Reliant Reveal Blog Archives

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Care Matters Spotlight: June 2020

Joseph Scopelliti was admitted to Laurel Brook after being diagnosed with COVID-19 at the hospital. Prior to his hospitalization, Joe was independent and living at home. Following his fight against COVID-19 he was debilitated and on oxygen. 

Joe’s PT and OT created patient centered plans of care to address functional mobility, ADLs, endurance and strategies to combat shortness of breath. He worked hard to get back to his prior level. In fact, Joe was such a hard worker that he motivated other residents at the facility including his own roommate.  The therapists report when they knocked on the door, Joe was ready to go. Despite having in-room treatments, Joe and the therapy crew used objects in his room to simulate his home environment to prepare him for a safe discharge.

Upon discharge, Joe was successfully weaned off his supplemental oxygen and was able to walk out of the SNF independently without an assistive device! He did an amazing job in a short amount of time and was able to return home completely independent. We are really proud of Joe and hope that he continues to succeed at home!

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Documenting the Picture for Skilled Need During a Health Care Emergency and Beyond

​During times of pandemic and national emergency, when flexibilities or waivers are allowed by CMS, supportive documentation is crucial to justify the need for our skilled care. Throughout the public health emergency, many providers have utilized the available waivers for SNFs, including “skilling in place.”  With use of these waivers the following should be considered:

  1. Physician involvement, skilled nursing notes, and therapy evaluations and treatments should demonstrate medical necessity and skilled interventions relative to specific patient care needs. ​
  2. A signed physician certification will not suffice; the documentation needs to clearly support the order. 
  3. ​The patient assessment, physician documentation,  justification for the reason why the patient should be skilled in place versus discharged to the hospital, and hospital notes that document rationale for not admitting a patient or discharging early should all be obtained and recorded.
  4. Consistent and thorough documentation related to the care being delivered and why the particular care being provided is appropriate to the patient’s diagnosis, illness, or condition should be included.
  5. Strong facility processes, ongoing communication, and frequent medical record spot checks are the most effective ways to ensure that your records can best support the patient-centered care that is provided through the health care emergency and beyond. ​

After the emergency declaration is rescinded, it is very likely that CMS, either through the Office of the Inspector General (OIG) or contractors, will look to ensure that Medicare dollars were spent appropriately without fraud, waste or abuse. ​ When evaluating the use of the waivers, it is important to focus on CMS’ goal to take “aggressive actions and exercise regulatory flexibilities to help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19).” ​ Documentation will be critical to explain the rationale for the use of the waivers as well as clinical decision making for application.

In conclusion, a thorough interdisciplinary treatment record is crucial to support the specialized services provided during this health care emergency. ​ As we continue to provide excellent resident-centered care, we should ensure that we demonstrate the complexity, sophistication, and medical necessity of the services that we provide in our documentation. ​Documentation is paramount to fortify defensibility following this pandemic and to ensure our residents continue to have access to quality care.

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CMS Releases Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results

CMS released a memorandum addressing COVID-19 survey activities, enhanced enforcement, and engagement of Quality Improvement Organizations (QIOs).  CMS also released a state-by-state report on COVID-19 cases for residents and staff along with numbers of infection control focused surveys completed. The memorandum includes guidance related to

  • Focused Infection Control Nursing Home Surveys and CARES Act Supplemental Funding 
    • States that have not completed focused infection control surveys in 100% of their state’s nursing homes by July 31, 2020 will be required to submit a corrective action plan outlining the strategy for completion of these surveys within 30 days. 
    • Access to CARES Act allocations will be impacted by state performance on completing the nursing home infection control focused surveys. 
  • COVID-19 Survey Activities 
    • Requiring states to implement the following COVID-19 survey activities. States that fail to perform these survey activities timely and completely could forfeit up to 5% of their CARES Act allocation, annually. 
  • Expanded Survey Activities 
    • Emphasizes Nursing Homes Re-opening Recommendations, which indicates that once a state has entered Phase 3 of the reopening process, states may use their discretion as to whether and how they decide to expand survey activity beyond the current survey prioritization.
  • Enhanced Enforcement for Infection Control Deficiencies 
    • For all infection control deficiencies at a scope and severity of D or above, CMS will impose a directed plan of correction that will include the use of root cause analysis. 
  • Support From Quality Improvement Organizations (QIOs) 
    • Nursing homes can take advantage of weekly National Nursing Home Training that focuses on infection control, prevention and management to help prevent the transmission of COVID-19.Nursing homes can locate the QIO responsible for their state here. 

