Clinical RUG-IV. RUG Qualifiers & Length of Stay. Part 1. for clients of: Content developed and presented by:

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1 Clinical RUG-IV RUG Qualifiers & Length of Stay Part 1 for clients of: Content developed and presented by: 3030 N. Rocky Point Drive, Suite 240 Tampa, FL

2 RUG Qualifiers & Length of Stay: Part 1 Limited Copyright: October 2015, Polaris Group All materials are protected under the copyright laws. The limited copyright allows the purchaser to copy for use but not for distribution. FH79 - Developed by Polaris Group Page 1 of 86

3 RUG Qualifiers & Length of Stay: Part 1 POST TEST 1. Three of the four ADLs need to be Extensive to achieve an ADL end split of B? a. True b. False 2. Therapy end date in Section O indicates which of the following? a. The last day that therapy was provided is the end date b. This is the first day billed at non-therapy rate c. All of the above 3. Which of the following statements are accurate related to therapy days and minutes in Section O? a. You can round units to minutes b. Group minutes should be coded as concurrent minutes on MDS c. You cannot include evaluation time in minutes d. All of the above 4. Which of the following are accurate statements? a. PHQ-9 score may impact RUG end splits b. BIMS score impacts qualifiers for Cognitive/Behavior RUG c. Cognitive Performance Scale (CPS) score can also impact RUG if resident is non-interviewable d. All of the above FH79 - Developed by Polaris Group Page 2 of 86

4 RUG Qualifiers & Length of Stay: Part 1 POST TEST ANSWERS 1. Three of the four ADLs need to be Extensive to achieve an ADL end split of B? a. True b. False 2. Therapy end date in Section O indicates which of the following? a. The last day that therapy was provided is the end date b. This is the first day billed at non-therapy rate c. All of the above True A 3. Which of the following statements are accurate related to therapy days and minutes in Section O? a. You can round units to minutes b. Group minutes should be coded as concurrent minutes on MDS c. You cannot include evaluation time in minutes d. All of the above C 4. Which of the following are accurate statements? D a. PHQ-9 score may impact RUG end splits b. BIMS score impacts qualifiers for Cognitive/Behavior RUG c. Cognitive Performance Scale (CPS) score can also impact RUG if resident is non-interviewable d. All of the above FH79 - Developed by Polaris Group Page 3 of 86

5 RUGs Part 1: RUG Categories & Qualifiers & LOS 1 Definitions Minimum Data Set (MDS) PPS Prospective Payment System is the payment system using the RUG category for payment Resource Utilization Group (RUG) Payment is determined by the resources needed to care for a resident as coded on MDS. The RUG-IV is a classification based on residents clinical condition and the extent of services needed and provided. Grouper Software which determines RUG classification 2 FH79 - Developed by Polaris Group Page 4 of 86

6 RUG-IV Review See RUG-IV coding detail 3 RUG-IV Classification System 8 Categories Rehab Plus Extensive (9) Rehab (14) Extensive Services (3) Special Care High (8) Special Care Low (8) Clinically Complex (10) Behavior Symptoms & Cognitive Performance (4) Reduced Physical Functioning (10) automatically meets Skilled LOC from first MDS (5-day) up through ARD 66 RUGs 4 FH79 - Developed by Polaris Group Page 5 of 86

7 RUG-IV 66 Group Model Calculation 5 RUG-IV 66 Group Model Calculation 6 FH79 - Developed by Polaris Group Page 6 of 86

8 CMI and RATES Index Maximization Grouper looks at all possible groups and picks the RUG with the highest Case Mix Index (CMI) Used for RUG-IV Medicare Nursing and Therapy Index Together = CMI Medicare is Index Maximizing Hierarchical Classification The first group the resident qualifies in 7 Payment Rate Changes Oct. 1, 2015 Based on proposed changes, CMS projects that aggregate payments to SNFs will increase by $750 million, or 2.0%, from payments in FY 2014 Represents a higher update factor than the 1.3% update finalized for SNFs last year. 8 FH79 - Developed by Polaris Group Page 7 of 86

9 RUG-IV CMI Maximizing First Letter = RUG category Second Letter = therapy level or ADL Level Third letter = ADL end split or other end split. RUG-IV Category RUG-IV URBAN FY 2016 (Eff. Oct 1, 2015) Case-Mix Adjusted Federal Rates and Associated Indexes Nursing Index Therapy Index Nursing Component Therapy Component Non-case Mix Therapy Comp Non-case Mix Component Total Rate Maximizing RUX $ $ $86.36 $ RUL $ $ $86.36 $ ES $ $16.98 $86.36 $ RVX $ $ $86.36 $ RHX $ $ $86.36 $ RVL $ $ $86.36 $ RUC $ $ $86.36 $ RUB $ $ $86.36 $ RMX $ $70.92 $86.36 $ RHL $ $ $86.36 $ ES $ $16.98 $86.36 $ RML $ $70.92 $86.36 $ RVC $ $ $86.36 $ RLX $ $36.10 $86.36 $ ES $ $16.98 $86.36 $ RUA $ $ $86.36 $ HE $ $16.98 $86.36 $ HD $ $16.98 $86.36 $ RHC $ $ $86.36 $ RVB $ $ $86.36 $ RVA $ $ $86.36 $ LE $ $16.98 $86.36 $ HC $ $16.98 $86.36 $ HB $ $16.98 $86.36 $ CMI 9 LD $ $16.98 $86.36 $ HE $ $16.98 $86.36 $ RHB $ $ $86.36 $ CE $ $16.98 $86.36 $ RMC $ $70.92 $86.36 $ RLB $ $36.10 $86.36 $ HD $ $16.98 $86.36 $ LC $ $16.98 $86.36 $ RUG-IV CMI Maximizing (continued) CD $ $16.98 $86.36 $ LE $ $16.98 $86.36 $ RMB $ $70.92 $86.36 $ CE $ $16.98 $86.36 $ PE $ $16.98 $86.36 $ HC $ $16.98 $86.36 $ HB $ $16.98 $86.36 $ LD $ $16.98 $86.36 $ RHA $ $ $86.36 $ LB $ $16.98 $86.36 $ PE $ $16.98 $86.36 $ CD $ $16.98 $86.36 $ PD $ $16.98 $86.36 $ CC $ $16.98 $86.36 $ PD $ $16.98 $86.36 $ FH79 - Developed by Polaris Group Page 8 of 86

