Aging and Disability Services Pressures and Priorities

Aging and Disability Services Pressures and Priorities

Nursing Facility Forum Call Case Mix Team / Office of MaineCare Services May 3, 2018 Nursing Facility Forum Call 5/3/18 Welcome to the 2nd Quarter Nursing Facility Forum call Department of Health and Human Services 2 Nursing

Nursing Facility Facility Forum Forum Call Call 5/5/16 5/3/18 Agenda o o o o o o o

Welcome HIPAA Reminders Review of MDS 3.0 Questions and Answers Snippet Training: Transportation Revisted Announcements Upcoming Training Questions Department of Health and Human Services 3 Nursing Nursing Facility Facility Forum Forum Call

Call 5/5/16 5/3/18 Department of Health and Human Services 4 Nursing Facility Forum Call May 3,2018 5/3/18 HIPAA Reminder: When sending email, please do not include any identifying information. This table

developed by the Federal Department of Health and Human Services gives definitions of 18 examples of identifying information. Department of Health and Human Services 5 Nursing Facility Forum Call May 3,20185/3/18 If you need to send a portion of an MDS

record: Fax is preferred over email If you must email, paste the document into an word document and apply a password. Do NOT send the password in the same email as the attached MDS document, OR Department of Health and Human Services 6 Nursing Facility Forum Call May 3,20185/3/18 Black out all identifying information, such as name, social security number, DOB, etc. It is

acceptable to refer to a resident as #1, #2, according to a list of residents left during a case mix review. If you mail information, please label as confidential and identify the person to whom it is being sent. Department of Health and Human Services 7 Nursing Facility Forum Call May 3,2018 /3/18 For more information: http://www.hhs.gov/ocr/privacy/hipaa/ understanding/coveredentities/De-iden

tification/guidance.html Department of Health and Human Services 8 Nursing Facility Forum Call 5/3/18 Questions, Questions, Questions and Answers Department of Health and Human Services 9

Nursing Facility Forum Call 5/3/18 Reminder Change in wording in the Section S manual on page 3: New or updated PASRR Level I changes will be captured for all assessment types, not just significant change or annual as changes can occur on a quarterly and may not meet the qualifications for a significant change assessment. Department of Health and Human Services 10 Nursing Facility

Forum Call 5/3/18 Section J Hospice I have a question about coding J1400 prognosis as 6 months or less. Can I code for hospice, since a hospice MD must certify 6 months or less to start Hospice services? Does this prognosis need to be in the residents chart as well? Some say it has to be in the chart and others say as long as the resident is receiving services through a certified hospice agency, you could code this as hospice since it is required by hospice regulations that a physician certify a prognosis of 6 months or less is expected. Department of Health and Human Services 11

Nursing Facility Forum Call 5/3/18 According to the manual, there must be documentation in the clinical record to support coding of a terminal prognosis RAI Manual, page J-23 and J-24: Steps for Assessment 1. Review the medical record for documentation by the physician that the residents condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness. 2. If the physician states that the residents life expectancy may be less than 6 months, request that he or she document this in the medical record. Do not code until there is documentation in the medical record.

3. Review the medical record to determine whether the resident is 12 receiving hospice services. Nursing Facility Forum Call 5/3/18 DEFINITION: CONDITION OR CHRONIC DISEASE THAT MAY RESULT IN A LIFE EXPECTANCY OF LESS THAN 6 MONTHS In the physicians judgment, the resident has a diagnosis or combination of clinical conditions that have advanced (or will continue to deteriorate) to a point that the average resident with that level of illness would not be expected to survive more than 6 months. This judgment should be substantiated by a physician note. It can be difficult to pinpoint the exact life expectancy for a single resident. Physician judgment should be

based on typical or average life expectancy of residents with similar level of disease burden as this resident. 13 Nursing Facility Forum Call 5/3/18 DEFINITION: HOSPICE SERVICES A program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. Under the hospice program benefit regulations, a physician is required to document in the medical record a life expectancy of less than 6 months, so if a resident is on hospice the expectation is that the

documentation is in the medical record. 14 Nursing Facility Forum Call 5/3/18 DEFINITION: TERMINALLY ILL Terminally ill means that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. Both providers must maintain their own documentation to meet regulatory requirements. 15

