care for the Elderly (PACE) is a risk-based managed care program for both Medicaid and Medicare benefits. Participants must be at least 55 years of age or older, required nursing home level of care, be in a PACE service area, and be to safely live in the community at time of enrollment. The program provides a wide-range of benefits from hospital and physician care to nursing care, home care, social services, meals and adult day care, and more. When a participant enrolls they are required to sign an agreement indicating they understand the PACE organization is their sole service provider.
The Franciscan Alliance in Indianapolis will be the first PACE program service provider and the Indiana Division of Aging will handle the enrollemnet process. Providers of all types will need to be sure the check a patient’s Medicare and Medicaid card to see if that person is a PACE enrollee. Indiana Medicaid will deny payment for any fee-for-service claims submitted by non-PACE providers for PACE members. Additional information will be distributed by Indiana Medicaid in the near future. To read the latest IHCP Bulletin click here.
The Franciscan Alliance in Indianapolis will be the first PACE program service provider and the Indiana Division of Aging will handle the enrollemnet process. Providers of all types will need to be sure the check a patient’s Medicare and Medicaid card to see if that person is a PACE enrollee. Indiana Medicaid will deny payment for any fee-for-service claims submitted by non-PACE providers for PACE members. Additional information will be distributed by Indiana Medicaid in the near future. To read the latest IHCP Bulletin click here.
Division of Aging and Press Ganey to Announce Webinars on 2014 Satisfaction Survey Results
Nursing facilities should be on the lookout for invitations that are to be sent in early October from Press Ganey for participation in webinars to review the 2014 Satisfaction Survey results. Recall that the Indiana Division of Aging contracted with Press Ganey in 2013 to conduct satisfaction surveys of residents, resident family or friends, and facility staff with the aim at determining whether such data could be mixed into the Indiana Medicaid nursing facility reimbursement Value Based Purchasing program. The dates for the webinars are as follows and more details are to come:
• October 24th at 9:00 a.m.
• October 29th 2:00 p.m.
• October 30th 9:00 a.m. and 2:00 p.m.
• October 24th at 9:00 a.m.
• October 29th 2:00 p.m.
• October 30th 9:00 a.m. and 2:00 p.m.
Thursday, October 2, 2014
Indiana Medicaid Rate Update
Discussions have continued with Indiana Medicaid and the Division of Aging concerning future changes to Indiana’s Medicaid reimbursement system. In particular, a move from RUGs III to RUGs IV is still being debated, in particular which grouper to utilize, and whether or not the Special Care Unit add-on will remain. In a new twist to the discussions, Indiana Medicaid indicated it was concerned with the growth in the overall percentage of residents that are categorized in the Rehabilitation groupers. As of the last reported data, 36% of all Medicaid residents were in a Rehabilitation RUG, which is up 6% in just the past 4 quarters. Indiana Medicaid seems to be making overtures that a return of an end of therapy assessment may be coming. However, the data presented to the association by Indiana Medicaid is not exactly clear and we will be having more detailed discussions with the agency on this issue. Also, as mentioned last month, IHCA has been working on an outline of a LTC policy plan that Indiana Medicaid requested our engagement on. The plan is meant to develop a road map to follow related to reimbursement changes, home and community based services rebalancing, quality initiatives, and overall funding. IHCA has presented a draft of this outline to the IHCA Board of Directors and general support was given to the IHCA staff to proceed with the discussion with the state.
Indiana Division of Aging Announces Provider Training and Public Comment Session on HCBS Transition Plan
As reported last month Indiana’s Medicaid office, Division of Aging, and other divisions of the Indiana Family and Social Services Administration are quickly preparing a transition plan that meets CMS’s new regulations for delivery of Home and Community Based Services in the Medicaid program. The Division of Aging has announced its next Provider Training that will also include a formal Public Comment session on the proposed transition plan. The formal Public Comment session is a requirement of CMS that states must meet in the development of the transition plan.
The training and comments session will take place on Nov. 10th from 9am-3pm at the Indiana Government Center, 402 West Washington Street in Indianapolis. This session will be particularly important for providers of Assisted Living and Adult Family Care waiver services, or those who wish to provide such services in the future. Anticipated topics for the day are:
• HCBS Final Rule: An overview of Indiana’s strategy to implement the new HCBS Final Rule and Public Comment session. While all providers need to be aware of the new requirements, providers of Assisted Living and Adult Family Care will be the most impacted.
• Fair Labor Standards Act (FLA): The “Companionship Exemption” - widely used in home health services, is being cancelled for most situations January 2015. This can substantially affect your business’ bottom line by requiring overtime and pay for travel between work sites. While we cannot give legal advice, you need to be aware of the new requirements.
• Billing: Avoiding Denials and Resolving Problems – This was our most popular session during the last training and it has been updated based on the feedback and experience gained from that session.
• Incident Reporting: This session is required for new waiver providers and is a good refresher for existing providers. The session will cover the basics of what is required to be reported, and how to file a report
• Person-Centered Compliance Reviews – Policy - What to Expect when one of your consumers is selected to undergo a review.
The training and comments session will take place on Nov. 10th from 9am-3pm at the Indiana Government Center, 402 West Washington Street in Indianapolis. This session will be particularly important for providers of Assisted Living and Adult Family Care waiver services, or those who wish to provide such services in the future. Anticipated topics for the day are:
• HCBS Final Rule: An overview of Indiana’s strategy to implement the new HCBS Final Rule and Public Comment session. While all providers need to be aware of the new requirements, providers of Assisted Living and Adult Family Care will be the most impacted.
• Fair Labor Standards Act (FLA): The “Companionship Exemption” - widely used in home health services, is being cancelled for most situations January 2015. This can substantially affect your business’ bottom line by requiring overtime and pay for travel between work sites. While we cannot give legal advice, you need to be aware of the new requirements.
• Billing: Avoiding Denials and Resolving Problems – This was our most popular session during the last training and it has been updated based on the feedback and experience gained from that session.
• Incident Reporting: This session is required for new waiver providers and is a good refresher for existing providers. The session will cover the basics of what is required to be reported, and how to file a report
• Person-Centered Compliance Reviews – Policy - What to Expect when one of your consumers is selected to undergo a review.
CMS Announces New Goals with National Partnership to Improve Dementia Care
CMS issued a press release (click here to view) announcing the new national goal to reduce use of antipsychotic medications in long-stay nursing home residents by 25% by the end of 2015 and 30% by the end of 2016. Between the end 2011 and the end of 2013, the national antipsychotic use rate in long-stay residents was reduced by just more than 15%. CMS also plans to add the antipsychotic measure to the Five Star Quality Rating calculation. Indiana has seen a reduction of 17.4% through the first quarter of 2014 since the tracking began in 2011. Click here for a the CMS Fact Sheet that includes data on the initiative.
Residential Care Facility Citation Update
In August 2014 the ISDH issued 38 Deficiency tags and 6 Offense tags to Residential Care Facilities. Of note in August, Tag 273 continues to be the most cited tag due to allegations of facility failure to maintain food preparation areas and service areas in accordance with state and local laws. Tag 414 is also trending in 2014 as the ISDH cites more facilities for staffs’ failure to wash hands after each direct contact with a resident. Tag 414 has been cited nearly twice as often in 2014 (11) than it was in 2013 (6) and 2104 is not yet over. Lastly, Tag 241 continues to be cited with regularity for alleged failure by the facility to ensure physician ordered medications are administered to residents by a QMA or licensed nursing personnel.
To review a summary of the August residential care citations, click here.
To review a summary of the August residential care citations, click here.
DEA issues Final Rule on Disposal of Controlled Substances
On September 8, 2014 the Drug Enforcement Administration (DEA) released their final rule regarding the disposal of controlled substances which takes effect October 9, 2014. This rule governs the secure disposal of controlled substances by registrants and ultimate users. These regulations will implement the Secure and Responsible Drug Disposal Act of 2010 by expanding the options available to collect controlled substances from ultimate users for the purpose of disposal, including: take-back events, mail-back programs, and collection receptacle locations. Significant changes are made in this final rule which the DEA states are to help ensure that long term care centers have adequate disposal options. These changes are outlined below:
• Expands authority of authorized hospitals/clinics and retail pharmacies to voluntarily maintain collection receptacles at long-term care centers.
o (1301.51 Modification in registration) A hospital/clinic with an onsite pharmacy or retail pharmacy applying for a modification in registration to authorize such registrant to be a collector to maintain a collection receptacle at a long term care facility in accordance with 1317.80, shall also include the name and physical location of each long term care facility at which the hospital/clinic with an onsite pharmacy, or the retail pharmacy, intends to operate a collection receptacle.
