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Review of Skilled Services by OIG
The OIG recently released a report on skilled services provided at a facility in Oklahoma. Summary of findings from the report identify that from the 100 rehabilitation claims sampled, which included 165 RUGs, that 127 RUGs included medically unnecessary, inadequately documented, or improperly billed services. The medical reviewers recommended that:
· 39 RUGs be denied, 81 RUGs be downcoded, and 3 RUGs be partially denied and partially downcoded because services were not medically necessary at the intense level provided at an SNF or at the RUG level claimed.
· 1 RUG be downcoded and 1 RUG be denied because services were nto supported by adequate documentation; and
· 2 RUGs be downcoded because the facility did not properly bill for skilled services.
The recommendations also included that the facility:
- Refund to the Medicare program $791,530 in overpayment
- Work with CMS to resolve the potential overpayments set aside totaling approximately $90,567,
- Work with the FI to determine the amount of any overpayment made subsequent to the audit period.
The full report is available to the public at http://oig.hhs.gov
Reducing Pressure Ulcers
The Advancing Excellence campaign produced a Webinar on prevention and treatment of pressure ulcers; the PowerPoint® and audio are available at no charge. There are several Web sites that also have useful information: Medqic is a clearinghouse for the quality improvement organizations (QIO) best practices; the National Pressure Ulcer Advisory Panel; and the Agency for Health Research and Quality, which is responsible for establishing standards for pressure ulcer prevention and treatment.
Updates from the National Guideline Clearinghouse
· Pressure Ulcers in the Long Term Care Setting
Pressure Ulcers in the long-term care setting is a new guideline released by the National Guideline Clearinghouse by the American Medical Directors Association. This guideline updates a previous 1996 version. The objectives of the guideline are:
- To improve the quality of care delivered to patients in long-term care facilities
- To offer care providers and practitioners in long-term care facilities a systematic approach to recognizing, assessing, treating, and monitoring patients with pressure ulcers
To read the entire guideline or obtain a copy, go to:http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=12381
· Diabetes Management in the Long Term Care Setting
Diabetes management in the long-term care setting is a new guideline released by the National Guideline Clearinghouse by the American Medical Directors Association. This guideline updates a previous 2002 version. The objectives of the guideline are:
- To improve the quality of care delivered to patients with diabetes in long-term care settings
- To offer care providers and practitioners in long-term care facilities a systematic approach to recognizing, assessing, treating, and monitoring patients with type 2 diabetes mellitus
To read the entire guideline or obtain a copy, go to:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=12382
· Delirium and Acute Problematic Behavior in the Long-Term Care Setting
Delirium and acute problematic behavior in the long-term care setting is a new guideline released by the National Guideline Clearinghouse by the American Medical Directors Association. This guideline updates a previous 1998 version. The objectives of the guideline are:
· to improve the quality of care delivered to patients in long-term care facilities
- To offer care providers and practitioners in long-term care facilities a systematic approach to recognizing, assessing, treating, and monitoring patients with delirium and acute problematic behavior
To read the entire guideline or obtain a copy, go to:
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=12379&nbr=&string=
HIPAA Enforcement
A recent article by AHIMA identifies that CMS plans to complete HIPAA assessments as part of its enforcement responsibility. CMS has contracted with PriceWaterhouseCoopers to conduct the assessments. The selection of entities will be based on complaints filed against them. The results will be published and made available for us to use as learning tools on data security. This is not the same as the audits being completed by the OIG. The OIG selects entities to audit on it's own criteria. Even though CMS plans to start with those entities with complaints them, it's a strong reminder for us to revisit our HIPAA security practices and stay current. CMS offers tools such as security guidance documents and checklist to assist your organization to validate your compliance levels. Materials are available at www.cms.hhs.gov/securitystandard and www.cms.hhs.gov/Enforcement. Make it a part of your overall QA process.
"Try This" February 2008 Programs
To read or view the articles and videos featured this month, go to: www.NursingCenter.com/AJNolderadults and click the How to Try This link. CEs available for both the articles and the videos.
How to Try This: Preventing Aspiration in Older Adults with Dysphagia : American Journal of Nursing, Janice L. Palmer MS, RN and Norma A. Metheny PhD, RN, FAAN
Dysphagia, the impairment of any part of the swallowing process, increases the risk of aspiration. Dysphagia and aspiration are associated with the development of aspiration pneumonia. While some changes in swallowing may be a natural result of aging, dysphagia is especially prevalent among older adults with neurologic impairment or dementia, leading to an increased risk of aspiration and aspiration pneumonia. This article discusses best practices for assessment and prevention of aspiration among older adults who are being hand-fed or fed by tube.
