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904-923-7229

Kerry.Dunning@kerrydunningllc.com

Rural Swing Bed Management Program

Best Practices

October 2018

Kerry Dunning has no proprietary interest in any product, instrument, device, service, or material discussed during this learning event.

1. Review of most important October 1st changes2. Outline key tips for MDS coding accuracy3. List changes to the Interdisciplinary Team (IDT)4. Define current audit risks5. Review Medicare intent for swing bed programs6. Outline key tips for training on appropriate swing bed

admissions7. List best practices for self-audit data tracking8. Outline action plans for fourth quarter program goals

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MDS 1.16.0 on October 1 jRAVEN does NOT automatically download – IT must

update Quality Reporting Program (QRP) Therapy eval must be done timely Nursing capture of function (ADLs) must be accurate IDT must meet for each patient State Operations Manual drops Section T (PPS SWB)

and includes it under Section A (Hospitals◦ Major changes made for PPS SWB and CAH SWB SOM

sections

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New MDS on October 1 . . . . and then an Errata document, dated October 1, was released

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In Chapter 3, page J-36, Example 1, in J2000: Prior Surgery, the rationale has been updated to remove the reference to general anesthesia

Rationale: Mrs. T’s skin tag removal surgery did not require an acute care inpatient stay, and general anesthesia was not administered; therefore, the skin tag removal does not meet all three the required criteria to be coded as major surgery. Mrs. T did not have any other surgeries in the last 100 days.

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Significant differences from SNF Assessment◦ A – No PASRR questions◦ F – No Preferences for Customary Routine and Activities◦ I – Active Diagnoses removed

Cancer A-Fib CAD DVT Cirrhosis GERD Ulcerative Colitis BPH ESRD Viral Hepatitis Thyroid Disorder Arthritis Osteoporosis Alzheimer’s Aphasia Cataracts Glaucoma Macular Degeneration

◦ K – Swallowing Disorder◦ L – No Oral/Dental Status◦ N – No Antipsychotic Medication Review◦ O – Special Treatments/Programs removed:

BiPAP/CPAP Respite Care RT Psychological Therapy Recreational Therapy

◦ P – Alarms◦ V – No CAAs◦ Z – No State Medicaid Billing or Alternative State Medicaid Billing

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NQF = National Quality Forum

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A – new card C – Cognitive Patterns (Not for SWB – CAAs) GG – Functional Abilities and Goals I – Active Diagnoses J – Health Conditions M – Skin Conditions N – Medications O – Special Treatments,

Procedures, and Programs

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THIS IS PAC – LTACH, IRF, SNF AND HH GETTING GRADED ON SAME STANDARDS LOOKING FOR BEST OUTCOMES AT LEAST AMOUNT OF $

This is changing the “skilled” way of showing improvement = functional gain

This is expected to replace ADLs in 2018 For now . . . .this takes Nursing and Therapy teamwork! Not collecting enough data may negatively impact your

annual percentage update by as much as 2% of your reimbursement.

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Patient’s ability to function prior to admission must be captured within 3 days AND it must represent the ability of the patient WHEN THEY CAME TO YOUR PROGRAM – not after therapy has worked with them, etc.

What will you do with Friday afternoon admissions? Saturday admissions?

Look carefully at some of the 46 new categories

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Expanded codes to be used when an activity is not attempted Not applicable Not attempted due to environmental limitations Not attempted due to medical condition or safety concern

RAI Manual revisions include More clarifications

More coding tips More coding examples

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GG0100 Prior Functioning: Everyday Activities: Indicate the patient’s usual ability with everyday activities prior to the current illness, exacerbation, or injury

GG0100A Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury.

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3. Independent—Resident completed the activities by him/herself, with or without an assistive device, with no assistance from a helper. 2. Needed Some Help—Resident needed partial assistance from another person to complete activities. 1. Dependent—A helper completed the activities for the resident. 8. Unknown. 9. Not Applicable.

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GG0100C. Stairs: Code the resident's need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.

GG0100D. Functional Cognition: Code the resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.

GG0130H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners, if applicable.

GG0170G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt.

GG0170M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.

GG0170O. 12 steps: The ability to go up and down 12 steps with or without a rail.

