MDS CHANGES FOR 2015: IMPACT ON 5-STAR, QMS AND AUDITS. Maureen McCarthy RN, BS, RAC-CT President & CEO Celtic Consulting, LLC

Transcription

1 1 MDS CHANGES FOR 2015: IMPACT ON 5-STAR, QMS AND AUDITS Maureen McCarthy RN, BS, RAC-CT President & CEO Celtic Consulting, LLC

2 2 OBJECTIVES Review MDS item set changes 10/1/14 Review the new policy regarding the Change of Therapy assessment (COT) Discuss new focused surveys IMPACT changes to QMs & 5-star ratings OMIG audits Identify reimbursement changes for FY 2015

3 3 MDS Coding changes The latest item set (book) is the 10/1/2014 version v Verify that you are using the most updates version Minimal impact on MDS coding for FY 2015

4 Readmission/return eliminated 4

5 5 A1500-A1550 Comprehensive assessments only: PASRR questions ID/DD (intellectual disability/developmental delay) checklist

6 6 A1600 Entry Date DEFINITION ENTRY DATE The initial date of admission to the facility, or the date the resident most recently returned to your facility after being discharged. Updated when there is a discharge return not anticipated, death, or discharge return anticipated where the resident returns after 30 days.

7 7 A1900 Admission date Item Rationale To document the date this episode of care in this facility began. An episode is one or more stays. Coding Instructions The Admission Date may be the same as the Entry Date (A1600) for the entire stay (i.e., if the resident is never discharged).

8 Section S 8 The data specs will not contain information about the Section S items that have been selected by each State. As with MDS 2.0, software vendors must obtain that information from individual States.

9 Section S 9

10 10 Section S Implications of miscoding may have an impact on how your CMI is calculated Still no answer from DOH as to the definitions/differences between Managed Medicaid (beginning 2/1/15?) Managed LTC

11 11 MDS changes COT COT changes and constraints imposed by CMS 10/1/11 will be overturned for FY 2015 New Guidance Once a resident index maximizes into a nursing RUG, CMS will allow us to do a COT to index back into a rehab RUG.IF.

12 COT Guidance COT can be used to RUG back into rehab RUG: 1. The resident RUGs into a rehab category on a prior MDS 2. The resident remains on program throughout 3. No EOT MDS was done 12 So in essence, you can reclassify into a rehab RUG, but not initially classify in a rehab RUG

13 Section O validation checks Therapy start and end dates must be on or after entry/admission date Number of therapy days reported for each discipline must be less than or equal to the number of days from therapy start date and ARD Distinct therapy days must be less than or equal to number of days between start and end of therapy dates or ARD 13

14 14 Focused Surveys 2 new surveys proposed by CMS due to roll out in 2015 Dementia Care MDS coding and accuracy 24 of 25 facilities surveyed showed errors in MDS coding

15 15 Focused Survey Deficient practices will result in a CMS Statement of Deficiencies being issued for non-compliance Additional concerns may be reported to the State Agency as complaints for further review 2 surveyors will be trained by CMS from each state which participates

16 16 MDS survey Will include the entire RAI and not just the MDS MDS, Care Area Assessments, Care Plans Case mix states have the most to lose F-Tags F272 through F287 may be cited CMS will again chose which facilities will be audited States may request

17 Dementia Care 17 Purpose is to improve dementia care practices across the country Areas of concern: Person-centered care Individualized care plans Enhanced resident and family engagement F-tags F309 & F329 using new guidance released in 2013

18 18 Dementia Care Will include a detailed review of residentlevel and organizational-level processes CMS will identify the facilities to be audited Dementia care experts (identified by the State) are expected to accompany surveyors on the first surveys

19 IMPACT Improving Medicare Post Acute Transformation Act of 2014 (IMPACT) Purpose is to compare outcomes across care settings Standardize assessment process-all settings Solves the problem of verifying self reported data Current areas of concern for SNF providers Changes to the domain weights 19

20 Staffing & QM Domains Improve reliability and utility of the data 20 CMS has been concerned about self reported data that is difficult to verify Shift more weight to verifiable data Changes as of Payroll-based staffing reporting Select facilities at first with fill roll out expected Focused survey inspections New QMs added

21 21 Payroll-based staffing reporting Quarterly electronic reporting of payroll Reported staffing levels auditable back to payroll Allows CMS to calculate QMs for staff turnover/retention and changes throughout yr Report types and levels of staffing for each facility CMS expects providers to use the data to improve staffing and quality of care Begins 1/1/15 as pilot with full expansion by the end of FY 2016 (9/30/16) Minimum staffing levels??

