Updates and regulatory changes: MDS PDPM QMs Mega Rule

1. Updates and regulatory changes:MDSPDPMQMsMega Rule Prepared for WNHSWA Fall 2019 Amy Ruedinger, RN RAC-CTPinnacle Innovative Healthcare Solutions

2. MA LEVEL OF CARE DENIALS

3. MA Level of Care Denials Providers need to be thoughtful prior to admission. Things to consider : • Are you confident that the prospective resident has long-term care needs that will meet the level of care requirement? • Forward Health is looking at the skilled nursing needs of the resident, not CNA care ( not “custodial care”) • Ensure that your ID team and the person responsible for admission decisions understands what may be considered skilled vs custodial care • Individuals in a lower RUG category (i.e. PA1, PB1, CA1) will be more likely to be denied SNF coverage.

4. MA Level of Care Denials Tips for managing/minimizing potential level of care denials • Proactively log into Forward Health Portal https://www.forwardhealth.wi.gov/WIPortal/ • Nursing home level of care reports in right hand margin of Provider page • Reports are run on Sundays to Monday morning info will be most current • Click “Approved levels of care” report to check status of residents • Ensure that MDS assessments are being completed and transmitted timely • Ensure that assessments are reflective of skilled level • Be aware of needs for significant change assessments and proper MDS documentation • Complete Significant change MDS as appropriate to reflect the level of care needed and provided to the resident

5. MA Level of Care Denials Appeals Process • Appeals can be done by sending in additional documentation to include •   Nursing notes •   MD note •  Care plans •   MARs •    TARs • Think: • How do I show that the resident needs care above and beyond what could be provided at home or in an Assisted Living setting • You will find out in a day or so the results of the review. • If denied again, you will need to contact the ADRC to complete a Functional Screen. The individual may need to consider enrollment in Family Care to reimburse expenses in the appropriate care setting.

6. UPDATES

7. Concern from colleague • Concern regarding “back dating” of completion dates for sections of the MDS • For example:  a 5 day/admit MDS for Med A is due no later than 8/15/19, was not completed until 8/20/19 but signed as completed on 8/15/19. • Regulatory and financial implications of late assessments and “back dating”

8. CMS and AANAC Updates AANAC: Resident Cognitive Level Determination AANAC: Interrupted-Stay Policy: CMS Clarifies Noncovered Days • Interrupted stay • Interruption window • First non covered day • Examples • Decision Trees

9. CMS and AANAC Updates AANAC: Spelling Out the Differences Between the IPA and SCSA • Criteria • Scheduling and timing implications • Payment and survey implications

10. CMS and AANAC Updates AANAC: The Evolution of the Nurse Assessment Coordinator (NAC) Under PDPM • Current tasks and focus and how that may change • The MDS • The PPS schedule • MDS auditing and supporting documentation • Supporting documentation must be in place by the ARD of the 5-Day assessment or you risk inaccurate payment for the entire stay. • NAC and IDT members must complete and evaluate all clinical assessments; determine the clinical diagnosis necessitating the SNF admission; determine active comorbidities, resident characteristics, and complexities (e.g., swallowing problems, the need for a mechanically altered diet, wounds, and infections); and conduct resident or staff interviews.  • Section GG coding • ICD 10 coding • Tracking and monitoring • 5 day assessment • PPS end of stay assessment • IPA if needed

11. CMS and AANAC Updates CONTINUED…… • Medicare Management and the Determination of a Skilled Level of Care • Ensure skilled care criteria is met ( therapy delivery and nursing cares) • Case Management • Coordinate alternate payment systems • Quality Measure Management • As Medicare reimbursement continues to have ties to quality outcomes through the SNF QRP and SNF Value-Based Purchasing (VBP) programs, the role of nursing and social services in Quality Measure management is likely to grow. • The team must understand, audit, review, correct, and process timely submissions of this valuable data • Care Coordination • Discharge planning

12. Quality Measures AANAC: SNF QRP Updates • Assessment based measures • Claims based measures • Tips for success • Ensure appropriate and thorough documentation in the EHR • Audit • Educate • Review findings Quality Measures Reporting • Discussion of how PDPM and MDS changes may impact quality measures • Increased medical complexity • Potential for shortened length of stay • Changes in expectations for discharge planning

13. CMS and AANAC Updates • Proposed Fiscal Year 2020 Payment and Policy Changes for Medicare Skilled Nursing Facilities (CMS-1718-P) • Proposed SNF QRP items- 2020