GG0170P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor.

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Nursing captures section GG information on days 1–3 of the resident’s stay

Therapy captures section GG information on evaluation Therapy/nursing collaboration should occur on about

day 3–4 of the resident’s stay, to discuss section GG items and determine the level to be coded on the Admission assessment

Be careful with “all” Nursing or Therapy . . . This MDS still based on 24 hour function and most need

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Nursing captures section GG information on the last 3 days before the resident’s planned discharge

Therapy captures section GG information when gathering data for the discharge summary

Prior to completing section GG, therapy and nursing collaborate and determine the level to be coded on the MDS

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Two new items: I0020 and I0020A (Indicate the Resident's Primary Medical Condition Category)

The primary medical condition coded in I0020 MUST ALSO BE CODED in I0100-I1800 (active diagnoses in the last 7 days

I0020 asks assessors to choose from a list of 13 codes to identify the resident’s primary medical condition category at the time of admission on the 5-day PPS MDS

If none of the 13 codes apply, assessors will code the 14th code and enter the relevant ICD-10-CM code in I0020A

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J2000 (asks whether the resident has had major surgery in the 100 days prior to the admission

CMS says most major surgeries will meet all three of the following criteria:◦ The resident was an inpatient in an acute-care hospital for at least

one day in the 100 days prior to admission to the SNF◦ The resident had general anesthesia during the procedure◦ The surgery carried some degree of risk to the resident’s life or the

potential for severe disability.

J2000 is a risk adjustor for 4 new self-care and mobility functional outcomes under QRP; however J2000 will not be an item impacting the 80% data submission threshold

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First Warning from CMS: accurately identify the primary etiology of the ulcer/injury

This is critical to BOTH medical necessity documentation and what is written in the plan of care◦ Still collect the information on skin documentation and care plans –

it is part of your medical necessity documentation to describe the wound characteristics

CMS added a new term: Microclimate (found in 2 areas)◦ Microclimate will now be included as an example in the definition

for pressure ulcer/injury risk factors. ◦ Microclimate also will be included in the list of external risk factors

in the item rationale for M0100 (determination of pressure ulcer/injury risk)

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NPUAP has used the term since 2016 but in an effort to standardize wound care definitions, CMS has continued a process to make sure evaluating and treating wounds use the NPUAP standards

What does it mean?◦ Perspiration◦ Drainage◦ Incontinence

Moisture increases friction and shear◦ Increased tissue deformation◦ Maceration

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GOAL: Address all issues leading to breakdown and determine/care plan options to control moisture and temperature

Skin Temperature◦ Alteration in superficial blood flow◦ Changes in positioning◦ Contact with skin (sleep positions)

Blood flow ◦ Blood flow differs from person to person◦ Over bony prominences . . .

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Determine “present on admission” accurately◦ Unstageable?◦ Return of patient/resident to SWB/SNF – what is different?◦ Address skin tears

CMS clarified MASD (Moisture-Associated Skin Damage stating it is “superficial skin damage – partial-thickness skin loss – and cannot be covered with slough or eschar.”

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“Injury” or “injuries” has been added to better reflect the most recent guidelines from the National Pressure Ulcer Advisory Panel (NPUAP)”

Section M items retired on 10/1:◦ M0300B3 (date of oldest Stage 2 pressure ulcer)◦ M0610A – M0610C (dimensions of unhealed stage 3 or 4 pressure

ulcers or eschar)◦ M0700 (most severe tissue type for any pressure ulcer)◦ M0800A – M0800F (worsening in pressure ulcer status since prior

assessment OBRA or scheduled PPS)◦ M0900A – M0900D (healed pressure ulcers)

Although removed from the MDS, the information must still be collected on the skin grids and/or care plans and your documentation describes the characteristics of wounds

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The new items are for Medicare A only and go to calculation of the new SNF QRP – a pharmacist is not required to complete the DRR for Section N

The drug regimen review (DRR) coded in Section N is completely separate from the regulatory requirement that all nursing homes have a pharmacist conduct a monthly review of each resident’s medications as detailed in F757 (Drug Regimen Review) in Appendix PP of the State Operations Manual.