10 LC $ $16.98 $86.36 $ RMA $ $70.92 $86.36 $ CC $ $16.98 $86.36 $ RUG-IV CMI Maximizing (continued) CB $ $16.98 $86.36 $ LB $ $16.98 $86.36 $ PC $ $16.98 $86.36 $ CB $ $16.98 $86.36 $ PC $ $16.98 $86.36 $ BB $ $16.98 $86.36 $ BB $ $16.98 $86.36 $ CA $ $16.98 $86.36 $ PB $ $16.98 $86.36 $ RLA $ $36.10 $86.36 $ CA $ $16.98 $86.36 $ PB $ $16.98 $86.36 $ BA $ $16.98 $86.36 $ BA $ $16.98 $86.36 $ PA $ $16.98 $86.36 $ PA $92.43 $16.98 $86.36 $ ADL Coding and Score 3 or more rule!!! Difference between ADL endsplits can be over $100 a day 12 FH79 - Developed by Polaris Group Page 9 of 86

11 13 14 FH79 - Developed by Polaris Group Page 10 of 86

12 ADL Tracking /2 2/2 2/2 3/2 3/3 2/2 2/ /2 3/2 3/3 3/2 2/2 2/2 3/ /1 1/1 3/2 2/2 2/2 1/1 1/1 15 ADL Scoring Score range from 0-16 Self Performance: Column 1 Code 0, independent Code 1, supervision Code 2, limited assist Code 3, extensive assist Code 4, total dependence Code 7, activity occurred only once or twice Code 8, activity did not occur Staff Support: Column 2 Code 0, no setup or physical help from staff Code 1, setup help only Code 2, one person physical assist Code 3, two+ person physical assist Code 8, activity did not occur ADL Scoring for Bed Mobility, Transfer and Toilet Use Self Performance Column 1 Staff Support Column 2 --, 0, 1, 7, or 8 and (any number) 2 and (any number) ADL Score 3 and --, 0, 1, and --, 0, 1, or 4 and FH79 - Developed by Polaris Group Page 11 of 86

13 ADL Scoring Score range from 0-16 Self Performance: Column 1 Code 0, independent Code 1, supervision Code 2, limited assist Code 3, extensive assist Code 4, total dependence Code 7, activity occurred only once or twice Code 8, activity did not occur Staff Support: Column 2 Code 0, no setup or physical help from staff Code 1, setup help only Code 2, one person physical assist Code 3, two+ person physical assist Code 8, activity did not occur ADL Scoring for Eating Self Performance Column 1 Staff Support Column 2 ADL Score --, 0, 1, 2, 7, or 8 and --, 1, or , 0, 1, 2,7, or 8 and 2 or or 4 and --, 0, or and 2 or and 2 or RUG-IV ADL Score #1 Bed Mobility Self Performance Support 2 2 RUG-IV 1 Transfers Eating Toilet Use RUG-IV ADL Score = 4 (A) 18 FH79 - Developed by Polaris Group Page 12 of 86

14 RUG-IV ADL Score #1 Bed Mobility Self Performance Support 3 2 RUG-IV 2 Transfers Eating Toilet Use RUG-IV ADL Score = 6 (B) 19 ADL Case Studies 20 FH79 - Developed by Polaris Group Page 13 of 86

15 ADL Scores 2 nd Quarter st Quarter th Quarter rd Quarter nd Quarter 2014 ADL Level % % % % % X L C B A * Source Polaris Group KIT Database 21 ADL Scores Identifies MDS Coordinator training needs Identifies documentation deficiencies Revenue between an A and a C can be over $100 a day 22 FH79 - Developed by Polaris Group Page 14 of 86

16 ADL Data Gathering ADL data gathering - score of 6 to achieve B 3 out of 4 ADLs need to be Extensive Assist Data gathering By Shift limits total events May have only two shifts with Extensive for an ADL Interview staff; likely ext. assist was provided 3 or more times during look back chart to true number of times. Collect ADL Data gathering to by event If transfer 3 times on one shift, capture all 3 times. 23 Documentation for Section G Have formal data gathering methods for Medicare residents. Have formal data gathering systems for OBRA Initial, Quarterly, and Annual Assessments as well as Significant Clinical Change Assessments, especially needed if a Case Mix State. Ideas to limit copycat charting: Have data sheets separated for each shift, consider having worksheets turned in at the end of the shift. Nurse then transfers to flow sheet like vital signs. May consider self-performance and support in therapy when coding Section G. 24 FH79 - Developed by Polaris Group Page 15 of 86

17 Documentation for Section G If the MDS Nurse is going to code ADLs on the MDS in conflict with medical record documentation, then a summary note of findings should be written in the clinical record. Implement MDS ADL training for aides, nurses, and MDS Nurse in orientation with competency test. Implement a MDS cheat sheet for new hires and temporary agency staff for quick reference. Post MDS/ADLs related posters and signs to serve as ongoing fun reminders. 25 Documentation for Section G Provide inservices every 3 months on MDS and related ADLs. Allow time for aides to document; get rid of any unnecessary documentation. 26 FH79 - Developed by Polaris Group Page 16 of 86

18 Therapy s Role in ADL Scoring Consider therapy documentation if needed to find a 3 rd Extensive. ADLs are clearly part of a therapy plan and the levels of assistance can be a component of the discussions with the MDS Coordinator following the Rule of Three. Provide feedback regarding the late loss ADLs as noted during therapy sessions in the last 7 day; consideration will always be towards scoring the most dependent status. Therapy documentation will provide continued support for late loss ADLs through daily and weekly notes. 27 Nursing (MDS Definitions) Crosswalk to Therapy Independent Independent No help or staff oversight Supervised Supervised Oversight, encouragement, or cueing Stand-by assist without provided (no hands on) touching Limited Assistance Contact Guard Physical help in guided maneuvering of limbs or other non weight-bearing assistance Extensive Assistance Weight bearing support provided by staff Total Dependence Full Staff Performance of the activity Stand-by assist with touching but no weight-bearing Minimum Assistance (some weight bearing support) Moderate Assistance Maximum Assistance Dependent or NT Not tested for Dependence 28 FH79 - Developed by Polaris Group Page 17 of 86

19 Rehab Plus Extensive 29 Rehab Plus Extensive RUG Level Ultra High Rehab 720+ minutes during observation period at least 2 disciplines: 1 for 5 days, and a second discipline for 3 days Or, Medicare Short Stay Indicator = Yes Average minutes 144 or more Qualifies for Extensive ADL Split RUX RUL FH79 - Developed by Polaris Group Page 18 of 86

20 Rehab Plus Extensive RUG Level Very High Rehab 500+ minutes during observation period 1 discipline for 5 days Or Medicare Short Stay Indicator = Yes Average minutes Qualifies for Extensive ADL Split RVX RVL Rehab Plus Extensive RUG Level High Rehab 325+ minutes during observation period 1 discipline for 5 days Or, Medicare Short Stay Indicator = Yes Average minutes Qualifies for Extensive ADL Split RHX RHL FH79 - Developed by Polaris Group Page 19 of 86