Nursing Facility Forum Call 8/3/17 Section A Husband and wife, both Med A, were to be discharged 4/3 with last covered day of 4/2. Both residents refused to sign the NOMNC and then appealed the decision. All of the steps were followed for the appeal and on 4/4, the appeal was denied. In the meantime, therapy worked with both residents. The son was notified of the denial for continued skilled care and arrangements were made for both residents to be discharged on 4/4 to avoid paying privately. Considering the facts as stated above, both residents were discharged from the facility on 4/4. Since the appeal was denied, I should do a PPS d/c for 4/2 for both, then do a d/c return not anticipated for 4/4. As I think this through, this makes sense to me. If anyone else has faced this and not sure how to proceed, this may

be helpful. Department of Health and Human Services 16 Nursing Facility Forum Call 5/3/18 RAI Manual, page A-33: The end of Medicare date is coded as follows, whichever occurs first: Date SNF benefit exhausts (i.e., the 100th day of the benefit); or Date of last day covered as recorded on the effective date from the Notice of Medicare Non-Coverage (NOMNC); or The last paid day of Medicare A when payer source changes

to another payer (regardless if the resident was moved to another bed or not); or Date the resident was discharged from the facility (see Item A2000, Discharge Date). Department of Health and Human Services 17 Nursing Facility Forum Call 5/3/18 Section O - Hospice When a resident elects hospice care, we complete a Significant Change assessment within 14 days, whether or not he/she had a notable decline in function. Would it be advisable or

acceptable to do follow-up SCSA two or three months later when resident is actually having notable decline in condition and needs care plan updates? Department of Health and Human Services 18 Nursing Facility Forum Call 5/3/18 From 2-27 of the RAI Users Manual: The key in determining if a SCSA is required for individuals with a terminal condition is whether or not the change in condition is an expected, well-defined part of the disease course and is consequently being addressed as part of the

overall plan of care for the individual. If a terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration and the criteria are met for a SCSA, a SCSA assessment is required. Department of Health and Human Services 19 Nursing Facility Forum Call 5/3/18 Section A A nonskilled resident is admitted to the facility, and is discharged return anticipated to the hospital on day 5. Resident returns on day 16. The OBRA Admission, which

had been opened in the software as an admission with an ARD of day 8, has not been completed. Does day 16 reset as day 1, as far as setting the ARD for the OBRA admission? Do we still have the 14 days to complete the admission? 20 Nursing Facility Forum Call 5/3/18 The original date of admission remains the date of admission. If there was no MDS completed to generate a RUG, the facility will have to bill at the default rate for the first 5 days. In the future, the ARD could have been changed to day 5 and the assessment completed, as much as possible

based on information available. If interviews had not been completed, the items would have been dash-filled. If the admission had been done at day 5, then a significant change could have been completed, as appropriate, upon return from the hospital. Department of Health and Human Services 21 Nursing Facility Forum Call 5/3/18 Section A A LTC MaineCare resident has a quarterly due, but was hospitalized at the time of the ARD. This scenario is addressed in the RAI Manual, 2-19, but I

am wondering how this would affect payment. For example, the resident is hospitalized from days 90100 since the ARD of the last OBRA assessment. Returns to facility on day 101 (still MaineCare), ARD of OBRA is set for day 110. Does this affect reimbursement in any way? Department of Health and Human Services 22 Nursing Facility Forum Call 5/3/18 An assessment cannot be completed if a resident is not in the facility. Document in the medical record the reason an assessment is not completed in a timely manner. When the resident returns, if there is no significant change, complete

the assessment as soon as practicable. If the resident qualifies for a significant change, the assessment must be completed (Z0500) by day 14. The previous RUG remains in effect until a new assessment is completed. Department of Health and Human Services 23 Nursing Facility Forum Call 5/3/18 Section A We have a long-term MaineCare resident whose quarterly was missed. It was not discovered until it was time for the next quarterly. What should we do? And what are the payment implications?