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The new DRR “intent” is to show whether the provider conducted a DRR◦ At admission (start of a Part A stay)◦ Throughout the stay to discharge AND ◦ There was significant discussion about med issues with the physician◦ There must be a reported response from the physician (in person,

phone, voice mail, fax, etc.) and it must show ACTION to the reported issue by midnight of the next calendar day – at the latest

DON’T FORGET: DRR includes prescribed, over the counter (including nutritional supplements, vitamins, and homeopathic/herbal products and TOTAL PARENTERAL NUTRITION (TPN) and OXYGEN

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CMS made a number of regulatory adjustments and/or additions. All of them impact your IDT:

◦ Person-Centered Care Planning (§483.21)◦ Baseline and comprehensive care plans depend on a strong

IDT interaction◦ Transitions of Care

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Beyond the regs . . . ◦ Every patient should have an IDT – combined with care plan?◦ Every program should have a brief morning meeting◦ IDT should include preparation List of outstanding signatures for MDS assessments Nursing notes Discharge planning Social services/Family concerns Billing and Coding Medical Record audits – Physician Cert, Practical Matter,

Physician signature on Therapy POC, Medical Necessity Documentation

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Reason for CMS involvement:◦ Medicare beneficiaries rose to almost 58 million at the end

of 2017◦ Increasing numbers of beneficiaries are living with multiple

chronic conditions (diabetes, dementia, COPD)◦ US will have a shortage of healthcare workers

Triple Aim◦ Improving the patient experience of care (including

QUALITY and SATISFACTION)◦ Improving the health of populations; and◦ Reducing the per capita cost of health care.

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Gets down to basics which is

Task Completion = Independence Things like . . . ◦ Access the health care services they need◦ Aware of risks and benefits of their care ◦ Calculate dosages for medication◦ Communicate with health care providers◦ Understand the implication of their test results

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Admissions Assessment◦ Poor or low health literacy◦ Fall risk◦ Active Diagnoses◦ Poor medication management

Practical Matter◦ Unsafe environment◦ Poor support system◦ Lack of resources

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Involve the patient / caregiver in decision making process as appropriate

Use language the patient / caregiver understands including using pictures, stories, literature and videos

Use the teach back method for patient AND caregiver Present information in chunks during a visit or by building

upon their knowledge each day of the stay Use handouts or post information in strategic areas in their

room AND provide things they should post in their home of the home Continually re-assess how much and how well the

information was retained

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Who was educated or trained What was covered Purpose of the education/

training How did they respond

(understanding, retention, demonstration ability, etc.)

Questions they asked Special needs Method used to educate/train Follow-up instructions given

Is the patient / caregiver retaining information from one visit to the next

Patient’s/caregiver’s level of interest/willingness

Are they meeting their personal/ clinical goals included in the POC (outcome)

Communication with in IDT Always include any skilled

services that were given

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This is the beginning of 2 years of distinct changes CMS released the revised v1.16 of the Long-Term Care Facility

Resident Assessment Instrument 3.0 User’s Manual The SNF QRP Measure Calculations and Reporting User’s

Manual will soon be updated to include the new/modified and revised assessment-based SNF QRP QMs that implement on Oct. 1

CMS is discontinuing public reporting of Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) and replacing it with Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury by October 2020

The only new MDS-based SNF QRP QM without a clear start date for public reporting is Drug Regimen Review Conducted With Follow-Up for Identified Issues – Post-Acute Care SNF QRP

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Description◦ Reasonable and Necessary Requirements and Coding Requirements:

Documentation will be reviewed to determine if SNF Stay meets Medicare coverage criteria.

Applicable Policy References◦ 42 Code of Federal Regulations, 409.30-409.36◦ 42 Code of Federal Regulations, 424.20◦ 42 Code of Federal Regulations, 483.20◦ CMS Pub. 100-01, Medicare General Information, Eligibility and

Entitlement Manual, Chapter 4, 40.4-40.5◦ CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.1,

and 6.3◦ CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 8, 20-40◦ CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 220.1.3

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Description◦ If inpatient care is being billed by the hospital as inpatient

hospital care, then hospital care codes apply. If inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply.

