quality & regulatory changes impacting snfs · •payroll based journal (staffing) regulatory...
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Quality & Regulatory Changes Impacting
SNFs
David R. Gifford MD MPH
Sr VP for Quality & Regulatory Affairs
Improving Lives by Delivering Solutions for Quality Care
Three Rs Impacting SNFs
Reimbursement
• Hospital paymentso HRRP, VBP & HACo CJR (hip & Knee replacement)o Episodic paymentso Bundle Payment demoso ACOs
• Managed Care Plans
• SNFo SNF PPS Changing to PDPMo SNF VBP (rehospitalization)o Bundle Payment demos
Reporting
• SNF QRP
• Payroll Based Journal (staffing)
Regulatory
• Requirements of Participation & Survey
• Emergency Preparedeness
Workforce Shortage
Improving Lives by Delivering Solutions for Quality Care
How to Navigate Changes
• Set goals to o reduce hospitalizations and assume all are preventableo focus on metrics with greatest impact on residents and points
• Work on nurse – physician communication
• Focus on staff retention
• Discuss end-of-life planning with residents & families
• Focus on Systemso Make sure changes can be followedo Engage staff in development and monitoringo Pursue Baldrige framework: Silver or Gold recognition
• Recognize your mindset
Improving Lives by Delivering Solutions for Quality Care
Mindset Model
The Arbinger Institute: Mindset Model
MINDSET
PRACTICES
CURRENTRESULTS
Improving Lives by Delivering Solutions for Quality Care
The First Law of Improvement
“Every system is perfectly designed to achieve exactly the
results it gets”
Patient Safety Nov 2009
-Paul Batalden, MD, Dartmouth
Improving Lives by Delivering Solutions for Quality Care
What is your Organizations Culture?
• We & us vs They or Them?
• Opportunity to improve vs not our fault
• All adverse events are preventable vs we can’t control ….
• Accept responsibility vs blame others
• How would your staff, residents and families describe your mission?o Person & care oriented or business and
• What does it feel like in your building?o Quiet & calm vs loud and hectico Clear and organized vs cluttered and storage spaceo Residents walking or all in wheelchairs
Pursue AHCA/NCAL Quality Award Program
Improving Lives by Delivering Solutions for Quality Care
4 out of 10 Members Recognized
http://qa.ahcancal.org
Improving Lives by Delivering Solutions for Quality Care
Silver & Gold Better in Quality
Improving Lives by Delivering Solutions for Quality Care
Antipsychotics Better in Silver & Gold
Improving Lives by Delivering Solutions for Quality Care
BUSINESS ADVANTAGE FOR SILVER
& GOLD
States Recognizing QA recipients
• Medicaid VBP programoFlorida1
oUtah
oTennessee
• State Quality Improvement requirementsoOhio
1Florida Medicaid VBP Program• 1 point = $1.27 increase in Medicaid per resident per day• FL Silver/Gold = 5 points out of max 40 points; or
$6.35 per day increase (~$156,000 per average SNF)
% Active QA Recipients
Active vs Inactive QA Recipients
Measure Active Inactive
Overall Five Star (4 or 5) 68% 46%
ED visits 11.6% 12.6%
Total staffing 3.83 3.72
RN staffing 0.63 0.62
Dates and Deadlines
• August: Applications Published
• November: Intent to Apply Deadline
• Jan-Feb: Application Deadline
• Early Summer: Gold Site Visits
• Summer: Notification
• October: Recognition at Convention
PDPM Overview
5/6/2019IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE16
Count Down to PDPM Starts October 1, 2019 in …..
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 17
144Calendar
Days
Transition Work
CMS PDPM will start Oct 1st 201.