Department of Health and Human Services 24 Nursing Facility Forum Call 5/3/18 The ARD cannot be set any earlier than the date the error was discovered. The previous RUG will remain in effect until the next assessment is completed. Document in the clinical record the reason for a late assessment. The case mix nurse might be aware of the late assessment and is looking for patterns of late assessments and reasons for late assessments in determining if sanctions will be applied.

The next assessment would be due 92 days from the ARD. Department of Health and Human Services 25 Nursing Facility Forum Call 5/3/18 Section J A long term resident was hospitalized, the resident was discharged from the hospital and fell in the transport van prior to reentry to the facility. Is the fall coded in J1700 or J1800?

Department of Health and Human Services 26 Nursing Facility Forum Call 5/3/18 The RAI Manual, page J-27, defines a fall as Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. Falls are not a result of an overwhelming external force (e.g., a

resident pushes another resident). Department of Health and Human Services 27 Nursing Facility Forum Call 5/3/18 Did the resident have a fall any time in the last month prior to admission/entry or reentry? If the residents fall meets this definition, then it would be coded in J1700A. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? If yes, the fracture would be coded in J1700C. The fall would not be coded in J1800 as it occurred prior to the

residents reentry to the facility, not since reentry, and the residents reentry to the facility is more recent than the prior assessment. Department of Health and Human Services 28 Nursing Facility Forum Call 5/3/18 Section G Scenario: We have a resident who requires complete Hoyer lift for transfer from bed to chair. Resident is transferred from bed to chair and back to bed every day during day shift. Day shift documents transfers one time during their shift, and they correctly coded documented the transfer as 4/3. Other shifts were compliant with proper coding during their shifts, coding 8/8 (as the

activity did not occur). For the 7-day look back period, there was one episode of documentation during each of the 7 day shifts, with 4/3 coded. Evening and night shift both have 7 episodes of documentation of 8/8 (activity did not occur during their shifts). There is a total of 21 episodes of documentation for transfers, encompassing all shifts. Department of Health and Human Services 29 Nursing Facility Forum Call 5/3/18 The MDS was coded at G0110B as 4/3 for transfer. Upon review of the ADLs, eight 4s and six 8's were coded with the highest level of support being 3.

During a recent survey, the surveyor called this a documentation error, and asked that the MDS be corrected to reflect 3/3 for transfers. There were blanks, compared to other ADLs. At times the CNA may go into the kiosk and chart only the ADL they have just done. They dont typically go through and mark 8s on the other ADLs that did not occur at that time. Department of Health and Human Services 30 Nursing Facility Forum Call 5/3/18 Response: If there were blanks in the documentation, you cannot code 4 unless there

is documentation of staff interviews to confirm what happened on the shifts where there was no documentation. In the example you have given, there was documentation of total dependence or that the activity did not occur for each shift during the look back; therefore, there was no documentation error and no need for correction. Department of Health and Human Services 31 Nursing Facility Forum Call 5/3/18 Section O

My facility recently switched to electronic signatures for therapy orders. A MaineCare LTC resident had a speech therapy evaluation on 1/30/18 and it was determined that the resident needed continuing speech therapy for swallowing issues. The start of care for speech therapy was 1/30/18. The physician signed the initial electronic order for speech therapy dated 1/30/18 on 2/5/18. And then again on 2/12/18, because of a change in POC. If our ARD is 2/5/18, when can we start to count minutes? Department of Health and Human Services 32 Nursing Facility Forum Call 5/3/18

Response from facilitys therapy manager to MDS Coordinator: The RAI manual makes reference to the Medicare Benefits manual and I am attaching the documentation necessary to support treating prior to physician signature on certification. 'Timely certification' as defined in the Medicare Benefit manual is 'as soon as possible' or within 30 days of the initial therapy treatment (including evaluation). This statement allows the therapist to treat the resident once the evaluation is completed and that the physician has within 30 days to sign. So yes, the plan of care must be certified by the physician but he/ she has up to 30 days to certify the plan. There is also a condition for delayed certification detailed in the Medicare Benefits Policy Manual Ch. 15 but I did not get into that for the purposes of this email. Department of Health and Human Services