Affected Codes◦ 99221-99223, 99231-99233 and 99238-99239

Applicable Policy References◦ Social Security Act, Section 1833 (e)◦ CMS Pub. 100-04, Medicare Claims Processing

Manual, Chapter 12, 30.6.9

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Description◦ The Nursing Facility Service codes represent a “per day” service. As

such, these codes may only be reported once per day, per beneficiary, provider and date of service.

Affected Code(s)◦ CPT Codes 99304, 99305, 99306, 99307, 99308, 99309, 99310

Applicable Policy References◦ Title XVIII of the Social Security Act, Section 1833(e)◦ Title XVIII of the Social Security Act, Section 1862(a) (1) (A)◦ CMS Pub. 100-04 Medicare Claims Processing Manual, Chapter 12,

Section 30.6.13(B)◦ American Medical Association (AMA), Current Procedure

Terminology 2014 to current

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Description◦ Payment for the majority of Skilled Nursing Facility (SNF) services

provided to beneficiaries in a Medicare covered Part A SNF stay are included in a bundled prospective payment. Entities that provide these services should look to the SNF for payment. Under the consolidated billing requirement, the SNF must submit all Medicare claims for the entire package of care that residents receive during a covered Part A SNF stay.

Affected Code(s)◦ CPT/HCPCS codes listed in the SNF Consolidated Billing Table, Major

Category I.F and V.A. Applicable Policy References◦ CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 23,

Section 30◦ Physician Fee Schedule, Addendum - MPFSDB Record Layouts

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NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for a specific medical service procedure or device

NCDs generally outline the conditions for which a service is considered to be covered (or not covered) and usually issued as a program instruction◦ In rare instances, if there is contradicting information in the NCD

and LCD, the NCD overrides the LCD

Providers may also access the various CMS CRs and associated documents issued as part of the ICD-10 conversion activities related to NCDs from the CMS ICD-10

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The CMS revision to NH regs are the first since 1991. They are aimed at aligning requirements with current clinical practice standards to improve resident safety along with quality and effectiveness of care and services delivered to residents

New Section: Facility responsibilities (§483.11)◦ Focuses on facility responsibilities (protecting the residents’ rights,

enhancing quality of life). This section parallels many residents’ rights provisions. Visitation: Would establish open visitation, similar to the hospital conditions

of participation (CoPs). Abuse/Neglect/Exploitation (§483.12): Would revise “Resident behavior and

facility practices,” to “Freedom from abuse, neglect, and exploitation”; and Prohibit employment of individuals with disciplinary actions against their

professional license by a state licensure body following a finding of abuse, neglect, mistreatment, or misappropriation of property.

Require implementation of written policies and procedures that prohibit and prevent abuse, neglect, mistreatment and/or misappropriation of property.

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Transitions of Care (§483.15): Revises “admission, transfer and discharge rights,” to apply to all transfers of resident care. ◦ Transfers / Discharge: Would require specific information/data elements, e.g.,

demographic; history of present illness including, e.g., active diagnoses, functional status, medications; reason for transfer and past medical/surgical history, be exchanged with the receiving provider. CMS is not proposing a specific form, format, or methodology

New Section: Comprehensive Person-Centered Care Planning (§483.21) – Would require development of a baseline care plan for each resident within 48 hours of admission, including instructions needed to provide effective and person-centered care meeting professional standards◦ Interdisciplinary Team (IDT): Would add a nurse aide, food and nutrition

services, and a social worker to the IDT that develops the comprehensive care plan

◦ Would require written explanation in the medical record if participation of the resident and their resident representative is determined not practicable

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Quality of Care and Quality of Life (§483.25) [retitled] –Would clarify that quality of care and quality of life are overarching principles in all care and services. ◦ Would clarify the requirements regarding a resident’s ability to

perform ADLs◦ Would modify requirements for nasogastric tubes to reflect current

clinical practice, and include enteral fluids in requirements for assisted nutrition and hydration.

