A Federal Update for Nursing Homes: The View from Inside the Beltway

1. A Federal Update for Nursing Homes: The View from Inside the Beltway National Association of State Veteran�s Homes August 12, 2008 Lyn Bentley, MSW

2. 2 Today�s Topics Quality Indicator Survey MDS 3.0 Update Five Star; Revised Surveyor Guidance; Special Focus Facilities Other Federal Activities Late Breaking News

3. 3 Quality Indicator Survey Developed under CMS contract over 15 years � work began in 1992 1992 � 1997: Preliminary tests of staged survey (U of CO) 1998 � 2005: QIS Development Contract (U of CO, U of WI, Maverick Systems, Alpine Systems, under subcontract to RTI) 2005 � 2007: Demonstration/refinement in CT, KS, OH, LA, CA; then statewide expansion in FL, CT, KS 2007 � 2008: Development/refinement (U of CO); statewide expansion in OH & LA; add MN

4. 4 Quality Indicator Survey Improve consistency/accuracy of QOC/QOL problem identification using a more structured process More comprehensive review of facilities Enhanced documentation � organize survey findings via computer Focus survey resources on facilities with largest number of quality concerns The reason QIS was developed was to improve the consistency and accuracy of quality of care and quality of life problem identification through a more structured process. Each surveyor has a PC Tablet � and each surveyor follows very specific steps throughout the survey, including the specific interview questions that they use with staff, families, patients and residents. Another goal of QIS is to enhance documentation to support deficiency citations and according to CMS, there are fewer cites going to IDR because the supporting evidence on the 2567 is so strong. CMS has also stated that they feel that the QIS will allow state agencies and CMS to focus their survey resources on the facilities who have more quality concerns.The reason QIS was developed was to improve the consistency and accuracy of quality of care and quality of life problem identification through a more structured process. Each surveyor has a PC Tablet � and each surveyor follows very specific steps throughout the survey, including the specific interview questions that they use with staff, families, patients and residents. Another goal of QIS is to enhance documentation to support deficiency citations and according to CMS, there are fewer cites going to IDR because the supporting evidence on the 2567 is so strong. CMS has also stated that they feel that the QIS will allow state agencies and CMS to focus their survey resources on the facilities who have more quality concerns.

5. 5 Quality Indicator Survey Two-stage process Stage I � preliminary investigation of residents, randomly selected, regarding a range of care areas (128 resident-centered Quality of Care and Quality of Life Indicators) Plus 34 facility-level Quality of Care/Life Indicators Stage II � an in-depth investigation of care areas identified in stage I that exceeded thresholds The QIS is a 2 stage process. Stage 1 is a preliminary investigation of randomly selected residents CMS looks at an �MDS Sample� � all residents who�ve had an MDS completed within 6 months �Census Sample � 40 residents randomly selected �Admission Sample� � 30 recent admissions The surveyors with the help of the computer assess the quality of care indicators and if the QCIs show a certain threshold (in other words, for example, 30 people have pressure sores) then they look at this more intensely in Stage 2. It is possible that no thresholds are met and the facility does not have the second stage of the survey.The QIS is a 2 stage process. Stage 1 is a preliminary investigation of randomly selected residents CMS looks at an �MDS Sample� � all residents who�ve had an MDS completed within 6 months �Census Sample � 40 residents randomly selected �Admission Sample� � 30 recent admissions The surveyors with the help of the computer assess the quality of care indicators and if the QCIs show a certain threshold (in other words, for example, 30 people have pressure sores) then they look at this more intensely in Stage 2. It is possible that no thresholds are met and the facility does not have the second stage of the survey.

6. 6 Quality Indicator Survey Stage I Samples MDS sample: all residents with an MDS within the prior six months of the survey Census sample � random sample of current residents (n=40) Emphasizes long-stay residents Admission Sample � random sample of new admissions (n=30) Captures the SNF post-acute and long-stay residents at critical point (e.g., rehospitalization, rehab) These are the samples that are used ---- a total of at least 70 residents � Each sample group is representing an important aspect of the population of the facility.These are the samples that are used ---- a total of at least 70 residents � Each sample group is representing an important aspect of the population of the facility.