21 Rehab Plus Extensive RUG Level Medium Rehab 150+ minutes during observation period And 5 distinct calendar days Or, Medicare Short Stay Indicator = Yes Average Minutes Qualifies for Extensive ADL Split RMX RML Rehab Plus Extensive RUG Level Low Rehab 45+ minutes of therapy And 3 distinct calendar days 2+ nursing rehab activities, at least 15 minutes/day for 6+ days Or, Medicare Short Stay Indicator = yes Average minutes Qualifies for Extensive ADL Split RLX FH79 - Developed by Polaris Group Page 20 of 86

22 Rehab Plus Extensive RUG Level Nursing Restorative Qualifiers Urinary or bowel toileting program** (Section H) Passive and/or active ROM** Splint or brace assistance Bed mobility and/or walking training** Transfer training Dressing and/or grooming training Eating and/or swallowing training Amputation/ prosthesis care Communication training ** Count as one service even if both provided 35 Changes to Rehab Medium and Low Qualifier ARD would determine past 7 days. 36 FH79 - Developed by Polaris Group Page 21 of 86

23 Rehab Medium and Low Qualifier Daily Skilled Service: 5 distinct days a week for therapy to be considered skilled. Not Daily: PT M, W, F, and OT M, W Must be 5 distinct days Must be 5 distinct days, for example: PT is scheduled 3 days each week (M, W, F) OT is scheduled 2 other days each week (T, Th) 37 Rehab Medium and Low Qualifier Daily Skilled Service: Requires a legitimate medical need for scheduling a therapy session each day or the daily basis requirement for skilled coverage. The basic issue here is not whether the services are needed, but when they are needed. No indication yet what this means to Short Stay qualifiers. 38 FH79 - Developed by Polaris Group Page 22 of 86

24 Extensive FH79 - Developed by Polaris Group Page 23 of 86

25 Extensive Tracheostomy care while a resident Ventilator/respirator while a resident Isolation for Active Contagious Disease while a resident 41 Strict Isolation Code only when the resident requires transmissionbased precautions and strict isolation alone in a separate room because of active infection (i.e., symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. 42 FH79 - Developed by Polaris Group Page 24 of 86

26 Strict Isolation Do not code this item if the resident only has a history of infectious disease (e.g., s/p MRSA or s/p C-Diff - no active symptoms). Do not code this item if the precautions are standard precautions, because these types of precautions apply to everyone. Standard precautions include hand hygiene compliance, glove use, and additionally may include masks, eye protection, and gowns. 43 Strict Isolation Code for strict isolation only when all of the following conditions are met: 1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. 2. Precautions are over and above standard precautions. That is transmission-based precautions (contact, droplet, and/or airborne) must be in effect. 44 FH79 - Developed by Polaris Group Page 25 of 86

27 Strict Isolation Code for strict isolation only when all of the following conditions are met: 3. The resident is in a room alone because of active infection and cannot have a roommate. Cannot cohort even with a resident with similar infection. 4. The resident must remain in his/her room. (This requires that services be brought activities, dining, etc.). 45 Isolation Coding Examples of when the isolation criterion would not apply include urinary tract infections, encapsulated pneumonia, and wound infections. Physician documentation to support diagnosis and isolation. Care plan address IC practices. Care plan is updated as needed and consider SCSA. Train therapy staff as indicated for resident s condition. 46 FH79 - Developed by Polaris Group Page 26 of 86

28 Extensive ADL Score of 2 or greater ADL score of 0-1 Classifies for Clinically Complex End-Splits 3 = Trach care & ventilator/respirator - ES3 2 = Trach care or ventilator/respirator ES2 1 = Isolation for active infectious disease ES1 Without Trach and Vent FH79 - Developed by Polaris Group Page 27 of 86

29 Section O Special Treatments and Procedures To be coded on MDS; therapy services would be skilled services Would not code therapy provided upon request of resident that is not skilled or maintenance Mode of each therapy received Residents time in therapy (which includes respiratory therapy) Number of minutes and number of days Include only therapy provided once living/being cared for in facility or readmitted 49 Section O Special Treatments and Procedures O0400 Therapy 1. Individual Minutes 2. Concurrent Minutes 3. Group Minutes Grouper will use sum of individual, concurrent, and group minutes to determine total RUG minutes 4. Total number of days at least 15 minutes or more considering all types of minutes. Consider ALL concurrent minutes 50 FH79 - Developed by Polaris Group Page 28 of 86

30 Section O Special Treatments and Procedures Counting minutes Count only minutes since admission Do not round minutes Do not count evaluation minutes or documentation minutes Re-evaluation minutes count Therapy Assistants can count per state oversight Family education can count if resident is present and documented 51 Section O Special Treatments and Procedures Counting minutes Therapy Aides cannot provide skilled services beyond set up minutes Setting up minutes do count Transport minutes do not count Co-treatment full resident minutes can be coded for each discipline as individual minutes Therapy Students can count within line of sight 52 FH79 - Developed by Polaris Group Page 29 of 86

31 Section O Special Treatments and Procedures Count/Code Resident Time in Therapy for each type of activity Individual Minutes Medicare Part A All Individual resident therapy minutes count - one therapist or assistant to one resident Co-treatments code as individual minutes 53 Section O Special Treatments and Procedures Concurrent Therapy Medicare Part A All concurrent minutes count toward daily minutes Two residents treated at same time by one therapist/assistant Each resident is performing different activities Regardless of payer source, if one resident is Part A, it applies to Part A resident in terms of coding on MDS. Both residents must be within line of sight of therapist/assistant Concurrent minutes do not need to be in clarification order 54 FH79 - Developed by Polaris Group Page 30 of 86

32 Section O Special Treatments and Procedures Under RUG-IV for Part A Concurrent Minutes Grouper will allocate only half of the concurrent minutes toward a therapy RUG category Resident concurrent minutes are 30; allocated minutes used for RUG is 15 minutes- divided in half by grouper Resident was in therapy for 46 minutes; 46 minutes are coded on MDS in Concurrent Therapy. The Grouper will only count 23 minutes toward RUG Grouper rounds mathematically up or down. 33 min = minutes used for grouper 55 Section O Special Treatments and Procedures Group Minutes Medicare Part A Group of 2-4 perform similar activities with one treating therapist or assistant Group minutes should be in clarification order 56 FH79 - Developed by Polaris Group Page 31 of 86

33 Section O Special Treatments and Procedures Group Minutes Medicare Part A Group of 4 perform similar activities with one treating therapist or assistant. Only 25% of Resident minutes contribute to RUG. Capped at 25% of total reimbursable minutes for each discipline Group minutes should be in clarification order 57 Group Minutes Impact: Groups must be planned for 4 residents. 30 minutes with 4 residents; is 30 minutes on each resident s MDS. However, only 7.5 (8) minutes is considered RTM by grouper to calculate RUG. Only 8 minutes is used to calculate the 25% cap. If one or two residents miss planned 4 person group therapy, SNF may still code as group minutes on MDS, and allocation still applies. 58 FH79 - Developed by Polaris Group Page 32 of 86