◦ Would add a new requirement that facilities ensure pain management needs are met

◦ Would move current provisions for unnecessary drugs, antipsychotics, medication errors, and influenza and pneumococcal immunizations to Pharmacy services

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Pharmacy services (§483.45); Drug Regimen Review◦ Would require pharmacist review of a resident’s medical chart

when the resident is new to the facility, a resident returns or is transferred from a hospital or other facility

New Section: Laboratory, radiology, and other diagnostic services (§483.50) ◦ Would clarify that a PA, NP, or CNS may order laboratory,

radiology, and other diagnostic services in accordance with state and scope of practice laws.◦ Would clarify that the ordering practitioner be notified of

abnormal laboratory results when they fall outside of clinical reference ranges, in accordance with facility notification policies and procedures

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New Section: Quality assurance and performance improvement (QAPI) (§483.75) ◦ Would require all LTC facilities to develop, implement, and maintain

an effective comprehensive, ongoing, data-driven QAPI programs that focus on systems of care, outcomes of care and quality of life

◦ QAA Committee requirements would be maintained with amendment

New Section: Compliance and ethics program (§483.85) ◦ Would require the operating organization for each facility to have in

operation a compliance and ethics program with established written compliance and ethics standards, policies and procedures capable of reducing the prospect of criminal, civil, and administrative violations in accordance with section 1128I(b) of the Act

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CoPs SOM Appendices (A or W + PP) Short Stay Medically Complex + Therapy Must be medically necessary NOT “insufficiently

explanatory”◦ Need for IP rather than OP Therapy or Home Health◦ Must need daily services from skilled nursing or rehabilitation

Medicare “paperwork”: Admissions Criteria, Physician Cert, Practical Matter, MSP, Therapy POC, Liability Notices, P&P

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Basics◦ Must document change in status from acute to SWB in the medical

record◦ Must have discharge orders from acute, appropriate progress notes, a

discharge summary◦ Must be able to meet ALL patient needs (staff competency, services)

when admitted to SWB◦ Must meet admissions criteria for your SWB◦ Must have admission orders, H&P, therapy orders, diagnoses list◦ Need a person-centered care plan within 48 hours (final by 14 days

or discharge) which is reviewed with the patient/patient representative

◦ Must have an expectation of improvement◦ Must have a discharge plan in place

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Source for CMS information, helpful websites, etc.

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Swing Bed patients are not SNF patients, nor are they hospital acute patients. Swing Bed patients in CAHs or PPS settings are considered patients of the rural hospital.

Many of the regulations that govern these patients are found in the Medicare long‐term care regulations

Use SOM Appendix W (CAH) or Appendix A (PPS) – and these have changed substantially for this year

CoPs are different for CAH and PPS The Medicare Swing Bed benefit includes 100 days of skilled

nursing care per benefit period. Skilled Nursing Care may be provided in a Swing Bed hospital or a long‐term care facility offering skilled nursing services. The first 20 days are covered in full. Coinsurance is required for days 21–100.

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Designed for short stay not long term care needs

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In order to charge Medicare for a Swing Bed patient, the following criteria must be met:

The patient has to be a Medicare Part A enrollee and have benefit days available;

There must be a three‐day qualifying stay; Medicare age or disability/disease eligibility requirements

must be met; Patient’s Swing Bed admission condition is the same as the

qualifying stay condition; Patient is being admitted to Swing Bed within thirty days of

discharge; and The patient’s condition meets criteria to necessitate daily

inpatient skilled nursing rehabilitation or combination of these services.

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The Swing Bed services must be provided for a condition which was treated during the beneficiary’s qualifying inpatient stay, or arose while the patient was in the Swing Bed for treatment of a condition for which he/she was previously treated in a hospital.◦ In this context, the applicable hospital condition need not have been

the principal diagnosis that actually precipitated the beneficiary’s admission to the hospital, but could be any one of the conditions present during the qualifying hospital stay.