PDPM remains a per-diem payment model but components have changed
RUGsTherapy
Non-Case-Mix Therapy
Nursing
Non-Case-Mix
PDPM PT
OT
SLP
Nursing
NTAS
Non-Case-Mix
PDPM adds variable per-diem payment adjustment
PT Base RatePT PT CMIPT Adjustment
Factor
OT Base RateOT OT CMIOT Adjustment
Factor
SLP Base RateSLP SLP CMI
Nursing Base
RateNursing Nursing CMI
NTA Base RateNTA NTA CMI
NTA
Adjustment
Factor
Non-Case-Mix
Base Rate
Non-Case
Mix
PDPM includes variable per-diem
payment adjustments that modify
payment based on changes in
utilization of these services over
a stay
• Day 4 – NTA rates drop by 2/3
• Day 21 and every 7 days after
the PT and OT rates drop 2%
Download AHCA PDPM PT OT
NTA Component Variable Per-
Diem Rate Tables on
ahcancalED
Example Calculator – PDPM
Component
Base
Fed
Rate
Case-
Mix
Index
Special
Adjustors
Variable
per diem
Payment
(per
diem)
PT $59.33 x x x =
OT $55.23 x x x =
SLP $22.15 x x x =
NTA $78.05 x x x =
Nursing $103.46 x x 1.00* x =
Non-Case-
Mix
Component
$92.63 x x x =
Total =
*Except when resident has HIV/AIDS, then variable per diem adjustment = 1.18
Note: Rates are for urban facilities, CMS estimated if program went into effect FY19
PT & OT Per Diem Adjustment Factors
NTA Per Diem Adjustment Factors
The engine that drives PDPM payments are Patient Characteristics represented by MDS items
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 24
Five independently
Determined PDPM
Component Rates Set
During 5-Day PPS
Assessment Window Using
188 MDS Item Fields
PT - 37
OT - 37
SLP -66
Nursing - 132
NTAS -34
Rehab RUG rates
Determined by 20
MDS Item Fields
Over 90% of
Resident Days
Reported Via
Rehab RUGs
RUG-IV Assessments
Day 5 MDS
Day 14 MDS
Day 30 MDS
Day 60 MDS
Day 90 MDS
PPS Discharge
MDS
Fewer Assessments Required Under PDPM
RUG-IV
Therapy OMRAs
PDPM Assessments
Day 5
MDS
- EXPANDED -
OPTIONAL Interim Payment
Assessment (IPA)- NEW -
PPS
Discharge
MDS
- EXPANDED -
PDPM
PDPM Daily Rate CalculationExample Rural 2017 – Days 1-3
ComponentUnadj Fed
Rate
Case-Mix
Index
Special
Adjustors
Variable
per diem
Payment
(per diem)
PT $59.33 x 1.88 x x 1.00 = $111.54
OT $55.23 x 1.68 x x 1.00 = $92.79
SLP $22.15 x 1.46 x x = $32.34
NTA $78.05 x 1.34 x x 3.00 = $313.76
Nursing $103.46 x 1.34 x 1.00* x = $138.64
Non-Case-
Mix
Component
$92.63 x x x = $92.63
Total = $781.70*
IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 26
Case Mix
Group
Case Mix
Index
Pa
tie
nt C
ha
racte
ristics fro
m M
DS
PT and OT Components
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 27
SLP Component
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 28
NTA Component Module
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 29
Nursing Component Module –example for clinically complex
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 30
CMS Concerns with Provider Responses to PDPM
Behavior
Concerns Motivation Implications
Upcoding Revenue
Maximization
CMS will have a direct line of sight via ICD-10
and other MDS document
Downsizing
Therapy
Overhead
Reduction
CMS is clear the SNF benefit and cover
requirements remain the same and will be
monitoring for outcomes (e.g., QRPs)
Over-Use of
Interrupted Stay
Restart Variable
Per Diem
Risk of losing VBP bonus or increasing penalty
up to 2% for all SNF stays & risk of being placed
under “heighten scrutiny”
Vague IPA Trigger
Definition
Room to Argue +/-
in CMGs and
Rates
SNFs should follow clear internal IPA policies
and demonstrate adherence
31
Next steps 1 of 3
●Calculate PDPM payment for few patients● Review MDS coding and ICD coding for high impact items
o NTAS, speech/neurologic conditions,
● Develop a plan to start coding and putting supporting documentation in medical record for high impact MDS items that have not been used commonly (e.g. morbid obesity).