14. CMS and AANAC Updates AANAC: First Comes PDPM, Then Comes a SNF QRP Tsunami • Revised Part A definition of group therapy—and some warnings • Updating ICD-10 code mappings and lists • CMS stresses the IPA is optional but available for resident monitoring •  PDPM monitoring • SNF QRP: No expansion to other payers yet • SNF QRP: Two new QMs for FY 2022 program year • Transfer of Health Information to the Provider–Post-Acute Care (PAC). • Transfer of Health Information to the Patient–PAC • SNF QRP: CMS considers data validation • SNF QRP: Existing claims-based Discharge QM updated • SNF QRP: FY 2022 SPADEs • SNF QRP: Another QM to be displayed publicly • Transition from QIES to iQIES data submission stalled

15. Patient Driven Payment Model Tips and strategies for successful implementation AANAC: Get MDS Section C Ready For PDPM • take advantage of new RAI Manual instructions—when you can • Staff assessments and unplanned discharges • Teach the RAI coding rules • Interviewable vs. non – interviewable residents • Orient new staff members who will code section C • Consider adding some variety to your ARDs • Assess PDPM transition needs • Doing the staff assessment? Check documentation

16. Patient Driven Payment Model • Impact of PDPM on processes • Medicare A meetings • Change in focus- no longer focusing on volume of minutes but still need to ensure 5 day/week therapy • More emphasis on quality outcomes and d/c planning • Collaboration regarding primary dx and treatment dx- ICD 10 coding • More focus on Triple Check components as part of weekly meeting • Therapy delivery patterns • Planning and management of therapy delivery • Length of stay metrics and expectation • Balancing reimbursement and managed care expectations against quality outcomes and successful discharge • Impact on QM reporting

17. Patient Driven Payment Model • Impact of PDPM on processes –continued • Discharge planning • Increased focus on successful discharge • Role of Social Workers in facilitating successful discharge • What is the d/c plan? • Is it realistic? • What are the potential/actual barriers? • What teaching is needed? • Services or equipment needed in home or AL? • When to start talking about alternative options

18. RAI MANUAL UPDATES

19. RAI updates • Chapter 2 • Interrupted Stay is a Medicare Part A SNF stay in which a resident is discharged from SNF care (i.e., the resident is discharged from a Medicare Part A-covered stay) and subsequently resumes SNF care in the same SNF for a Medicare Part A-covered stay during the interruption window. • Interruption Window is a 3-day period, starting with the calendar day of discharge and including the 2 immediately following calendar days. In other words, if a resident in a Medicare Part A SNF stay is discharged from Part A, the resident must resume Part A services, or return to the same SNF (if physically discharged) to resume Part A services, by 11:59 p.m. at the end of the third calendar day after their Part A-covered stay ended. If both conditions are met, the subsequent stay is considered a continuation of the previous Medicare Part A-covered stay for the purposes of both the variable per diem schedule and PPS assessment completion. • IPA item set

20. RAI updates • Chapter 3-Section A • OSA • A0310G1, Is This a SNF Part A Interrupted Stay? • Chapter 3, section C • New instructions for interviews • Chapter 3, Section D • Removes language about safety notification • Chapter 3, Section GG • Instructions for “prior functioning” updated • Numerous other updates, including decision tree

21. RAI updates • Chapter 3, Section I • Updated coding guidelines • Chapter 3, Section J • Updated coding and expanded items • Chapter 3, Section K • Some items removed • Chapter 3, Section O • Respite care removed • Changes to therapy questions and coding guidelines • Chapter 6 • Extensive changes

22. REQUIREMENTS OF PARTICIPATION

23. Requirements of Participation AANAC: CMS Proposes New Revisions to the Requirements for Participation • Proposals in the Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency and Transparency Proposed Rule would affect the requirements for participation related to resident rights, clinical care, documentation requirements, and survey. • These changes would range from substantially reducing the detailed, specific requirements in the Quality Assurance and Performance Improvement (QAPI) regulations to removing the existing prescription renewal requirements for PRN antipsychotic medications to make them the same as the prescription renewal requirements for other psychotropic medications.

24. Requirements of Participation • CMS also proposes a one-year delay (i.e., one year after the effective date of the final rule when it is issued) for certain Phase 3 requirements that were supposed to go into effect this November 28 to give providers a break from “unnecessary work, confusion, and burden associated with implementing provisions that are proposed to be changed in this rule.” • The one-year delay would relate only to: (1) QAPI and QAPI training requirements (2) compliance and ethics program and training requirements. However, Phase 3 requirements not discussed in this rule (e.g., trauma-informed care) will implement on schedule.

25. Requirements of Participation • Resident Rights (§483.10) • Grievance policy • Providing physician contact information • Admission, Transfer, and Discharge Rights (§483.15) • Current regulations require providers to send transfer or discharge notices to the State Long-term Care Ombudsman. • CMS proposes to revise this requirement to apply only to facility-initiated involuntary transfers and discharges.