34 Co-Treatment Item Co-treatment minutes are coded as individual minutes. If there is one discipline with co-treatment minutes, there would have to be a second with co-treatment minutes. These minutes would match. No indication this item will impact RUG calculations. 59 Co-Treatment Coding Example PT delivered 221 individual minutes over the last 7 days. Of those individual minutes, 101 were cotreatment minutes with OT. Code 221 Individual Minutes Code 101 Co-treatment Minutes OT delivered 101 individual minutes over last 7 days. Of those individual minutes, all were cotreatment minutes with PT. Code 101 Individual Minutes Code 101 Co-treatment Minutes. 60 FH79 - Developed by Polaris Group Page 33 of 86

35 Section O Special Treatments and Procedures 5. Therapy Start date first day therapy started Start of Therapy Rehab RUG billed first day with therapy Day Evaluation done even if treatment not provided 6. Therapy End date - End of Therapy This is the last day of therapy date. (CMS ongoing clarifications) A non-therapy/medical RUG is billed the first day without therapy Carry Start and End dates over to subsequent MDS 61 Therapy End Date Therapy End Date Record the date the most recent therapy regimen (since the most recent entry) ended. This is the last date the resident received skilled therapy treatment. Enter dashes if therapy is ongoing. Scenario One: End of Therapy date is planned. Once the last therapy is discontinued/end date is last day received; and resident stays on Part A for another skilled service; an End of Therapy MDS must be completed to bill Medical RUG. Scenario Two: Resident is on Part A, still on case load, when unexpectedly discharged. 62 FH79 - Developed by Polaris Group Page 34 of 86

36 Rehab Category 63 Rehab RUG Level Ultra High Rehab 720+ minutes during observation period at least 2 disciplines: 1 for 5 days, and a second discipline for 3 days Or, Medicare Short Stay Indicator = Yes Average minutes 144 or more ADL Split RUC RUB 6-10 RUA FH79 - Developed by Polaris Group Page 35 of 86

37 Rehab RUG Level Very High Rehab 500+ minutes during observation period 1 discipline for 5 days Or Medicare Short Stay Indicator = Yes Average minutes ADL Split RVC RVB 6-10 RVA Rehab RUG Level High Rehab 325+ minutes during observation period 1 discipline for 5 days Or, Medicare Short Stay Indicator = Yes Average minutes ADL Split RHC RHB 6-10 RHA FH79 - Developed by Polaris Group Page 36 of 86

38 Rehab RUG Level Medium Rehab 150+ minutes during observation period 5 Distinct Calendar Day Or, Medicare Short Stay Indicator = Yes Average Minutes ADL Split RMC RMB 6-10 RMA Rehab RUG Level Low Rehab 45+ minutes of therapy 3 Distinct Calendar days 2+ nursing rehab activities, at least 15 minutes/day for 6+ days Or, Medicare Short Stay Indicator = yes Average minutes ADL Split RLB RLA FH79 - Developed by Polaris Group Page 37 of 86

39 Nursing Restorative Nursing Restorative Qualifiers Urinary or bowel toileting program** (Section H) Passive and/or active ROM** Splint or brace assistance Bed mobility and/or walking training** Transfer training Dressing and/or grooming training Eating and/or swallowing training Amputation/prosthesis care Communication training ** Count as one service even if both provided 69 Rehab RUGs and Therapy Minutes 70 FH79 - Developed by Polaris Group Page 38 of 86

40 71 Special Care High 72 FH79 - Developed by Polaris Group Page 39 of 86

41 Special Care High Comatose & 4 ADL = 4 or 8 Septicemia Diabetes with daily insulin injections and Insulin order change on 2 or more days Quadriplegia with ADL score >=5 Chronic obstructive pulmonary disease and Shortness of breath when lying flat; Other diagnosis can be coded for I Special Care High Fever with pneumonia, vomiting, Feeding tube (calories >= 51% or calories = 26-50% and fluid >= 501cc) coding during the entire last 7 days or weight loss Parenteral/IV feedings During Entire Last 7 Days apply to RUG Respiratory therapy for 7 days AND ADL score of 2 or more End Splits 2 = Signs of Depression PHQ-9 Score >=10 1 = Without Depression 74 FH79 - Developed by Polaris Group Page 40 of 86

42 Special Care High Mood Indicators Res. Staff Description D0200A D0500A Little interest or pleasure in doing things D0200B D0500B Feeling down, depressed, or hopeless D0200C D0500C Trouble falling/staying asleep, sleeping too D0200D D0500D Feeling tired or having little energy D0200E D0500E Poor appetite or overeating D0200F D0500F Feeling bad or failure or let self or others D0200G D0500G Trouble concentrating on things D0200H D0500H Moving or speaking slowly or being fidgety D0200I D0500I Thoughts better off dead or hurting self D0500J Short-tempered, easily annoyed 75 Special Care High Depression Score PHQ-9 Total Severity Score can be used to track changes in severity over time. Total Severity Score can be interpreted as follows: Scale is 0-27 for interview and 0-30 for observations. Applied to Interview or Observations 1-4: minimal depression 5-9: mild depression 10-14: moderate depression 15-19: moderately severe depression 20-27(30): severe depression 76 FH79 - Developed by Polaris Group Page 41 of 86

43 Special Care High ADL Score Depressed RUG-IV Class Yes HE No HE Yes HD No HD Yes HC No HC1 2-5 Yes HB2 2-5 No HB1 77 Special Care Low 78 FH79 - Developed by Polaris Group Page 42 of 86

44 Special Care Low ADL score of 2 or more AND Cerebral Palsy, Multiple Sclerosis, Parkinson s Disease with ADL score >=5; Respiratory failure and oxygen while a resident; Feeding tube (calories >= 51% or calories = 26-50% and fluid >= 501cc) coding during the entire last 7 days average across last 7 days. 79 Item Changes Related to Tube & Parenteral Feedings 80 FH79 - Developed by Polaris Group Page 43 of 86

45 Special Care Low 2+ stage 2 pressure ulcers with 2+ skin treatments** Stage III or IV pressure ulcer with 2+ skin treatments** 2+ venous/arterial ulcers with 2+ skin treatments** 1 stage 2 pressure ulcer and 1 venous/arterial ulcer with 2+ skin treatments** 81 Special Care Low Skin Treatments** Pressure relieving chair and/or bed* Turning/repositioning Nutrition or hydration interventions Ulcer care Dressing (not to foot) Ointments (not to foot) * Count as one treatment even if both provided 82 FH79 - Developed by Polaris Group Page 44 of 86