● Start checking to see if the ICD codes currently being used are “allowable” in PDPM, to start making the switch now
● Review how Depression, BIMS and swallowing is assessed on the MDS
● Review your process for completing section GG
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 32
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 33
Next steps 2 of 3
◦Develop a policy for completing the IPA◦ May want to test the policy to see if its “works”
◦Evaluate your admission process to identify the primary diagnosis and supporting documentation in the medical record
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 34
Next Steps 3 of 3
•Talk to managed care plans
•Talk to rehab company or therapy department and review your contract
•Develop a plan to approach the hospital about how to get information
•Talk to your EMR and MDS vendors on how they will support the change to PDPM
5/6/2019 IMPROVING LIVES BY DELIVERING SOLUTIONS FOR QUALITY CARE 35
Public Reporting Changes
Improving Lives by Delivering Solutions for Quality Care
Reporting Changes
• Five Staro Froze the Survey Component based on 2 cycles from April
to Dec 2018
o Replace Staffing Measures w/ PBJ data July 2018
o Invoked penalty to Staffing rating for missing data (July 2018)
o Rebase cut-points to assign stars for QM and Staffing
• Nursing Home Compareo SNF QRP measures in October
o Long Stay Hospitalization and ER use measures
o Add new staffing measures in Spring 2019
Improving Lives by Delivering Solutions for Quality Care
CURRENT SNF QRP Measures
• SNF QRP measures posted NHC Oct 2018oPressure Ulcers
oFalls with injury
oCompleting functional improvement MDS sections
oDischarge to the community
oPotentially Preventable 30d Readmissions AFTERSNF discharge
o90d Medicare Spending Per Beneficiary (MSPB)
Improving Lives by Delivering Solutions for Quality Care
2019 QRP Measures
• Drug Regime Review
• FOUR Functional Improvemento Change in Mobility
o Level of Mobility at discharge
o Change in Self-Care
o Level of Self-care at discharge
Improving Lives by Delivering Solutions for Quality Care
SNF QRP Payment Penalty
• To avoid 2% payment adjustment SNFs must >80% of MDS submissions with 100% complete MDS elements used to calculate QRP measureso “-” does NOT count as complete data element
oMost common elements with missing data is section GG
• List of MDS items used in QRP measures o CMS QNF QRP website or direct at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QRP-Table-for-Reporting-Assessment-Based-Measures-for-the-FY-2020-SNF-QRP-APU.pdf
Impact of Changes to Five-Star
Quality Rating Distribution
Overall Five-Star Scoring Methodology
Step 1: Initial rating based on your state rank on survey score
Step 2: Add or subtract one star based on staffing component• Subtract 1 star if staffing rating is 1 star• Add 1 star if staffing is 4 or 5 stars & > Survey rating
Step 3: Add or subtract one star based on QM component • Subtract 1 star if QM rating is 1 star• Add 1 star if QM rating is 5 stars
• Note: If you are 1 star on survey you can only add 1 star
Changes to Health Inspection Rating Domain
• Lifting of survey freeze April 2019:oWill include surveys/citations from Nov 28, 2017
onward
oReturn to 3-cycle scoring
• Special Focus Facilities (SFFs):oStar ratings for SFF will be suppressed in all
domains
Survey Score in Five-Star
▪ Cycle 1 Most recent standard survey
+
All complaint surveys in prior (1-12 months)
▪ Cycle 2 Prior standard survey
+
All complaint surveys in prior (13 - 24 months)
▪ Cycle 3 Prior to cycle 2 standard survey
+
All complaint surveys in prior (25 - 36 months)
50%
33%
17%
60%
40%
0%
WeightingDuring
April 19 Freeze
Changes to Staffing Domain
• Staffing rating:oHPRD thresholds to assign stars are changing
oStaffing grid increases the impact of RN hours
• Reduction in days with 0 RN hours that impact star ratingsoRegulations require 8 RN hours per day, 7 days a
week▪ Currently:
• 7+ days/quarter w/o RN = 1 star staffing rating
