Care Matters
Every month on the third Thursday, Reliant’s Clinical Services offers a webinar to our partners on relevant topics within our industry.
January’s training An Overview of PDPM provided participants with the big picture of PDPM. In the coming months, we will be offering “deep dives” into various components of PDPM.
Join us in February to brush up on the long term care survey process and requirements of participation:Survey Preparedness: Ready, Set, Go!
Sharing patient success stories inspires clinicians and other patients alike. It’s vital to ensure the proper policy for sharing that information is followed.
We have provided you with a reference for these HIPAA requirements and Reliant’s Photo Release Form.
As we move into 2019, our focus is honed on the new payment model going into effect in October, PDPM. However, CMS continues to review current trends and initiate audits without a break in sight. With the continuation of Targeted Probe and Education (TPE) audits on the rise, strong supporting documentation, accurate billing practices and managing patient stays appropriately must be the focus of our treatment each and every day.
Read article here .
This week, Baltimore hosted CMS’ Quality Conference. McKnight’s Long Term Care News featured a recap of CMS administrator, Seema Verma’s “fiery speech” in which she indicated the Patient Driven Payment Model is the first step to move SNFs toward an “outcomes-based system.” She acknowledged continued focus on meaningful measures and offered insight into the future for CMS’s new app eMedicare and quality measure ratings.
Read full McKnight’s article .
A new DRAFT version of the 2019 MDS item sets (v1.17.0) , which is scheduled to take effect on October 1, 2019, was posted earlier this month to the MDS technical information webpage .
The files are located in the Downloads section at the bottom of the webpage (see MDS 3.0 Item Sets v1.17.0 (DRAFT) for October 1, 2019 Release [ZIP, 3MB] ).
This early draft is promising of more information to come. Reliant is monitoring CMS’ updates and postings for more information regarding October 2019 MDS and RAI changes.
CMS has finished mailing the new Medicare cards to beneficiaries across the United States.
CMS states Medicare fee-for-service health care providers submitted 58% of claims with new Medicare Beneficiary Identifiers (MBIs) indicating some success with integration. They encourage providers to utilize the new MBIs for all Medicare transactions even though the former Social Security Number-based health insurance claim numbers are permissible during the transition period.
Old cards may be used through December 2019. If a Medicare beneficiary states they have not yet received a new card, instructions are providedhere .
| by Connie Welcome, OT As America mourns the passing of our 41 st President, Mr. George H. W. Bush, what has become almost palpable is how his influence is intertwined within the fabric of our society. There are so many contributions he made that continue to penetrate our current democracy; foremost in my mind is the passage of the landmark civil rights law, the Americans with Disabilities Act (ADA) of 1990. On the day President Bush signed the bill into law, he remarked, “Every man, woman, and child with a disability can now pass through once-closed doors into a bright new era of equality, independence, and freedom.” He went on to say, “Today’s legislation brings us closer to that day when no American will ever again be deprived of their basic guarantee of ‘life, liberty, and the pursuit of happiness’. Together, we must remove the physical barriers we have created and the social barriers that we have accepted. For ours will never be a truly prosperous nation until all within it prosper.” The ADA was passed my freshman year in college, so I well remember how it impacted society, from the grumblings of business owners who had to comply with the demands of the law, to the excitement of those with disabilities who could access previously unknown worlds. For the first time in my life, I became more keenly aware that there was a large population of society who did not have access to many things that I took for granted. I began to look at the world differently, seeing it from their eyes. When I would enter a small restroom stall, I wondered what someone in a wheelchair did when they needed to go to the bathroom. Did they just stay home because it was too much trouble? I surmised that staying home was probably what I would have done. This was a time of change, change for the better, and it intrigued me to the point that I eventually went to graduate school and became an occupational therapist, with the goal of making my world a more accessible place. Today, nearly 29 years later, society often takes for granted the sweeping changes this law made. As therapists, it means that the patients we serve can access public transportation without having to leave their wheelchairs behind, shop at grocery stores without fear of being turned away and bravely enter a restaurant without fear of being refused service. There is access to public restrooms, ramps to access federal buildings and shopping centers, handicap parking spaces and doors that open with the push of a button, crosswalk signs and sounds, braille