46 Special Care Low Foot infection/diabetic foot ulcer/open lesions of foot with treatment** ** Application of dressing to foot Radiation therapy while a resident; Dialysis while a resident End Splits 2 = Signs of Depression PHQ-9 Score >=10 1 = Without Depression 83 Special Care Low ADL Score Depressed RUG-IV Class Yes LE No LE Yes LD No LD Yes LC No LC1 2-5 Yes LB2 2-5 No LB1 84 FH79 - Developed by Polaris Group Page 45 of 86

47 Clinically Complex 85 Clinically Complex Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1 OR Pneumonia; Hemiplegia with ADL score >=5; Surgical wounds or open lesions with treatment; Selected Skin Treatments M1200F Surgical wound care M1200G Application of dressing (not to feet) M1200H Application of ointments (not to feet) 86 FH79 - Developed by Polaris Group Page 46 of 86

48 Clinically Complex Burns; Chemotherapy while a resident; IV medications while a resident; Oxygen therapy while a resident; Transfusions while a resident End Splits 2 = Signs of Depression PHQ-9 Score >=10 1 = Without Depression 87 Clinically Complex ADL Score Depressed RUG-IV Class Yes CE No CE Yes CD No CD Yes CC No CC1 2-5 Yes CB2 2-5 No CB1 0-1 Yes CA2 0-1 No CA1 88 FH79 - Developed by Polaris Group Page 47 of 86

49 Behavior Symptoms and Cognitive Performance 89 Behavior Symptoms and Cognitive Performance ADL score of <=5 Qualify for Cognitive Impairment CPS>=3 OR BIMS <=9 OR Qualify for Behavior Symptoms at least one of the following: Hallucinations or Delusions or One occurring on 4 or more days: Physical behavioral symptoms directed toward others Verbal behavioral symptoms directed toward others Other behavioral symptoms not directed toward others Rejection of care Wandering 90 FH79 - Developed by Polaris Group Page 48 of 86

50 Cognitive Performance BIMS C0500 Add scores Add up numerical value of coding of each item in the interview: Qualifies if <=9 The BIMS total score is highly correlated with Mini- Mental State Exam; suggest the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment FH79 - Developed by Polaris Group Page 49 of 86

51 Behavior Symptoms and Cognitive Performance ADL Score Restorative Nursing 2 or more or more 0 1 RUG-IV BB2 BB1 BA2 BA1 93 Physical Functioning Reduced Physical Functioning (10) Only changes with ADL score/splits Nursing restorative qualifiers remain the same 94 FH79 - Developed by Polaris Group Page 50 of 86

52 Physical Functioning 95 Nursing Restorative Nursing Restorative Qualifiers Urinary or bowel toileting program** (Section H) Passive and/or active ROM** Splint or brace assistance Bed mobility and/or walking training** Transfer training Dressing and/or grooming training Eating and/or swallowing training Amputation/prosthesis care Communication training ** Count as one service even if both provided 96 FH79 - Developed by Polaris Group Page 51 of 86

53 Physical Functioning Nursing Rehab. Services ADL Index Score: 0 or 1 2 or More 0-1 = PA PA1 PA2 2-5 = PB PB1 PB = PC PC1 PC = PD PD1 PD = PE PE1 PE2 97 Strategies for Oversight Monitor RUG levels achieved and compare to national norms. Number of days billed at each RUG level. ADL END-SPLITS TRENDS 98 FH79 - Developed by Polaris Group Page 52 of 86

54 RUG Distribution Polaris Group KIT data 2 nd Quarter st Quarter th Quarter rd Quarter 2014 RUG Group % % % % Ultra / Ext Very High / Ext High / Ext Medium / Ext Low / Ext Ultra High Very High High Medium Low RUG Distribution Polaris Group KIT data 2 nd Quarter st Quarter th Quarter rd Quarter 2014 RUG Group % % % % Extensive Extensive Extensive Special High Special Low Special Complex Complex Other FH79 - Developed by Polaris Group Page 53 of 86

55 Strategies for Oversight Monitor RUG levels achieved and compare to national norms. Number of days billed at each RUG level. ADL END-SPLITS TRENDS 101 Impact Use Urban Rate Sheet Increase RUA to RUB times 100 days RUA x 100 days = RUB x 100 days = Increased revenue = 102 FH79 - Developed by Polaris Group Page 54 of 86

56 Impact Use Urban Rate Sheet Increase RMB to RHB times 100 days RMB x 100 days = RHB x 100 days = Increased revenue = 103 STRATEGIES TO INCREASE LENGTH OF STAY 104 FH79 - Developed by Polaris Group Page 55 of 86

57 Impact of Increasing Length of Stay Increase in LOS by 2.0 days Average discharges per month = 4 Average per diem $325 per day 105 Impact of Increasing Length of Stay Financial Impact 12 patient discharges X 2.0 increase in LOS X $325/day $7,800/quarter $31,200/year $2,600/month 106 FH79 - Developed by Polaris Group Page 56 of 86

58 Length of Stay Trends Average LOS by Quarter (Discharged Part A Patients Only) st Quarter nd Quarter rd Quarter th Quarter st Quarter nd Quarter 2015 * Source Polaris Group KIT Database Discharges Within 30 Days Percent Discharged based on Length of Stay Discharges to Hospital LOS 0-5 LOS 6-10 LOS LOS LOS nd Quarter % 20.63% 16.05% 11.90% 14.82% 1 st Quarter % 20.41% 16.31% 11.82% 15.03% * Source Polaris Group KIT Database FH79 - Developed by Polaris Group Page 57 of 86

59 Discharges Within 30 Days Discharges by Day of Week Discharges to Hospital 2 nd Quarter st Quarter 2015 Sun Mon Tue Wed Thu Fri Sat 10.84% 13.74% 13.06% 13.89% 13.93% 13.33% 10.99% 10.06% 14.37% 13.85% 12.40% 13.50% 14.09% 10.36% * Source Polaris Group KIT Database Return to Hospital Percent of SNF discharges back to hospital 2 nd Quarter st Quarter th Quarter rd Quarter % 12.76% 12.37% 13.01% * Source Polaris Group KIT Database FH79 - Developed by Polaris Group Page 58 of 86

60 Length of Stay Nursing Once therapy is discontinued, nursing should assess for skillable nursing services EOT OMRA can now be measured 111 Length of Stay Therapy When does therapy start to treat When are patients discharged On Fridays All disciplines on the same day At the end of the month 112 FH79 - Developed by Polaris Group Page 59 of 86