33 Nursing Facility Forum Call 5/3/18 Case Mix Team Response: For Medicare A and any payer other than Medicare B (RAI Manual, page O-21, last bullet) the facility obtains an eval and treat order and proceeds with services. For Medicare B, there must be physician certification of the plan prior to starting services. (RAI Manual, page O-21, second bullet, then first dash below that bullet). Department of Health and Human Services

34 Nursing Facility Forum Call 5/3/18 Certified by a physician means the physician must approve of the plan prior to initiating treatment. This could be accomplished verbally as a telephone order or face-to-face contact. The telephone order must be signed within 30 days, in accordance with the Medicare Benefits Manual. It does not mean the therapist can treat without physician approval of the plan of care. Department of Health and Human Services

35 Nursing Facility Forum Call 5/3/18 Section S If a resident has Maine Care as a copay payer, do we check this box on admission, or when the copay goes into effect (Day 21)? Code S8010 as of the ARD. So, at day 14, a resident who has MaineCare as co-pay that will go into effect as of day 21 would not be coded as MaineCare is paying no portion of the residents stay as of the ARD. Department of Health and Human Services

36 Nursing Facility Forum Call 5/3/18 Section G ADL Self-Performance question. Here is a scenario for SelfPerformance: 11 times coded as Independent (0) 3 times coded as Dependent (4) 1 time coded as Supervision (1) Department of Health and Human Services 37 Nursing Facility

Forum Call 5/3/18 In utilizing the instructions at the top of the ADL SelfPerformance Rule of 3 Algorithm, Page G-8, the answer that I come up with is Supervision (1). If I utilize the algorithm, the answer that I come up with is Extensive (3). I feel that the correct answer should be Supervision (1), but that the algorithm leads you to coding Extensive assist because of the box that says "Did the resident fully perform the ADL activity without ANY help or oversight at least 3 times AND require help or oversight at any other level, but not three times at any other level? (Item 1 Rule of 3 with Independent exception)." Department of Health and Human Services 38

Nursing Facility Forum Call 5/3/18 Department of Health and Human Services 39 Nursing Facility Forum Call 5/3/18 Department of Health and Human Services 40

Nursing Facility Forum Call 5/3/18 Was weight-bearing support provided three or more times? OR Was full staff performance of activity provided three or more times during part but not all of the last 7 days? If you answered yes to either of these questions, the correct code would be 3, extensive assistance. 41 Nursing Facility Forum Call 5/3/18 Section M

I have a question about Skin Prep, Im finding conflicting info as to whether it can coded if used to prevent breakdown of the heels at Section M, M1200 I Application of dressing to feet, apparently it dries to an invisible dressing. Department of Health and Human Services 42 Nursing Facility Forum Call 5/3/18 ( http://www.smith-nephew.com/professional/products/advanced-wound-management/skin -prep/

) SKIN-PREP is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films. SKIN-PREP can also be used to prepare skin attachment sites for drainage tubes, external catheters, surrounding ostomy sites and adhesive dressings. Features & Benefits Helps tape and film adhesion. Fast and easy to use, only one coat is required, so less product is used per application. Removes easily using skin cleanser or soap and water, so unsanitary residue isn't left in or around the wound area. Applies easily, even on awkward areas such as elbows, knees, and heels. Moves naturally with patients' skin and won't crack or peel. Allows skin to "breathe" so tapes and films adhere better. Department of Health and Human Services 43 May increase intervals between dressing changes.

Nursing Facility Forum Call 5/3/18 Indications Apply as a coating to prepare the skin for adhesives. Provides a protective interface that may reduce friction during the removal of tape. For skin attachment sites: drainage tubes, external catheters, surrounding ostomy sites and other adhesive dressings. For use in sensitive stoma areas as a skin protectant. May reduce irritation from contact with body wastes and stoma fluid. Forms a protective film on skin which may reduce exposure to urine and feces. SKIN-PREP should only be used on intact skin. Im not reading in information from the manufacturer