signs for those with visual impairments, and telephones and television access for the hearing impaired. From the perspective of an occupational therapist, possibly one of the most important changes was employers had to accommodate those with disabilities without discrimination. It meant our patients could and continue to be able to be gainfully employed, becoming active members of society, enjoying the benefits that work and interaction within the environment afford. For our elderly, it meant they no longer had to be “shut-ins”, but could freely access society and be accepted, not shunned. The ADA not only opened doors for patients, but for therapists alike. It provided a way for me personally to channel my desire to help others and created opportunities for therapists to implement their skills and advocate for their patients like never before. It opened a world of possibilities for successes for many in our society who had experienced few, allowing them to demonstrate their abilities. Without its passage, I would truly not be the therapist I am today, and our world would be a vastly different place! So today, as we honor the legacy of Mr. George H. W. Bush, let us continue to carry the torch and be “points of light” for the patients we serve. In his words, “Our success with this act proves that we are keeping faith with the spirit of our courageous forefathers who wrote in the Declaration of Independence, ‘We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights.'” |
| Connie is an Occupational Therapist and Clinical Services Specialist with Reliant Rehabilitation. |
Reliant offers education opportunities monthly. Each topic is selected based on your feedback, regulatory changes, and industry trends. 2019’s schedule will be packed with information you don’t want to miss! Below are topics from 2018; let your Regional Director of Operations know if you missed one of these training sessions, and you’d like to know more!
Refresh your memory with some of the Privacy Rule points below.
• HIPAA’s Privacy Rule goal is to protect the confidentiality of patient/resident healthcare information.
• Protected Health Information (PHI) is individually identifiable health information collected from an individual and created or received by a health care provider, health plan, or health care clearing house relating to past, present, or future physical or mental health conditions of an individual.
• Information is “individually identifiable” when any one or more of 18 types of identifiers can be used to identify an individual (e.g. name, address, dates such as birth date, account number etc.)
• The HIPAA Privacy Rule applies to healthcare organizations, healthcare plans, healthcare clearinghouses, and Business Associates with access to Protected Health Information (PHI).
• PHI can be in paper form, electronic as well as in verbal communications.
• Photos and videos of patients/residents are PHI and require documented authorization to take and use. • Access to PHI must be restricted to the minimum access needed to accomplish the intended objective.
• PHI cannot be used or disclosed without documented patient authorization unless it is for any of the following purposes or situations:
o Use or disclosure to the patient
o Use or disclosure for treatment, payment, or general healthcare operations
o Use or disclosure if the individual has the opportunity to agree or object to a disclosure such as a patient bringing a family with them when discussing care with a physician
• Covered Entities (CE) are required to provide residents/patients with a Notice of Privacy Practices (NPP) to tell how the CE may use and share their health information.
• Disposal of documents containing PHI must be rendered unreadable. Shredding is the most common method of disposal. Before disposal, be sure to follow your organization’s data retention policies.
For more information regarding HIPAA Privacy, visit www.hhs.gov.
On November 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.
Reliant’s Real Time Memo, which summarizes the final rule, can be downloaded here. The following is included in the summary:
Payment provisions
CMS issued an informational bulletin earlier this month notifying providers of changes that will impact states’ payments for Medicaid beneficiaries in the nursing home setting.
The bulletin indicates with the implementation of PDPM in October 2019 a new optional assessment, specific for states that rely on RUG-III and RUG-IV assessment schedule, will be available. The assessment will be active from 10/1/2019 through 9/30/2020, at which time states will have to determine an alternate calculation system for Medicaid payment. Additional detail was provided in the December 11th MLN call. Read full bulletin here.
On December 11, 2018, CMS hosted a national Medicare Learning Network call which provided a detailed look at the Patient Driven Payment Model (PDPM).
Some specific details are provided in the article above, and additional resources are available at the PDPM webpage.
Reliant is actively following CMS updates and clarification to ensure our resources and training are up to date and accurate. Watch for education opportunities in early 2019! Full audio recording and transcript are now available on the MLN homepage for download.