• Alleviates two security requirements proposed to apply to collection receptacles at long term care centers:
o DEA is permitting authorized hospitals/clinics and retail pharmacies to store inner liners that have been sealed upon removal from collection receptacle at long term care centers in securely locked, substantially constructed cabinet or securely locked room with controlled access for up to three business days until liners can be transferred for destruction.
o DEA relaxed the two employee integrity requirement for inner liner installation, removal, storage, and transfer at long term care centers. Collectors will retain the option to authorize two of their own employees to install, remove, store, and transfer inner liners; however, the DEA is permitting collectors the option to designate a supervisor-level employee of the long term care center (e.g., a charge nurse, supervisor, or similar employee) to install, remove, store, or transfer inner liners with only one employee of the collector.
o With this rule, the DEA allows all pharmaceutical controlled substances collected through take-back events, mail-back programs, and collection receptacles to be comingled with non-controlled substances, although such comingling is not required.
o Collection receptacle must be located in an area regularly monitored by long term care center personnel.
AHCA/NCAL would like to highlight three aspects of this rule that are important considerations from an operational perspective:
1. Definition of long term care facilities (LTCFs) - DEA’s definition of long term care facilities is broad and seems to include assisted living. LTCF is defined at 1300.01(b) and “means a nursing home, retirement care, mental care or other facility or institution which provides extended health care to resident patients.” (see page 53540 of Federal Register)
2. Definition of ultimate user - An ultimate user is defined by the CSA as a “person who has lawfully obtained, and who possesses, a controlled substance for his own use or for the use of a member of his household or for an animal owned by him or by a member of his household.”…Individuals lawfully entitled to dispose of an ultimate user decedent’s property are authorized to dispose of the ultimate user’s pharmaceutical controlled substances by utilizing any of the three disposal options. All of the collection methods are voluntary and no person is required to establish or operate a disposal program. The rule also does not require ultimate users to utilize any of these three methods for disposal of controlled substances…this rule does not prohibit ultimate users from using existing lawful methods. (see page 53521 of Federal Register)
3. Exposure to DEA inspection - The location of the collection receptacle is both a registered location and a controlled premise…LTCFs with authorized collection receptacles are “controlled premises” pursuant to 21 U.S.C. 880(a) and 21 CFR 1316.02(c); accordingly, the DEA may enter LTCFs and conduct administrative inspections in furtherance of, and in carrying out, the responsibilities charged to the DEA by the CSA pursuant to 21 U.S.C. 880 (b) and 21 CFR 1216.03. (see page 53541 of Federal Register)
Under the Secure and Responsible Drug Disposal Act of 2010, DEA already has the authority over disposal of controlled drugs (including in long term care centers), and they also have the authority to issue regulations governing disposal of drugs in long term care centers and to ensure compliance with those regulations. It is not clear how frequently DEA will visit centers if they do or do not have collection receptacles.
While the rule states it is voluntary to maintain collection receptacles at long term care centers, AHCA/NCAL recommends members seek advice of their legal counsel.
• Expands authority of authorized hospitals/clinics and retail pharmacies to voluntarily maintain collection receptacles at long-term care centers.
o (1301.51 Modification in registration) A hospital/clinic with an onsite pharmacy or retail pharmacy applying for a modification in registration to authorize such registrant to be a collector to maintain a collection receptacle at a long term care facility in accordance with 1317.80, shall also include the name and physical location of each long term care facility at which the hospital/clinic with an onsite pharmacy, or the retail pharmacy, intends to operate a collection receptacle.
• Alleviates two security requirements proposed to apply to collection receptacles at long term care centers:
o DEA is permitting authorized hospitals/clinics and retail pharmacies to store inner liners that have been sealed upon removal from collection receptacle at long term care centers in securely locked, substantially constructed cabinet or securely locked room with controlled access for up to three business days until liners can be transferred for destruction.
o DEA relaxed the two employee integrity requirement for inner liner installation, removal, storage, and transfer at long term care centers. Collectors will retain the option to authorize two of their own employees to install, remove, store, and transfer inner liners; however, the DEA is permitting collectors the option to designate a supervisor-level employee of the long term care center (e.g., a charge nurse, supervisor, or similar employee) to install, remove, store, or transfer inner liners with only one employee of the collector.
o With this rule, the DEA allows all pharmaceutical controlled substances collected through take-back events, mail-back programs, and collection receptacles to be comingled with non-controlled substances, although such comingling is not required.
o Collection receptacle must be located in an area regularly monitored by long term care center personnel.
AHCA/NCAL would like to highlight three aspects of this rule that are important considerations from an operational perspective:
1. Definition of long term care facilities (LTCFs) - DEA’s definition of long term care facilities is broad and seems to include assisted living. LTCF is defined at 1300.01(b) and “means a nursing home, retirement care, mental care or other facility or institution which provides extended health care to resident patients.” (see page 53540 of Federal Register)
2. Definition of ultimate user - An ultimate user is defined by the CSA as a “person who has lawfully obtained, and who possesses, a controlled substance for his own use or for the use of a member of his household or for an animal owned by him or by a member of his household.”…Individuals lawfully entitled to dispose of an ultimate user decedent’s property are authorized to dispose of the ultimate user’s pharmaceutical controlled substances by utilizing any of the three disposal options. All of the collection methods are voluntary and no person is required to establish or operate a disposal program. The rule also does not require ultimate users to utilize any of these three methods for disposal of controlled substances…this rule does not prohibit ultimate users from using existing lawful methods. (see page 53521 of Federal Register)
3. Exposure to DEA inspection - The location of the collection receptacle is both a registered location and a controlled premise…LTCFs with authorized collection receptacles are “controlled premises” pursuant to 21 U.S.C. 880(a) and 21 CFR 1316.02(c); accordingly, the DEA may enter LTCFs and conduct administrative inspections in furtherance of, and in carrying out, the responsibilities charged to the DEA by the CSA pursuant to 21 U.S.C. 880 (b) and 21 CFR 1216.03. (see page 53541 of Federal Register)
Under the Secure and Responsible Drug Disposal Act of 2010, DEA already has the authority over disposal of controlled drugs (including in long term care centers), and they also have the authority to issue regulations governing disposal of drugs in long term care centers and to ensure compliance with those regulations. It is not clear how frequently DEA will visit centers if they do or do not have collection receptacles.
While the rule states it is voluntary to maintain collection receptacles at long term care centers, AHCA/NCAL recommends members seek advice of their legal counsel.
Health Facility Administrators Board Listens to Proposal to Create HFA Bachelors and Masters Programs
At its September 23rd meeting the Indiana Chapter of the American College of Health Care Administrators briefly addressed the members of the Indiana Health Facility Administrators Board to describe recent discussions with universities in Indiana, including St. Francis in Ft. Wayne and Indiana University, to create 4-year baccalaureate programs and a masters program in Health Facility administration. The focus of the presentation was to test the Board’s interest in creating a more flexible regulatory structure within the AIT program so that the requisite AIT hours could be partially satisfied during the academic process and completed at the end of the academic program with a “capstone” AIT program. This flexibility would be critical to universities developing any baccalaureate or masters level programs in order to attract students. Any change to the AIT program in this fashion would require changes to the regulations, which is at best a year-long process. IHCA is coordinating with the Indiana ACHCA Chapter, as well as colleagues at LeadingAge and HOPE. We will keep membership up to date on any progress.
Tuberculin Guidelines Rescinded Effective September 5, 2014
Per and ISDH Long Term Care Newsletter the ISDH TB Program has rescinded its recommendations to deal with a Tuberculin shortage that began last year. Facilities should return to pre-shortage practices, but not do any testing to “catch-up” and rather begin any required testing on the next due date. For more information and to read the ISDH announcement, click here.
ISDH IJ/SSQC Update
In the month of August 2014 there were two events that were both IJ and SSQC, leading to 4 tags being cited.
The first event involved allegations of verbal, physical, and mental abuse of a resident that were not thoroughly investigated and for which the facility’s policies and procedures were not followed, for which F223, F225 and F226 were cited. The issue stemmed from a resident being given a shower against her will, and the resident’s complaints to other staff members of being given a shower against her will and the staff’s failure to immediately report allegation of abuse to the administrator. The resident had experienced a large bowel movement overnight and was in need of a shower, even though it was known she did not like them. The DON determined that it was in the resident’s best interest to receive a shower and, even though the resident was known to be difficult (though documentation was lacking on this point), the staff was directed to give the resident a shower. During the shower the resident complained of the water temperature being too hot and scalding and the verbal abuse of staff.
The second event involved the alleged failure of a facility to prevent progress of a pressure ulcer that developed into a stage 4 ulcer, for which F314 was cited. Upon review of the clinical record, the ISDH took issue with the facility’s failure to provide treatment to the ulcer twice daily as ordered by a physician. The clinical record lacked documentation to support physician ordered treatment.
To read the 2567s from August and for a summary of the 2014 IJ/SSQC citations, click here.