that it is used to reduced friction on heels, it is used to reduced friction when removing tape or other dressings. Department of Health and Human Services 44 Nursing Facility Forum Call 5/3/18 Section A Just recently I had to retract some MDS assessments from the QIES system because I found out months after that the resident was not on regular Medicare but instead a Managed Medicare. The last section of the form states A0410 (Submission Requirement) Values and then it asks for the submitted (incorrect) value and the correct

value. We have always put 3 under A0410 on all of our MDS assessments. I started thinking once I filled out this form that maybe we should be putting different numbers. Department of Health and Human Services 45 Nursing Facility Forum Call 5/3/18 I read through the RAI manual again its still not clear. If we have a VA or managed Medicare care resident for their Admission assessment Im thinking that we should code A0410 as a 2. This would mean the resident is not Medicare or Medicaid but their MDS is required by the state. I coded their 5day and 14day with a 1, meaning the unit is neither

Medicare/Medicaid and MDS not required by the state. The assessments that I coded with a 1 didnt even show up on my roster to submit to CMS which is what Ive been wanting all along. There is no chance that they will be submitted by mistake. The admission assessments that I coded with a 2 were rejected when I tried to submit them to the QIES system. How should I be coding in A0410? Department of Health and Human Services 46 Nursing Facility Forum Call 5/3/18 Great question! You would code A0410 with 3 because all of

the beds in your facility are Medicare/Medicaid certified. You would not submit any PPS assessments to CMS if the resident had a payer that was anything other than Medicare Part A. You would submit all OBRA assessments to CMS and submit any PPS assessments, as requested, to the managed care company only. Department of Health and Human Services 47 Nursing Facility Forum Call 5/3/18 PPS Scheduling Question Last rehab treatment (i.e., discharged from therapy)

was on 2/5 Next COT checkpoint (i.e., day 7 of the COT observation period) was 2/6 Last covered day for Medicare is 2/7 Are we able to complete an EOT on 2/6, and then the NPE (Part A PPS Discharge) on 2/7 in this scenario? Department of Health and Human Services 48 Nursing Facility Forum Call 5/3/18 RAI Manual, Page 2-53: End of Therapy: May be combined with any scheduled PPS assessment. In such cases,

the item set for the scheduled assessment should be used. (However, the Part A PPS is not considered to be scheduled or unscheduled) Establishes a new non-therapy RUG classification and Medicare payment rate (Item Z0150A), which begins the day after the last day of therapy treatment regardless of day selected for ARD. In cases where a resident is discharged from the SNF on or prior to the third consecutive day of missed therapy services, then no EOT is required. More precisely, in cases where the date coded for Item A2000 is on or prior to the third consecutive day of missed therapy services, then no EOT OMRA is required. If a SNF chooses to complete the EOT OMRA in this situation, they may combine the EOT OMRA with the discharge assessment. 49 Nursing Facility Forum Call 5/3/18

In cases where the last day of the Medicare Part A benefit, that is the date used to code A2400C on the MDS, is prior to the third consecutive day of missed therapy services, then no EOT OMRA is required. If the date listed in A2400C is on or after the third consecutive day of missed therapy services, then an EOT OMRA would be required. You are not required to complete the EOT. If you choose to complete the EOT, it will generate a new non-therapy RUG that would take effect on the first day after therapy ends (2/6/18). Department of Health and Human Services 50 Nursing Facility

Forum Call 5/3/18 Questions??? Department of Health and Human Services 51 Nursing Facility Forum Call 5/3/18 Snippet Training Transportatio n Revisited MDS 3.0

The Mini Series Department of Health and Human Services 52 Nursing Facility Forum Call 2/2/17 NET Transportation NET = Non-Emergency Transportation Residents receiving skilled services (nursing or therapy) are not eligible for NET transportation. MaineCare Benefits Manual, Chapter II, Section 67.0514A and 67.05-14B MaineCare Benefits Manual, Chapter 1, Section 1.15

Department of Health and Human Services 53 Nursing Facility Forum Call 5/3/18 NET Transportation NET = Non-Emergency Transportation Residents receiving skilled services (nursing or therapy) may be eligible for NET transportation if the member has full MaineCare (not just QMB) and if facility transportation is not available. The decision to use NET will be determined by a licensed nurse at the facility, based on safety considerations*. There must be documentation to support all decisions. Ambulance transport is needed if other transportation endangers health.

