AVOID FINANCIAL PENALTIES BY PREPARING FOR MDS 3.0 UPDATE

AVOID FINANCIAL PENALTIES BY PREPARING FOR MDS 3.0 UPDATE SNF QRP Quality Measures or Not? August 25, 2016 Carol Smith, RN,BSN, RAC-CT Managing Consultant csmith@bkd.com Suzy Harvey, RN-BC, RAC-CT Managing Consultant sharvey@bkd.com 1

TO RECEIVE CPE CREDIT Participate in entire webinar Answer polls when they are provided If you are viewing this webinar in a group Complete group attendance form with Title & date of live webinar Your company name Your printed name, signature & email address All group attendance sheets must be submitted to training@bkd.com within 24 hours of live webinar Answer polls when they are provided If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar LEARNING OBJECTIVES Describe CMS guidance on how to comply with Section GG of the MDS 3.0 Recognize why dashes should be avoided on the MDS 3.0 with new requirements starting October 1, 2016 Identify different programs that track facility quality measures 2

WHAT WE WILL COVER Learn how the IMPACT ACT of 2014 will impact your facility Understand the 3 SNF Quality Reporting Program Measures Be able to complete the new Section GG & PPS discharge assessment with confidence Understand consequences of not completing & submitting PPS assessments related to SNF QRP Understand how the 3 Quality Measures for SNF QRP are different from the 6 new QMs SNF QUALITY REPORTING PROGRAM (SNF QRP) IMPACT ACT of 2014 signed into law October 6, 2014 Requires Standardized Patient/Resident Data Uniformity Quality care & improved outcomes Ability to compare quality & data across Post-Acute Care (PAC) settings Improve discharge planning Exchangeability of data Coordination of care 3

SNF QUALITY REPORTING PROGRAM (QRP) Established by CMS in the FY2016 SNF PPS Final Rule SNF that does not submit the required QMs receives a 2% point reduction to their annual payment update (APU) for the applicable payment year Three QMs for SNF QRP will be collected beginning October 1, 2016 for FY 2018 & subsequent annual payment update determinations All three QMs use assessment data from the MDS SNF QUALITY REPORTING PROGRAM FY2018 Payment Determination & Subsequent Years CMS will collect data on residents who are admitted to the SNF on & after October 1, 2016 & discharged from the SNF up to & including December 31, 2016 SNFs must submit data for 80% of MDS assessments (No Dashes) A SNF is compliant with the QRP if all data necessary to calculate the QM has been submitted 4

SNF QUALITY REPORTING PROGRAM SNF may request an exception or extension for the QRP within 90 days of the date of an extraordinary circumstances Request for exception or extension for one of more quarters by submitting a written request via email to the SNF Exception & Extension mailbox. The mailbox will be activated when the QRP is implemented SNFQRPReconsiderations@cms.hhs.gov Requests sent to CMS through any other channel will not be considered valid SNF QUALITY REPORTING PROGRAM Beginning with the FY2018 payment determination, SNFs will receive notification of noncompliance Identified as being non-compliant for the applicable FY SNF will be scheduled to receive the 2% reduction to APU for applicable FY SNF may file a request for reconsideration if it believes the finding of noncompliance are in error SNF must follow a defined process for request for reconsideration 5

SNF QUALITY REPORTING PROGRAM Public reporting begins in fall of 2018 SNFs will have a period for review & correction of quality data prior to public reporting No word from CMS on how SNF QRP quality measure will effect the 5-Star Rating system THREE SNF QRP QUALITY MEASURES (QM) Application Percent of Long-Term Care Hospital Patients with an Admission & Discharge Functional Assessment & a Care Plan That Addresses Function Process Measure Percent of Residents with Pressure Ulcers That Are New or Worsened - Outcome Measure Application Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) - Outcome Measure 6

PROCESS & OUTCOME MEASURES Process measures indicate what a provider does to maintain or improve health, either for healthy people or for those diagnosed with a health care condition Outcome measures reflect the impact of health care services or interventions on the health status of patients SNF QRP IMPACT ON MDS 7