The first event involved allegations of verbal, physical, and mental abuse of a resident that were not thoroughly investigated and for which the facility’s policies and procedures were not followed, for which F223, F225 and F226 were cited. The issue stemmed from a resident being given a shower against her will, and the resident’s complaints to other staff members of being given a shower against her will and the staff’s failure to immediately report allegation of abuse to the administrator. The resident had experienced a large bowel movement overnight and was in need of a shower, even though it was known she did not like them. The DON determined that it was in the resident’s best interest to receive a shower and, even though the resident was known to be difficult (though documentation was lacking on this point), the staff was directed to give the resident a shower. During the shower the resident complained of the water temperature being too hot and scalding and the verbal abuse of staff.
The second event involved the alleged failure of a facility to prevent progress of a pressure ulcer that developed into a stage 4 ulcer, for which F314 was cited. Upon review of the clinical record, the ISDH took issue with the facility’s failure to provide treatment to the ulcer twice daily as ordered by a physician. The clinical record lacked documentation to support physician ordered treatment.
To read the 2567s from August and for a summary of the 2014 IJ/SSQC citations, click here.
Wednesday, September 3, 2014
2014 IHCP Annual Provider Seminar – October 14-16 in Indianapolis
The Indiana Family and Social Services Administration (FSSA) and HP Enterprise Services invite Indiana Health Coverage Programs (IHCP) providers to attend the 2014 IHCP Annual Provider Seminar October 14-16, 2014, in Indianapolis. There is no cost for the seminar. The seminar features three full days of important information. Topics include program overviews and specific program billing guidelines, as well as tips and reminders on various session topics. For more details and registration links, see IHCP Bulletin BT201441.
WPS Medicare Full Day Training
WPS Medicare, the Medicare carrier for Indiana and Michigan , is offering a full day educational event designed for providers and suppliers of all types. The multi-breakout sessions will allow providers to choose from 20 different topics of interest. This exciting program, A Day with Medicare, is coming to Indianapolis, IN on October 7, 2014. This event includes both Part A and Part B topics to gain insight into the cause for errors and the best ways to avoid them in the future. The agenda includes a general session, 20 breakout sessions, and opportunities to meet with WPS Medicare staff. WPS Medicare is able to offer this event free of charge due to special funding from the Centers for Medicare & Medicaid Services. The event capacity is limited to 200 people, so register today.
To register, go to the WPS Medicare J8 website for Part A or Part B, click on the Training tab, choose Live Training, and click on the "Live training event catalog" link
October 7, 2014 - Indianapolis, IN - Click here for more information
October 9, 2014 - Detroit, MI - Click here for more information
For the schedule, a list of breakout sessions and speakers, please click here to access the program brochure.
To register, go to the WPS Medicare J8 website for Part A or Part B, click on the Training tab, choose Live Training, and click on the "Live training event catalog" link
October 7, 2014 - Indianapolis, IN - Click here for more information
October 9, 2014 - Detroit, MI - Click here for more information
For the schedule, a list of breakout sessions and speakers, please click here to access the program brochure.
Tuesday, September 2, 2014
Indiana Begins Work to Implement CMS Home and Community Based Settings Rule
In March 2014 CMS released a toolkit to state agencies to use as they move forward with creating or amending Home and Community Based Services (HCBS; also referred to as Home and Community Based Settings) programs within Medicaid. CMS’s website devoted to the CMS HCBS rule and guidance is great resource to understand the agency’s direction for the Medicaid waiver programs that serve persons with mental illness, intellectual or developmental disabilities, and/or physical disabilities. The CMS rule and interpretive guidance spell out a significant shift in the way CMS will support state HCBS program with federal funding. Only those programs that meet specific criteria, much of which differs substantially from prior rule and guidance, will be eligible for federal funding. Transition to compliance may take up to 5 years in each state, depending on specific state circumstances.
One of Indiana’s HCBS waivers is the Aged & Disabled Waiver (A&D Waiver) that includes the Assisted Living Services (amongst many others – see FSSA’s Medicaid Waivers page). Approximately 1,500 Medicaid recipients currently reside in licensed Residential Care Facilities through the AL services wavier, and more than 16,000 Medicaid recipients receive one of the services listed under the A&D waiver. All of these recipients quality for institutional care but are being served in the community under one of the waiver programs. The Indiana Division of Aging (DA) manages the A&D Waiver and will be applying later this year to increase the number of slots available so that more Medicaid recipients can access these services. A well known goal of federal and state governments is to increase the number and level of spending for HCBS so that more recipients can be cared for, when appropriate, in a lower cost community setting.
The CMS rule and guidance set out a number of new requirements and limitations for HCBS programs, and a new option to add HCBS into a state’s Medicaid plan rather than operating it as a waiver to the state plan. More guidance is expected to be released in order to distinguish application of the requirements on the very different populations covered, but as they read now the rules and guidance are likely to result in significant change to Indiana’s HCBS programs. CMS’s guidance titled Regulatory Requirements for Home and Community Based Settings spells out CMS’s expectations that states design programs that integrate recipients with the broader community, promote choice and person-centered care, provides autonomy and ensure protection of individual rights, and excludes settings that are de-facto institutions (like Nursing Facilities, ICF-IIDs, and Hospitals), or that have qualities of institutions or qualities that isolate HCBS recipients.
Impact on Indiana Providers
There will be impact on Indiana’s AL services providers – licensed Residential Care Facilities. Under CMS’s guidance, any provider-owned or controlled residential setting, in addition to the qualities discussed above (qualities which are evaluated based on other extensive guidance), must permit or provide:
- The unit/dwelling is a specific space that can be owned, rented, or occupied under a legally enforceable agreement and provides the same protections that tenants would have under landlord/tenant laws of a state or other municipality.
- Each unit must provide for privacy and have entrance doors that are lockable by the individual, with only appropriate staff having keys to doors; individuals must have a choice of roommate; individuals must have the freedom to decorate and furnish the unit within the lease or other agreement.
- Individuals must have the freedom to control their own schedules and have access to food at any time.
- Individuals must be able to have visitors of their choosing at any time.
- The setting must be physically accessible to the individual.
- Any modification to the above must be done through a person-centered service plan that meets specified requirements.
Settings that are presumed to have qualities of institutions, as defined by CMS, will require special attention by each state if these settings are to continue participate in HCBS programs. Such settings are required to be identified by the state with a plan as to what changes to licensing or certification standards may be necessary to use such settings in a HCBS program. Settings that are presumed to have qualities of institutions that are included in a HCBS waiver plan will go through a “heightened scrutiny” process (see also Steps to Compliance for HCBS Setting Requirements). Settings that are presumed to have qualities of institutions are:
- Any setting located in a building that is also a publically or privately operated facility that provides inpatient institutional treatment;
- Any setting that is located in the building on the grounds of, or immediately adjacent to, a public institution; or
- Any other setting that has the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS (see CMS Guidance on Settings That Have the Effect of Isolating Individuals).
Indiana Division of Aging Work To Date
The Indiana DA has begun work, along with its sister divisions at FSSA, to develop a transition plan that includes timeframes and benchmarks for developing/changing Indiana’s programs to comply with the CMS rule and guidance. The first draft of a transition plan is due to CMS in December 2014. The state will have one year to submit a final transition plan and the transition period may be up to 5 years depending on circumstances discovered in the planning process (required statutory/regulatory changes that may be necessary, etc.).
As it relates to the Assisted Living Services component of the Indiana A&D waiver, the DA is developing a survey tool that will be sent to current AL service waiver providers in order for the DA to have hard data on the housing stock and operations of Residential Care Facilities. This data is essential to gather in order to allow the DA to develop a transition plan that can include Residential Care Facilities and/or design alternative programs to continue Assisted Living Services in Indiana’s HCBS waiver program. This survey is to be sent later this summer. This entire process will be a long one, but it is critically important to follow and provide input into.
IHCA/INCAL will continue to monitor Indiana’s implementation of the CMS rule. Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with questions or comments.
One of Indiana’s HCBS waivers is the Aged & Disabled Waiver (A&D Waiver) that includes the Assisted Living Services (amongst many others – see FSSA’s Medicaid Waivers page). Approximately 1,500 Medicaid recipients currently reside in licensed Residential Care Facilities through the AL services wavier, and more than 16,000 Medicaid recipients receive one of the services listed under the A&D waiver. All of these recipients quality for institutional care but are being served in the community under one of the waiver programs. The Indiana Division of Aging (DA) manages the A&D Waiver and will be applying later this year to increase the number of slots available so that more Medicaid recipients can access these services. A well known goal of federal and state governments is to increase the number and level of spending for HCBS so that more recipients can be cared for, when appropriate, in a lower cost community setting.
The CMS rule and guidance set out a number of new requirements and limitations for HCBS programs, and a new option to add HCBS into a state’s Medicaid plan rather than operating it as a waiver to the state plan. More guidance is expected to be released in order to distinguish application of the requirements on the very different populations covered, but as they read now the rules and guidance are likely to result in significant change to Indiana’s HCBS programs. CMS’s guidance titled Regulatory Requirements for Home and Community Based Settings spells out CMS’s expectations that states design programs that integrate recipients with the broader community, promote choice and person-centered care, provides autonomy and ensure protection of individual rights, and excludes settings that are de-facto institutions (like Nursing Facilities, ICF-IIDs, and Hospitals), or that have qualities of institutions or qualities that isolate HCBS recipients.