61 Considerations for Length of Stay Restorative Programming Establishing an individualized restorative program and training the caregivers must occur while the patient is in a skilled bed. Caregiver education as evidenced by return demonstration as well as the training/modification related to precautions has occurred. Implementing the restorative program prior to the discharge day will allow the patient to provide feedback regarding the program. Written restorative programs must be a part of the medical record to demonstrate the skilled intervention in creating and training the program. 113 Considerations for Managing LOS Screening within 30 days When the patient is discharged to a long term care bed, rescreen the patient within 30 days to ensure the patient has maintained the functional level obtained while under Part A. If there has been a significant change, consult with the nursing for consideration of a transfer back into skilled care. When the patient is discharge to home or an ALF, establish a call back system to ensure the patient has retained the functional level since discharge. If there has been a significant change, consult with the physician/nursing for consideration of a readmission to skilled care. 114 FH79 - Developed by Polaris Group Page 60 of 86

62 Considerations for Managing LOS Re-rugging to a lower level Consider re-rugging the patient into a medium or low category prior to discharge. Allows final few higher-level goals to be addressed Allows continued assessment of the functional level when therapy has lessened RL 45 min over 7 days; therapy at least 3 days per week; any combination of PT, OT, ST; 2 or more restorative services RM 150 min over 7 days; therapy 5 days per week; any combination of PT, OT, ST 115 Considerations for Managing LOS Caregiver teaching and training Caregiver education is vital to the ongoing success of a patient s achieved therapeutic outcome. Nursing and therapists demonstrate the ongoing skilled needs and specific precautions through comprehensive education throughout the skilled stay Documentation in the medical record of ongoing education is vital to the process Education may require multiple sessions to train and observe return demonstration by the patient/caregiver 116 FH79 - Developed by Polaris Group Page 61 of 86

63 Considerations for Managing LOS Home Assessment: Can be conducted for patients receiving Medicare Part A and Part B services Requires a physician order for the home assessment May complete several weeks to several days prior to discharge The home assessment, significant findings, and goals should be clearly documented in the medical record along with specific activities and minutes spent conducting the home assessment 117 Considerations for Managing LOS Other Considerations: Review residents who expire within 72 hours of admission to determine if admission was appropriate. 118 FH79 - Developed by Polaris Group Page 62 of 86

64 Unnecessary Hospital Transfers Increase focus by CMS related to hospital transfers with a LOS 30 days or less. If hospitals readmission rate is outside threshold CMS will take money back from hospital. Can impact relationships with hospitals and physician. 119 Unnecessary Hospital Transfers At a monthly or weekly risk management meeting, review all transfers to hospital to determine if they were avoidable. Perform ongoing audit and analysis. Day of week Physician Care need issues Early or late intervention? 120 FH79 - Developed by Polaris Group Page 63 of 86

65 Evaluation of Transfers Once the evaluation is complete possible follow-up: If there were opportunities to prevent or anticipate the immediate reason for the transfer by earlier identification and management of a change in status then training should be provided to involved staff. If the resident could have been cared for here if the provider had been available or returned calls earlier work with the provider and the medical director to ensure more timely response to nursing home calls. 121 Evaluation of Transfers If the resident could have been cared for safely if the necessary tests or procedures (e.g. continuous IV) were available at the facility then review whether there are additional services could be instituted. Staff training: Review preadmission and admission practices How to identify changes in status early How to use early warning tool What to do if changes in status occur How to communicate effectively with physicians 122 FH79 - Developed by Polaris Group Page 64 of 86

66 Strategies for Oversight 123 Strategies for Oversight Monitor number of EOT and COT during weekly meetings. Monitor RUG levels at routine meetings. Daily PPS management between MDSC and Therapy. Administrator ask the tough questions Accurate MDS coding of ADLs 124 FH79 - Developed by Polaris Group Page 65 of 86

67 Strategies for Oversight Implement strategies to increase LOS. Perform review hospital transfers to determine if avoidable Identify trends Identify staff training needs Adjust culture Monitor RUG levels achieved and compare to national norms monthly. Number of days billed at each RUG level 125 FH79 - Developed by Polaris Group Page 66 of 86

68 RUG-IV Quick Reference FY 2016 CATEGORY ADL INDEX END SPLITS MDS RUG-IV CODES CMI Rural ULTRA HIGH REHABILITATION PLUS EXTENSIVE SERVICES Rehabilitation Rx 720 minutes/week minimum AND At least 1 rehabilitation discipline 5 days/week; Not Used RUX AND A second rehabilitation discipline 3 days/week 2-10 Not Used RUL Or, Medicare Short Stay = Yes Average minutes 144 or more AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more CMI Urban VERY HIGH REHABILITATION PLUS EXTENSIVE SERVICES: Rehabilitation Rx 500 minutes/week minimum AND At least 1 rehabilitation discipline 5 days/week Or, Medicare Short Stay = Yes Average minutes Not Used Not Used RVX RVL AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more HIGH REHABILITATION PLUS EXTENSIVE SERVICES Rehabilitation Rx 325 minutes/week minimum AND At least 1 rehabilitation discipline 5 days/week; Or, Medicare Short Stay = Yes Average minutes Not Used RHX Not Used RHL AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more MEDIUM REHABILITATION PLUS EXTENSIVE SERVICES Rehabilitation Rx 150 minutes/week minimum AND a minimum of 5 distinct calendar days; Or, Medicare Short Stay = Yes Average minutes Not Used RMX Not Used RML AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more LOW REHABILITATION PLUS EXTENSIVE SERVICES Rehabilitation Rx 45 minutes/week minimum AND a minimum of 3 distinct calendar days; AND Restorative nursing 6 days/week, 2 services (see Reduced Physical Function (below) for restorative nursing services); 2-16 Not Used RLX Or, Medicare Short Stay = Yes Average minutes AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more Developed by Polaris Group Page 1 FH79 - Developed by Polaris Group Page 67 of 86

69 RUG-IV Quick Reference FY 2016 CATEGORY ADL INDEX END SPLITS MDS RUG-IV CODES CMI Rural ULTRA HIGH REHABILITATION Rehabilitation Rx 720 minutes/week minimum Not Used RUC AND 6-10 Not Used RUB At least 1 rehabilitation discipline 5 days/week 0-5 Not Used RUA AND A second rehabilitation discipline 3 days/week Or, Medicare Short Stay = Yes Average minutes 144 or more VERY HIGH REHABILITATION Rehabilitation Rx 500 minutes/week minimum Not Used RVC Not Used RVB AND At least 1 rehabilitation discipline 5 days/week 0-5 Not Used RVA Or, Medicare Short Stay = Yes Average minutes HIGH REHABILITATION Rehabilitation Rx 325 minutes/week minimum Not Used RHC Not Used RHB AND At least 1 rehabilitation discipline 5 days/week 0-5 Not Used RHA Or, Medicare Short Stay = Yes Average minutes MEDIUM REHABILITATION Not Used RMC Rehabilitation Rx 150 minutes/week minimum 6-10 Not Used RMB AND a minimum of 5 distinct calendar days; 0-5 Not Used RMA CMI Urban Or, Medicare Short Stay = Yes Average minutes LOW REHABILITATION Rehabilitation Rx 45 minutes/week minimum AND a minimum of 3 distinct calendar days; Not Used Not Used RLB RLA AND Restorative nursing 6 days/week, 2 services (see Physical Function for restorative nursing services) Or, Medicare Short Stay = Yes Average minutes EXTENSIVE SERVICES 2-16 Trach care & ES Tracheostomy care, ventilator/respirator, or isolation for active ventilator infectious disease while a resident /respirator AND ADL score of 2 or more 2-16 Trach care or ES ventilator /respirator Isolation for 2-16 active infectious disease ES Developed by Polaris Group Page 2 FH79 - Developed by Polaris Group Page 68 of 86