ASSESSMENTS USED IN SNF QRP OBRA-required assessments Scheduled PPS assessments Discharge assessments Discharge assessment return not anticipated Discharge assessment return anticipated Part A PPS Discharge assessment (NEW) THREE TYPES OF DISCHARGE ASSESSMENTS There are now 3 types of Discharge Assessments required The first two are well-known to you! OBRA Discharge Assessment Return Anticipated OBRA Discharge Assessment Return NOT Anticipated New: Part A PPS Discharge Assessment Completed when a resident s Medicare Part A stay ends BUT The Resident REMAINS IN THE FACILITY (Is not physically discharged from the facility) Effective: OCTOBER 1, 2016 8

PART A PPS DISCHARGE ASSESSMENT The Part A PPS Discharge assessment is a Discharge assessment developed to gather data to calculate current & future SNF QRP measures It consists of demographic, administrative & clinical items. The Part A PPS Discharge assessment is completed when a resident s Medicare Part A stay ends, but the resident remains in the facility (i.e., is not physically discharged from the facility) PART A PPS DISCHARGE ASSESSMENT If the Medicare Part A stay ends on the day of or one day before the date of physical discharge, the OBRA Discharge Assessment & PPS Part A Discharge Assessment are both required & may be combined When the OBRA & Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to the Discharge Date (A2000) 9

PART A PPS DISCHARGE ASSESSMENT For a standalone Part A PPS Discharge assessment, the ARD (Item A2300) is not set prospectively as with other assessments The ARD (Item A2300) for the standalone Part A PPS Discharge assessment is always equal to the End Date of Most Recent Medicare Stay (Item A2400C) The ARD may be coded on the assessment any time during the assessment completion period (i.e., End Date of Most Recent Medicare Stay [A2400C] + 14 calendar days.) Item A2300 = A2400C PART A PPS DISCHARGE ASSESSMENT THINGS YOU KNOW The Part A PPS Discharge assessment must be completed (Item Z0500B) within 14 days after the End Date of Most Recent Medicare Stay (A2400C + 14 calendar days) The Part A PPS Discharge assessment must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days) If the resident s Medicare Part A stay ends & the resident subsequently returns to a skilled level of care & Medicare Part A benefits resume, the Medicare schedule starts again with a 5-day PPS assessment If the resident s Medicare Part A stay ends & the resident is physically discharged from the facility, an OBRA Discharge assessment is required 10

MDS CHANGES RELATED TO PPS DISCHARGE ASSESSMENT CODING TIPS - A2000 A standalone Part A PPS Discharge assessment (NPE Item Set) is required under the SNF QRP when the resident s Medicare Part A stay ends (as documented in A2400C,End Date of Most Recent Medicare Stay) but the resident remains in the facility If a resident receiving services under Part A has a Discharge Date (A2000) that occurs on the day of or one day after the End Date of Most Recent Medicare Stay(A2400C), then both an OBRA Discharge assessment & a Part A PPS Discharge assessment are required, but these two assessments can be combined. When the OBRA & Part A PPS Discharge assessments are combined, the ARD(A2300) must be the same as the Discharge Date(A2000) 11

CODING TIPS - A2400C, END OF MOST RECENT MEDICARE STAY The end of Medicare date (A2400C) is coded as follows, whichever occurs first Date SNF benefit exhausts (i.e., the 100th day of the benefit); or Date of last day covered as recorded on the effective date from the Notice of Medicare Non-Coverage(NOMNC); or The last paid day of Medicare A when payer source changes to another payer (regardless if the resident was moved to another bed or not); or Date the resident was discharged from the facility (see Item A2000, Discharge Date) NEW CODING TIPS FOR A2400C The End Date of Most Recent Medicare Stay (A2400C)may be earlier than the actual Discharge Date (A2000)from the facility. If this occurs, the Part A PPS Discharge assessment is required. If the resident subsequently physically leaves the facility, the OBRA Discharge assessment would be required If the End Date of Most Recent Medicare Stay(A2400C) occurs on the same day that the resident dies, a Death in Facility Tracking Record is completed, with the Discharge Date(A2000) equal to the date the resident died. In this case, a Part A PPS Discharge assessment is not required 12

