Indiana Medicaid and Division of Aging Kick-off 2015 Nursing Facility Survey Project

Through a series of webinars held the week of March 23rd, Indiana Medicaid and the Division of Aging announced the steps being taken to resume surveys of nursing facility residents, resident family/friend, and staff.  The effort is led by Press Ganey, a contractor to the State.  Press Ganey in turn hires GoResource and Knowledge Services to perform the in-person resident interview and interface with nursing facilities to complete data uploads for the resident family/friend and staff surveys.  Results from the prior 2 years of surveys, plus this coming year’s data, will be considered by the Division’s Clinical Expert Panel (CEP) as that group considers recommendations to alter the nursing facility quality add-on that is part of the Medicaid rate.  Any such alterations to the add-on methodology would not take effect until July 1, 2016, at the earliest.

The survey process has already begun as facility administrators should have already received a certified letter from the Family and Social Services Administration that explains the 2015 project timeline and provides certain contact information.  If you have not received this letter, please contact
Paul Huelskamp, Press Ganey, at PHuelskamp@pressganey.com.  To view the PPT used in the webinars, click here.

If you have questions or concerns, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Residential Care Citation Update

The ISDH issued 2 Offense tags and 19 Deficiency tags to Residential Care Facilities in the month of February.  Five citations were issued Tag 273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation and food handling standards.  Tag 247, concerning charting of medication errors and physician notification of such errors when there is potential or actual harm, was cited 2 times in February.  The tag was also cited 7 of the past 8 months, which is an interesting trend as the tag has not normally been cited that frequently (8 times in 2014, 3 times in 2013).   

To review the February Residential Care Facility citations, click here.

ISDH IJ/SSQC Update

After issuing no IJ or SSQC citations in January, the ISDH issued one IJ citation in February.  The citation in February was no SSQC.  The citation, F155, was issued due to the failure of the facility to have a system in place to determine code status and failed to perform CPR on a resident who was full code.  The facility also failed to ensure advance directive/code status was clearly documented for 4 of 23 residents reviewed of the total census of 99 residents.  The first issue in the above citation stemmed around confusion between social services and nursing staff about the code status of the patient and the involvement of a guardian that had been appointed upon admission.  Admitting orders indicated that the resident was full code, the CPR consent form indicated no code.  The CPR consent was not dated and it may have been signed by the resident, even though not competent, and it was not also signed by the guardian.  The other 4 residents for which documentation issues concerning code status were identified, problems with documentation ranged from the lack of advance directives with physician orders stating that code had not been established, to unsigned and undated DNR forms, to conflicting DNR forms and physician orders for full code.

February’s citation of F155 marks the 3rd month out of the past 4 months in which a citation has been issued related to errors with determining code status and/or performing CPR on a resident that was or should have been full code.  In November and December 2014, F309 was cited in each month for the failure to obtain code status for a resident then the downstream failure to perform CPR on that resident for which code status was unknown (policy requires CPR to be administered when code status is unknown/not determined).

To review the February 2567 and a summary of the 2015 IJ/SSQCs, click here.

ISDH Planning to Require Online Submission of Incidents

In May of 2014 the ISDH rolled out the online Incident Reporting System and it has been used on a voluntary basis by nursing facilities since it was released.  The May 2014 ISDH Newsletter discusses the system, which is part of the Survey Report System facilities currently use.  Initial kinks in the system concerning log-ins, the website timing out, and accessing previously saved incidents that have not been submitted have been worked out .

The ISDH wants to make the online Incident Report System mandatory this year, likely in the May or June.  Before it does this, however, the ISDH is asking for additional feedback on any problems with the system or suggestions on how to improve it.   Please email any issues or suggestions you may have to Zach Cattell at zcattell@ihca.org or call 317-616-9001.

CMS Approves Indiana Medicaid State Plan Amendment Extending the QAF

OMPP notified IHCA on February 4th this afternoon that CMS approved the State Plan Amendment (SPA) to extend the effective date of the QAF to July 1, 2017.  You can access approval packet from CMS by clicking here.  The SPA changes various dates within rate setting formula to the July 1, 2017 date, and make some non-material formatting changes.  Also, the approved SPA implements a 10% rate penalty for untimely filing of the Checklist Management Representations as part of the Change of Ownership process, adds to the direct care definition reimbursement for PRN skin protectants, and adds the end date for the current 3% rate cut of June 30, 2015 (this end date was omitted in a prior filing with CMS).