Impact on Indiana Providers
There will be impact on Indiana’s AL services providers – licensed Residential Care Facilities. Under CMS’s guidance, any provider-owned or controlled residential setting, in addition to the qualities discussed above (qualities which are evaluated based on other extensive guidance), must permit or provide:
- The unit/dwelling is a specific space that can be owned, rented, or occupied under a legally enforceable agreement and provides the same protections that tenants would have under landlord/tenant laws of a state or other municipality.
- Each unit must provide for privacy and have entrance doors that are lockable by the individual, with only appropriate staff having keys to doors; individuals must have a choice of roommate; individuals must have the freedom to decorate and furnish the unit within the lease or other agreement.
- Individuals must have the freedom to control their own schedules and have access to food at any time.
- Individuals must be able to have visitors of their choosing at any time.
- The setting must be physically accessible to the individual.
- Any modification to the above must be done through a person-centered service plan that meets specified requirements.
Settings that are presumed to have qualities of institutions, as defined by CMS, will require special attention by each state if these settings are to continue participate in HCBS programs. Such settings are required to be identified by the state with a plan as to what changes to licensing or certification standards may be necessary to use such settings in a HCBS program. Settings that are presumed to have qualities of institutions that are included in a HCBS waiver plan will go through a “heightened scrutiny” process (see also Steps to Compliance for HCBS Setting Requirements). Settings that are presumed to have qualities of institutions are:
- Any setting located in a building that is also a publically or privately operated facility that provides inpatient institutional treatment;
- Any setting that is located in the building on the grounds of, or immediately adjacent to, a public institution; or
- Any other setting that has the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS (see CMS Guidance on Settings That Have the Effect of Isolating Individuals).
Indiana Division of Aging Work To Date
The Indiana DA has begun work, along with its sister divisions at FSSA, to develop a transition plan that includes timeframes and benchmarks for developing/changing Indiana’s programs to comply with the CMS rule and guidance. The first draft of a transition plan is due to CMS in December 2014. The state will have one year to submit a final transition plan and the transition period may be up to 5 years depending on circumstances discovered in the planning process (required statutory/regulatory changes that may be necessary, etc.).
As it relates to the Assisted Living Services component of the Indiana A&D waiver, the DA is developing a survey tool that will be sent to current AL service waiver providers in order for the DA to have hard data on the housing stock and operations of Residential Care Facilities. This data is essential to gather in order to allow the DA to develop a transition plan that can include Residential Care Facilities and/or design alternative programs to continue Assisted Living Services in Indiana’s HCBS waiver program. This survey is to be sent later this summer. This entire process will be a long one, but it is critically important to follow and provide input into.
IHCA/INCAL will continue to monitor Indiana’s implementation of the CMS rule. Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with questions or comments.
Indiana Medicaid Issues Home Health Telehealth Proposed Rule
Pursuant to legislative action in the past 2014 session of the Indiana General Assembly, Indiana Medicaid issued a proposed rule to provide reimbursement for home health agencies providing telehealth services. A public hearing on the proposed rule was held on August 28, 2014. The rule defines telehealth services and establishes rates of $14.45 per client for the initial client visit to train and orient the client on use of the equipment and a rate of $9.84 for each date the telehealth equipment is used by an RN to monitor and managed the client’s care in accordance with physician orders. In addition, the rule removes the current 20 mile geographic limitation for telemedicine services for FQHCs, rural health clinics, community mental health centers and critical access hospitals. To review the rule, click here.
Indiana Medicaid Rate Update
As reported last month the State has begun to reprocess rates to implement a 2% increase and to implement a slightly increased Quality Assessment Fee, both effective 1/1/14. Also reported in the past, IHCA has been in discussions with Indiana Medicaid and the Division of Aging concerning a transition to RUGS IV, as well as the ongoing payment of the Special Care Unit add-on. IHCA recently met again with the State on these matters and no decisions have been made. The state has asked the IHCA and other long term care associations to engage assembling a 5-8 year plan concerning nursing home reimbursement, home and community based services, and quality initiatives. As part of that planning process, the RUGs IV and Special Care Unit add-on will be addressed. IHCA will be working internally with our Board of Directors, and externally with our fellow trade associations to determine next steps.
CMS Issues New Survey & Certification Memos for Nursing Homes
The below S&C Memos have been issued by CMS that are applicable to nursing homes:
- S&C 14-42-NH – Release of Learning Tool on Building Respect for Lesbian, Gay, Bisexual, Transgender (LGBT) Older Adults. CMS has developed and released a free learning tool designed to educate nursing facilities on the needs and right of older LGBT adults. The program presented in six online training modules. There are approximately 1.5M older adults over the age of 65 that identify as LGBT, and estimates indicated that number will double by 2030. To access the learning tool go to http://lgbtagingcenter.org/training/buildingRespect.cfm.
- S&C 14-43-NH - Completion of Minimum Data Set (MDS) 3.0 Discharge Assessments for Resident Transfers from a Medicare- and/or Medicaid-Certified Bed to a Non-Certified Bed. CMS reminds nursing homes of the requirement for MDS 3.0 discharge assessments to be completed when a resident transfers from a Medicare or Medicaid certified bed to a non-certified bed. The requirement is based in federal regulation and law. To read more, click on the above linked memo.
- S&C 14-42-NH – Release of Learning Tool on Building Respect for Lesbian, Gay, Bisexual, Transgender (LGBT) Older Adults. CMS has developed and released a free learning tool designed to educate nursing facilities on the needs and right of older LGBT adults. The program presented in six online training modules. There are approximately 1.5M older adults over the age of 65 that identify as LGBT, and estimates indicated that number will double by 2030. To access the learning tool go to http://lgbtagingcenter.org/training/buildingRespect.cfm.
- S&C 14-43-NH - Completion of Minimum Data Set (MDS) 3.0 Discharge Assessments for Resident Transfers from a Medicare- and/or Medicaid-Certified Bed to a Non-Certified Bed. CMS reminds nursing homes of the requirement for MDS 3.0 discharge assessments to be completed when a resident transfers from a Medicare or Medicaid certified bed to a non-certified bed. The requirement is based in federal regulation and law. To read more, click on the above linked memo.
QIO Changes Update
As reported last month two new QIO entities have begun work in Indiana. KEPRO is in charge of beneficiary complaints and appeals, and quality of care reviews, while QSource will be responsible for working with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm, and improve clinical care at their local and regional levels.
Providers have experience some transition pains with KEPRO in the area of processing beneficiary appeals. It appeared that KEPRO was not able to handle the volume of appeals, which has created problems for beneficiaries and providers alike with obtaining appropriate Medicare coverage. To assist with the appeal process, providers are encouraged to use the Expedited Determination Contact Information for Discharge Appeals for appeals that are time sensitive.
On the quality improvement side, Indiana’s long term care community is thrilled that Kathy Hybarger has been hired by QSource to continue her great work in quality improvement. Kathy’s contact information is below. QSource issued this introduction letter to providers about their operations and the name of the territory that they cover, dubbed the Atom Alliance (covering IN, TN, KY, AL, and MS). Congratulate Kathy as you are able and you’ll be hearing more from her and QSource in the very near future.
Kathy Hybarger RN, MSN
Task Lead for Nursing Homes, Hospital, and Care Coordination
Phone:765-413-9764
e-mail: Kathy.Hybarger@hcqis.org
Providers have experience some transition pains with KEPRO in the area of processing beneficiary appeals. It appeared that KEPRO was not able to handle the volume of appeals, which has created problems for beneficiaries and providers alike with obtaining appropriate Medicare coverage. To assist with the appeal process, providers are encouraged to use the Expedited Determination Contact Information for Discharge Appeals for appeals that are time sensitive.
On the quality improvement side, Indiana’s long term care community is thrilled that Kathy Hybarger has been hired by QSource to continue her great work in quality improvement. Kathy’s contact information is below. QSource issued this introduction letter to providers about their operations and the name of the territory that they cover, dubbed the Atom Alliance (covering IN, TN, KY, AL, and MS). Congratulate Kathy as you are able and you’ll be hearing more from her and QSource in the very near future.
Kathy Hybarger RN, MSN
Task Lead for Nursing Homes, Hospital, and Care Coordination
Phone:765-413-9764
e-mail: Kathy.Hybarger@hcqis.org
ISDH Announces the Advanced Healthcare Education Project
In partnership with the University of Indianapolis Center for Aging & Community, the ISDH is developing and implementing a series of advanced education programs on geriatric care issues. The project will provide introductory certification-level educational programs throughout the state on several advanced education topics. The programs are intended to prepare the participant to be eligible for a level of certification in the specified area. The programs will offer education in the following areas:
- Wound Care
- Infection prevention
- Alzheimer’s and dementia care
- Quality/Process improvement
Assessment of the project will be done by monitoring the number of deficiencies cited during long term care surveys, specifically for F314 and F441, and track the percent of Indiana nursing homes with an individual that has “certification level education” in wound care, infection prevention, Alzheimer’s and dementia care, PHI abuse prevention, and yellow and green belt Six Sigma.