SPECIAL INSTRUCTION CHANGE OF THERAPY (COT OMRA) In cases where the last day of the Medicare Part A benefit (the date used to code A2400C on the MDS) is prior to Day 7 of the COT observation period, no COT OMRA is required If the date listed in A2400C is on or after Day 7 of the COT observation period, then a COT OMRA would be required if all other conditions are met (Not Optional) If the date listed in A2400C is on Day 7 of the COT observation period, then the SNF must complete both the COT OMRA & the Part A PPS Discharge assessment (Separately) SPECIAL INSTRUCTIONS COMBINING ASSESSMENTS When combining Medicare scheduled or unscheduled assessments with the Part A PPS Discharge assessment The ARD (Item A2300) must be set for the last day of the Medicare Part A Stay (A2400C) AND The Medicare Part A stay must fall within the allowed window of the Medicare scheduled assessment, or must fall within the parameters allowed for the Medicare unscheduled assessment being completed 13

SUMMARY OF PART A PPS DISCHARGE ASSESSMENT Part A PPS Discharge assessment is a new Discharge assessment type It is required under the IMPACT Act for the purposes of collecting standardized data on admission & discharge for quality measure reporting in the SNF QRP The Part A PPS Discharge assessment is completed as a standalone assessment when a person s Medicare Part A stay is ending but he/she is planning to remain in the facility as along-term care resident When a resident discharges from the facility within one day of the Medicare Part A stay, the Part A PPS Discharge may be combined with the OBRA Discharge assessment SNF QRP INCOMPLETE STAYS Residents who have incomplete stays are defined as those residents Who are discharged unexpectedly due to a medical emergency Who leave the SNF against medical advice Who die while in the SNF Residents NOT meeting the criteria for incomplete stays will be considered complete stays 14

RESOURCE Skilled Nursing Facility Quality Reporting Program - Specifications for the Quality Measures Adopted through the Fiscal Year 2016 Final Rule https://www.cms.gov/medicare/quality-initiatives-patient- Assessment-Instruments/NursingHomeQualityInits/Downloads/ SNF-QRP-Measure-Specifications_August-2015R.pdf MDS Items That Impact SNF QRP 15

MDS CODING FOR FALLS WITH MAJOR INJURY (LONG STAY) The items used for this measure collect data that indicates whether or not a fall took place (J1800), & if so, the number of falls in each of the following categories (J1900) J19000A J1900B J1900C No Injury Injury (except major) Major injury Only the data on number of falls resulting in major injury (J1900C) are included to calculate this measure MDS CODING FOR FALLS WITH MAJOR INJURY (LONG STAY) 16

MDS CODING FOR FALLS WITH MAJOR INJURY (LONG STAY) MDS CODING FOR FALLS WITH MAJOR INJURY (LONG STAY) Coding Instructions for J1900C, Major Injury Code 0, none: if the resident had no major injurious fall since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS) Code 1, one: if the resident had one major injurious fall since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS) Code 2, two or more: if the resident had two or more major injurious falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS) 17

MDS 3.0 CODING FOR NEW OR WORSENED PRESSURE ULCERS New or worsened pressure ulcers are determined based on complete Medicare stays (defined as a 5-day PPS & a discharge assessment which may be a standalone Part A PPS discharge or combined with an OBRA Discharge assessment) that end during the selected time window with one or more new or worsened Stage 2 4 pressure ulcers at the end of the stay determined by the discharge assessment Stage 2 (M0300B1) (M0300B2) > 0, OR Stage 3 (M0300C1) (M0300C2) > 0, OR Stage 4 (M0300D1) (M0300D2) > 0. MDS 3.0 CODING FOR NEW OR WORSENED PRESSURE ULCERS 18

SNF QRP Application of Percent of Long-Term Care Hospital Patients With an Admission & Discharge Functional Assessment & a Care Plan That Addresses Function CMS has adopted this measure to satisfy the IMPACT Act requirements for CMS to specify QMs & post acute care (PAC) providers to report standardized data regarding functional status, cognitive function & changes in function & cognitive function This QM reports the percent of patients/residents with an admission & a discharge functional assessment & a goal that addresses function Will use Section GG effective October 1, 2016 SNF QRP When a resident has an incomplete stay, collection of discharge functional status data might not be feasible For residents with incomplete stays, admission functional status data & at least one treatment goal would be required, discharge functional status data would not be required to be reported 19

Section GG: Functional Abilities & Goals SNF QRP - SECTION GG Application of Percent of Long-Term Care Hospital Patients With an Admission & Discharge Functional Assessment & a Care Plan That Addresses Function These items assess the need for assistance with self-care & mobility activities Items focus on resident s self-care & mobility Admission performance Discharge goals Discharge performance 20