26. Requirements of Participation • Quality of Care (§483.25) • CMS proposes to modify the current requirements at §483.25(n) “to remove references to the ‘installation’ of bed rails and replace them with the ‘use’ of bed rails.” • Nursing Services (§483.35) • Current regulations at §483.35(g) require providers to post certain daily nurse staffing data and to maintain that posted data for at least 18 months, or as required by state law, whichever is greater. • CMS proposes to reduce that minimum length of time “to 15 months, or as required by state law.”

27. Requirements of Participation • Pharmacy Services (§483.45) • “We propose to remove the existing requirement that Pro re Nata (PRN), or as needed, prescriptions for anti-psychotics cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication,” says CMS. “This proposed revision would increase flexibility by allowing each facility to allow for PRN orders of all psychotropic medications to be extended beyond 14 days if the attending physician or prescribing practitioner believes it appropriate and documents his or her rationale in the resident’s medical record and indicates the duration for the PRN order.” • In other words, CMS would revise §483.45(e)(4) so that “there would be no distinction between anti-psychotics and other psychotropic medications.” In addition, §483.45(e)(5) “would be revised to require, in addition to the current requirements, that the facility’s policies, standards, and procedures use recognized standards of practice; including the circumstances upon which PRN orders for psychotropic drugs could be extended beyond the 14-day limitation; and that the facility take into consideration individualized resident’ needs for psychotropic drugs,” says the agency.

28. Requirements of Participation • Administration (§483.70) • CMS proposes the following changes to the facility assessment requirements at §483.70(e): • Clarify that providers can use data collected for the facility assessment to inform policies and procedures for other requirements. “For example, the requirements for Nursing services (§483.35), Behavioral health services (§483.40(a)) and Food and nutrition services (§483.60(a)) would all be able to utilize data from the facility assessment,” • Remove facility assessment requirements that duplicate emergency preparedness regulations.  • Change the minimum requirement for reviewing and updating the facility assessment from annual to biennial.  

29. Requirements of Participation • Quality Assurance and Performance Improvement (§483.75) • CMS proposes a one-year delay (i.e., one year after the effective date of the final rule) in implementing the Phase 3 QAPI requirements, including training requirements. • CMS proposes to remove much of the “specificity and detail” in the QAPI requirements. However, the agency does not propose to revise the existing language at §483.75(a)(1) through (4), which requires that providers “develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life” and meet related basic QAPI requirements (e.g., present the QAPI plan at each annual survey), notes CMS.

30. Requirements of Participation • Infection Control (§483.80) • Even though CMS proposes to make a change to the infection preventionist requirements that will go into effect this November 28 as part of the Phase 3 rollout, the agency does not seek any implementation delay. • “The requirements related to the infection preventionist’s required training and role remain unchanged, and we therefore believe this requirement can be implemented as scheduled.” • The proposed change would remove the requirement at §483.80(B)(3) that the infection preventionist work at the facility “at least part-time” since that could be interpreted different ways. Instead, the regulation would state that the infection preventionist “must have sufficient time at the facility to meet the objectives set forth in the facility’s IPCP [infection prevention and control plan],” says CMS.

31. Maximizing the power of the MDS in your organization

32. FINANCIAL PREDICTABILITY AND THE MDS

33. Financial impact of the MDS • Reimbursement which is directly related to MDS coding-- dependent on accurately capturing diagnoses, conditions, treatments and care needs (physical, behavioral, psychosocial) • Medicaid CMI- predictive of future reimbursement rates • Family care rates • Medicare A- PDPM rates • Additional consideration regarding the variable per diem for NTA and PT/OT component • Managed Care- rates may be set based on information reflected on the MDS

34. Financial impact of the MDS • Reimbursement that may be affected by MDS coding and completion • SNF QRPs • The SNF QRP measures affect the SNF’s revenue. Failure to submit the required data, or failure to meet the 80% benchmark on those measures, can result in a reduction of the provider’s Annual Payment Update (APU) by two percentage points for the program year. • Example: The calendar year 2019 data currently being collected will determine payment amounts for FY 2021 program year (October 1, 2020 through September 30, 2021). • Eight assessment based measures and three claims based measures

35. REGULATORY CONCERNS AND THE MDS

36. Regulatory concerns related to the MDS process • CMS has stringent regulatory guidelines related to the overall MDS process • Scheduling/timing of assessments • Opening, closing and completion of assessments • Regulations related to coding MDS items • These regulations can impact job roles, staffing patterns and work flow • Concern: MDS coordinators may be pulled to work the floor and/or take on multiple roles/responsibilities • MDS coordinator “drives the bus” • If focus shifts, will the MDS process suffer –potential for regulatory and reimbursement gaps