Read the memo from CMS here.

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COVID-19 Data and Inspection Results Available on Nursing Home Compare

The Centers for Medicare and Medicaid Services (CMS) initiated posts of COVID-19 nursing home data which will be updated weekly.

In addition, results of targeted inspection surveys and reports are available on Nursing Home Compare. CMS plans to post the results of the inspections monthly as they are completed.

Available Links

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Medicare COVID-19 Testing for Nursing Home Residents and Patients

The Centers for Medicare & Medicaid Services (CMS) instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes that provides recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID-like symptoms in an outbreak.

Medicare Advantage plans must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.

For the full Medicare Learning Network article, CLICK HERE.

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CMS Releases FAQs on Nursing Home Visitation

The Centers for Medicare and Medicaid Services (CMS) issued a Frequently Asked Questions document on visitation for nursing home residents that provides clarifications and considerations including:

Visitation for compassionate care situations

  • CMS clarifies compassionate care situations are not exclusive to end-of-life situations.   An example is provided explaining a resident who was living with their family prior to being admitted to the nursing home may experience trauma due to the change in their environment and sudden lack of family.  Therefore, this may qualify as a compassionate care situation.

Outside visits

  • CMS encourages creative means of connecting residents and families including visitation outside of the facility while ensuring all actions for preventing COVID-19 transmission are followed.

Communal activities

  • Residents (without COVID-19 symptoms) may eat in the same room with social distancing.
  • Group activities may be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask.

Steps for reopening to visitors

  • Nursing homes should continue to follow CMS and CDC guidance for preventing the transmission of COVID-19 and follow state and local direction.
  • CMS does not recommend reopening facilities to visitors (except for compassionate care situations) until phase three when the following criteria are met:
    • No new onset of COVID-19 in the nursing home for 38 days
    • No staff shortages
    • Adequate supplies of PPE and essential cleaning and disinfection supplies
    • Adequate access to testing for COVID-19
    • Referral hospitals have bed capacity on wards and ICUs

Factors to consider regarding visitation

  • CMS encourages that any decisions to relax requirements or conduct creative alternatives within nursing homes be made in coordination with state and local officials after a careful review of facility-level, community, and state factors/orders.

To access the complete FAQs document from CMS’ Current Emergencies webpage, CLICK HERE.

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A Picture is Worth a Thousand Words: Photos, Videos, & HIPAA

It has been said “a picture is worth a thousand words.”  That quote is so true in this COVID-19 era where friends and family must keep their distance from loved ones in nursing homes. The compassion and care that nursing home staff provide includes, now more than ever, the social wellbeing of residents and patients.  Sharing photographs and videos is a wonderful way to keep connected.  However, don’t forget Health Insurance Portability and Accountability Act (HIPAA) compliance still is required.

Photos or videos containing any portion of a resident’s or patient’s face are considered Protected Health Information (PHI). That doesn’t mean you cannot take and share photos or videos.  HIPAA allows use and disclosure of photos or videos when proper authorization is provided by the resident, patient, or responsible party.

To be HIPAA compliant, authorization documentation must include the following:

  • The purpose for using and disclosing photos or videos; for example, “to share with her daughter/son” 
  • The timeframe the authorization applies; for example, “to send to daughter/son while the facility is on lockdown”
  • Explanation that the resident, patient, or responsible party have the right to revoke the authorization at any time
  • Explanation that the health care provider will not condition treatment, payment, or enrollment or eligibility for benefits on the resident, patient, or responsible party signing the authorization
  • Signature of the resident, patient or responsible party

Thanks to all for keeping residents and patients safe and connected while remaining HIPAA compliant.

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Recovery and Rehabilitation Following COVID-19

As research and data collection regarding the recovery from COVID-19 grows, valuable information from research studies identifying correlations between contracting the virus and other acute medical complications, as well as the increased risk of readmission to the hospital, is clear. Current data suggests that patients hospitalized for COVID-19 are at increased risk for blood clots, strokes, heart and lung damage, speech and swallowing difficulties due to prolonged intubation, and neurological impairments.  It is our job to have a heightened awareness of potential complications associated with COVID-19 and communicate any findings to the interdisciplinary team (IDT).  With proper notification of subtle observed symptoms, the IDT can work together to minimize the side effects of COVID-19 and decrease the need for rehospitalization, consequently avoiding delayed recovery, increased potential for exposure to other contagions, and development of further complications.

