ICD-10 Delayed

In case you missed it last month, the legislation that fixed the Medicare physician payment formula, known as the Doc Fix, also contained a delay of implementing ICD-10 at least until sometime in 2015.  That legislation, reported on by IHCA and AHCA (click here), also contained language to develop a Value Based Purchasing program in Medicare for SNFs.  The ICD-10 delay is causing a good deal of confusion as providers and insurers across the nation were training and preparing for implementation this  year.  The collective health care industry awaits further guidance from CMS on when the 2015 implementation deadline will be, whether organizations that are ready to implement may do so voluntarily, and will ICD-10 be skipped altogether and wait for 2017 to roll around when ICD-11 is to be released. Stay tuned!

Indiana Medicaid Models Fiscal Impact of Transition To RUGs IV

 IHCA met with representatives of the Division of Aging, Indiana Medicaid, and Myers & Stauffer on April 28th to review the State’s latest RUGs IV proposal.  They distributed two documents, one that shows the fiscal impact of moving to either the RUGs IV 48 or 66 grouper, and a second that compares CMIs between the two groupers according to rehab and non-rehab groups (click here for both documents).  No decision has been made as to which grouper they will choose, but IHCA suspects it will be the 66 grouper since that grouper saves the State money (i.e. reduces Medicaid rates for many facilities).  An announcement is being delayed until late-May as the State is also preparing fiscal impact on potential reduction to the occupancy penalty that would increase Medicaid rates for most facilities.

In addition, the State continues to contemplate the efficacy of the Special Care Unit Add-on as they argue that data from a Medicare-only study in 2009 indicates that such add-ons do not increase staffing.  IHCA has presented data to the State indicating that Special Care Units in-fact do have higher staffing.  The discussion about eliminating the Special Care Unit add-on began when the State first proposed a RUGs IV transition and at that time the State thought it would cost the State money and they were looking for an offset for that increased cost.

IHCA is not agreeable to any of the above changes, at least as they are currently proposed, and we are working with our Payment Committee and meeting with State officials and legislators to protect our profession and the residents we serve.

SNF Medicare Prospective Payment System Proposed Rule Released

CMS released the proposed rule for the SNF Prospective Payment System, indicating our Medicare rates for the coming fiscal year. CMS is proposing a 2.0% increase, estimated to be $750 million for the profession. There are several aspects to this proposed rule that look positive. (Find the fact sheet on CMS' website.)

This reflects the third year in a row of market basket increases, and an increase from last year's 1.3% market basket update.  Below is a short summary of the key provisions in the SNF PPS proposed rule that could have a direct impact on the long term and post-acute care profession.

Market Basket Update
• The proposed rule provides for a market basket increase for SNFs of 2.0% beginning October 1, 2014. The 2.0% market basket update reflects a full market basket increase of 2.4%, less a 0.4% multifactor productivity adjustment required by Section 3401(b) of the Affordable Care Act (ACA).
• CMS estimates that the net market basket update would increase SNF payments by approximately $750 million in FY 2015.

Other Key Provisions
• In response to our concerns, CMS is proposing a revision to the current Change of Therapy (COT) Other Medicare Required Assessment (OMRA) policy that would permit providers to use the COT OMRA to reclassify a resident into a therapy RUG from a non-therapy RUG, but only in certain limited circumstances.
• The proposed rule also provided clarification regarding the approval and use of Civil Money Penalties (CMPs). CMS clarifies that states may use federal CMP funds only after obtaining prior approval from CMS, along with proposing that States provide more public transparency on the projects that have been funded by CMP funds.
• Wage Index Update: CMS is proposing to use new Office of Management and Budget (OMB) definitions issued last year for the FY 2015 SNF PPS wage index and to identify a provider's urban or rural status. The purpose is to help determine which set of rate tables would apply to the provider. In an effort to mitigate the potential negative wage index impacts for some providers, CMS is proposing to implement these changes by providing a one-year transition with a blended wage index for all providers. The wage index for each provider would consist of a blend of 50 percent of the FY 2015 wage index using the revised OMB delineations. We are studying the impact this proposal would have on the profession and will inform members about our findings.

CMS Releases Proposed Rule to Adopt 2012 Life Safety Code, NFPA 101, and Health Care Facilities Code, NFPA 99

As reported previously, CMS released a rule on April 16th concerning adoption of the 2012 Life Safety Code and the updated Health Care Facilities Code, NPFA 99.  In addition to that rule, CMS released S&C 14-21-NH (click here) to further announce that proposed rule.

Focused MDS and Dementia Care Surveys

 On April 18, 2014 CMS issued S&C 14-22-NH (click here) concerning more thorough examination of antipsychotic prescribing and other dementia care practices in nursing facilities.  There are also two focused survey processes under development: 1) a detailed review of dementia care in nursing centers, including reviewing resident-level and organizational-level processes; and 2) evaluation of MDS 3.0 coding practices and the MDS assessments and the associated care planning for residents.  CMS will identify the specific facilities to be surveyed for each type of focused survey.  CMS plans to pilot these surveys beginning in mid-2014.

Special Focus Facility Revisions

On April 18, 2014 CMS issued S&C 14-20-NH (click here) concerning adjustments to the Special Focus Facility program for nursing homes.  As you may recall additional enrollment into the SFF program was put on hold during the FY2013 sequestration, and due to that budget sequestration the program is being re-built with a reduced number of slots.  For Indiana, effective May 1 the required number of SFF slots is 3 (down from 5) and the size of the candidate list is 15 (down from 20).  Note that the previous direction from CMS on “last chance” surveys for SFF facilities on the list for more than 12 months is still in effect.  Additional information appears to be forthcoming from CMS concerning the development of pilot programs for future adjustments to the SFF program.

March 2014 IJ/SSQC Update

In March 2014 there were three events at two facilities leading to five IJs, all of which were also SSQC.  The first issue stemmed from allegations that the facility did not do enough to prevent residents verbal and physical aggression from a known aggressive resident.  Other residents expressed fear of the subject resident and nursing notes include a long history of verbal and physical aggression, and one noted that reporting the aggression to facility staff didn’t help anything.  Facility appeared to have a good record of interventions with the subject resident (morning meetings, active monitoring and redirection) and the resident’s behavior did improve when he was given an iPad as a redirection tool, however surveyors still took exception with the adequacy of interventions, lack of investigation, and failure to follow policy and procedure.  F223, F225 and F226 were cited for this event.

The next issue was the alleged failure by facility staff to indentify a resident as being “full code” at the time of death and initiate CPR.  LPN discovered the resident after a breathing treatment and stated he had already passed.  CPR was not attempted, and the facility did not have a policy on when not to perform CPR on a full code resident. IJ was lifted when house audit of all charts for code status was performed, CPR verification of all nurses completed, and in-services related to code status, CPR and EMT notification completed.  F309 was cited for this event.

The last issue was the alleged failure of facility staff to supervise a new CNA, working on orientation, to ensure she followed MD orders for a pureed diet. Resident received solid foods, resulting in choking and death.  The CNA was directed to get Jello for the resident, but also to get a different resident a peanut butter and jelly sandwich.  The food was mixed up, and the resident on the pureed diet received the sandwich and was left to eat it unattended.  CNA was also left unsupervised by her preceptor.

A summary of the 2014 IJ/SSQC citations and the March 2567s can be found here.