Indiana Medicaid 5-8 Year Long Term Care Plan

Following up on the February 3rd meeting with OMPP, IHCA met with OMPP and Division of Aging to further discuss the four work groups that are being established to being the detail work on formation of the plan.  The agencies will utilize existing work that has already begun within OMPP and the Division of Aging concerning changes to the Pre-Admissions Screening process (for the Entry Point workgroup), and reach out to the agencies that oversee development of affordable housing (for the Supportive Housing workgroup).  The Assisted Living and Reimbursement work groups will essentially start from scratch, although both of those topics have been part of ongoing meetings that IHCA has with OMPP and the Division of Aging on a monthly basis.  No specific timelines have been set as of yet as we await further direction from the State.

If you have any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001

RUGs IV Transition for Medicaid Reimbursement

The Indiana Office of Medicaid Policy and Planning (OMPP) accepted the proposal made by IHCA, HOPE, and LeadingAge Indiana concerning a transition to RUVs IV.  Effective July 1, 2016 Indiana Medicaid nursing facility rates will be calculated using the 48 grouper under RUGs IV.  OMPP had been pressing for use of the 66 grouper.  The 48 grouper that will be used will spend approximately $6.9M more than the current RUGs III 34 grouper.  In order to cover that cost unspent dollars from the Quality Assessment Fee will be used.  Approximately $5.8M dollars, which becomes $17.2M once leveraged with federal match, are unspent QAF.

OMPP has accepted this proposal with one caveat.  The use of the 48 grouper will be for at least 1 year, and potentially more.  OMPP will not commit to using the 48 grouper beyond 1 year (July 1, 2016 to June 30, 2017) until additional discussions and progress is made on the 5-8 year long term care plan occurs.  That plan, reported on last month, is focused on rebalancing OMPP’s long term supports and services spend from institutional care to home and community based services.

Additional details from OMPP concerning the RUGs IV 48 grouper transition are expected in the coming weeks and IHCA will report those to members as they become available.

If you have any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001

Five Star Quality Rating System Changes

On February 12, CMS announced changes to the Five-Star Quality Rating System that will impact how CMS assigns stars for both the Staffing and Quality Measure components, which may impact a skilled nursing center's Overall rating.  These changes were made public and are posted on February 20, 2015. CMS also will add two new measures to the Quality Measure component: the short-stay antipsychotic measure and the long-stay antipsychotic measure that CMS has been using on Nursing Home Compare for the past several years.  Following is a summary of the changes to the Five-Star components:

Overall Five-Star rating
No changes to methodology but changes to Staffing and Quality Measure (QM) components will impact your overall rating

Survey component
No changes

Staffing component
Changed how 3- and 4-Star ratings are determined on Staffing component.

Quality Measure component
Added two new Quality Measures to the current nine QMs:
 - Short-Stay use of antipsychotics
 - Long-Stay use of antipsychotics

Rescaled the Cut Points
For each star level on the Quality Measure component, the cut points were moved. CMS did not provide the new cut points on the call but will release this information in the new technical user's manual.  This will result in many members losing one or two stars on the Quality Measure component. Since the QM component contributes to the Overall rating, a sizable number of centers may also lose a star on their Overall rating.

• Resources

AHCA has been working to put together a number of resources on these changes for its members and state associations.  AHCA has a dedicated website for this information at www.ahcancal.org/FiveStar.  IHCA has taken this information and placed it in our member’s only website as well.  Click here to access that information.  For either the AHCA or IHCA websites, you will need a member ID and login.  The resources are:

• A PowerPoint explaining the Five Star Changes
• Instructions on How to access Five Star Preview Reports
• Sample Letter to Payers Regarding Five Star Changes
• Templates for Communications to Families and Media, as well as general talking points
• Overview of Five Star revisions for the Nation and Indiana
• An Excel spreadsheet of all Indiana NFs with estimated impacts, comparing January 2015 under the old system with February 2015 under the new system.

IHCA and AHCA will continue to monitor and analyze the changes to the Five Star system and keep you updated.

Residential Care Facility Citation Update

There were 3 Offense citations and 15 Deficiency citations issued to Residential Care facilities in January 2015.  Bucking a trend that had been prominent in 2014 and in years past Tag 273, concerning maintenance of food preparation areas in accordance with state and local standards, was only cited twice.  In 2014, Tag 273 was cited an average of 5.75 times per month.  The leading tag for January 2015 was Tag 217, which was cited 4 times.  Tag 217 requires use appropriately trained staff to complete an evaluation that identified and documented the scope, frequently, need, and resident’s preference for the services to be provided by the facility, and have the resident sign and date the plan.  At the time of this writing of this writing only 1 of the 4 surveys was publicly available.  The survey that was available indicated the tag was issued due to service plans not having been signed by the resident or their legal representative.  The residents reviewed had been recently admitted and a signed service plan had not yet been signed.

To review a summary of the other tags from January 2015, click here.