Recovery is not only needed for those who have survived COVID-19; recovery, although different, is also needed for those who did not contract the virus but find themselves dealing with side effects from the modification of routines and activities in an effort to combat the spread of COVID-19. Current data shows that older adults who have not contracted the virus are seeing physical and psychosocial effects due to social distancing that result in deconditioning, increased effects of chronic disease, and reduced functional capacity. Facilities can provide ways to keep residents active while still maintaining social distancing guidelines. To thwart the effects of isolation and inability to see family, facility staff can provide technology, such as Facetime, to allow for residents to check in with their loved ones. Another consideration would be to reach out to family members and encourage them to send pictures and care packages to brighten the residents’ day.  We must ensure minimal impact to those who have made the skilled nursing facility their home by increasing opportunities for social and physical activities while maintaining precautions and social distancing during the COVID-19 pandemic.

COVID-19 has touched everyone, either directly or indirectly, and the effects of the virus may linger for an indefinite amount of time.   However, through increased communication among the IDT, we can potentially aid in speeding up the recovery process and in minimizing the risk of rehospitalization.   Additionally, through increased social and physical opportunities, our residents who have not contracted COVID-19 can explore alternative ways to stay connected and physically active.  Through the actions of a proactive interdisciplinary team, we can assist all our residents in achieving functional and quality outcomes allowing for enhanced quality of life.

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Aging on the inside and the outside, plus reminders about protecting the skin

Safe Summer Sun Tips from Reliant Rehabilitation

Summer sunshine abounds in June! And without the extreme heat of July, it’s a great time to be outdoors soaking up wonderful, bone strengthening vitamin D. Just remember simple sun safe tips.

Must-do sun safe sun reminders:

Whether you are a new believer in protecting your skin against harmful UV rays or have been a regular protector of your skin, it’s never too late to take precautions to help ensure you don’t get too much of a good thing.

•          Wear wide brimmed hats

•          Show us your shades – protect the eyes

•          Wear loose-fitting, long-sleeved shirts to keep cool but protect the skin

•          Make sunscreen a daily morning ritual

•          Take breaks in the shade and eliminate extended sun exposure

•          Hydrate, hydrate, hydrate

•          Be sure medications don’t interact with the sun

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Honking for Hugs #CareNotCOVID

With the restrictions on visitors, several communities across the country have gotten creative showing appreciation for patients and residents by coordinating “Honk for Hugs” events in a reverse parade fashion.

Forest Hills Care and Rehabilitation, Broken Arrow, OK

The Forest Hills Care and Rehabilitation team in Broken Arrow, OK participated in two community parades, which allowed the patients and residents to see friends and family from a safe distance.

Let’s recognize the team:

Rachel Blanchard DOR
Dianna Sunday PT
Rebecca DeVilliers OTR
Chelsea Holmes OTR
Shannon Pinson SLP
Kelsey Farragher SLP
Saundra Fite PTA
Tara Stephenson PTA
Katie Forler PTA
Candice Ertman PTA
Michelle Kellam COTA
Kimberly Luu COTA

Cottonwood Creek Healthcare Center, Richardson, TX

Cottonwood Creek Healthcare Center in Richardson, TX held a Honk for Hugs event with patients and residents. The patients and residents had so much fun!

CareCore at Westmoreland, Chillicothe, OH

CareCore at Westmoreland’s therapy team in Chillicothe, OH decorated and had patients participate in a “Honk for Hugs” event where the community showed how much they cared for the facility patients and residents.

Let’s recognize the team:

Angie Nartker PT
Kelly Davidson SLP
Crystal Steele PTA
Amanda Karr PTA
Jill Burton COTA
Penelope George PTA/DOR

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When Will We Begin Seeing Medical Review Audits Following the COVID-19 PHE?

While it is still unclear at this time when we will begin to see normal audit activity resume from traditional Medicare entities, some Managed Care companies have lifted their suspensions and may have resumed normal auditing practices as early as May 15, 2020. Humana released a memo on May 14, 2020 stating the following

“Given that health system capacity is opening up and procedures are increasing steadily, we will begin to resume some of the regular processes that we suspended on April 1, 2020, to support providers with the strain on the healthcare system posed by COVID-19 at the heart of the crisis…The first of these is for medical record requests for claim reviews, which we will resume effective May 15, 2020.

  1. Resuming pre-payment medical record claims review. As of May 15, Humana may begin to request medical records from your organization prior to issuing payment, consistent with our policy in place prior to the April 1 suspension.
  2. Resuming post-payment medical record claims review. Since April 1, Humana has not requested medical records in connection with our post-payment review process. Our post­ payment claims review team will now resume making requests for medical records as required, consistent with our policy in place prior to April 1.