MaineCare Benefits Manual, Chapter II, Section 67.05-14A and 67.05-14B MaineCare Benefits Manual, Chapter 1, Section 1.15 Department of Health and Human Services 54 Nursing Facility Forum Call 5/3/18 A Licensed nurse will make the determination based on the following safety considerations: Can the member safely:

Be transported independently attend the appointment independently attend to all physical needs during transport manage any equipment and/or medications he/she brought If the answer to any of the above consideration is no, does the member require an escort to assist with any of those needs? Department of Health and Human Services 55 Nursing Facility Forum Call 5/3/18

There is a specific request form that must be sent to the broker. The request must include a letter on facility-letterhead identifying the good cause for the facility to be able to provide the transportation and include documentation of the safety considerations defined on the previous slide. Department of Health and Human Services 56 Nursing Facility Forum Call 5/3/18 57 Nursing Facility

Forum Call 5/3/18 MDS 3.0 The Mini Series Session 1 Session 2 Department of Health and Human Services 58 Nursing Facility Forum Call 5/3/18 Session 4

Session 3 Session 5 Department of Health and Human Services 59 Nursing Facility Forum Call 5/3/18 Department of Health and Human Services 60

Nursing Facility Forum Call 5/3/18 10-144 Chapter 110 REGULATIONS GOVERNING THE LICENSING AND FUNCTIONING OF SKILLED NURSING FACILITIES AND NURSING FACILITIES CHAPTER 12 12.D.2. There must be documentation by the CNA of the specific tasks carried out to implement the part of the care plan assigned to the CNA. 61 Nursing Facility Forum Call

5/3/18 Any evidence of back dating, which may be falsifying MDS records, will be referred to program integrity for review. While AANAC / RAC training is good training, it is not a substitute for attending State training. Please consider attending a state MDS 3.0 training session. OMS is not required by policy to give advance notice of a case mix review. There may be unannounced visits coming. Facilities, according to policy, are required to give access to all records used to code the MDS. Department of Health and Human Services 62 Nursing Facility

Forum Call 5/3/18 The first line of information is the RAI manual for the MDS 3.0. If you have a situation that you are unsure of how to code, call your case mix nurse or the MDS help desk for more guidance. Department of Health and Human Services 63 Nursing Facility Forum Call 5/3/18

The web site to obtain copies of the training calendar, the training power point and handouts, etc. is: http://www.maine.gov/dhhs/oms/provider/case_ mix_manuals.html Dont forget the training portal: http://www.maine.gov/dhhs/dlrs/mds/training/index.shtml Department of Health and Human Services 64 Nursing Facility Forum Call 5/3/18 Upcoming MDS 3.0 training:

Plan for 2-day training in Augusta in May 5/17/18 - Biddeford (documentation and payment items) 6/15/18 - Augusta (documentation and payment items) Let the Help desk know if you are interested in MDS 3.0 2-day training or Restorative Nursing training. We keep a wait list and schedule when there are sufficient participants. Call or email to register: [email protected] OMS website for handouts: http://www.maine.gov/dhhs/oms/provider/case_mix_manuals.html Next Forum call: August 2, 2018 Department of Health and Human Services 65

Nursing Facility Forum Call 5/3/18 Contact Informatio n: MDS Help Desk: 624-4019, or 1-844-288-1612 (toll free) [email protected] Lois Bourque RN: 592-5909 [email protected] Darlene Scott-Rairdon RN: 215-4797 [email protected] Maxima Corriveau RN: 215-3589 [email protected]

Sue Pinette RN: 287-3933 or 215-4504 (cell) [email protected] Department of Health and Human Services 66 Questions? Thanks for spending time with the case mix team! Join us again in August for the next call. Department of Health and Human Services 67 Nursing Facility Forum Call 5/3/18

Department of Health and Human Services 68 Nursing Facility Forum Call 5/3/18 Department of Health and Human Services 69 Nursing Facility Forum Call 5/3/18

Department of Health and Human Services 70

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