37. QUALITY MONITORING AND THE MDS

38. The MDS as a tool for measuring quality outcomes • Under PDPM, resident outcomes will be key to avoiding medical review  • CMS measures the quality of care provided to SNF patients/residents in a variety of ways: • SNF QMs ( all residents) • SNF Quality Reporting Program ( traditional Medicare A) • SNF Value Based Purchasing ( traditional Medicare A) • Nursing Home Compare Star Ratings ( all residents) • Value driven care is, by definition, a balance between care quality and care cost: • High - value, efficient providers are those who are able to deliver high quality care for low cost.

39. The MDS as a tool for measuring quality outcomes • Moving forward in the PDPM model, CMS will be monitoring quality outcomes and correlating with service delivery • Changes in therapy delivery patterns/replacing formal therapy with Restorative Nursing Programs • Changes in care delivery • Changes in measured outcomes Example: • Increase in pressure injuries with a decrease in therapy delivery • Is there a correlation- did care delivery change the outcome negatively?

40. Quality Measures/Quality reporting and the MDS • Quality Measures/CASPER report- generated with the MDS transmission process • Data collected from all MDS assessments that are transmitted, regardless of payor source • Measures are separated by short term stay ( <100 days) and long term stay • Measures are calculated based on MDS coding • All ID team members need to understand coding guidelines • QMs are: • Reflective of quality of care, care delivery trends and resident acuity • Part of the state survey process • One component of the 5 Star rating

41. Quality Measures/Quality reporting and the MDS QM Resources: • QM Users manual contains all metrics and calculations used to calculate percentages • Numerator, denominator, exclusions, risk adjustments and MDS items used in each QM https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-USERS-MANUAL-v121.pdf

42. Quality Measures/Quality reporting and the MDS • SNF Quality Reporting Program- QRPs • Medicare A residents only ( at this point) • Eight assessment based measures and three claims based measures • Calculations are determined based on multiple considerations: • Are all applicable MDS items answered ( no “dashes”) • Accuracy of MDS coding

43. Quality Measures/Quality reporting and the MDS Assessment based measures: • One or More Falls with Major Injury (Long Stay) Lower percentages are better • Admission and Discharge Functional Assessment and a Care Plan That Addresses FunctionHigher percentages are better • SNF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients Higher scores indicate greater independence. • SNF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients Higher scores indicate greater independence

44. Quality Measures/Quality reporting and the MDS Assessment based measures- con. • SNF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients Higher scores indicate a higher percentage of residents met or exceeded expected discharge self-care scores • SNF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients  Higher scores indicate a higher percentage of residents met or exceeded expected discharge mobility scores. • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury. Lower percentages are better. • Drug Regimen Review (DRR) Conducted With Follow-Up for Identified Issues - Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). Higher percentages are better.

45. Quality Measures/Quality reporting and the MDS • Claims based measures ( do not currently affect the APU) • Medicare Spending Per Beneficiary (MSPB) — Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program No additional data collection is needed besides claims data. • Discharge to Community (DTC) - Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). Higher rates are better. No additional data collection is needed besides claims data. • Potentially Preventable 30-Day Post-Discharge Readmission (PPR) Measure for Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). This measure is currently not publicly available on the Nursing Home Compare website, but facilities can see their own data in the confidential reports.

46. Quality Measures/Quality reporting and the MDS SNF QRP Resources: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QRP-Quarterly-FAQ-Update-Q1-2019.pdf

47. Quality Measures/Quality reporting and the MDS SNF Value Based Purchasing-Impact on Medicare A rates • The SNF VBP Program rewards SNFs with incentive payments based on the quality of care they provide to Medicare beneficiaries, as measured by a hospital readmissions measure. • SNFs: • Are evaluated by their performance on a hospital readmission measure; • Are scored on both improvement and achievement; • Receive quarterly confidential feedback reports containing information about their performance • Earn incentive payments based on their performance.

48. Quality Measures/Quality reporting and the MDS SNF VBP Resources: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/SNF-VBP/SNF-VBP-Page.html https://www.youtube.com/watch?v=H1KNTTEpDXw&feature=youtu.be https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP-FAQs-Final.PDF

49. Quality Measures/Quality reporting and the MDS 5 Star rating/Nursing Home Compare • Staffing ratios • QMs • State survey results 5 Star rating can impact ACO partnerships and census https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/Five-Star-Users-Guide-April-2019.pdf

50. Correlations- Pulling it all together