If you still insufflate feeding tubes with air to check their placement, this program's one you can't skip! You might also be surprised to know how often intubated patients with feeding tubes are likely to have silent, micro-aspirations. To view this video featuring best practice in preventing aspiration, whether nutrients are taken orally, or via a feeding tube, go to http://links.lww.com/A226.
How to Try This: The Mini Nutritional Assessment: American Journal of Nursing; Rose Ann DiMaria-Ghalili PhD, RN, CNSN and Peggi A. Guenter PhD, RN, CNSN
Older adults are especially vulnerable to malnutrition, which often goes undetected and increases the risks of illness and death. The Joint Commission has required U.S. hospitals to provide nutrition screening to all patients within 24 hours of admission, but that doesn't cover patients in other settings, nor is there a standardized assessment tool for finding malnutrition in older adults. The Mini Nutritional Assessment is an effective, easily administered tool designed to identify older adults who have or are at risk for developing malnutrition. It consists of 18 questions and can be completed in about 15 minutes.
Six simple questions specifically developed to screen nutritional status in the older adult can open the door to far more comprehensive information and determine if a fuller assessment is warranted. How to administer the Mini-Nutritional Assessment is shown in this video, including a demonstration on how to measure mid-calf and upper arm circumference. Also included is a discussion among the interdisciplinary team which provides tips on enhancing the nutritional value of foods and outlines a wide range of community resources which can vastly improve the ability of older adults to meet nutritional needs. For a free online video demonstrating the use of this tool, go to http://links.lww.com/A221
Duragesic Recalled
On 2/12/08, patches containing the prescription pain medication fentanyl were voluntarily recalled because of a flaw that could cause patients or caregivers to overdose on the potent mediation inside. This product is sold in the U.S. under the brand name Duragesic by PriCara and generically by Sandoz, Inc. The recall includes all 25 microgram-per-hour patches with expiration dates on or before December 2009. Other strength patches are not effected. If you have this medication in your building, notify your pharmacy for further instructions.
Iowa Medicaid Enterprise Release New Informational Letters
The following informational letters have recently been released by IME. Please review as some of these may affect your organization.
#680 – Patient Management Tool for Home Health Providers
#682 - A Template is Now Available for the Waiver Claim Form – for all providers enrolled with Iowa Medicaid under the HCBS waiver program.
#684 – Provider Quality Management Process – Training information with dates and locations.
# 687 – Completion of Medicare Part A Paper Cross-Over Claims – clarifies the payment and submission process for nursing facility providers when filing Medicare Part A crossover claims in paper format.
To get these informational letters, go to http://www.ime.state.ia.us/Providers/Bulletins/Bulletins2008.html
Medicare Resources to Help you Succeed
The following products are now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network:
· The revised Medicare Physician Fee Schedule Fact Sheet (January 2008), which provides general information about the Medicare Physician Fee Schedule, can be accessed at http://www.cms.hhs.gov/MLNProducts/downloads/MedcrePhysFeeSchedfctsht.pdf .
· The revised Skilled Nursing Facility (SNF) Spell of Illness Quick Reference Chart (January 2008), which provides Medicare claims processing information related to SNF spells of illness, can be accessed at
http://www.cms.hhs.gov/MLNProducts/downloads/SNFSpellIllnesschrt.pdf
Person Directed Care Web Site
The Iowa Person Directed Care Coalition today announced release of new tools for Iowa nursing homes via a new website. The site, www.iowapersondirectedcare.org, provides information and resources for nursing homes that are interested in implementing a person directed care philosophy. "Our hope is that providers will use this site to find out more about person directed care and identify steps they can take to put the shared practices into use in their facilities," said Kathy Strang, co-chair.
In person directed care, individual choice directs lifestyle, care, systems and daily routine. Research has shown that person directed care improves the quality of care and quality of life for nursing home residents and the quality of work experience for staff.
In addition to tools and resources, nursing homes can read about the successes of other nursing homes that have implemented person directed care. "We encourage homes to share their own stories," said Kathy. "Learning from others is powerful. We hope this site will begin to open the lines of communication for nursing home providers and will begin to break down the barriers some providers may associate with implementing person directed care."
If you have any questions, contact Angie at 1-800-532-3213.
Process for Accepting Stories on the IPDCC Website
Process Intent: The process will facilitate screening and posting of provider success stories that have been submitted.
Cast of Characters: IFMC Operation Resource Team, IFMC Quality Improvement Advisor, IFMC Communication Specialist, DIA Webmaster, IPDCC membership
Process Steps
- The IPDCC allows providers to submit stories for posting on the website.