22 2014 Focused MDS Survey Pilot 22 CMS found the pilot to be successful In addition to annual survey visits Verifying coding accuracy and data used in QMs F-tags Mainly LTC MDSs involved in QMs May verify staffing levels, in some cases Compare results to what the facility reported during survey

23 New QMs Nursing Home 23 Compare Beginning 1/1/2015 report Antipsychotic use Currently reported QM but not on 5 star Additional QMs Rehospitalizations Return to community rates Will be collected through claims submissions

24 Calculating the overall rating 24

25 25 5 Star ratings Example 3 stars for survey = 3 5 stars for QMs = 5 (adds a star) 4 stars for staffing = 5 (4 or 5 adds a star) Overall Star rating = 5 stars

26 26 5 Star Ratings/Quality Metrics Star Ratings fluctuate MDS Data can go back as far as 369 days Monitor your QM reports regularly CASPER vs. Nursing Home Compare Survey sets the basis for your stars, then QMs and staffing add to the star basis

27 27 5 Star calculation Survey Points are assigned to individual health deficiencies according to their scope and severity more points are assigned for more serious, widespread deficiencies, and fewer points for less serious, isolated deficiencies

28 28 Survey weights 3 most recent annual inspections Includes complaint surveys Each deficiency is weighted by scope & severity More recent surveys weigh more heavily Most recent= ½ of survey score total 1 st prior survey= 1/3 of survey score 2 nd prior survey= 1/6 of survey score

29 29 How resurvey weighs in Revisit # 1 st 2 nd 3 rd 4 th Takes into account multiple revisits to achieve compliance Noncompliance points 0 50% of survey score 70% of survey score 85% of survey score

30 30 Complaint surveys Substantiated findings from last 36 months Within the last calendar year= ½ weight months ago= 1/3 weight months ago=1/6 weight

31 31

32 32 Cut point tables Survey score thresholds for NY 1 star 2 star 3 star 4 star 5 star 49.3 or^ thru 25.3 thru 14.6 thru 6.0 below 6 December 2014

33 33 Staffing Stars Expected staffing levels calculated based on resident acuity levels using RUGs (MDS data) 2 separate staffing measures with equal weight, score based on combination RN staffing hours PPD Total nurse staffing hours PPD RNs, LPNs, Aides

34 Where does CMS get staffing data Staffing numbers come from the CMS-672 form completed during survey 34 Full time employees Part time employees Contracted staff Census from the 672 (total residents) Resident census & conditions report

35 Staffing Stars 35 Compares 3 areas of staffing Actual staffing hours per patient day (PPD) Expected staffing hours PPD-based on CMI/RUGs Adjusted staffing hours PPD

36 Expected Staffing weights Staffing is a case-mix adjusted based on RUG categories 36 RUGs for each resident are calculated on the last business day of each quarter using the most recent assessment for each resident at the facility during the quarter Facilities with higher acuity are expected to have higher staffing levels

37 37 Expected Staffing Stars Based on percentile ranking compared to other facilities nationwide Staffing thresholds for RUGs from time studies (STRIVE) Uses the quarter closest to the date of the most recent standard (annual) survey

38 Case mix adjustment-rugs Case-mix adjustment PPD 38 Hours reported on 672 divided by hours expected times National average hours Hrs reported/hrs expected x national hrs= adjusted hrs Reported hours-672 form at survey Expected hours-reported hours with case-mix adjustment National average- average across the country

39 IMPACT Act of Will have a major effect on the 5-star rating system We can expect much more fluctuation in ratings than we currently see

40 IMPACT on 5-star 40 Domain weights will be effected Verifiable data will hold more weight CMS expects to see a decrease in the number of facilities with 5 stars in QMs and Staffing 77% of facilities are 4 or 5 star for QMs July 2014 This will have a direct impact on overall 5- star

41 41 Changes to 5 star from IMPACT More frequent updates of staffing PPDs Will be reporting quarterly through payroll So changes in staffing can be expected quarterly Currently staffing stars fluctuate mainly related to RUG changes