When PDPM was finalized in July’s final rule, there was no stopping the development of training and resources by those in our industry who make us successful. It’s what educators do, dissect, synthesize and disseminate information. However, PDPM’s outline in the final rule lacked detail in certain areas and created questions in others. Chances are, some of the training and resources you have saved (even CMS’) are now inaccurate or incomplete.
During the Medicare Learning Network call earlier this month many elements of PDPM were clarified and a few were introduced including:
1. Mapping to the PDPM clinical category will come from new items set, I0020B (What’s the main reason this person is being admitted to the SNF?) coupled with possible responses to new item set J2100-J5000 (Surgical procedures that occurred during the inpatient hospital stay that immediately preceded the SNF admission).
2. PDPM classification groups designated under administrative presumption including
a. Nursing groups within Extensive Services, Special Care High, Special Care Low, and Clinically Complex,
b. PT and OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO,
c. SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL; and d. NTA highest category of 12+.
3. Revised Health Insurance Prospective Payment System (HIPPS) coding algorithm.
4. Further instruction on the Interim Payment Assessment including use of Interim Section GG column for reporting and look back.
5. Addition of Optional State Assessment for Medicaid determination (Not a Part A PPS assessment).
6. Examples to clarify Interrupted stay policy and group and concurrent calculation.
7. Extensive instruction on RUG-IV and PDPM transition and mandated transitional IPA if patient is receiving skilled part A services prior to 10/1/2019 and continuing.
8. RAI Manual draft expected “early” 2019.
So with all of the PDPM chatter, how do we filter for quality and accuracy? How do we trust the resource we have is accurate and up to date? Here are a few tips for just that:
1. Gather information from multiple sources. Subscribe to industry leaders and state associations for updates. Read the Reliant Reveal and Real Time Memos as they arrive.
2. Take it a step at a time. No one becomes an expert overnight. Start with the clinical component and case mix groups, then move on to ICD-10 coding, or assessment time frames and rules, but be confident in one element before you begin learning the next.
3. Look for cited sources (RAI Manual, CMS material) and revision dates to resource materials. CMS has indicated they will begin time stamping the FAQ documents to indicate revisions made. Resources from other entities should do the same.
4. When possible, go to CMS webpage for clinical and NTA crosswalk information. These references are available in savable zip file format but have been updated at least two times since their initial release in August.
5. If something clicks and suddenly makes sense, write it down. Don’t assume you’ll remember.
6. Ask questions! If a comment or statement does not make sense, ask for clarification and citation.
Your partners in patient care should want to support you in your journey for knowledge and a successful transition to PDPM. Reliant is ready to keep you up to date, answer your questions, and problem solve for strategic success!
Morgan Woods was a high spirited life-of-the-party kind of guy. He was always smiling, loved to dance and was an avid wood worker. Prior to his admit he lived in another SNF and was sent out to the hospital with symptoms of Altered Mental Status. He was treated for bacteremia and toxic metabolic encephalopathy and admitted to our facility to be evaluated by Hospice.
I know all of this because at admit, I spoke at length with his daughter, Temika, as she was really on the fence about either trying therapy or admitting to hospice. I explained the process therapy would follow and she decided to give us a chance, and let us see what we could do to help.
At evaluation, he was bedridden with numerous bed sores, received nutrition via a PEG tube, and was unable to sit up or make purposeful movements. Over the past few weeks, nursing has worked hard to treat his ulcers and they have completely healed. Therapy began with small goals, such as sitting on the side of the bed, reaching out for objects, etc. As therapy progressed this is what we are able to share:
September 6, 2018  He stood in the standing frame for the first time. He fatigued very quickly and would not reach out to engage in any tabletop activity. |
| September 18, 2018 He took his first steps using a rolling walker and the assistance of two therapists. The week prior he took his first steps in the therapy gym with the assistance of three therapists. October 17, 2018 |
 He is now walking down the hallway with no assistive device and hand held assistance of two therapists. |
Morgan has started tapping his feet and dancing in his wheelchair when we play his favorite music like Michael Jackson or Motown. He will reach out to play balloon toss and will flash you the best smile!