The programs are funded by ISDH Civil Money Penalties and are free of charge to participants. There may be a small charge for cost of food and beverage during the education sessions.
The training schedule has already been developed for the Quality/Process Improvement trainings that begin in September and go through January in different areas of the State. For additional details on the ISDH project and the training schedule please see the ISDH Long Term Care Newsletter from August 25, 2014.
- Wound Care
- Infection prevention
- Alzheimer’s and dementia care
- Quality/Process improvement
Assessment of the project will be done by monitoring the number of deficiencies cited during long term care surveys, specifically for F314 and F441, and track the percent of Indiana nursing homes with an individual that has “certification level education” in wound care, infection prevention, Alzheimer’s and dementia care, PHI abuse prevention, and yellow and green belt Six Sigma.
The programs are funded by ISDH Civil Money Penalties and are free of charge to participants. There may be a small charge for cost of food and beverage during the education sessions.
The training schedule has already been developed for the Quality/Process Improvement trainings that begin in September and go through January in different areas of the State. For additional details on the ISDH project and the training schedule please see the ISDH Long Term Care Newsletter from August 25, 2014.
Changes Approved to the Indiana Medicaid Formulary
On August 15th the Indiana Drug Utilization Review (DUR) Board approved changes to the preferred drug list for Indiana Medicaid recipients. In addition, the DUR Board approved utilization edits reviewed by the Mental Health Quality Advisory Committee. Changes to the formulary and utilization edits are effective for dates of service on or after Oct. 1, 2014. See IHCP Bulletin BT 201440 for additional detail.
Residential Care Citation Update
In July 2014 the ISDH issued 59 Deficiency tags and 4 Offense tags to Residential Care Facilities. This is the high mark in 2014 for Deficiency and Offense tags by the ISDH. Leading the way is Tag 0273, which was cited 11 times in July, concerning maintenance of food preparation and service areas in accordance with state and local standards. Tag 0217 was cited 7 times in July, and having been cited 8 times in the first 6 months of the year, ISDH surveyors appear to be paying extra attention to the use of appropriately trained staff to complete evaluations and resident service plans. Another trend that has appeared in the last few months is citation of Tag 0214, another resident evaluation tag, concerning initiation of an evaluation prior to admission and upon a change of condition with a licensed nurse evaluating the resident’s need for nursing care. Tag 0214 was cited 5 times in July, 2 times in June, and 3 times in May.
For a summary of all Deficiency and Offense tags issued in July, click here.
For a summary of all Deficiency and Offense tags issued in July, click here.
ISDH IJ/SSQC Update
There were three events in the month of July that led to 7 IJ citations being issued all of which were also SSQC.
The first event, citing F225 and 226, involved the lack of investigation and reporting of allegations of sexual abuse by a staff member of a resident. In this particular case, a resident who apparently had a history of making false accusations reported that a female staff member was having sex with a male resident in the resident’s room (the resident making the accusation was the roommate). The Administrator did not take the accusation as credible due to the resident’s history and the details of the accusation. However, the ISDH took exception with the lack of investigation and reporting to the ISDH of this allegation.
The second event involved the failure to order and monitory lab values for 2 residents receiving Warfarin. The failure resulted in citation of F329 and was cited as past noncompliance as the facility caught its error and corrected it prior to survey. The error was due to miscommunication during a conversion of physician orders to a new computer system.
The third event involved the failure of the facility and the facility’s management to address and report verbal abuse by the Administrator to residents and staff. Citations were issued for F223, F225, F225, and F490, all related to the alleged verbal abuse by the Administrator. Behavior of the Administrator was described as demeaning, humiliating, and threatening to residents and staff. Staff reported to ISDH that they had called the corporate hotline several times concerning the Administrator. F490 was issued due to the management’s alleged failure to ensure the facility was administered to attain or maintain the highest practicable mental and psychosocial well-being of each resident based upon the behavior of the Administrator.
To review the 2567s for the July IJs/SSQCs and for a summary of all IJs/SSQCs in 2014, click here.
The first event, citing F225 and 226, involved the lack of investigation and reporting of allegations of sexual abuse by a staff member of a resident. In this particular case, a resident who apparently had a history of making false accusations reported that a female staff member was having sex with a male resident in the resident’s room (the resident making the accusation was the roommate). The Administrator did not take the accusation as credible due to the resident’s history and the details of the accusation. However, the ISDH took exception with the lack of investigation and reporting to the ISDH of this allegation.
The second event involved the failure to order and monitory lab values for 2 residents receiving Warfarin. The failure resulted in citation of F329 and was cited as past noncompliance as the facility caught its error and corrected it prior to survey. The error was due to miscommunication during a conversion of physician orders to a new computer system.
The third event involved the failure of the facility and the facility’s management to address and report verbal abuse by the Administrator to residents and staff. Citations were issued for F223, F225, F225, and F490, all related to the alleged verbal abuse by the Administrator. Behavior of the Administrator was described as demeaning, humiliating, and threatening to residents and staff. Staff reported to ISDH that they had called the corporate hotline several times concerning the Administrator. F490 was issued due to the management’s alleged failure to ensure the facility was administered to attain or maintain the highest practicable mental and psychosocial well-being of each resident based upon the behavior of the Administrator.
To review the 2567s for the July IJs/SSQCs and for a summary of all IJs/SSQCs in 2014, click here.
Wednesday, August 6, 2014
CMS Finalizes FY 2015 SNF Medicare Payment Rule
CMS issued the final rule for FY 2015 Medicare payments. As published previously the aggregate increase is 2%, which is the result of the 2.5% market basket increase and the .5% reduction from the multifactor productivity adjustment. AHCA has assembled a thorough overview of the final rule which you can access by clicking here. The final wage index will be posted to the following website: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html. The final rule may be accessed at: http://www.ofr.gov/inspection.aspx. To read the CMS release on the payment rule, click here.
Indiana Medicaid Rate Update – Reprocessing of Claims Has Begun for 1/1/14 and Forward
Regular updating of Indiana Medicaid NF rates had been held up for all of 2014 due to the pending State Plan Amendment (SPA) that proposed to increase NF rates by 2% effective 1/1/14 (i.e. to decrease the existing 5% cut to 3%). CMS finally approved the rate increase SPA in late July that has set in motion a number of rate reprocessing activities. Concurrent with the rate cut SPA being approved, CMS also approved an amended waiver for the Quality Assessment Fee that increases the fee. This increase was required as it was found that the old fee structure failed the meet the Federal regulatory “B1/B2 test” that is a test to demonstrate Indiana’s QAF as “generally redistributive” when such a tax or fee is neither uniform nor broad based (Indiana’s tax is not uniform or broad based due to certain exemptions from the fee and due to a two-tiered fee structure). See July’s IHCA Insights article for more detail on the QAF Waiver and the new rates by clicking here.
Indiana Medicaid through its contractor HP has already begun reprocessing rates for the 1/1/14 Rate Effective Date. Indiana Medicaid released a timeline and reprocessing schedule on the website of Myers & Stauffer. Click here for the rate plan release and click here for the nursing facility listing indicating what batch a particular nursing facility’s rate will be released. Note that the release plan includes ICF/IIDs as those facility’s rates were also impacted by this SPA.
If you have any questions, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
Indiana Medicaid through its contractor HP has already begun reprocessing rates for the 1/1/14 Rate Effective Date. Indiana Medicaid released a timeline and reprocessing schedule on the website of Myers & Stauffer. Click here for the rate plan release and click here for the nursing facility listing indicating what batch a particular nursing facility’s rate will be released. Note that the release plan includes ICF/IIDs as those facility’s rates were also impacted by this SPA.
If you have any questions, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.
ICD-10 Deadline Reset for October 1, 2015
The US Department of Health and Human Services (HHS), has just issued a final rule that finalizes Oct. 1, 2015, as the new compliance date for health care providers, health plans and health care clearinghouses to transition from ICD-9 to ICD-10. According to Center for Medicare & Medicaid Services (CMS) Administrator, Marilyn Tavenner, the new “ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics.” HHS also points out that implementation of ICD-10 codes will better detect and prevent fraud waste and abuse and lead to greater accuracy of reimbursement for medical services. AHCA will provide a more in-depth analysis of the final rule; but wanted to get this information out tonight. To obtain a copy of the press release go to http://cms.hhs.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-07-31.html. To obtain a copy of the final rule go to https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-18347.pdf (Note, this final rule has not been published in the Federal Register yet; but is expected to be printed on Monday, August 4, 2014). To obtain additional information about ICD-10 go to http://www.cms.gov/ICD10.