The IFMC OR Team member who receives the submissions from the e-mail address (nhqi@ifmc.org) will forward them to the IFMC QI Advisor.
- The QI Advisor will review the story for content and appropriateness to post on the website and forward it to the Communication Specialist. If additional detail or clarification is needed, the QI Advisor will contact the provider to gather the information prior to forwarding to the Communication Specialist.
- The Communication Specialist will edit the story and return it electronically to the QI Advisor.
- The QI Advisor will take the story to the IPDCC membership for review.
- Accepted stories will be forwarded by the QI Advisor to the DIA Webmaster for posting to the website.
- The QI Advisor will contact the provider if a story is rejected and ask the provider to resubmit an edited version.
The Advancing Excellence in America's Nursing Homes national campaign continues to gain momentum. Currently, 48.6% or 221 of Iowa's nursing homes have signed on to the campaign. These homes have made a commitment to improve the quality of care and quality of life for their residents. As a participant, nursing homes have a number of tools and resources available to them by accessing the campaign's website, www.nhqualitycampaign.org.
To provide technical assistance to participants, the national campaign is hosting a series of free teleconferences to help nursing homes improve in their quality efforts. Each call is designed to educate nursing homes on the process frameworks, which is a systematic approach to improve in both clinical and organizational goals. By implementing this process, nursing homes can improve efficiency and gain an understanding of the key principles of improving quality.
The next teleconference, Treatment of Pressure Ulcers in the Nursing Home will be held Thursday, February 21, at 1:00 p.m. Nursing homes can register for the call by going to
http://www.directeventreg.com/registration/event/31896650 by February 15 or by calling (888) 869-1189. The event number for this call is 31896650. You will be given call in instructions and a unique pass code that will allow you to participate. Handouts for the teleconference will be posted on www.nhqualitycampaign.org by February 19, 2008.
To register go to www.nhqualitycampaign.org and begin your journey to quality.
IME Informational Letters
The following is a list of informational letters from Iowa Medicaid Enterprise. Use the following links to access the information.
Informational Letter No. 666: Changes in the HCBS Specialist Regional Coverage
Informational Letter No. 671: Correct format for Completing Claim for Targeted Medical Care form (HCBS & CDAC providers)
Informational Letter No. 672: Voluntary Submission of Employee Turnover Data (Form)
Informational Letter No. 673: Medicaid Provider Enrollment Renewal Deadline
Informational Letter No. 680: Iowa Medicaid Electronic Record System (I-MERS)
Use of Interpretive Guidance by Surveyors for Long Term Care Facilities
CMS has been asked to clarify the use of the Interpretive Guidance to Surveyors for Long Term Care Facilities in reviewing for compliance with the regulatory requirements for nursing homes. Surveyors must cite all deficiencies based on a violation of statutory and/or regulatory requirements.
In a CMS memo (S&C – 08-10) dated 1/18/08, it identifies that providing updated interpretive guidance to nursing home surveyors is one method used by CMS to improve the survey process. In providing new interpretive guidance, CMS is careful not to prescribe new requirements. There are portions of the interpretive guidelines that specify such things as permissive duties or tools that facilities may be using to care for residents. Permissive duties are not requirements, and lack of use of any particular tool does not, by itself, constitute sufficient grounds for the citation of a deficiency. To read the full memo, use the following link:
http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter08-10.pdf
MDS 3.0 Summary of Open Door Forum
Attached is a brief summary of the MDS 3.0 Special Open Door Forum: a short background to the 3.0 development and implementation, a summary of nurses' feedback on using the 3.0, an overview of the primary advances of the 3.0, and a list of the improved/revised MDS sections and items. Overall, the MDS 3.0 represents many significant and positive improvements on the 2.0.
A recording will be available for 30 days beginning on January 30 at the website: http://www.cms.hhs.gov/OpenDoorForums/05_ODF_SpecialODF.asp#TopOfPage
The PowerPoint used during the presentation is available at: http://www.cms.hhs.gov/OpenDoorForums/Downloads/MDS30PowerPoint012408.pdf
You may send comments and questions on the MDS 3.0 to mds30comments@cms.hhs.gov
Preventive Services for Adults
The National GuidelineClearinghouse www.guideline.gov has recently released an updated guideline for Preventive Services for Adults. Even though this guideline addresses younger adults it also has a very good grid for those adults over the age of 65. For the complete recommendations go to the following website:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=11699
Resident Satisfaction Surveys:
Letters have gone out to facilities that have asked or we have historically completed the Resident Satisfaction Survey compilation. This letter includes a form that each facility will need to copy and determine as its best approach for completion. The survey's must be returned for compilation no later than March 31, 2008.