During all of this, he took his first bites of food and is now feeding himself and enjoying food daily. Morgan has worked hard and is making wonderful progress. His family is thrilled and so are we!We look forward to seeing him progress even further and one day be able to dance again!
No Patient Left Behind (NPLB) trains our therapists in interpretation of quality indicator reports and the impact of quality measure reporting to aid in the care of facility residents. This month we’ll look a little closer at the final element: Being an Advocate.
Reliant believes it is our moral imperative to do right by our patients and ensure dignity, quality, and the highest level of independence possible. Each care partner plays a role in the resident’s success and it’s important to remember, you don’t have to go to Washington to be an effective advocate for your patients. Advocacy starts at the facility level and means you’ll be the voice for the resident who can’t speak, the movement for the resident who isn’t independently mobile, or the reliable provider for the resident who needs reassurance.
From admission to discharge, your actions are contagious and by advocating for your patients through simple acts, others will want to be a part of that passion. There is purpose in what you do, never forget that!
Last November, CMS issued a Temporary moratorium on imposing certain enforcement remedies for specific Phase 2 requirements. It was advised that this 18 month moratorium on the imposition of certain enforcement remedies be used to educate facilities about specific new Phase 2 standards.
• The following F-Tags included in this moratorium are:
• F655 (Baseline Care Plan); §483.21(a)(1)-(a)(3)
• F740 (Behavioral Health Services); §483.40
• F741 (Sufficient/Competent Direct Care/Access Staff-Behavioral Health); §483.40(a)(1)- (a)(2)
• F758 (Psychotropic Medications) related to PRN Limitations §483.45(e)(3)-(e)(5)
• F838 (Facility Assessment); §483.70(e)
• F881 (Antibiotic Stewardship Program); §483.80(a)(3)
• F865 (QAPI Program and Plan) related to the development of the QAPI Plan; §483.75(a)(2) and,
• F926 (Smoking Policies). §483.90(i)(5) While this moratorium is still active, providers should have these requirements in place now. In the same memorandum, CMS revealed changes to Nursing Home Compare (NHC) relative to survey and health inspection.
• Freeze on Health Inspection Star Ratings: Following implementation of the new LTC survey process on November 28, 2017, CMS held constant the current health inspection star ratings on NHC for any surveys occurring between November 28, 2017 and November 27, 2018.
• Availability of Survey Findings: The Survey findings of facilities surveyed under the new LTC survey process would be published on NHC, but not incorporated into calculations for the Five-Star Quality Rating System for 12 months. Link to full memorandum.
Chart review of the 3 phases of implementation:
Phase 1: Implemented November 28, 2016 *indicates this section is partially implemented in Phase 2 and/or 3
• Resident Rights and Facility Responsibilities*
• Freedom from Abuse Neglect and Exploitation*
• Admission, Transfer and Discharge*
• Resident Assessment
• Comprehensive, Person-Centered Care Planning*
• Quality of Life • Quality of Care*
• Physician Services • Nursing Services*
• Pharmacy Services*
• Laboratory, radiology and other diagnostic services
• Dental Services*
• Food and Nutrition*
• Specialized Rehabilitation
• Administration (Facility Assessment- Phase 2)*
• Quality Assurance and Performance Improvement* – QAPI Plan
• Infection Control- Program*
• Physical Environment*
Phase 2: Implemented November 28, 2017
• Behavioral Health Services*
• Quality Assurance and Performance Improvement*- QAPI Plan
• Infection Control- Facility Assessment and Antibiotic Stewardship**
• Physical Environment- smoking policies*
Phase 3: Implementation November 28, 2019
• Quality Assurance and Performance Improvement*- Implementation of QAPI
• Comprehensive Person-Centered Care Plan: Trauma informed care
• Infection Control- Infection Control Preventionist*
• Compliance and Ethics Program*
• Physical Environment- Call lights at resident bedside*
• Training Requirements*
Last month we proceeded with our series which dives into critical elements of PDPM by looking at ICD-10 coding. Due to updates provided by CMS we will take one more look at ICD-10 processes for PDPM.