SNF QRP - SECTION GG Physical therapists, occupational therapists, speech language pathologists & nurses are the typical staff involved in the assessment of self-care & mobility items Coding Section GG very different than coding Section G 3 day look-back from start of & end of Medicare stay No rule of three Coding Usual Performance not related weight-bearing assist Scoring the reverse of Section G CMS DEFINITION OF USUAL PERFORMANCE Usual or Baseline Performance Usual activity/performance for self-care or mobility Not the most independent or dependent over the assessment period If fluctuations in performance during the 3-day assessment period The performance wouldn t be the worst or best but the usual 21

SNF QRP - SECTION GG Coding for Section GG begins October 1, 2016 Original Medicare Part A residents only Section GG completed with PPS Assessments only 5-day PPS (A0310B=1) Part A PPS Discharge (A0310H=1) Planned discharged (A0310G=1) Completed for residents who admit/readmit or resume Medicare Part A coverage on or after October 1, 2016 SECTION GG NEW DEFINITION: HELPER A helper is defined as facility staff who are direct employees & facility-contracted employees (e.g., rehabilitation staff, nursing agency staff) Does not include individuals hired, compensated or not, by individuals outside of the facility s management & administration such as hospice staff, nursing/cna students, etc. Therefore, when helper assistance is required because a resident s performance is unsafe or of poor quality, only consider facility staff assistance when scoring according to amount of assistance provided 22

SECTION GG Intent: Assesses the need for assistance with self-care & mobility activities GG0130: Self-Care GG0170: Mobility At least one of the Section GG items MUST have a coded Discharge Goal to be considered for the quality measure calculation 23

GG0130: SELF-CARE Admission Performance & Discharge goals completed on 5-day PPS assessment for self-care items Eating, oral hygiene & toileting hygiene Code using data from day one to three of stay Discharge Performance completed on a planned, Part A PPS Discharge assessment for self-care items Eating, oral hygiene & toileting hygiene Code using data from last 3 days of stay GG0130: SELF-CARE Steps for Assessment Observe self-care status Direct observation Resident s self-report Family & direct care staff reports Allow to perform activities as independently as possible If helper required, only consider staff assistance when scoring Activities may be completed with or without assistive devices Code based on usual performance 24

GG0130 ADMISSION OR DISCHARGE PERFORMANCE CODING Complete only if A0310B = 01, PPS 5-day assessment or A0310G = 1, Planned and A0310H = 1, Part A PPS Discharge If resident discharges two days or less after admission Section GG is not required 6-POINT SCALE FOR SCORING 06 = Independent resident requires no assistance from helper 05 = Setup or clean-up assistance resident completes activity but helper sets up or cleans up 04 = Supervision or touching assistance helper provides verbal cues or touching/steadying 03 = Partial/moderate assistance Helper does less than ½ the effort 02 = Substantial/maximal assistance-helper does more than ½ the effort 01 = Dependent helper does ALL of the effort or two or more helpers are needed for assistance 25

GG0130 ADDITIONAL CODING If Activity is not attempted, code the reason 07. Resident Refused: if the resident refused to complete the activity 09. Not Applicable: if the resident did not perform the activity prior to the current illness, exacerbation or injury 88. Not Attempted due to medical condition or safety concerns GG0130: CODING QUESTIONS Does the resident need assistance (physical, verbal/non-verbal cueing, setup/clean-up) to complete the self-care activity? If no, Code 06, Independent If yes Does the resident need only setup or clean-up assistance? If yes, Code 05, Setup or clean-up If no 26

GG0130: CODING QUESTIONS Does the resident need only verbal/non-verbal cueing, or steadying/touching assistance? If yes, Code 04, Supervision or touching assistance If no Does the resident need lifting assistance or trunk support with the helper providing less than half of the effort? If yes, Code 03, Partial/moderate assistance If no GG0130: CODING QUESTIONS Does the resident need lifting assistance or trunk support with the helper providing more than half of the effort? If yes, Code 02, Substantial/maximal assistance If no Does the helper provide all of the effort to complete the activity OR is the assistance of two or more helpers required? If yes, Code 01, Dependent 27