70 RUG-IV Quick Reference FY 2016 CATEGORY SPECIAL CARE HIGH Comatose; septicemia; diabetes with daily injections and order change on 2 or more days; quadriplegia with ADL score >=5; chronic obstructive pulmonary disease and shortness of breath when lying flat; fever with pneumonia, or vomiting, or tube feeding (received in the entire last 7 days: calories >= 51% or calories = 26-50% and fluid >= 501cc), or weight loss; parenteral/iv feedings (both while a resident or while not a resident); respiratory therapy for 7 days AND ADL score of 2 or more Signs of Depression PHQ Score >=9.5 SPECIAL CARE LOW Cerebral palsy, multiple sclerosis, or Parkinson s disease with ADL score >=5; respiratory failure and oxygen while a resident; feeding tube (received in the entire last 7 days - calories >= 51% or calories = 26-50% and fluid >= 501cc); ulcers (2 or more stage II or one or more or stage III or IV pressure ulcers; or 2 or more venous/arterial ulcers; or one stage II pressure ulcer and one venous/arterial ulcer) with 2 or more skin care treatments; foot infection/diabetic foot ulcer/open lesions of foot with treatment; radiation therapy while a resident; dialysis while a resident AND ADL score of 2 or more Signs Depression PHQ Score >=9.5 ADL INDEX END SPLITS Depression Not Depressed Depression Not Depressed Depression Not Depressed Depression Not Depressed Depression Not Depressed Depression Not Depressed Depression Not Depressed MDS RUG-IV CODES HE2 HE1 HD2 HD1 HC2 HC1 HB2 HB1 LE2 LE1 CMI Rural Depression Not Depressed LB2 LB CLINICALLY COMPLEX Depression CE Extensive Services, Special Care High or Special Care Low qualifier and Not Depressed CE ADL score of 0 or 1 OR Pneumonia; hemiplegia with ADL score >=5; surgical wounds or open lesions with treatment; burns; chemotherapy while a resident; IV medications while a resident; oxygen therapy while a resident; transfusions while a resident Depression Not Depressed Depression Not Depressed 2-5 Depression CB Signs of Depression PHQ Score >= Not Depressed CB LD2 LD1 LC2 LC1 CD2 CD1 CC2 CC CMI Urban Depression CA Not Depressed CA1 6 6 Developed by Polaris Group Page 3 FH79 - Developed by Polaris Group Page 69 of 86

71 RUG-IV Quick Reference FY 2016 CATEGORY ADL INDEX END SPLITS MDS RUG-IV CODES CMI Rural BEHAVIORAL SYMPTOMS and COGNITIVE PERFORMANCE RNS 6+ BB Cognitive impairment BIMS score <=9 or CPS >=3 days/wk OR hallucinations or delusions OR physical or verbal behavioral symptoms toward others, other behavioral 2-5 Less RNS BB symptoms, rejection of care, or wandering exited 4 or more days RNS 6+ BA2 4 4 AND ADL score <=5 days/wk 0-1 Less RNS BA1 3 3 REDUCED PHYSICAL FUNCTION RNS 6+ PE Restorative nursing services: days/wk Urinary and/or bowel training program Less RNS PE passive and/or active ROM amputation/prosthesis care training RNS 6+ PD splint or brace assistance days/wk dressing or grooming training eating or swallowing training Less RNS PD transfer training PC NOTES: 6-10 Less RNS PC No clinical variables used bed mobility and/or walking training RNS 6+ communication training days/wk RNS 6+ days/wk CMI Urban PB Less RNS PB RNS 6+ PA2 2 2 days/wk 0-1 Less RNS PA1 1 1 DEFAULT AAA Developed by Polaris Group Page 4 FH79 - Developed by Polaris Group Page 70 of 86

72 RUG-IV Quick Reference FY 2015 CATEGORY ADL INDEX END SPLITS MDS RUG-IV CODES CMI Rural ULTRA HIGH REHABILITATION PLUS EXTENSIVE SERVICES Rehabilitation Rx 720 minutes/week minimum AND At least 1 rehabilitation discipline 5 days/week; Not Used RUX AND A second rehabilitation discipline 3 days/week 2-10 Not Used RUL Or, Medicare Short Stay = Yes Average minutes 144 or more AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more CMI Urban VERY HIGH REHABILITATION PLUS EXTENSIVE SERVICES: Rehabilitation Rx 500 minutes/week minimum AND At least 1 rehabilitation discipline 5 days/week Or, Medicare Short Stay = Yes Average minutes Not Used Not Used RVX RVL AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more HIGH REHABILITATION PLUS EXTENSIVE SERVICES Rehabilitation Rx 325 minutes/week minimum AND At least 1 rehabilitation discipline 5 days/week; Or, Medicare Short Stay = Yes Average minutes Not Used RHX Not Used RHL AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more MEDIUM REHABILITATION PLUS EXTENSIVE SERVICES Rehabilitation Rx 150 minutes/week minimum AND a minimum of 5 distinct calendar days; Or, Medicare Short Stay = Yes Average minutes Not Used RMX Not Used RML AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more LOW REHABILITATION PLUS EXTENSIVE SERVICES Rehabilitation Rx 45 minutes/week minimum AND a minimum of 3 distinct calendar days; AND Restorative nursing 6 days/week, 2 services (see Reduced Physical Function (below) for restorative nursing services); 2-16 Not Used RLX Or, Medicare Short Stay = Yes Average minutes AND Tracheostomy care, ventilator/respirator, or isolation for active infectious disease while a resident AND ADL score of 2 or more Developed by Polaris Group Page 1 FH79 - Developed by Polaris Group Page 71 of 86