Administrator License Renewal:
Most of you should have recently recieved a card from the Bureau of Professional Licensure. This card has the instructions for the renewal of our administrator licenses. As you know we are required to have 40 hours every two years. The time table is suppose to be through the end of December, however upon reading the instructions for completion, our renewal must be completed 30 days prior to the expiration of our license.
To be sure everyone recieves the renewal information I will retype the card instructions;
Offical Notice Of License Renewal
Renew Your License Online
Online Renewal Is Fast, Safe and Easy.
Follow the instructions at the secure web site:
Your License number and Visa or Mastercharge credit or debit card are required.
Paper renewal applications will not be mailed.
You may download a paper renewal application
at the Professional Licensure web site;
Iowa Department of Public Health
Bureau of Professional Licensure
(515 281-0254
Submit your renewal 30 days prior to expiration of your current licensure.
Continuing education is subject to random audit.
Failure to respond may result in loss of license
A recent CMS transmittal 73 clarifies the need for a new therapy evaluation upon admission to your SNF.
Implementation Date: October 1, 2007
I. GENERAL INFORMATION
A. Background: Section 1861(h) of the Social Security Act defines certain services covered under the Extended Care Benefit to include physical or occupational therapy or speech-language pathology services furnished by the skilled nursing facility or by others under arrangements with them made by the facility. To be covered, the care provided to the beneficiary in the SNF must meet the requirements set forth in 42 C.F.R. 409 Subpart D. In the SNF PPS final rule for FY 2000, (FR 41662, July 30, 1999) CMS clearly stated that the initial evaluation, performed by the licensed therapist and necessary for the development of the plan of treatment, must be performed during the beneficiary's SNF stay. It is not acceptable to use an evaluation that was performed for instance, in the acute care hospital or the rehabilitation hospital setting as the evaluation of the beneficiary in the SNF, because the beneficiary's status must be evaluated as he or she presents in the SNF setting.
B. Policy: Therapy evaluations of a beneficiary who is admitted for care in a SNF must take place in the SNF. Coverage of initial evaluations and reevaluations is set forth at 42 C.F.R. 409.33(c)(1). The cost of an initial therapy evaluation in the SNF is included in the SNF PPS payment made for covered SNF services.
July 1, 2007 Rebasing and Provider Rates
DHS and IME recently have explained that the rebasing and provider rate calculations to stay within the FY 2008 budget. The full SNF market basket was 3.38 percent and, to stay within the budget amount of $184,117,323, the market basket will be reduced by .8 percent (.008).
DHS will complete public notice requirements in the next 10 days to preserve the July 1 effective date. IME will submit State Plan Amendments to CMS in early July. CMS must respond within 90 days. Provider rate letters and payment adjustments will not occur until CMS approval is obtained. Estimates indicate that July–September rates changes will be paid by the end of October as July 1 rate letters should be released to providers the first week in October.
This outcome is more favorable than anticipated. Average rates will move from $112.80 to approximately $120.77 (per IME estimates). All of the accountability measures will also be reset and each percent is estimated to be approximately $1.22 per day. Most providers should experience and 6-8 percent increase in their Medicaid rate. Some providers could see substantially more, however, approximately 15 percent of the facilities will have a rate reduction as a result of the rebasing. IME provided ESTIMATED medians and cautioned these could change slightly as not all of the cost report desk reviews and audits are completed. The direct care median is estimated at $54.37 (4.9 percent increase) and the non-direct care median is estimated at $67.98 (6.1 percent increase).
Department of Inspections
We have been tracking surveys throughout Iowa over that past few months and have been concern in regard to the trends that have been identified. Of greatest concern is the increase in fining activity through out Iowa. We have seen trends that would indicate that fining activity has quadrupled. We feel this activity is related to two primary reasons. One: CMS recent sent a directive to all states in regard to their attempt to make fine actions consistent through out the nation. As a result we believe that Iowa has used this as a vehicle to implement specific changes in the states approach. Two: The department has new leadership since the new administration and as a result the new director is making changes and the department has experienced a 60% turnover in surveyors which obviously resulted in inconsistent surveyor approach and interpretations.
The other serious trend being tracked is the delay in the facilities receipt of the 2567 (survey report). Code calls for the states to provide the facility their 2567 within 10 days of the conclusion of the survey. Many facilities are not receiving their 2567 until 4 to as much as 8 weeks after their surveys conclusion. In some of these examples surveys were unaware of associated CMP (Civil Money Penalties) fines. These daily fines start the last of the survey process. So in cases where facilities receive a fine, they may be unaware that a daily fine was implemented and for 4-8 weeks this fine was accumulating.
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