42 42 QM star ratings Long Term & Short Term measures Determined by CDIF (cumulative days in facility) Long Term-101 or more days in the facility Short Term-100 or fewer days in the facility

43 43 Long Term QM areas Moderate to severe pain (interview) High risk for pressure ulcers New/worsening pressure ulcers Restraints Falls with major injury Low risk for loss of bladder or bladder UTI

44 44 Long Term QM areas Catheter use Increased assist with ADLs Weight loss Increased incidence of depression or anxiety Antipsychotic use

45 45 Short Term QM areas Moderate to severe pain (interview) New or worsened pressure ulcers Antipsychotic use

46 Clinical impact on QM s ADL changes- based on state comparisons 46 Late loss ADLs (currently 40% of QM weight ) Bed Mobility Transfer Toileting Eating Self performance changes in 2 areas of ADLs OR 2 level change in 1 area of self performance Supervision to Extensive Assist Limited Assist to Total Independent to Limited Assist

47 OMIG Auditing Tips Interview sections 47 Is the resident rarely or never understood? Check your Section B700 answers If the resident is interviewable, the assessment should not be used, the interview should be completed. If auditors are on-site, they may interview residents themselves

48 OMIG Auditing Tips 48 Diagnosis codes Supportive documentation from MD or extender Some cause increases in RUG level Dementia add-on, MS, Quadriplegia, etc. Care plans should also support the diagnoses

49 OMIG Auditing Tips ADL coding 49 Code what is documented, not what you know If not using flow sheets, make sure staff interviews or observations are documented and support the frequency of the task and the number of staff Only include assist from staff: agency, or contract Care plan should support coding

50 OMIG Auditing Tips Respiratory 50 Oxygen use MD order for continued use Documentation should support that the service was performed-mar signed off Respiratory treatments Document minutes RN assessment O2 sats documented

51 OMIG Auditing Tips MD orders & visits 51 Routine orders vs. order changes Orders in look-back for services in the future Rehab services Same Part B residents every window Is there really a decline, and is it documented by nsg? Skills of a therapist required Cognition impact on follow through

52 OMIG Auditing Tips 52 Restorative Nursing Programs Assessment, goals, progress notes, minutes 2 programs 6 of 7 days Includes Section H bowel & bladder programs

53 OMIG Auditing Tips Preparation 53 Get records ready once list is sent Tracking system for RUG triggers for consistency Flag documents for review that support RUGs Speeds up the process Gives you time to find missing documentation

54 QUICK FIXES 54 ICD-10 was delayed until 10/1/2015 Begin to form transition plans for your staff Identify which staff members utilize diagnosis information now (i.e. MDS, rehab, ICN, finance) Recommend beginning the conversion in the Spring of 2015 as the regulatory MDS is due Clean up any old or resolved diagnoses first

55 Part B Rehab 55 The Doc fix is extended until 4/1/2015 Therapy cap exception process extended Payment reviews are likely to be post-pay rather than pre-pay, as has been the case in NY CMS intends to increase performance standards, including penalties for overturned denials

56 56 Hospital Readmissions Value-Based Purchasing Readmission Policy Readmission rates will be risk-adjusted CMS is looking at phasing in readmission penalties for SNFs Financial impact to hit in 2019

57 CBSA changes counties will move from urban to rural 105 counties will move from rural to urban 15% of facilities have rate increases 22% of facilities have rate decreases

58 Transition Rates For those counties transitioning to a new CBSA a 1-year transition rate will be set up 58 50% of the rate will be based on the new CBSA structure and 50% of the original CBSA region AHCA has a transition rate tool available

59 59 HIPPS & RUGs for HMOs RUGs and HIPPS modifiers are required for managed care payers beginning 7/1/14 This does NOT mean that a PPS MDS assessment need to be completed in all cases! Only an OBRA admission MDS is required 10/31/14 direction from CMS on what to do if the resident is discharged prior to day 14.

60 60 HIPPS & RUGs for HMOs If a resident is not in the facility long enough for an admission assessment (14 days), a RUG score and HIPPS modifiers of AAA00 may be used. No assessment is required Unless you are contracted to be paid by the RUG See CMS handout

61 61 Questions? Maureen McCarthy President & CEO of Celtic Consulting Medicare/MDS & CMI services Phone: East Main Street, Suite 308 Torrington, CT 06790