Admission to Swing Bed within 30 Days of Discharge ◦ The Swing Bed services must be provided within thirty (30) days of

discharge from: An acute inpatient bed in the Swing Bed hospital Discharge from another acute hospital Discharge from a Swing Bed or skilled nursing facility

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As a practical matter, the daily skilled services can only be provided on an inpatient basis in a skilled nursing facility or Swing Bed◦ In making a “practical matter” determination, consideration must be

given to the patient’s condition and to the availability and feasibility of using more economical alternative facilities and services

Example:◦ A 83-year-old female patient who lives alone had a hip replacement

in XYZ Hospital. Since the patient lives 47 miles away from that hospital and Home Health services cannot provide the therapy she needs five days a week, as a practical matter, the patient can only receive services from a SNF or SWB

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Patients and/or their representatives must understand the patient must meet skilled care criteria and participate in his/her treatment program to stay in the Swing Bed

The patient must continue to meet Medicare criteria for Skilled Nursing Care admission

Medicare requires a SWB to meet certain requirements to be reimbursed by CMS

Patients and/or their representative need to be given understandable information about their Medicare benefit coverage

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1. Abuse, Neglect and Exploitation2. Accommodation of Needs3. Activities4. Admissions Policy5. Admission of a Resident6. Admission and Discharge Rights7. Admission, Emergency8. Admissions from Other Healthcare Facilities9. Background Screening Investigations10. Baseline Care Plan11. Behavior Challenge – Problem Solving12. Behavior Management Plan13. Behavior Management Program14. Care Planning – Resident Participation15. Change of Room or Roommate16. Confidentiality of Personal and Medical Records17. Dental Services Policy18. Discharge Summary and Plan of Care19. Elopement Decision Tree20. Elopement Incident Search Assignment21. Elopement: Missing Resident22. Elopement: Missing Resident Policy Audit

23. Elopement Policy24. Elopement Policy and Procedure25. Emergency: Hurricanes26. Emergency Planned Evacuation27. Emergency MDS28. HIPAA Organizational Requirements29. Leave of Absence30. Leave of Absence Consent Form31. Leave of Absence Log32. MDS Assessment Completion, Transmission and Validation33. MDS Assessments Timely Completion34. MDS Completion and Submission Timeframes35. MDS Error Correction36. Notice of Privacy Practices37. Nursing Responsibility in Pain Management38. Pain Management39. Physician Care40. Physician Visits and Physician Delegation41. Practical Matter42. QAPI and QRP in Swing Beds43. QAPI Facility Self-Assessment

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The CAH/PPS is substantially in compliance with the following SNF requirements ◦ §483.10 Resident Rights◦ §483.10(b)(5-6) List examples of items and services that the facility may

charge to the patient◦ §483.10(d) Free Choice. The resident has the right to choose a personal

attending MD/DO ◦ §483.10(d)(2) Be fully informed in advance about care and treatment and of

any changes in that care or treatment that may affect the resident’s well-being

◦ §483.12(a) Transfer and Discharge Definition: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not.

◦ §483.13(b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

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A CAH has 25 ED visits per day, 25 certified beds, 23 of which, on average, are used for swing-bed services and are occupied by nursing home or skilled nursing facility residents.

The CAH transfers out to a neighboring hospital an average of eight ED patients per week who require admission, and admits an average of one patient per month for acute inpatient services.

The CAH has fifteen physicians on staff, is performing an average of 800 outpatient surgeries per year, provides outpatient chemotherapy, cardiology and advanced diagnostic imaging, and has a total of about 20,000 outpatient visits per year, not counting ED visits.

In this situation the CAH’s services are skewed towards outpatient and long-term care services and the needs of its patient population for inpatient services do not appear to be met by the CAH. T

he CAH would be expected to demonstrate to the surveyor why it could be reasonable for its inpatient acute care capacity and admissions to be so disproportionately small compared to its outpatient and long term care services and to the needs of its ED patients for inpatient services. The surveyor would also review the medical records of a sample of ED patients transferred out to see if they required services the CAH’s professional healthcare staff is not able to provide. (

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Verify that the CAH is furnishing acute care inpatient services by reviewing data on the number of patients admitted over the prior year.

Determine the percentage of ED visits that result in an admission to the CAH. If fewer than eight percent of ED visits lead to an inpatient admission, review data on transfers of ED patients, overall staffing, the volume and type of outpatient services offered, including observation services, and swing bed services to determine whether there is a reasonably proportionate relationship among the various services the CAH provides.

Review a sample of records of the patients the CAH transferred and determine if the transfers were appropriate based on the services available at the CAH.