7. 7 Quality Indicator Survey Surveyor can initiate investigation at any time Observation of residents that causes concern Observation of care areas in residents not in the sample F-Tag Over time, the number of surveyor-initiated investigations go down � surveyors find that if there is a problem in the facility, the QIS sample reveals that problemOver time, the number of surveyor-initiated investigations go down � surveyors find that if there is a problem in the facility, the QIS sample reveals that problem

8. 8 Quality Indicator Survey Facility-level tasks e.g., kitchen, food service Highly structured interviews with: residents staff family Observations of dining and medication administration There are also �unstaged� survey tasks such as kitchen, food service, medication administration. There are also very structured interviews with residents, staff, and families.There are also �unstaged� survey tasks such as kitchen, food service, medication administration. There are also very structured interviews with residents, staff, and families.

9. 9 Quality Indicator Survey Thresholds The rate established to determine whether to conduct a Stage II investigation in a particular Care Area. Concept is similar to medical screening procedures

10. 10 Quality Indicator Survey Triggers for Stage II Investigation Resident Interview � 21% Resident Observation � 16% MDS QIs � 13% Family Interviews � 12% New MDS Indicators � 11% Admission Chart � 10% Staff Interviews � 9% Census Chart � 8%

11. 11 Quality Indicator Survey Draft final report from Abt Associates Improve consistency and accuracy of quality of care and quality of life problem identification through a more structured process More comprehensively review regulatory areas within current survey resources

12. 12 Quality Indicator Survey Enhance documentation through greater automation to organize survey findings Target survey resources on facilities with the largest number of quality concerns

13. 13 Quality Indicator Survey Some observations by Dr. Andrew Kramer Provider use of QIS tools to assess and improve quality Fewer IDR requests

14. 14 Quality Indicator Survey Survey outcomes: 4% facilities - deficiency free 25% facilities - 25 or more deficiencies average increase of 2 deficiencies 55% facilities � more deficiencies under QIS 35% facilities � fewer deficiencies 10% facilities � about the same

15. 15 Quality Indicator SurveyMoving Forward CMS issued a notice to states � apply to implement QIS 14 states responded � only MN chosen Most recent information from CMS - expanding into three more states: NC, WV, and NM

16. 16 Quality Indicator SurveyAHCA concerns First, we think it could be a good and more objective process But We still need a better understanding about how the system works internal to the computer Clarity about decision tree in software It is important to note that we think this may be a very good objective survey process. As mentioned on an earlier slide, if a surveyor is having a bad day, it doesn�t influence the survey outcome. On the other hand, we don�t feel that CMS has been totally transparent about the process, including most importantly the decision tree in the software. We want to understand very clearly that citations are only cited based on noncompliance with the regulation and NOT on surveyor guidance. We have discussed this with CMS and AHCA�s Legal Subcommittee is investigating legal options available to the association to get the information we believe we need.It is important to note that we think this may be a very good objective survey process. As mentioned on an earlier slide, if a surveyor is having a bad day, it doesn�t influence the survey outcome. On the other hand, we don�t feel that CMS has been totally transparent about the process, including most importantly the decision tree in the software. We want to understand very clearly that citations are only cited based on noncompliance with the regulation and NOT on surveyor guidance. We have discussed this with CMS and AHCA�s Legal Subcommittee is investigating legal options available to the association to get the information we believe we need.

17. 17 MDS 3.0 Goals Clinical To make the MDS more clinically relevant while still achieving the federal payment & quality initiatives mandates. Technical Improve tool technology to decrease provider burden, standardize terminology and scales, and link to CARE, STRIVE, and other initiatives.

18. 18 MDS 3.0 Development - Multi-Phase Process Began in 2003 Pilot-tested using Veteran�s Administration Nursing Homes Electronic Health Records and Quality Mgt. Review & analysis of the pilot Modifications of tool Validation study

19. 19 MDS 3.0 Tool validated in 8 states � NJ, PA, GA, NC, CO, IL, CA & TX 90 nursing homes � 70 community-based and 20 VA 2,800 residents � short and long stay Final revisions to MDS 3.0 � based on feedback from national validation studies � March 2008

20. 20 MDS 3.0 and AHCA Analysis of changes to MDS 3.0 and impact on other areas Survey Value-Based Purchasing Measures QIs and QMs Government Performance Results Act Goals (GPRA) Medicare Quality Improvement Community (MedQIC) This was an extensive and detailed analysis taking one element of the MDS 3.0 that had changed � pressure sores � and determining the impact this change would have on other programs that impact nursing homes. This change would also impact the reimbursement - it resulted in a downward migration of the RUG categories.This was an extensive and detailed analysis taking one element of the MDS 3.0 that had changed � pressure sores � and determining the impact this change would have on other programs that impact nursing homes. This change would also impact the reimbursement - it resulted in a downward migration of the RUG categories.