CMS also released revised MLN Matters articles to follow the reset deadline of October 1, 2015. Those articles are as follows:
MM8350 – Diagnosis Code Reporting on Religious Nonmedical Health Care Institution Claims
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8350.pdf
MM8494 – Changes to the Laboratory National Coverage Determination (NCD) Software for ICD-10 Codes
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8494.pdf
SE1240 – Partial Code Freeze Prior to ICD-10 Implementation
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1240.pdf
SE1408 – Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) – A Re-Issue of MM7492
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1408.pdf
SE1410 – Special Instructions for the International Classification of Diseases, Clinical Modification 10th Edition (ICD-10-CM) Coding on Home Health Episodes that Span October 1, 2015
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf
CMS also released revised MLN Matters articles to follow the reset deadline of October 1, 2015. Those articles are as follows:
MM8350 – Diagnosis Code Reporting on Religious Nonmedical Health Care Institution Claims
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8350.pdf
MM8494 – Changes to the Laboratory National Coverage Determination (NCD) Software for ICD-10 Codes
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8494.pdf
SE1240 – Partial Code Freeze Prior to ICD-10 Implementation
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1240.pdf
SE1408 – Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) – A Re-Issue of MM7492
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1408.pdf
SE1410 – Special Instructions for the International Classification of Diseases, Clinical Modification 10th Edition (ICD-10-CM) Coding on Home Health Episodes that Span October 1, 2015
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf
Interact for Assisted Living
NCAL is excited to share that INTERACT for Assisted Living, a quality improvement program to reduce hospital readmissions, has been released! Interventions to Reduce Acute Care Transfers (INTERACT) was originally designed to improve the early identification, management, documentation and communication about acute changes in condition of skilled nursing center residents. The program has now expanded to include tools specifically targeted toward assisted living providers. You can find all the new tools at the INTERACT website and via a link to the INTERACT website on the NCAL Quality Initiative website under “Resources” for the hospital readmission goal.
NCAL is working closely with the INTERACT team on an official announcement but wanted to inform members of this exciting news now.
NCAL is working closely with the INTERACT team on an official announcement but wanted to inform members of this exciting news now.
Serving Alcohol to Residents – IHCA Guidance Released
Several members contacted the IHCA last month after a news story appeared in the paper and on TV concerning the State Excise police warning a skilled nursing facility for serving alcohol to its residents during a social hour. IHCA has developed helpful guidance for your company to review. If you have any questions, please contact me at zcattell@ihca.org or 317-616-9001.
QIO Program Changes
• KEPRO – Beneficiary Complaints and Quality of Care reviews
The Centers for Medicare & Medicaid Services (CMS) has made dramatic changes to the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) program. Beginning August 1, 2014, the BFCC-QIO program will be managed by one of two organizations nationally. The organization assuming the QIO work for Indiana will be KEPRO. Health Care Excel will no longer be conducting QIO activities after July 31, 2014. KEPRO will manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. Click here an information sheet about the changes to the QIO program and contact information for KEPRO.
This change will impact your Notice of Medicare Noncoverage forms. You will need to change the name and toll-free # for the QIO on those forms, but do NOT distribute the new number to patients prior to August 1, 2014. Click here for information on KEPRO. Your facility will receive additional information from KEPRO.
• QSource – Quality Improvement Initiatives
IHCA is under the impression that QSource of Tennessee has been awarded the Quality Innovation Network (QIN) QIO for Indiana, replacing Health Care Excel. QSource will be responsible for working with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm, and improve clinical care at their local and regional levels. A formal announcement is expected in the near future.
The Centers for Medicare & Medicaid Services (CMS) has made dramatic changes to the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) program. Beginning August 1, 2014, the BFCC-QIO program will be managed by one of two organizations nationally. The organization assuming the QIO work for Indiana will be KEPRO. Health Care Excel will no longer be conducting QIO activities after July 31, 2014. KEPRO will manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. Click here an information sheet about the changes to the QIO program and contact information for KEPRO.
This change will impact your Notice of Medicare Noncoverage forms. You will need to change the name and toll-free # for the QIO on those forms, but do NOT distribute the new number to patients prior to August 1, 2014. Click here for information on KEPRO. Your facility will receive additional information from KEPRO.
• QSource – Quality Improvement Initiatives
IHCA is under the impression that QSource of Tennessee has been awarded the Quality Innovation Network (QIN) QIO for Indiana, replacing Health Care Excel. QSource will be responsible for working with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm, and improve clinical care at their local and regional levels. A formal announcement is expected in the near future.
Residential Care Citation Update
In June 2014 the ISDH issued 40 Deficiency tags and 7 Offense tags to Residential Care Facilities. Tag 273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation standards was cited 7 times, and Tag 241 concerning the administration of medications by licensed nurses or QMAs was cited 5 times. These continue to be the most cited tags in 2014 with Tag 273 issued 31 times and Tag 241 issued 21 times.
• Citation Trends
It appears also that the ISDH surveyors are paying more close attention to hand washing when they survey residential care facilities. Tag 414 was issued 3 times in June for failure of staff to wash hands after each direct resident contact. The tag was also cited twice in March and April, and once in May, for a total of 8 citations in 2014. The tag was only issued 6 times in all of 2013. In addition, Tag 301 concerning the proper labeling of prescription drugs has been cited 3 times in June, once in March and once in May, for a total of 5 citations in 2014. The tag was cited 6 times in all of 2013. Tag 301 requires prescription drugs to be labeled 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. Reasonable variations to these requirements can apply to units does packaging. Lastly, Tag 154 has been cited 4 times in June, 3 times in May and 1 time in each of April and March, for failure to keep kitchen and dining areas clean and in good repair. Though Tag 154 has been frequently cited in the past, including 20 times in 2013, it had not been cited in 2014 with much frequency until the last 2 months.
To review the June citations click here.
• Citation Trends
It appears also that the ISDH surveyors are paying more close attention to hand washing when they survey residential care facilities. Tag 414 was issued 3 times in June for failure of staff to wash hands after each direct resident contact. The tag was also cited twice in March and April, and once in May, for a total of 8 citations in 2014. The tag was only issued 6 times in all of 2013. In addition, Tag 301 concerning the proper labeling of prescription drugs has been cited 3 times in June, once in March and once in May, for a total of 5 citations in 2014. The tag was cited 6 times in all of 2013. Tag 301 requires prescription drugs to be labeled 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. Reasonable variations to these requirements can apply to units does packaging. Lastly, Tag 154 has been cited 4 times in June, 3 times in May and 1 time in each of April and March, for failure to keep kitchen and dining areas clean and in good repair. Though Tag 154 has been frequently cited in the past, including 20 times in 2013, it had not been cited in 2014 with much frequency until the last 2 months.
To review the June citations click here.
ISDH IJ/SSQC Update
The ISDH issued 4 citations at the IJ and SSQC levels in June related to two incidents. The first incident involved a CNA having been found on the floor next to a resident’s bed after having fallen out of the bed, according to the resident. It appeared upon investigation that the CNA had been lying in the resident’s bed. Staff had observed this behavior of the CNA, but it was not immediately reported to the Administrator. The resident alleged sexual abuse by the CNA. F224, F225, and F226 were issued in this incident. The second incident involved an elopement of a resident on a non-secured unit that was displaying exit seeking behaviors. The facility had not yet implemented the physician order for a Wanderguard prior to the elopement. The resident was a 5 of 5 on the BIMS and after the elopement was moved to the facility’s secured unit and a Wanderguard was put in place.
For a summary of the 2014 IJs/SSQCs and for the June 2567s, click here.
For a summary of the 2014 IJs/SSQCs and for the June 2567s, click here.
Monday, June 30, 2014
An Update on Indiana’s Progress in Implementing CMS’s Home and Community-Based Services Rule
Indiana’s Office of Medicaid Policy and Planning (OMPP) provided the following update to IHCA concerning the implementation of the CMS HCBS rule. To view a PowerPoint from CMS concerning the final rule, click here. IHCA will maintain active involvement with OMPP as the implementation plans become more clear.
The Centers for Medicare and Medicaid Services (CMS) issued a final rule for home and community-based services (HCBS) effective March 17, 2014. Indiana has six 1915(c) HCBS waivers, one grant and three 1915(i) HCBS State plan programs that are affected by this rule:
1915(c) HCBS Waivers
• Aged and Disabled Waiver (A&D)
• Traumatic Brain Injury Waiver (TBI)
• Money Follows the Person Grant (MFP)
• Community Integration and Habilitation Waiver (CIH)
• Family Supports Waiver (FSW)
• Psychiatric Residential Treatment Facility Transition Waiver (PRTF)
1915(i) HCBS State Programs
• Adult Mental Health & Habilitation Services (AMHH)
• Child Mental Health Wraparound Services (CMHW)
• Behavioral and Primary Healthcare Coordination (BPHC)
States submitting a 1915(c) waiver renewal or waiver amendment within the first year of the effective date of the rule need to develop a transition plan to ensure that the specific waiver meets the settings requirements. Within 120 days of the submission of that 1915(c) waiver renewal or waiver amendment the state must submit a plan that lays out timeframes and benchmarks for developing a transition plan for all the state’s approved 1915(c) waiver and 1915(i) HCBS state plan programs.