73 RUG-IV Quick Reference FY 2015 CATEGORY ADL INDEX END SPLITS MDS RUG-IV CODES CMI Rural ULTRA HIGH REHABILITATION Rehabilitation Rx 720 minutes/week minimum Not Used RUC AND 6-10 Not Used RUB At least 1 rehabilitation discipline 5 days/week 0-5 Not Used RUA AND A second rehabilitation discipline 3 days/week Or, Medicare Short Stay = Yes Average minutes 144 or more VERY HIGH REHABILITATION Rehabilitation Rx 500 minutes/week minimum Not Used RVC Not Used RVB AND At least 1 rehabilitation discipline 5 days/week 0-5 Not Used RVA Or, Medicare Short Stay = Yes Average minutes HIGH REHABILITATION Rehabilitation Rx 325 minutes/week minimum Not Used RHC Not Used RHB AND At least 1 rehabilitation discipline 5 days/week 0-5 Not Used RHA Or, Medicare Short Stay = Yes Average minutes MEDIUM REHABILITATION Not Used RMC Rehabilitation Rx 150 minutes/week minimum 6-10 Not Used RMB AND a minimum of 5 distinct calendar days; 0-5 Not Used RMA CMI Urban Or, Medicare Short Stay = Yes Average minutes LOW REHABILITATION Rehabilitation Rx 45 minutes/week minimum AND a minimum of 3 distinct calendar days; Not Used Not Used RLB RLA AND Restorative nursing 6 days/week, 2 services (see Physical Function for restorative nursing services) Or, Medicare Short Stay = Yes Average minutes EXTENSIVE SERVICES 2-16 Trach care & ES Tracheostomy care, ventilator/respirator, or isolation for active ventilator infectious disease while a resident /respirator AND ADL score of 2 or more 2-16 Trach care or ES ventilator /respirator Isolation for 2-16 active infectious disease ES Developed by Polaris Group Page 2 FH79 - Developed by Polaris Group Page 72 of 86

74 RUG-IV Quick Reference FY 2015 CATEGORY SPECIAL CARE HIGH Comatose; septicemia; diabetes with daily injections and order change on 2 or more days; quadriplegia with ADL score >=5; chronic obstructive pulmonary disease and shortness of breath when lying flat; fever with pneumonia, or vomiting, or tube feeding (received in the entire last 7 days: calories >= 51% or calories = 26-50% and fluid >= 501cc), or weight loss; parenteral/iv feedings (both while a resident or while not a resident); respiratory therapy for 7 days AND ADL score of 2 or more Signs of Depression PHQ Score >=9.5 SPECIAL CARE LOW Cerebral palsy, multiple sclerosis, or Parkinson s disease with ADL score >=5; respiratory failure and oxygen while a resident; feeding tube (received in the entire last 7 days - calories >= 51% or calories = 26-50% and fluid >= 501cc); ulcers (2 or more stage II or one or more or stage III or IV pressure ulcers; or 2 or more venous/arterial ulcers; or one stage II pressure ulcer and one venous/arterial ulcer) with 2 or more skin care treatments; foot infection/diabetic foot ulcer/open lesions of foot with treatment; radiation therapy while a resident; dialysis while a resident AND ADL score of 2 or more Signs Depression PHQ Score >=9.5 ADL INDEX END SPLITS Depression Not Depressed Depression Not Depressed Depression Not Depressed Depression Not Depressed Depression Not Depressed Depression Not Depressed Depression Not Depressed MDS RUG-IV CODES HE2 HE1 HD2 HD1 HC2 HC1 HB2 HB1 LE2 LE1 CMI Rural Depression Not Depressed LB2 LB CLINICALLY COMPLEX Depression CE Extensive Services, Special Care High or Special Care Low qualifier and Not Depressed CE ADL score of 0 or 1 OR Pneumonia; hemiplegia with ADL score >=5; surgical wounds or open lesions with treatment; burns; chemotherapy while a resident; IV medications while a resident; oxygen therapy while a resident; transfusions while a resident Depression Not Depressed Depression Not Depressed 2-5 Depression CB Signs of Depression PHQ Score >= Not Depressed CB LD2 LD1 LC2 LC1 CD2 CD1 CC2 CC CMI Urban Depression CA Not Depressed CA1 6 6 Developed by Polaris Group Page 3 FH79 - Developed by Polaris Group Page 73 of 86

75 RUG-IV Quick Reference FY 2015 CATEGORY ADL INDEX END SPLITS MDS RUG-IV CODES CMI Rural BEHAVIORAL SYMPTOMS and COGNITIVE PERFORMANCE RNS 6+ BB Cognitive impairment BIMS score <=9 or CPS >=3 days/wk OR hallucinations or delusions OR physical or verbal behavioral symptoms toward others, other behavioral 2-5 Less RNS BB symptoms, rejection of care, or wandering exited 4 or more days RNS 6+ BA2 4 4 AND ADL score <=5 days/wk 0-1 Less RNS BA1 3 3 REDUCED PHYSICAL FUNCTION RNS 6+ PE Restorative nursing services: days/wk Urinary and/or bowel training program Less RNS PE passive and/or active ROM amputation/prosthesis care training RNS 6+ PD splint or brace assistance days/wk dressing or grooming training eating or swallowing training Less RNS PD transfer training PC NOTES: 6-10 Less RNS PC No clinical variables used bed mobility and/or walking training RNS 6+ communication training days/wk RNS 6+ days/wk CMI Urban PB Less RNS PB RNS 6+ PA2 2 2 days/wk 0-1 Less RNS PA1 1 1 DEFAULT AAA Developed by Polaris Group Page 4 FH79 - Developed by Polaris Group Page 74 of 86

76 Impairment Count (Number of the following): Decision Making: Not Independent = 1-2 Understood: Not Independent = 1-3 Short-Term Memory: Not OK = 1 CPS SCORING RULES All Residents Severe Impairment Count (Number of the following): Decision Making: Mod: Impaired = 2 Understood: Sometimes/Never = 2-3 No (0, -) Coma? Yes (1) Not Severely Impaired (0-2, -) 0 Impairment 2 or 3 Count? Decision- Making Severely Impaired (3) No (0-3, -) Total Dependent Eating? Yes (4, 8) 1 0 Severe 2 Impairment Count? Average mini mental score in field trial where 30 is best and 0 is worst Intact 24.9 Borderline Intact 24.9 Mild Impairment (0) (1) (2) (3) (4) (5) (6) NOTE: Values are denoted as (0-2,-); dash signifies missing data. Moderate Impairment 15.4 Mod. Severe Impairment 6.9 Severe Impairment 5.1 Very Severe Impairment 0.4 The CPS scale is used in the RUG-IV classification system to measure a resident s cognitive performance. The RUG-IV Classification system uses the CPS scale to identify residents who demonstrate moderate to severe cognitive impairment as a basis for classification in Impaired Cognition RUG-IV groups. FH79 - Developed by Polaris Group Page 75 of 86