▪ April 2019:
• 4+ days/quarter w/o RN = 1 star staffing rating
CHANGED Staffing HPRD Thresholds
OLD Staffing Scoring Matrix
Loose 1 Star Add 1 Star
New Staffing Star Assignment Grid
Loose 1 Star
Gain 1 Star
Change 1 to 2 Star
Change 3 to 4 Star
Change 4 to 3 Star
Change 4 to 5 Star
QM Domain: Changed Measures
• Addition of measures:oLong-stay emergency department transfers
oLong-stay stay hospitalizations
• Dropping of measures:oLong-stay use of physical restraints
• Replacement of measures with QRP measures:oShort-stay pressure ulcers
oShort-stay successful discharge to community
QM Domain: Change Scoring
• QM domain split:o Short-stay (SS) and Long-stay (LS) components
o Overall QM domain score is based on a 50/50 SS/LS
• QM assigning points changed:oMeasure thresholds for points rebased
o Going forward they will be adjusted every six months by
50% of average national improvement
• QM individual measures weighting o Two weight categories:
▪ high – 150 pts by deciles
▪ medium – 100 pts by quintiles
Quality Measures & Points
Long Stay
Max
Points Short stay
Max
Points
ADL worsening 150 Functional improvement 150
Antipsychotic use 150 30 day rehospitalization 150
Mobility decline 150 Emergency room visits 150
Long Stay Hospitalization 150 Discharge Back to the Community 150
Emergency room visits 150 Pressure Ulcers worse 100
Pressure ucler 100 Pain 100
Catherter use 100 New antipshycctoic use 100
UTI 100
Pain 100
Falls with injury 100
Total Points 1250 Total Points 900
Note: SS total scorre rescaled to 1250 max points
Points for Star Assignment
New Survey & Regulations
Improving Lives by Delivering Solutions for Quality Care
Overview of Phase III Changes
• Infection Preventionist
• Trauma-informed care
• QAPI program
• Compliance and Ethics Program
• Centralized Bedside Call System
• Comprehensive Training Requirements
Improving Lives by Delivering Solutions for Quality Care
Infection Preventionist 483.80(b)
Regulations To Do b. Infection preventionist. The facility must designate
one or more individual(s) as the infection
preventionist(s) (IPs) who are responsible for the
facility’s IPCP. The IP must:
1. Have primary professional training in nursing,
medical technology, microbiology,
epidemiology, or other related field;
2. Be qualified by education, training, experience
or certification;
3. Work at least part-time at the facility; and
4. Have completed specialized training in
infection prevention and control.
1. Designate or hire a staff person (e.g.
nurse or other clinician) who has or
will obtain additional training in
infection control.
2. Take advantage of AHCA’s IPCO
Qualification Training
Improving Lives by Delivering Solutions for Quality Care
AHCA IPCO Certificate Program
• 23 hour online, self-study
• 9 modules with guides, quizzes and final testo80% test pass requirement
• CertificatesoANCC contact hours credit
oSpecialized training, 3 year expiration (renewal option)
https://educate.ahcancal.org/p/ipco
Improving Lives by Delivering Solutions for Quality Care
QAPI Intent & Purpose
Have a system that
a. monitors and investigates current practices to
o prevent adverse events
o increases consistent use of evidence based practices
b. Creates teams to make changes to achieve better outcomes
QAPI Approach to Quality Organization
P
D
S
A
Assess system
Review performance
Pilot test change
Formulate plan to change system
Evaluate change
Revise plan & Repilot test
Res
ult
YE
S
NO
Disseminate within organization
YE
S
N
O
Res
ult
Improving Lives by Delivering Solutions for Quality Care
Data Required to be reviewed by QAA
• Abuse, neglect & misappropriate of property allegations
• Drug Regime Review
• GDR including physician’s response
• Antibiotic Stewardship
• Infection control
o Hand washing
o use of PPE
• Medication error rates
• Widespread QOC issues
o Mobility, ROM
o Diet and weight-loss
o Pressure ulcers
o Unnecessary medications
• Resident Grievances
Improving Lives by Delivering Solutions for Quality Care