The Community Integration & Habilitation Waiver (CIH) is due to expire September 30th. Given the short time frame since the March 17, 2014 effective date of the final rule, CMS has advised the state to develop a high level transition plan specific to the CIH waiver for submission with the renewal.
This initial transition plan will outline timeframes for the assessment of current licensure and certification requirements, for assessing those settings which may not be compliant, and for developing a comprehensive transition plan and process for bringing all HCBS settings into compliance. The CIH initial transition plan, or “work plan”, will be posted for 30 day public comment by the middle of July. Following review of the public comments the CIH renewal will be submitted to CMS.
Submission of the CIH renewal will trigger the 120 day period for Indiana to develop a more comprehensive transition plan for all the state’s approved 1915(c) and 1915(i) HCBS programs. We anticipate that the comprehensive transition plan will be released for additional public comment in late October with submission to CMS due by early December.
The HCBS Final Rule Compliance Project team is being lead by Angie Amos and is composed of staff from each of the FSSA Divisions (DA, DDRS, DMHA, and OMPP). The team has been reviewing standards (e.g. licensing, certification, etc.) to possibly address provider groups on the basis of state requirements (both in identifying compliant settings and possibly targeted elements to be addressed). This triage approach will allow us to systematically focus on those areas most at risk of being noncompliant. Assessment tools are being developed which can then be used to evaluate individual settings.
Assuring compliance with the HCBS Final Rule is a large, long term project. CMS is developing additional guidance which will address the implications regarding the Final Rule for non-residential settings, transition planning, and person-centered planning. Indiana will submit a more fully developed transition plan for assuring compliance with these areas after receipt of the technical guidance from CMS. A 30 day public input period will be provided prior to the submission of any revised Transition Plan.
The Centers for Medicare and Medicaid Services (CMS) issued a final rule for home and community-based services (HCBS) effective March 17, 2014. Indiana has six 1915(c) HCBS waivers, one grant and three 1915(i) HCBS State plan programs that are affected by this rule:
1915(c) HCBS Waivers
• Aged and Disabled Waiver (A&D)
• Traumatic Brain Injury Waiver (TBI)
• Money Follows the Person Grant (MFP)
• Community Integration and Habilitation Waiver (CIH)
• Family Supports Waiver (FSW)
• Psychiatric Residential Treatment Facility Transition Waiver (PRTF)
1915(i) HCBS State Programs
• Adult Mental Health & Habilitation Services (AMHH)
• Child Mental Health Wraparound Services (CMHW)
• Behavioral and Primary Healthcare Coordination (BPHC)
States submitting a 1915(c) waiver renewal or waiver amendment within the first year of the effective date of the rule need to develop a transition plan to ensure that the specific waiver meets the settings requirements. Within 120 days of the submission of that 1915(c) waiver renewal or waiver amendment the state must submit a plan that lays out timeframes and benchmarks for developing a transition plan for all the state’s approved 1915(c) waiver and 1915(i) HCBS state plan programs.
The Community Integration & Habilitation Waiver (CIH) is due to expire September 30th. Given the short time frame since the March 17, 2014 effective date of the final rule, CMS has advised the state to develop a high level transition plan specific to the CIH waiver for submission with the renewal.
This initial transition plan will outline timeframes for the assessment of current licensure and certification requirements, for assessing those settings which may not be compliant, and for developing a comprehensive transition plan and process for bringing all HCBS settings into compliance. The CIH initial transition plan, or “work plan”, will be posted for 30 day public comment by the middle of July. Following review of the public comments the CIH renewal will be submitted to CMS.
Submission of the CIH renewal will trigger the 120 day period for Indiana to develop a more comprehensive transition plan for all the state’s approved 1915(c) and 1915(i) HCBS programs. We anticipate that the comprehensive transition plan will be released for additional public comment in late October with submission to CMS due by early December.
The HCBS Final Rule Compliance Project team is being lead by Angie Amos and is composed of staff from each of the FSSA Divisions (DA, DDRS, DMHA, and OMPP). The team has been reviewing standards (e.g. licensing, certification, etc.) to possibly address provider groups on the basis of state requirements (both in identifying compliant settings and possibly targeted elements to be addressed). This triage approach will allow us to systematically focus on those areas most at risk of being noncompliant. Assessment tools are being developed which can then be used to evaluate individual settings.
Assuring compliance with the HCBS Final Rule is a large, long term project. CMS is developing additional guidance which will address the implications regarding the Final Rule for non-residential settings, transition planning, and person-centered planning. Indiana will submit a more fully developed transition plan for assuring compliance with these areas after receipt of the technical guidance from CMS. A 30 day public input period will be provided prior to the submission of any revised Transition Plan.
Federal Guidance Issued: Protecting Residents from Financial Exploitation
The federal Consumer Financial Protection Bureau (CFPB) released a new manual on June 26, 2014 that is designed to help assisted living and nursing facilities identify and report fraud committed against their residents. Titled, “Protecting Residents From Financial Exploitation: A Manual for Assisted Living and Nursing Facilities,” the manual focuses heavily on financial abuse committed by residents’ friends and family members. The manual also discusses common senior scams and is designed to be used by providers. Click here for to access the manual. The CFPB provided the following summary statement about the manual, including instruction on how to order free copies of the manual:
To equip assisted living and nursing facility staff with the know-how to prevent and spot the warning signs of elder financial abuse, today the Consumer Financial Protection Bureau released a guide to protecting residents from financial exploitation.
Too often, vulnerable adults fall prey to con artists, family members, fiduciaries, professional advisers and others who steal their nest eggs and threaten their financial security. Here are just a couple of examples:
A son steals $315,000 from his elderly mother’s retirement accounts and frequents casinos. When he doesn’t pay his mother’s rent, she’s evicted from her assisted living facility.
The pastor of a 77-year-old man with Alzheimer’s and Parkinson’s diseases makes 130 withdrawals from the man’s bank account but fails to make nursing home payments on his behalf for nine months. The man was nearly discharged from his nursing home.
CFPB’s action-oriented guide gives facility staff the tools to:
• Prevent financial exploitation and scams by educating staff, residents, and family members about warning signs and precautions
• Recognize, record, and report financial abuse as early as possible using a model protocol and a team approach
• Get help from first responders in the community.
While the guide is geared for assisted living and nursing facilities, it will also be helpful to operators of other senior living facilities. Family members of residents can read the guide to learn the red flags of financial exploitation, and can share the guide with staff of their loved ones’ facilities. Long-term care ombudsman can benefit from tips in the guide.
You can read our blog and download the manual from the CFPB’s website. Also, you can order free hard copies—single or bulk orders (if the listing is not up yet, it will be later today). See our Director talk about elder financial exploitation on video. Today’s press release about the guide is here.
To report cases of financial abuse in Indiana, a facility must follow the ISDH incident reporting procedures and if a crime is suspected report to local law enforcement. In addition, financial exploitation should be reported to the Indiana Attorney General at 317- 232-6330, Adult Protective Services at 800-246-8909, and your local ombudsman. The Indiana Attorney General’s office also has an Identity Theft unit that can be reached at 800-382-5516 or by email at IDTheft@atg.in.gov.
To equip assisted living and nursing facility staff with the know-how to prevent and spot the warning signs of elder financial abuse, today the Consumer Financial Protection Bureau released a guide to protecting residents from financial exploitation.
Too often, vulnerable adults fall prey to con artists, family members, fiduciaries, professional advisers and others who steal their nest eggs and threaten their financial security. Here are just a couple of examples:
A son steals $315,000 from his elderly mother’s retirement accounts and frequents casinos. When he doesn’t pay his mother’s rent, she’s evicted from her assisted living facility.
The pastor of a 77-year-old man with Alzheimer’s and Parkinson’s diseases makes 130 withdrawals from the man’s bank account but fails to make nursing home payments on his behalf for nine months. The man was nearly discharged from his nursing home.
CFPB’s action-oriented guide gives facility staff the tools to:
• Prevent financial exploitation and scams by educating staff, residents, and family members about warning signs and precautions
• Recognize, record, and report financial abuse as early as possible using a model protocol and a team approach
• Get help from first responders in the community.
While the guide is geared for assisted living and nursing facilities, it will also be helpful to operators of other senior living facilities. Family members of residents can read the guide to learn the red flags of financial exploitation, and can share the guide with staff of their loved ones’ facilities. Long-term care ombudsman can benefit from tips in the guide.
You can read our blog and download the manual from the CFPB’s website. Also, you can order free hard copies—single or bulk orders (if the listing is not up yet, it will be later today). See our Director talk about elder financial exploitation on video. Today’s press release about the guide is here.