21. 21 MDS 3.0 and AHCA Make all appropriate changes before providers use MDS 3.0 Communication & Training Partner with national and state provider associations to provide training for surveyors, providers, FIs, MACs, RAI Coordinators and QIOs simultaneously to minimize discrepancies in coding interpretation CMS would not committee to this first request. However, CMS is meeting with the AHCA Clinical Practice Committee this week and will provide a through update. Also, during that meeting, CMS will lay out a plan for the communication and training piece. CMS would not committee to this first request. However, CMS is meeting with the AHCA Clinical Practice Committee this week and will provide a through update. Also, during that meeting, CMS will lay out a plan for the communication and training piece.

22. 22 MDS 3.0 Implementation Timeline Implementation Announcement � 10/07 Web Posting of Timeline � 12/07 Web Posting of MDS Tool � 1/16/08 MDS 3.0 Open Door Forum � 1/24/08 Education to State Medicaid � 3/08 MDS 2.0 & 3.0 Crosswalk & Transition Plan to States, Providers & Vendors � Spring 08 This slide is a copy of a CMS slide � the bullet that says � Education to State Medicaid � should say education to state Medicaid directors. The crosswalk is a crosswalk of the technical changes between 2.0 and 3.0.This slide is a copy of a CMS slide � the bullet that says � Education to State Medicaid � should say education to state Medicaid directors. The crosswalk is a crosswalk of the technical changes between 2.0 and 3.0.

23. 23 MDS 3.0 Implementation Timeline Draft MDS 3.0 Specifications to Vendors, Providers with Preliminary STRIVE Changes � 11/08 Final MDS 3.0 Specifications with STRIVE Changes to Providers & vendors � 2/09 MDS 3.0 Focus at RAI Conference with State Survey & Medicaid Automation Staff � Spring 09 MDS 3.0 Satellite Broadcasts (two)� TBD FY 2010 SNF payment Update with Federal Register Notice & RUG Changes � 7/09

24. 24 MDS 3.0 Implementation Timeline Final MDS 3.0 Implementation � 10/1/09 MDS 3.0 Used in the Survey Process � 10/09

25. 25 Final MDS 3.0 What�s New Not all look-back periods are 5-days Adds self-report interview items Assessment is more resident-centered Some wording has been improved and standardized for interoperability of records across provider settings Items needed for RUGs and QMs retained So far, we still are retaining a 14-day look-back period for teh MDS Section on Special Treatment & Procedures. This will allow clinicians to look back in to the hospital stay for chemotherapy, radiation treatment, Oxygen therapy, suctioning, tracheostomy care, ventilator, IV medications, transfusions, dialysis, hospice and respite care. The resident-centered focus comes from the number of MDS sections that will now provide resident interview and resident-voice � assessing cognitive status, establishing mood and behaviour, and finding resident preferences.So far, we still are retaining a 14-day look-back period for teh MDS Section on Special Treatment & Procedures. This will allow clinicians to look back in to the hospital stay for chemotherapy, radiation treatment, Oxygen therapy, suctioning, tracheostomy care, ventilator, IV medications, transfusions, dialysis, hospice and respite care. The resident-centered focus comes from the number of MDS sections that will now provide resident interview and resident-voice � assessing cognitive status, establishing mood and behaviour, and finding resident preferences.

26. 26 Final MDS 3.0What�s New Section on pressure ulcer coding is based on NPUAP�s PUSH tool & measurement guidelines (length & width) End reverse staging coding for healing pressure ulcers Pressure ulcer QMs will be based on stages 2, 3 & 4 Allows for identification of ulcers found on admission The MDS 3 Section M for skin care will allow clinicians to separate developing from healing pressure ulcers. This is a major refinement ----- this means we are separating prevalence of pressure ulcers from their status (e.g., healing). Additionally, we will be able to identify those pressure ulcers that are noted on admission. Our current MDS is limited in extracting this information from the quality measure. As a result, the current QM is a prevalence-based measure meaning it captures all pressure ulcers, no matter where they developed. The MDS 3 Section M for skin care will allow clinicians to separate developing from healing pressure ulcers. This is a major refinement ----- this means we are separating prevalence of pressure ulcers from their status (e.g., healing). Additionally, we will be able to identify those pressure ulcers that are noted on admission. Our current MDS is limited in extracting this information from the quality measure. As a result, the current QM is a prevalence-based measure meaning it captures all pressure ulcers, no matter where they developed.