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§483.20(k)(2) A comprehensive care plan must be--◦ (i) Developed within 7 days after the completion of the

comprehensive assessment; ◦ (ii) Prepared by an interdisciplinary team, that includes the

attending MD/DO, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident’s needs, and, to the extent practicable, the participation of the resident, the resident’s family or the resident’s legal representative; and ◦ (iii) Periodically reviewed and revised by a team of qualified

persons after each assessment.

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In Florida, four hospitals and 11 nursing facilities were closed, according to the Federal Emergency Management Agency. Panama City has five hospitals, according to the Florida Health Association. Bay Medical, with 323 beds, and Gulf Coast Regional Medical Center, with 238, are the biggest◦ Florida officials also said food and supplies were being dropped in by air to the

state’s mental hospital in Chattahoochee, which is cut off by land. Gov. Nathan Deal of Georgia said 35 hospitals or nursing homes in that

state were without electricity and operating with generators. When a storm like Michael rapidly intensifies, leaving little advance

warning, it can be difficult to organize enough specialized medical transportation and patient beds to evacuate people in time, disaster experts said. ◦ In previous natural disasters, notoriously Hurricane Katrina, that has left hospital

and nursing home patients among the most vulnerable. ◦ In the wake of Hurricane Irma last year, a dozen residents died at a Hollywood,

Fla., nursing home when temperatures spiked and the facility lost air-conditioning.

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1. Facility Assessment2. Transfer Agreement3. Inservice Training4. Debrief Meeting

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Patients Hospital Staff Physicians Referring Hospitals Insurance Providers Home Health/OP

Therapy Community

(churches)

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LaSalle General Hospital Designs Marketing Strategy(National Rural Health Resource Center)

1. You have to be able to get past the secretary

2. Involve staff members with a variety of skills

3. If you can get 3 minutes, it’s a good visit

4. Keep a calendar with deadlines and upcoming events

5. Divide and conquer when creating marketing collateral

6. Not every idea will work out

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Higher Level of Care Top Patient Referral Indicators◦ Recent Surgery◦ Respiratory Infections◦ High Flow Oxygen◦ BiPAP or CPAP◦ Complex Wounds and Grafts◦ Wound Vac Management◦ Blood Administration◦ Hemodialysis◦ Central Lines Placement & Management◦ TPN, PEG and NG Feeding◦ Transportation from Referring Hospital◦ Family & Caregiver Training◦ A Resident of Snoqualmie Valley Area

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4 Ways this is most important to all SWB programs:1. CMS is targeting reviews on multiple medicine reviews

(unnecessary meds, psychotics, hypnotics, antianxiety, antidepressants, pain/opioid usage, over use of antibiotics

2. Multiple medications treating chronic diseases, raise the chances of dangerous drug interactions and serious side effects

Example: some drugs can cause confusion, falling, excessive bleeding, low blood pressure. and respiratory complications in older patients

3. PPS (per diem) and CAH (medical necessity) should be controlling unnecessary cost

4. Patients are going home to co-pays and deductibles – when they can’t pay for them, they don’t take meds, etc.

= Readmission Penalties

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GUIDANCE §483.45(d) Unnecessary drugs and §483.45(c)(3) and (e) Psychotropic Drugs◦ Medications are an integral part of the care provided to residents of

nursing facilities◦ Proper medication selection and prescribing (including dose,

duration, and type of medication(s)) may help stabilize or improve a resident’s outcome, quality of life and functional capacity

Choices◦ Rx review prior to or at admission◦ IDT needs to review and implement non-pharmacological

approaches to meet patient needs◦ Physician and Staff education on use of meds – this is quality of life

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Involvement of the resident, his or her family, and/or the resident representative in the medication management process

The monitoring of medications for efficacy and adverse consequences

Resident Choice –If a resident declines treatment, the facility staff and physician should inform the resident about the risks related to the lack of the medication, and discuss appropriate alternatives such as offering the medication at another time or in another dosage form, or offer an alternative medication or non-pharmacological approach.

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100

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Reviews are on . . .◦ # of Meds◦ Psych and Anti-psych◦ Antianxiety◦ Hypnotics◦ Antidepressants◦ Pain/Opioids◦ Antibiotic Stewardship

Dr. Beers List List by physician?