Humana leaders will continue to monitor service volumes as well as the progression of the COVID-19 curve and recovery and will review our policies and procedures as necessary as this crisis evolves.”

Please be prepared to start seeing these requests again in the coming days and weeks and notify your Medical Review/Appeals department as soon as possible. It is highly possible that there will still be barriers to obtaining medical records timely and extensions may need to be requested. We are all in this together and are happy to assist in any way possible.

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Updated MDS 3.0 Item Sets v1.17.2 and Technical Data Specifications

In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications.  These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1.  This will allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM codes and thereby inform their future payment models.

For more information, visit MDS 3.0 Technical Information page. Supporting materials including the 1.17.2 Item Change History report and the revised 1.17.2 Item Sets can be accessed in the file:  MDS 3.0 Final Item Sets v1.17.2 for October 1 2020 zip, also posted in the Downloads section of the MDS 3.0 Technical Information page.

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Delayed: Release of Updated Versions of SNF Assessment Instrument

CMS has delayed the release of the updated versions of the Minimum Data Set (MDS) needed to support the Transfer of Health (TOH) Information Quality Measures and new or revised Standardized Patient Assessment Data Elements (SPADEs) in order to provide maximum flexibilities for providers of Skilled Nursing Facilities (SNFs) to respond to the COVID-19 Pubic Health Emergency (PHE).

The release of updated versions of the MDS will be delayed until October 1st of the year that is at least 2 full fiscal years after the end of the COVID-19 PHE. For example, if the COVID-19 PHE ends on September 20, 2020, SNFs will be required to begin collecting data using the updated versions of the item sets beginning with patients discharged on October 1, 2022.

For more information, visit CMS’ SNF Quality Reporting Program Training page.

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CMS Releases Toolkit for Nursing Homes

CMS has released a toolkit to aid nursing homes, governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. Access the toolkit here.

The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency.

The toolkit is comprised of best practices from a variety of front line health care providers, governors COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalog of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

View the full press release from CMS here. The toolkit can be accessed here.

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CMS Issues Guidance to Ensure the Safe Reopening of Nursing Homes

After President Trump revealed Guidelines for Opening Up America Again on May 18, the Centers for Medicare and Medicaid Services (CMS) announced new guidance for state and local officials to ensure the safe reopening of nursing homes across the country.  State leaders are encouraged to collaborate with the state survey agency and local health departments to develop a plan on how these criteria should be implemented.

CMS recommends that decisions on relaxing restrictions in nursing homes be made with careful review of the following facility-level, community, and state factors:

  • Case status in community
  • Case status in the nursing home(s)
  • Adequate staffing
  • Access to adequate testing
  • Universal source control
  • Access to adequate personal protective equipment (PPE) for staff
  • Local hospital capacity

Reliant’s Real Time Memo on this topic can be accessed here.

CMS’ guidance can be accessed here.

The Frequently Asked Questions (FAQ) document can be accessed here.

or questions or concerns related to this memo, please email the DNH Triage Team.

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Connection Through Video Chat

As the country continues to take a proactive, preventative approach to reduce the spread of COVID-19, social distancing and visitor restrictions in long-term care challenge us to use alternative means for connecting patients, family members/responsible parties, and long-term care staff.  On March 13, 2020, the Centers for Medicare & Medicaid Services (CMS) issued Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised) stating:

“In lieu of visits, facilities should consider offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.)”1

When choosing to use video communication, the US Department of Health and Human Services provides guidance regarding which video communication platforms are safe to use and which are not. For example, FaceTime and Skype* are classified as non-public facing remote communication products while TikTok, Facebook Live, and Twitch are public-facing products.  Public-facing products are not acceptable to use. 

When video chatting, be mindful of the following:

  • Obtain proper authorization for use or disclosure from the resident/patient/responsible party.
  • Make reasonable efforts to ensure others, not authorized to participate in the video chat, cannot hear the discussions.
  • Ensure other patients are not in the background of the video chat to prevent unauthorized use or disclosure of that individual.
  • Confirm the party answering the video chat is the appropriate party before proceeding with discussions.
  • Be sure when ending video chat that it successfully ends so that other conversations or videos are not accidentally seen or overheard.