27. 27 Final MDS 3.0What�s New Expanded Return to Community Section to better identify residents who can benefit from Money Follows the Person state resources Expanded Section on Pain which is incorporated with assessment of health conditions. Clarifies definition of restraint Restraint definition: Physical restraints are any manual method, physical or mechanical devise, material or equipment attached or adjacent to the resident�s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one�s body. This key definition is on the MDS form itself. There will be additional clarification about what constitutes a restraint on the RAI.Restraint definition: Physical restraints are any manual method, physical or mechanical devise, material or equipment attached or adjacent to the resident�s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one�s body. This key definition is on the MDS form itself. There will be additional clarification about what constitutes a restraint on the RAI.

28. 28 Five Star Quality Rating Ranking of facilities on Nursing Home Compare Rank based on: Survey data Staffing data Quality Measures Updated quarterly

29. 29 Five Star Quality Rating Posted in December 2008 Additional elements may be added over time: Specialization of facility Patient/family satisfaction scores Other information? Comments due to Centers for Medicare & Medicaid Services (CMS) by July 23, 2008

30. 30 Revised Surveyor Guidance F 325 and F 371 implementation date Sep. 1, 2008 Later this year: F309 � Management of Pain F441 - Infection Control F223 through F226 � Abuse � FY 2009 F309 � Guidance for End-of-Life - FY 2009

31. 31 Special Focus Facilities Concept began 1998 � called Poor Performing Chains List of 100 2005 � Special Focus Facilities 18 months to improve � no deficiencies higher than an E Surveyed every six months 2007 � began to close facilities

32. 32 Special Focus Facilities CMS uses a formula to identify 15 facilities in each state that qualify to be on the list (range 0 � 6) State chooses their requisite number of Special Focus Facilities Identified on Nursing Home Compare (CMS Web site)

33. 33 Special Focus Facilities Listed on a section of CMS Web site Recently added Show improvement Did not show improvement Recently graduated Terminated from Medicare Updated monthly

34. 34 Special Focus Facilities What is the formula? What guidance are states given for choosing the special focus facilities? How does a facility get off the list?

35. 35 Other Federal Activities Bill by Senator Grassley and Senator Kohl Revisit User Fees Restructuring of CMS

36. 36 Bill by Senator Grassley and Senator Kohl �The Nursing Home Transparency and Improvement Act of 2007� Extensive disclosure requirement re: ownership and affiliated parties; accuracy must be certified Requires additional information on Nursing Home Compare Summary information on ownership Name of Administrator Attempted to attach language to the big Health Care Bill Attempted to attach language to the big Health Care Bill

37. 37 Bill by Senator Grassley and Senator Kohl Information on Special Focus Facility Program and location of facilities in the initiative Staffing data Links to state websites with the 2567 and facility�s Plan of Correction New standardized complaint form

38. 38 Bill by Senator Grassley and Senator Kohl Information submitted from �corporate accountability entities� Summary of information on enforcement including remedies proposed during preceding 3 years Information must be timely and accurate States required to send 2567s to Central Office on same date they are sent to the facility

39. 39 Bill by Senator Grassley and Senator Kohl Standardized Complaint Form All residents must receive one States must establish a complaint resolution process Significant increase in civil money penalties that can be imposed

40. 40 Bill by Senator Grassley and Senator Kohl One year pilot program for facilities to electronically report staffing information Category of work LPN, RN, CNA Resident census data Turnover Retention Hours are provided by each category or employee specified Includes data on agency and contract staff

41. 41 Revisit Fees In place from Sep. 19, 2007 through Dec. 25, 2007 Flat fee Off-site - $168 On-site - $2,072 Was in proposed President�s budget and a few iterations of Congressional budgets � officially gone until maybe October 2009

42. 42 Medicare Therapy Caps Instituted July 1, 2008 Maximum annual benefit for therapies of $1,810 per illness Congressional interest in blocking implementation of the caps

43. 43 Full Sprinklering for all Nursing Homes Phase-in No funding VA is way ahead of CMS requirements

44. 44 A New Survey Process How would you change the survey process?

45. Questions/Discussion Lyn Bentley Lbentley@ahca.org