Quality & Regulatory Changes Impacting SNFs · •Payroll Based Journal (staffing) Regulatory...

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


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


Mindset Model

The Arbinger Institute: Mindset Model

MINDSET

PRACTICES

CURRENTRESULTS


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


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


4 out of 10 Members Recognized

http://qa.ahcancal.org

http://qa.ahcancal.org/


Silver & Gold Better in Quality


Antipsychotics Better in Silver & Gold


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

https://educate.ahcancal.org/pdpmacademyhttps:/educate.ahcancal.org/pdpmacademy

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


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


SLP Component


NTA Component Module


Nursing Component Module –example for clinically complex


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


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


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


Public Reporting Changes


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


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)


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


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

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


Overview of Phase III Changes

• Infection Preventionist

• Trauma-informed care

• QAPI program

• Compliance and Ethics Program

• Centralized Bedside Call System

• Comprehensive Training Requirements


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


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


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


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


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


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


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


The Most Common Reason for Citations?

What is the most common reason for receiving a citation?


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


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.ahcapublications.org/ProductDetails.asp?ProductCode=6775S-1619

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

[email protected]

202-898-3161

www.ahcancal.org

mailto:[email protected]

Quality & Regulatory Changes Impacting SNFs · •Payroll Based Journal (staffing) Regulatory...

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