*FaceTime and Skype means of communication are not supported by HIPAA regulations outside of the current healthcare emergency. The Office of Civil Rights states:

“Health care providers may use popular applications that allow for video chats, such as FaceTime and Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.”2  

1 https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf

2https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

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Implementation Strategies: Trauma-Informed Care During the COVID-19 Pandemic

The COVID-19 pandemic introduces unique considerations related to patient-specific care plans, the execution of trauma-informed care (TIC) and the implementation of protocols to prevent disease transmission allowing for the continued provision of quality care.  In order to incorporate TIC, each patient’s unique history, specifically those relevant to the current environmental demands, should be addressed with strategic care planning. 

Interdisciplinary teams must help alleviate the unintended consequences of social isolation and source control strategies (i.e. face mask use) while in pursuit of infection control.  Now, more than ever, we must be familiar with our residents and newly admitted patients, their histories, potential triggers and preferences in order to develop and employ patient-specific TIC successfully. 

Consider the following strategies:

  1. Determine the health literacy of each resident/patient and provide education concerning infection control and prevention at their level of understanding to the diminish potential for new trauma
  2. Adapt protocols as necessary and modify care plans accordingly to prevent re-traumatization.
  3. Provide patients reassurance as often as necessary that protocols in place are in their best interest.
  4. Address needs for a sense of normalcy by developing new routines, roles, and habits. 
  5. Mitigate the psychosocial effects of isolation through creative implementation of activities to promote socialization and engagement.
  6. Utilize technology to facilitate connections with family and friends, when possible.

There are no shortages of avenues for success with TIC, but communication is critical for them all.  At its core, TIC requires communication with the patient and their designated representative for historical knowledge and care plan updates. It takes each member of the interdisciplinary team offering specific insight resulting from their familiarity with the patient, to develop a thorough and comprehensive care plan for the individual that accomplishes preventing traumatization or re-traumatization.  Do not diminish the explicit value each member brings as their contribution may very well be the one to enable positive patient outcomes. 

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Strike Out Against Potentially Devastating Brain Attacks

Learn the three types of risk factors for stroke. While you may not be able to change them all, there are still ways to stack the odds in your favor.

Non-modifiable risk factors

• Age    

• Gender    

• Race/ethnicity

Modifiable risk factors

• High blood pressure                                   

• Lack of exercise

• Smoking                                                                  

• Diabetes

• High cholesterol                                                     

• Atrial fibrillation

• Sickle cell disease                                                   

• Obesity

• Alcohol abuse                                                         

• Drug abuse

• Presence of other cardiovascular disease

Harder to change or possible indicators

• Obstructive sleep apnea                                        

• Migraine

• Certain infections                                                   

• Gum disease

• Blood markers like factor V Leiden, lipoprotein(a) or others

Stroke Awareness and Prevention
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CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program

On April 26, the Centers for Medicare & Medicaid Services (CMS) announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. The agency made this announcement following the successful payment of over $100 billion to health care providers and suppliers through these programs and in light of the $175 billion recently appropriated for health care provider relief payments.

CMS had expanded these temporary loan programs to ensure providers and suppliers had the resources needed to combat the beginning stages of the 2019 Novel Coronavirus (COVID-19). Funding will continue to be available to hospitals and other health care providers on the front lines of the coronavirus response primarily from the Provider Relief Fund.

Read press release here.

Access updated fact sheet here.

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Will Your Documentation Stand Up in a Post-Pay Review Following the COVID-19 Pandemic?

The current SNF coverage decisions, under the COVID-19 Section 1135 Waivers, allow providers to render skilled services to LTC residents, considered “skilling in place.” It is important to note that the previous requirements for skilled care need as defined in Chapter 8, Section 30 of the Medicare Benefit Policy Manual remain unchanged.

The quality of our documentation should not change regardless of payer; however, when an 1135 waiver is evoked, extensive care should be taken to document the reasoning for the initiation of the Part A benefit (e.g., change in condition) and why the qualifying event (e.g., 3 day hospital stay or wellness period) was waived. According to CMS FAQs regarding the waivers, if “continued skilled care need…is unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her SNF benefits.”

Relation to the emergency may include:

  • early hospital discharge due to resource need or
  • avoiding hospital transfer due to exposure risk.

Documentation is our defense when under review—as we continue to provide care to our residents, educate nursing and therapy to demonstrate the complexity, sophistication, and medical necessity of the services provided throughout the episode of care. Our services have a positive impact on many areas of the patient’s life. It’s important that the work we do with each of them carries over onto paper to fortify defensibility following this pandemic and to ensure our patients continue to have access to quality care. 

Review the Medicare Part A waive memo here.

Review CMS FAQs for 1135 waivers here. (SNF Services may be found on pages 34-35)

AHCA Waiver Application Decision Making Flowcharts:

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