Intermediate Care Facilities, Long Term Care & Rehabilitation Records

1. Intermediate Care Facilities,Long Term Care& Rehabilitation Records HIM 2000

2. Intermediate care facilities • Mentally retarded • Developmentally disabled individuals ICF/MR funded by Title XIX (Medicaid) and must meet the standards in the Conditions of Participation for ICFs/MR.

3. ICF/MR Surveys performed by the state’s department of health. Coding: ICD-9-CM and some DSM-IV coding for psychology/psychiatry services

4. Long Term Care Settings • Freestanding Nursing Facility • Nursing home • Long-term care facility • Skilled nursing facility • Acute care hospital, skilled nursing unit

5. Types of Surveys • State licensing agency • Annual licensure renewal (unannounced) • Complaint investigation • CMS • Annual certification for participation • JCAHO -Optional survey for LTC

6. Documentation • Vital in evaluation of how a facility impacts its residents quality of care and life • Impacts facility reimbursement by Medicare • Vital to the defense of litigation involving negligence for poor care outcomes • Care plans must be individualized to the resents’ care needs, strengths and individual preferences.

7. Comprehensive Resident Assessment • Primary vehicle for evaluating care outcomes • Resident assessment instrument (RAI)3 components -Minimum Data Set (MDS) -Resident Assessment Protocols(RAPs) -Utilization guideline (specified in State Operations Manual)

8. Minimum Data Set • MDS data are utilized to classify patients into resource utilization groups (RUGs), which are the basis of payment under the skilled nursing facility (SNF) prospective payment system (PPS). • MDS data used to track specific care and quality outcomes

9. Quality Indicators SNF monitor some of the following quality indicators: • Pressure ulcer care • Incontinence care • Nutrition • Prevalence of dehydration • Incidence of contractures • Psychotropic drug use

10. Time requirements • Within 14 days of admission or after any significant change in condition and on an annual basis • Between comprehensive assessments, staff must complete a quarterly review of physical, mental, and psychological information.

11. Basic Reimbursement categories and pay sources • Medicaid • Medicare Part A • Medicare Part B • Managed Care • Commercial Insurance • Private Pay

12. Case study You are the consultant for the long-term-care facility that has recently undergone a survey in which the facility received several deficiencies for noncompliance with federal requirements. The most significant deficiency involved a noted pattern (7 out o10 examples) in which comprehensive assessments (MDS) were not completed within the required time frame (within 14 days of admission). In addition, suveyors identified that there was no documentation to support that the triggered RAPs were being used in the assessment and care planning process. It was also noted that the nursing staff stated they did not understand what the resident assessment protocols were and they were unaware of the federal criteria for determining when a significant change had occurred. The administrator of this facility has called you to help develop a plan to correct these deficiencies.

13. Case Study questions? • What would be your recommendations for overall system evaluation and revision? • What would be your recommendations for staff education? • How could the facility medical records specialist be utilized to prevent similar problems from occurring in the future?

14. Rehabilitation Rehabilitation is the development of a person to the fullest physical, psychological, social, vocational, and educational potential consistent with his or her physiological anatomic impairment and environmental limitations.

15. Rehab levels Acute rehabilitation- rehabiliative care provided for two to ten weeks until the patient is medicallly stable and has reached his or her maximum short-term improvement Postacute rehab- a setting providing long-term therapy to maximize functional status for patients who have successfully completed acute rehab, or have passed all acute medical problems, or are medically stable and ready for postacute rehab. Subacute rehab- rehabilitative care of lesser intensity provided to patients who have a discharge goal to return home or to a less restrictive environment, but are unable to participate or benefit from a higher level of rehabilitative care.

16. Rehabilitation Services 2 voluntary accrediting agencies for rehab facilities Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Commission for Accreditation of Rehabilitation Facilities (CARF)

17. CMS criteria for inpatient rehabilitation • 75% or more of the population must be treated for specific rehabilitation conditions with the remaining 25% or less being either rehab diagnoses or of a deconditioned nature that has the potential to be discharged to an independent living situation

18. Documentation in Rehab CARF guidelines in patient’s medical records. • The assessment of the patient • Determination, modification, and implementation of the individual (discharge plans) • Active participation in conferences • Provision of direct services consistent with the needs of the patient • Promotion of interdisciplinary functions and mutual support among all team members • Promotion of the program’s evaluation and treatment philosophy

19. Functional Independent measure (FIM) FIM scores are an reliable and valid instrument in documenting the severity of disabilities as well as outcomes in rehabilitation. FIM scores are issued in thirteen motor and five cognitive areas. Each area receives a score ranging from one to seven.

20. Changes in Rehab • Due to rising hospital costs and shorter inpatient stays, there is an increased need for more sub-acute and outpatient rehabilitation facilities. Outpatient and freestanding rehabilitation clinics will also increase.