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Dr. Beers List1. Criteria used for potentially

inappropriate medication use in older adults

2. Specific list of meds, doses and durations that should be avoided in geriatric patients

3. Developed from expert consensus through literature review

4. For all patients 65 and older5. Adopted by CMS in 1999 for

nursing home patients

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Excessive Doses (including duplicate therapy) Excessive duration Without adequate monitoring Without adequate indications for usage In the presence of adverse consequences which indicate

the dose should be reduced or discontinued OR ANY COMBINATION OF THE ABOVE

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Includes: antipsychotics, antidepressants, anti-anxiety and hypnotics◦ “Any drug that affects brain activities associate with the mental

process and behavior”

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105

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Clinical◦ Medical Necessity

documentation◦ Therapy POCs◦ IDT notes per patient◦ Physician signatures

Financial◦ PPS – Validation report◦ CAH – all charges collected

Other◦ Activities◦ Practical Matter

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Complacency Misunderstanding

Audits Surveys Training and Education

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Make Your List1.

2.

3.

4.

5.

PPS◦ Validation Report◦ Correct RUGs◦ ADLs

CAHAdmissions CriteriaTypes of Admissions/graphUnnecessary/excessive charges

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MDS v 1.16 item sets specific to Swing Beds Latest RAI Manual An Action Plan

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Increased payments for 2018-2019◦ Medicare is working on meaningful QM reporting, reduced

paperwork and reduced administrative costs

CMS is proposing a new case-mix model that focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment for 2019-2020◦ Paying for medically complex conditions

Just need to stay on top of your program, your admissions, your training . . . .

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http://www.npuap.org/wp-content/uploads/2016/11/Margaret-Goldberg-Microclimate-presentation-final.pdfCMS Post-Acute Care Quality Initiative websitehttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Proposed-MDS-30-V1160-Change-Table.pdfInformation on the IMPACT Act of 2014 can be found at:http://www.gpo.gov/fdsys/pkg/BILLS-113hr4994enr/pdf/BILLS-113hr4994enr.pdfhttps://www.govtrack.us/congress/bills/113/hr4994For SNF Quality Reporting Program comments or questions: SNFQualityQuestions@cms.hhs.govSNF QRP Table for Reporting Assessment-Based Measures for the FY 2020 SNF QRP APU [PDF, 122KB] Final MDS 3.0 Data Set Version 1.16.0 - Effective October 1, 2018.pdf [PDF, 1MB] Final MDS 3.0 Data Set Version 1.16.0 Change Table - Effective October 1, 2018.pdf [PDF, 317KB] Final Specifications for SNF QRP Quality Measures and Standardized Resident Assessment Data Elements-Effective October 1 2018.pdf [PDF, 593KB] SNF QM User's Manual V1.0 FINAL 5-22-17 [PDF, 394KB] SNF QRP Measure Specifications October 2016.pdf [PDF, 138KB] 2016_07_20_mspb_pac_ltch_irf_snf_measure_specs [PDF, 822KB] SNF Function Quality Measures TEP Summary Report August 2016 [PDF, 2MB]

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Kerry has over 30 years in the health care industry, and over 25 specifically working in post-acute. She worked for national rehabilitation chains in varied roles and in hospital leadership positions. Kerry has experience with start-up units/facilities, programs beginning Medicare services, ongoing management of hospital business office operations, IRF units, skilled facility operations, and in 100-day turn around programs centered on cost reduction, cost avoidance and revenue enhancement.

As a consultant, Kerry has worked with swing beds (CAH and PPS), skilled nursing units, freestanding and hospital-owned long term care facilities. She has served as an educator for hospital and LTC associations, hospital associations and for CAH associations in the areas of corporate compliance, Medicare compliance, medical necessity documentation, therapy services, and coding/billing. She is the primary SNF/Swing Bed consultant for two rural health state associations and a presenter at two other rural health associations annually.

Her international work includes projects in Russia (training and starting the first nursing home services), China (teaching graduate students on western post-acute services and training on western inpatient rehabilitation); volunteering with an orphanage in Bolivia; teaching on outpatient surgery (National Health Services, England); Home Health (European Health Conference, Spain); presentations on Chinese Health in a Poster Session and a Free Theme Session at the 36th World Hospital Congress (Brazil); and study projects in Italy, Cuba, and Canada.

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