GG0130: CODING QUESTIONS Was the activity not attempted? Indicate why Code 07, Resident refused, if the resident refused to complete the activity Code 09, Not applicable, if the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88, Not attempted due to medical condition or safety concerns, if the activity was not attempted due to medical condition or safety concerns GG0130 CODING TIP Coding a dash ( - ) in these items indicates No information. CMS expects dash use for SNF QRP items to be a rare occurrence. Use of dashes for these items may result in a 2% reduction in the annual payment update If the reason the item was not assessed was that the resident refused (code 07), the item is not applicable(code 09), or the activity was not attempted due to medical condition or safety concerns (code 88), use these codes instead of a dash ( - ) 28

GG0130: SELF CARE ITEMS GG0130A. Eating: The ability to use suitable utensils to bring food to the mouth & swallow food once the meal is presented on a table/tray. Includes modified food consistency GG0130B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove & replace dentures from & to the mouth & manage equipment for soaking & rinsing them.] GG0130C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before & after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment EXAMPLE OF CODING EATING GG0130 Ms. S has multiple sclerosis, affecting her endurance & strength, she prefers to feed herself as much as she is capable. During all meals, and after eating three-fourths of her meal by herself, Ms. S becomes fatigued and requests assistance from CNA to feed her remainder of meal Eating would be coded 03 partial/moderate assistance 29

EXAMPLE OF CODING TOILETING HYGIENE GG0130 Mrs. L uses the toilet to void & have bowel movements. Mrs. L is unsteady, so the certified nursing assistant walks into the bathroom with her in case she needs help. During the assessment period, a staff member has been present in the bathroom, but has not needed to provide any physical assistance with managing clothes or cleansing Toileting hygiene would be coded 04 - Supervision or touching assistance GG0130. SELF-CARE - DISCHARGE GOAL 30

GG0130 DISCHARGE GOAL CODING TIPS Use the 6-point scale to code discharge goal(s) Do not use codes 07, 09, or 88 to code discharge goal(s) Establish discharge goal(s) at the time of admission Goals should be established as part of the resident s care plan A minimum of one self-care or mobility goal must be coded per resident stay on the 5-day PPS assessment Clinicians may code one goal for each self-care & mobility item included in Section GG at the time of the 5-day PPS assessment GG0130 DISCHARGE GOAL CODING TIPS Discharge Goal higher than 5-day PPS Admission Performance Code Facility expects resident to improve Discharge Goal same as 5-day PPS Admission Performance Code Resident medically complex & facility expects no progress Discharge Goal less than 5-day PPS Admission Performance Code Facility expects a decline with therapy services slowing progress 31

EXAMPLE OF DISCHARGE GOAL CODING Mrs. T has a progressive neurological illness that affects her strength, coordination & endurance. Mrs. T prefers to use a bedside commode rather than incontinence undergarments for as long as possible. The certified nursing assistant currently supports Mrs. T while she is standing so that Mrs. T can release her hand from the grab bar (next to her bedside commode) & pull down her underwear before sitting onto the bedside commode. When Mrs. T has finished voiding, she wipes her perineal area. Mrs. T then requires the helper to support her trunk while Mrs. T pulls up her underwear The clinician codes the 5-Day PPS assessment admission performance as 03, Partial/moderate assistance. The certified nursing assistant provides less than half the effort for Mrs. T s toileting hygiene Toileting Hygiene Discharge Goal: By discharge, it is expected that Mrs. T will need assistance with toileting hygiene & that the helper will perform more than half the effort. The clinician codes her discharge goal as 02, substantial/maximal assistance GG0170:MOBILITY 32

GG0170. MOBILITY Same steps for assessment as with GG0130 Self-Care Same 6-Point scale for scoring, including activity not attempted scoring Completed with same PPS assessment 5-day, Planned Part A PPS Discharge Discharge Goals completed on 5-day PPS at start of Medicare Part A stay GG0170: CODING ITEMS Some Admission Performance & Discharge Performance items different on 5-day & Part A PPS Discharge Assessment Admission- H1, Q1, RR1 & SS1 Discharge H3, Q3, RR3 & SS3 Other items same guidance for Admission Performance & Discharge Performance GG0170B, C, D, E, F, J, K, R & S 33

GG0170: CODING ITEMS GG0170B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed GG0170C. Lying to sitting on side of bed: The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor & no back support GG0170D. Sit to stand: The ability to safely come to a standing position from sitting in a chair or on the side of the bed GG0170E. Chair/bed-to-chair transfer: The ability to safely transfer to & from a bed to a chair (or wheelchair) GG0170F. Toilet transfer: The ability to safely get on & off a toilet or commode GG0170: CODING ITEMS GG0170H1. Does the resident walk? 0. No, and walking goal is not clinically indicated Skip to GG0170Q1, Does the resident use a wheelchair/scooter? 1. No, and walking goal is clinically indicated Code the resident s discharge goal(s) for items GG0170J and GG0170K 2. Yes Continue to GG0170J, Walk 50 feet with two turns GG0170H1 is done with Admission (Start of SNF PPS Stay) 34