Top 20 F-Tags Since Nov 2017
From CMS Qcor website: FY 2019: downloaded May 5th 2019
Tag # Tag Description
New York
Rank
F0880 Infection Prevention & Control 2,927 17.6% 69 11.0% 2
F0689 Free of Accident Hazards/Supervision/Devices 2,654 14.8% 54 8.4% 3
F0812 Food Procurement, Store/Prepare/Serve Sanitary 2,403 14.8% 40 6.5% 6
F0656 Develop/Implement Comprehensive Care Plan 2,206 13.1% 72 10.8% 1
F0684 Quality of Care 2,019 11.3% 42 6.1% 4
F0761 Label/Store Drugs and Biologicals 1,618 9.9% 26 4.2% 9
F0657 Care Plan Timing and Revision 1,401 8.4% 29 4.7% 7
F0758 Free from Unnec Psychotropic Meds/PRN Use 1,313 8.1% 42 6.8% 5
F0677 ADL Care Provided for Dependent Residents 1,245 7.0% 18 2.6% 16
F0550 Resident Rights/Exercise of Rights 1,151 6.8% 12 1.9% 24
F0686 Treatment/Svcs to Prevent/Heal Pressure Ulcer 1,136 6.7% 22 3.2% 12
F0842 Resident Records - Identifiable Information 1,107 6.5% 21 3.4% 13
F0641 Accuracy of Assessments 1,097 6.8% 11 1.8% 31
F0755 Pharmacy Srvcs/Procedures/Pharmacist/Records 1,081 6.4% 7 1.1% >35
F0609 Reporting of Alleged Violations 1,068 6.0% 9 1.5% >35
F0623 Notice Requirements Before Transfer/Discharge 1,066 6.5% 26 4.2% 8
F0690 Bowel/Bladder Incontinence, Catheter, UTI 973 5.8% 12 1.9% 27
F0584 Safe/Clean/Comfortable/Homelike Environment 962 5.5% 22 3.4% 11
F0658 Services Provided Meet Professional Standards 921 5.4% 12 1.9% 26
F0695 Respiratory/Tracheostomy Care and Suctioning 829 5.1% 16 2.6% >35
Nation
N= 15,616
New York
N=619
Improving Lives by Delivering Solutions for Quality Care
Scope & Severity By CMS Region
From CMS Qcor website From Nov 2017 to May 2019 downloaded May 5th 2019
Region B C D E F G H I J K L Total
(I) Boston 442 184 5,565 1,566 232 447 24 - 89 36 - 8,585
(II) New York 196 43 3,847 972 152 85 - - 24 6 10 5,335
New Jersey 111 3 1,423 412 72 11 - - 14 2 8 2,056
New York 85 34 2,407 554 69 74 - - 10 4 2 3,239
Puerto Rico - 6 17 6 11 - - - - - - 40
(III) Philadelphia 523 676 13,112 4,738 817 423 18 1 72 36 13 20,429
(IV) Atlanta 225 432 14,162 3,012 1,130 448 9 - 700 195 27 20,340
(V) Chicago 313 1,295 31,548 7,056 3,611 1,796 16 1 344 108 37 46,125
(VI) Dallas 405 468 5,773 12,604 2,583 435 160 6 254 401 70 23,159
(VII) Kansas City 206 453 8,964 4,441 1,524 461 20 2 163 46 17 16,297
(VIII) Denver 37 67 3,567 1,773 273 258 42 1 17 12 2 6,049
(IX) San Francisco 770 101 16,773 5,923 725 529 13 1 34 41 55 24,965
(X) Seattle 36 397 6,102 2,082 403 613 25 - 88 61 14 9,821
National Total 3,153 4,116 109,413 44,167 11,450 5,495 327 12 1,785 942 245 181,105
Improving Lives by Delivering Solutions for Quality Care
Let the Purpose & Intent Guide Implementation
• Approach practice to the purpose and intent rather than to the regulation
o Will allow you to be flexible when facing unique and “exceptions to the rule” individuals
o How would you implement the regulation if it was you or your parents in your Center?
o Staff will follow regulations more consistently
Improving Lives by Delivering Solutions for Quality Care
The Most Common Reason for Citations?
What is the most common reason for receiving a citation?
Improving Lives by Delivering Solutions for Quality Care
Survey Process is Not a Mystery
• Based on new interpretive guidance in the SOM
• Emphasizes observation of care and resident interviews
• Relies on Critical Element Pathways
Improving Lives by Delivering Solutions for Quality Care
Mandatory CEPs
◦Dining
◦ Infection Control
◦SNF Beneficiary Protection Notification Review
◦Kitchen Observation
◦Medication Administration and Medication Storage
◦Resident Council Meeting
◦Sufficient and Competent Nurse Staffing Review
◦Environment
66
CEP Example
LTC Survey Subscription with Updates Through November 2019
Order Now:
AHCA Bookstore
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html
CEPs
Entrance Matrix
Contact Information
David Gifford MD MPH
SR VP for Quality & Regulatory Affairs
American Health Care Association
1201 L St. NW
Washington DC 20005
202-898-3161
www.ahcancal.org