During the open door forum on 11/29/2018, CMS validated information on the PDPM webpage indicating a new MDS item set will be active on October 1, 2019 which will guide the clinical category mapping for the resident. According to CMS’ training materials, new item set I0020B “What is the main reason this person is being admitted to the SNF?” allows for the primary SNF diagnosis to be entered when the response to I0020 “Indicate the resident’s primary medical condition category” is identified as 01-13. The training also provides detailed information about the new items for recording the patient’s surgical history using J2100-J5000. (As of 11/29/2018 CMS notes an error on the PDPM webpage resource New MDS Items which records I0020 as I0200).
It’s important to recognize that although this new item set replaces 18000A as the primary diagnosis mapping line, the codes entered in I8000 and identified throughout section I still require critical thinking and accuracy to ensure accurate reimbursement as these areas contribute directly to SLP comorbidities and conditions, nursing conditions and the non-therapy ancillary comorbidity score.
In the last open door forum of the year, CMS provided the following information:
• PDPM Webpage is now active. The site provides CMS created fact sheets, FAQ’s, training presentation, and resources specific to PDPM preparation CMS has created as PDPM specific email for questions or clarification needs.
• SNF VBP updates included clarification that providers incentive multipliers are available via CASPER reports. Phase I correction request review is currently in progress. Reconciled corrections will be updated via reports in the CASPER system. The Medicare Administrative Contractor (MAC) will directly apply the incentive percentage when making payment. More information is available on the SNF VBP webpage.
• SNF QRP data now posted on Nursing Home Compare. The next refresh will be in late January. Providers will receive preview reports 30 days prior. CMS directs any questions to the SNF QRP help desk.
• CMS indicated SNF QRP edit 3907 for discharge goal coding will be retired due to stakeholder feedback regarding its relevance; however, edit 3891, warning for discharge coding, will continue.
• CMS reiterated the resources available through the Civil Money Penalty Reinvestment Program (CMPRP). CMPRP is a three-year effort to reduce adverse events, improve staffing quality and improve dementia care in nursing homes.
Unless you’ve slept through the second half of 2018, you’re aware this year introduced updates to Section GG (Functional Abilities and Goals) and are at least familiar with the concept that Section GG plays a role in the Patient Driven Payment Model (PDPM). Today, let’s break down exactly how important of a role Section GG it plays in PDPM and the importance of accurate data collection.
Physical Therapy, Occupational Therapy and Nursing case mix groupers will be directly impacted by Section GG scoring and the PDPM Function Score. Read the full article here so when PDPM officially launches, communication is streamlined and your assessment team is confident in their data.
Reliant’s Section GG Flow Chart
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| Monday, October 8th: Catherine Schuman (Katie), an SLP at a facility in Ponte Vedra, FL, received notification their facility would be housing displaced residents evacuating from the path of Hurricane Michael. The residents and staff arrived with a few changes of clothes, prepared to return to Port St. Joe after Michael’s dissipation. Wednesday, October 10th: Hurricane Michael devastated Port St. Joe in a way none of them expected. Homes were destroyed, vehicles flooded, and possessions lost. Katie recognized the need immediately, not only for the residents, but the CNAs and nursing staff who accompanied them, and now had no idea when they would return home or what would be left. Katie has been part of a moms group in Ponte Vedra for several years now, and when it came time to elicit the generosity of the “Real House Moms of Nocatee” she didn’t hesitate. The response to her call for adult clothing and toiletries was overwhelming. The donations received filled two rooms in the facility. Today she says “They’re good. There is enough.” Other organizations continue gathering for children and families affected, but Katie’s desire was to ensure her residents and colleagues were comfortable. Katie was insistent in sharing the thanks and praise with her fellow neighborhood moms because without them it wouldn’t have been possible to meet the need. To the Real House Moms of Nocatee and Katie Schuman, thank you for your compassion and deliberate action to ensure our residents and staff are cared for. Katie, we are honored to have you as one of our own. |