GG0170: CODING ITEMS GG0170H3. Does the resident walk? 0. No Skip to GG0170Q3, Does the resident use a wheelchair/scooter? 2. Yes Continue to GG0170J, Walk 50 feet with two turns GG0170H3 is done with Discharge (End of SNF PPS Stay) GG0170: CODING ITEMS GG0170J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet & make two turns GG0170K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space GG0170Q1. Does the resident use a wheelchair/scooter? 0. No Skip to GG0130, Self Care 1. Yes Continue to GG0170R, wheel 50 feet with two turns GG0170Q1 is done with Admission (Start of SNF PPS Stay) 35

GG0170: CODING ITEMS GG0170Q3. Does the resident use a wheelchair/scooter? 0. No Skip to H0100, Appliances 1. Yes Continue to GG0170R, Wheel 50 feet with two turns GG0170Q3 is done with Discharge (End of SNF PPS Stay) GG0170: CODING ITEMS GG0170R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, can wheel at least 50 feet & make two turns GG0170RR1. Indicate the type of wheelchair/ scooter used 1. Manual 2. Motorized GG0170RR1 is done with Admission (Start of SNF PPS Stay) 36

GG0170: CODING ITEMS GG0170RR3. Indicate the type of wheelchair/ scooter used 1. Manual 2. Motorized GG0170RR3 is done with Discharge (End of SNF PPS Stay) GG0170S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space GG0170: CODING ITEMS GG0170SS1. Indicate the type of wheelchair/ scooter used 1. Manual 2. Motorized GG0170SS1 is done with Admission (Start of SNF PPS Stay) 37

EXAMPLE OF CODING SIT TO LYING GG0170B Mrs. F requires assistance from a certified nursing assistant to get from a sitting position to lying flat on the bed because of postsurgical open reduction internal fixation healing fractures of her right hip & left and right wrists. The certified nursing assistant cradles & supports her trunk & right leg to transition Mrs. F from sitting at the side of the bed to lying flat on the bed. Mrs. F assists herself a small amount by bending her elbows & left leg while pushing her elbows & left foot into the mattress only to straighten her trunk while transitioning into a lying position Sit to lying would be coded 02 - Substantial/maximal assistance EXAMPLE OF CODING CHAIR TO BED TRANSFER GG0170E Mr. C is sitting on the side of the bed. He stands & pivots into the chair as the nurse provides contact guard (touching) assistance. The nurse reports that one time Mr. C only required verbal cues for safety, but usually Mr. C requires touching assistance Chair/bed-to-chair transfer would be coded 04 - Supervision or touching assistance 38

EXAMPLE OF CODING TOILET TRANSFER GG0170F Mr. H has paraplegia incomplete, pneumonia & a chronic respiratory condition. Mr. H prefers to use the bedside commode when moving his bowels. Due to his severe weakness, history of falls & dependent transfer status, two certified nursing assistants assist during the toilet transfer Toilet transfer would be coded 01 - Dependent EXAMPLE OF CODING WHEELS 50FT. /W 2 TURNS GG0170R Mrs. M is unable to bear any weight on her right leg due to a recent fracture. The certified nursing assistant provides steadying assistance when transferring Mrs. M from the bed into the wheelchair. Once in her wheelchair, Mrs. M propels herself about 60 feet down the hall using her left leg & makes two turns without any physical assistance or supervision Wheel 50 feet with two turns would be coded 06 - Independent 39

SECTION GG - OVERVIEW Assessment period 5-day PPS: days 1 3 for both admission performance & Discharge Goals Part A PPS Discharge Assessment, planned only: last 3 days of stay including the last covered day Scoring not the same as Section G Coding a dash [-] in items may result in 2% reduction in APU SECTION GG MANAGEMENT Determine staff to be involved in coding Section GG IDT Team MDS, direct care staff, social services, resident Family Therapy staff talk to them before Oct. 1 How you will gather data & document findings Identify all new Medicare Part A admission within first 24 hours Track all residents during the first 3 days for usual performance Document findings Discuss finding to develop reasonable Discharge Goals Weekly meetings to have effective discharge plans Track functional performance for last 3 days of stay 40