To report cases of financial abuse in Indiana, a facility must follow the ISDH incident reporting procedures and if a crime is suspected report to local law enforcement. In addition, financial exploitation should be reported to the Indiana Attorney General at 317- 232-6330, Adult Protective Services at 800-246-8909, and your local ombudsman. The Indiana Attorney General’s office also has an Identity Theft unit that can be reached at 800-382-5516 or by email at IDTheft@atg.in.gov.
CMS Established a Provider Relations Coordinator for the RAC Process
The Centers for Medicare and Medicaid Services (CMS) recently announced the establishment of a Provider Relations Coordinator to help increase program transparency and offer more efficient resolutions to providers affected by the medical review process (here).
The Provider Relations Coordinator’s purpose is to improve communication between providers and CMS. While providers should continue to take questions about specific claims directly to the Recovery Auditor or Medicare Administrative Contractor (MAC) who conducted the review, providers can raise larger process issues to the Coordinator. For example, if a provider believes that a Recovery Auditor is failing to comply with the documentation request limits or has a pattern of not issuing review results letters in a timely manner, CMS encourages providers to contact the Provider Relations Coordinator. Prior to the establishment of this new CMS initiative, AHCA members often contacted AHCA staff to help facilitate an escalation of their medical review issues with CMS. Hopefully this new process will help streamline the resolution of such issues.
CMS indicted that providers can also send suggestions about how to improve the Recovery Auditor or MAC medical review process to the CMS Provider Relations Coordinator.
The CMS Provider Relations Coordinator is Latesha Walker, and she can be contacted at:
• RAC@cms.hhs.gov (for Recovery Auditor review process concerns/suggestions)
• MedicareMedicalReview@cms.hhs.gov (for MAC review process concerns/suggestions)
If you have any questions or are not satisfied with CMS follow-up when using this new process, please contact Dianne De La Mare or Dan Ciolek at AHCA.
The Provider Relations Coordinator’s purpose is to improve communication between providers and CMS. While providers should continue to take questions about specific claims directly to the Recovery Auditor or Medicare Administrative Contractor (MAC) who conducted the review, providers can raise larger process issues to the Coordinator. For example, if a provider believes that a Recovery Auditor is failing to comply with the documentation request limits or has a pattern of not issuing review results letters in a timely manner, CMS encourages providers to contact the Provider Relations Coordinator. Prior to the establishment of this new CMS initiative, AHCA members often contacted AHCA staff to help facilitate an escalation of their medical review issues with CMS. Hopefully this new process will help streamline the resolution of such issues.
CMS indicted that providers can also send suggestions about how to improve the Recovery Auditor or MAC medical review process to the CMS Provider Relations Coordinator.
The CMS Provider Relations Coordinator is Latesha Walker, and she can be contacted at:
• RAC@cms.hhs.gov (for Recovery Auditor review process concerns/suggestions)
• MedicareMedicalReview@cms.hhs.gov (for MAC review process concerns/suggestions)
If you have any questions or are not satisfied with CMS follow-up when using this new process, please contact Dianne De La Mare or Dan Ciolek at AHCA.
Indiana Medicaid Rate Update
- January, April and July 2014 Rate Setting
As of June 30, 2014 Indiana Medicaid has been unable to set the 1/1/14 rates, and will not be issuing 4/1/14 or 7/1/14 rates, as CMS has yet to approve the State Plan Amendment (SPA) filed late last year to increase nursing facility reimbursement by 2% effective 1/1/14. It is not entirely clear why CMS has yet to approved the SPA, but IHCA has become aware that CMS has been asking many rounds of questions to Indiana Medicaid concerning issues that are not related to nursing facility reimbursement rates. Once the SPA is approved, Indiana Medicaid will work to implement the rate increase as soon as possible, but no definitive timeline is available. As mentioned above, this delay is impacting issuance of 4/1 and 7/1 rates.
- Quality Assessment Fee Waiver
As reported in February 2014, Indiana Medicaid was required to re-submit its waiver to CMS for the Indiana Quality Assessment Fee. IHCA has been informed that the waiver has been approved by CMS, however implementation of the increased QAF rates will not take place until the above mentioned SPA concerning the rate increase is implemented. Below is the list of QAF rates (imposed on all non-Medicare patient days) under the new waiver:
$4.09 (formerly $4.00) per non-Medicare day if the total patient census is 62,000 days or more (formerly 70,000 days)
$16.37 (formerly $16.00) per non-Medicare day if the total patient census is less than 62,000 days (formerly 70,000 days)
$4.09 (formerly $4.00) per non-Medicare day for non-state government owned or operated (NSGO) nursing facilities that became a NSGO prior to 7/1/03
$16.37 (formerly $16.00) per non-Medicare day for non-state government owned or operated (NSGO) nursing facilities that became a NSGO on or after 7/1/03
Continuing Care Retirement Communities (CCRCs) as defined at IC 16-28-15-7(2), hospital based, or state owned (Indiana Veteran's Home) facilities are exempt from paying the assessment. In addition, Indiana Medicaid has filed notice to file a new State Plan Amendment to extend the effective date of the QAF until June 30, 2017 as is authorized by State law.
- Value Based Purchasing
Satisfaction surveys for residents, family and staff are now in the field for the second year as part of Indiana Medicaid’s Value Based Purchasing program. While these surveys are not yet part of the official reimbursement add-on, they are setting the baseline data for possible inclusion in the future. It has been reported to IHCA that the roll-out of these surveys this year has gone much smoother than last year. If you have any questions or concerns, please contact Zach Cattell at zcattell@ihca.org or 317-340-6416.
- RUGs IV
As previously reported, Indiana Medicaid has proposed changing the Medicaid reimbursement formula to utilized RUGs IV rather than RUGs III. No decisions have been made concerning a transition to RUGs IV, specifically in terms of what grouper would be used, and ongoing discussions between Indiana Medicaid, the FSSA Division of Aging, and IHCA are taking place. IHCA has been assured that no change will occur until July 1, 2016, at the earliest, thereby giving providers ample time to plan for the fiscal and operational impact that the transition will have.
As of June 30, 2014 Indiana Medicaid has been unable to set the 1/1/14 rates, and will not be issuing 4/1/14 or 7/1/14 rates, as CMS has yet to approve the State Plan Amendment (SPA) filed late last year to increase nursing facility reimbursement by 2% effective 1/1/14. It is not entirely clear why CMS has yet to approved the SPA, but IHCA has become aware that CMS has been asking many rounds of questions to Indiana Medicaid concerning issues that are not related to nursing facility reimbursement rates. Once the SPA is approved, Indiana Medicaid will work to implement the rate increase as soon as possible, but no definitive timeline is available. As mentioned above, this delay is impacting issuance of 4/1 and 7/1 rates.
- Quality Assessment Fee Waiver
As reported in February 2014, Indiana Medicaid was required to re-submit its waiver to CMS for the Indiana Quality Assessment Fee. IHCA has been informed that the waiver has been approved by CMS, however implementation of the increased QAF rates will not take place until the above mentioned SPA concerning the rate increase is implemented. Below is the list of QAF rates (imposed on all non-Medicare patient days) under the new waiver:
$4.09 (formerly $4.00) per non-Medicare day if the total patient census is 62,000 days or more (formerly 70,000 days)
$16.37 (formerly $16.00) per non-Medicare day if the total patient census is less than 62,000 days (formerly 70,000 days)
$4.09 (formerly $4.00) per non-Medicare day for non-state government owned or operated (NSGO) nursing facilities that became a NSGO prior to 7/1/03
$16.37 (formerly $16.00) per non-Medicare day for non-state government owned or operated (NSGO) nursing facilities that became a NSGO on or after 7/1/03
Continuing Care Retirement Communities (CCRCs) as defined at IC 16-28-15-7(2), hospital based, or state owned (Indiana Veteran's Home) facilities are exempt from paying the assessment. In addition, Indiana Medicaid has filed notice to file a new State Plan Amendment to extend the effective date of the QAF until June 30, 2017 as is authorized by State law.
- Value Based Purchasing
Satisfaction surveys for residents, family and staff are now in the field for the second year as part of Indiana Medicaid’s Value Based Purchasing program. While these surveys are not yet part of the official reimbursement add-on, they are setting the baseline data for possible inclusion in the future. It has been reported to IHCA that the roll-out of these surveys this year has gone much smoother than last year. If you have any questions or concerns, please contact Zach Cattell at zcattell@ihca.org or 317-340-6416.
- RUGs IV
As previously reported, Indiana Medicaid has proposed changing the Medicaid reimbursement formula to utilized RUGs IV rather than RUGs III. No decisions have been made concerning a transition to RUGs IV, specifically in terms of what grouper would be used, and ongoing discussions between Indiana Medicaid, the FSSA Division of Aging, and IHCA are taking place. IHCA has been assured that no change will occur until July 1, 2016, at the earliest, thereby giving providers ample time to plan for the fiscal and operational impact that the transition will have.
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