Quality Measures Are You Confused Yet? SIX NEW QUALITY MEASURES NOT SNF QRP Short-Stay 1. Discharge to Community* (claims-based) 2. Emergency Room Use* (claims-based) 3. Re-hospitalization* (claims-based) 4. Improvement in Function Since Admission* (MDS-based) Long-Stay 5. Decline in Mobility* (MDS-based) 6. Use of Hypnotics/Anxiolytics (MDS-based) * Included in 5-Star Rating effective July 2016 41

QUALITY MEASURES Casper QM Report 17 QMs 5 Short-Stay & 15 Long-Stay Nursing Home Compare Now has 24 QMs 9 Short-Stay & 15 Long-Stay Five-Star Quality Rating System 16 QMs including 5 new QMs 7 Short-Stay & 9 Long-Stay QM Label Short / Long Stay CASPER NHC FIVE STAR Self-report Moderate/Severe Pain Short Yes Yes Yes Pressure Ulcer New or Worsened Short Yes Yes Yes Assessed & given Seasonal Flu vaccine Short No Yes No Received Seasonal Flu vaccine Short/Long No No No Offered/declined Flu Vaccine Short/Long No No No Didn t receive Flu Vaccine due to contraindicated Short/Long No No No Assessed & given Pneumonia vaccine Short No Yes No Received Pneumonia vaccine Short/Long No No No Offered/declined Pneumonia vaccine Short/Long No No No Didn t receive Pneumo vaccine due to contraindication Short/Long No No No Newly received antipsychotic medication Short Yes Yes Yes Improved Function Admit to Discharge - NEW Short No Yes Yes Re-hospitalized after NH Admission - NEW Short No Yes Yes 42

QM Label Short / Long Stay CASPER NHC FIVE STAR Residents who had outpatient ED visit NEW Short No Yes Yes Residents successfully Discharge to Community-NEW Short No Yes Yes 1 or more Fall with Major Injury Long Yes Yes Yes Self-report Moderate/Severe Pain Long Yes Yes Yes High Risk Resident with Pressure Ulcer Long Yes Yes Yes Assessed & given Seasonal Flu vaccine Long No Yes No Assessed & given Pneumonia vaccine Long No Yes No Residents with UTI Long Yes Yes Yes Low-risk Lose Control of bowel or bladder Long Yes Yes No Have/had catheter inserted & left in bladder Long Yes Yes Yes Physically Restrained Long Yes Yes Yes ADL need Increased Long Yes Yes Yes QM Label Short / Long Stay CASPER NHC FIVE STAR Excessive weight Lose Long Yes Yes No Have Depressive symptoms Long Yes Yes No Received an Antipsychotic medication Long Yes Yes Yes Antianxiety/ Hypnotic Use Long Yes Yes -NEW No Behavior symptoms affecting others Long Yes No No Prevalence Falls Long Yes No No Ability to move independently worsened - NEW Long Yes Yes Yes Resources from: Quality Measure Manual 4/2016 Casper Provider Manual Updated 4/2016 Nursing Home Compare Updated 7/2016 Five-Star Manual Updated: 7/2016 43

CASPER REPORTS Retention Time Period Changing Currently store preview reports for 230 days Effective November 1, 2016, period will change to 90 days Recommended Print & save MDS 3.0 Facility-Level & Resident-Level Quality Measure Preview reports prior to November 1, 2016 Note: Reports cannot be recreated once deleted SUMMARY For success in Quality Measures Ensure accurate MDS coding Develop process for gathering all MDS data including Section GG Use QAPI & PIPs for improvement Collaboration with IDT Remember dashes are not your friend Perform routine internal & external MDS audits 44

QUESTIONS? THANK YOU! FOR MORE INFORMATION Suzy Harvey 417.865.8701 sharvey@bkd.com Carol Smith 918.584.2900 csmith@bkd.com 45

CONTINUING PROFESSIONAL EDUCATION (CPE) CREDITS BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.learningmarket.org. The information in BKD webinars is presented by BKD professionals, but applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any matters covered in these webinars. CPE CREDIT CPE credit may be awarded upon verification of participant attendance For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at training@bkd.com. 46

47