Indiana LTC Case Mix Audits

1. Indiana LTC Case Mix Audits HP Enterprise Services January 2011

2. What’s New EDS now HP Enterprise Services Frequency of audits Refer to Bulletin BT200936 No list of residents with traumatic brain injury (TBI) No list of residents who receive outside mental health services No abbreviation list – if needed, auditors will request. Audits now completed electronically

3. LTC Case Mix Audit Process HP Enterprise Services completes a Level of Care audit for all IHCP facilities in the state of Indiana according to the following categories: Low Risk – 90-100 percent validation rate will be audited at a maximum of every three years. Medium Risk – 80-89.9 percent validation rate will be audited at a maximum of every two years. High Risk – 79.9 percent or lower validation rate will be audited every four to twelve months. Refer to Bulletin BT200936 for audit frequency. HP audits the minimum data set (MDS) supporting documentation maintained by nursing facilities for all residents, regardless of payer type.

4. LTC Case Mix Audit Process HP provides advance notification to the nursing facility. This notification is as many as 72 hours before the audit. See 405 IAC 1-15-5 for more information. The audit includes: The greater of 30 percent of the total assessments or a minimum of 25 assessments. The facility provides the census list. The MDS assessments subject to audit are those most recently transmitted to Myers and Stauffer LC.

5. The audit team conducts an entrance conference with each nursing facility. The nursing facility is required to produce, upon request, a computer-generated copy of the MDS assessment that is transmitted, which is the basis for the MDS audit. LTC Case Mix Audit Process

6. Alphabetical resident list, which includes the following: Last name First name Date of birth Date of admission Medicaid number or Social Security number Alphabetic Level II Resident List Current facility e mail address for future correspondence LTC Case Mix Audit Process Requested Information

7. The audit team reviews the following two parts of each record: Activities of daily living (ADL) component Element component The team considers a record to be unsupported when there is a lack of documentation to support the RUG as a result of the audit. LTC Case Mix Audit Process

8. When the audit team is unable to support a record, the team requests that the nursing facility find supporting documentation. The nursing facility must provide documentation to support records prior to the exit conference. LTC Case Mix Audit Process

9. “If the percentage of assessments of all residents that are unsupported is greater than the threshold percentage … a corrective remedy shall apply.” See 405 IAC 1-14.6-4 for more information. When the preliminary validation rate for the initial sample is below 80 percent, the audit expands to include the greater of an additional 20 percent of the assessments or a minimum of 10 additional assessments consisting of 90 percent Medicaid payer source assessments and 10 percent non-Medicaid payer source assessments. LTC Case Mix Audit Process

10. The nursing facility must provide documentation to support records prior to the exit conference. The threshold percent is 20 percent and therefore, the required validation rate for case mix audits is 80 percent or greater. Prior to exit auditors will observe all residents that were audited The team then informs the nursing facility that it is ready for the exit conference. LTC Case Mix Audit Process

11. HP sends the final summary letter to the nursing facility approximately 10 business days following the exit conference. The letter details the Summary of Findings and the Final validation rate. LTC Case Mix Audit Process

12. Informal Reconsideration Process The letter contains instructions for the informal reconsideration process. Informal reconsideration is conducted by an HP LTC registered nurse (RN) who is separate and distinct from the audit. During the informal reconsideration process, the HP audit team does not review supporting documentation provided after the audit exit conference . See 405 IAC 1-15-5 for more information.

13. Informal Reconsideration Process The request must include specific audit issues that the nursing facility believes were misinterpreted or misapplied during the audit. HP must receive the request in writing no later than 15 business days from the date of the letter. HP forwards final results to Myers and Stauffer LC upon completion of the audit process.

14. RUG Classifications • Extensive Services • Rehabilitation • Special Care • Clinically Complex • Impaired Cognition • Behavior • Reduced Physical

15. RUG Classifications Extensive • K0500A – Parenteral IV Feeding • O0100D, 1 or 2 – Suctioning • O0100E, 1 or 2 – Tracheostomy Care • O0100F, 1 or 2 – Ventilator or Respirator • O0100H, 1 or 2 – IV Medication

16. RUG Classifications Rehabilitation • O0400A 1, 2, 3, & 4 • O0400B 1, 2, 3, & 4 • O0400C 1, 2, 3, & 4 • Therapies: Speech – Language Pathology and Audiology Services; Occupational Therapy and Physical Therapy

17. RUG Classifications Special Care • I4400 – Cerebral Palsy • I5100 – Quadriplegia • I5200 – Multiple Sclerosis • J1550A – Fever; J1550B – Vomiting; J1550C – Dehydration; K0300 – Weight loss; K0500B – Feeding tube; I2000 – Pneumonia, included in fever string impacting special care

18. RUG Classifications Special Care • K0700A – Proportion of total calories the resident received through parenteral or tube feeding. For residents receiving po nutrition and tube feeding, documentation must demonstrate how the facility calculated the percentage of calorie intake the tube provided and include: • Calories tube feeding provided during observation period • Calories oral feeding provided during observation period • Percent of total calories provided by tube feeding • Calories by tube/total calories consumed

19. RUG Classifications Special Care • K0700B – Average fluid intake per day by IV or tube; and I4300 – Aphasia are included in string impacting special care with feeding tube • M0300A – Number of Stage I pressure ulcers • M0300B,1 – Number of Stage 2; M0300C,1 – Number of Stage 3; M0300D,1 – Number of Stage 4; M0300F,1 – Number of Unstageable • Note: Documentation must include staging within the observation period. Each ulcer should have an entry noting observation date, location, and measurement/description.

20. RUG Classifications Special Care • M1030 – Number of venous and arterial ulcers • M1040D – Open lesions • M1040E – Surgical wounds • M1200A, B – Pressure reducing device, chair, bed • Note: Facilities providing pressure-reducing mattresses for all beds should have a documented policy noting such and be prepared to provide evidence of the policy to the audit team.

21. RUG Classifications Special Care • M1200C – Turning/repositioning program • M1200D – Nutrition or hydration intervention to manage skin problems • M1200E – Ulcer care • All impact strings with staged wounds

22. RUG Classifications Special Care • M1200F – Surgical wound care impacting strings with surgical wounds • M1200G – Application of non-surgical dressings other than to feet; and M1200H – Application of ointments/medications other than to feet both impact strings with staged wounds and surgical wounds

23. RUG Classifications Special Care • O0100B,1 or 2 – Radiation • O0400D2 – Respiratory therapy – Days and minutes – Assessment – Performed by qualified individuals

24. RUG Classifications Clinically Complex • D0200A – I, 2 – Resident Mood Interview (PHQ-9); minimum documentation – resident mood interview symptom frequency codes are sufficient. MDS will be considered source document.

25. RUG Classifications Clinically Complex • D0500A – J, 2 – Staff assessment of Resident Mood (PHQ-9-OV) • Documented examples demonstrating the presence and frequency of the clinical mood indicators must be provided during the observation period.

26. RUG Classifications Clinically Complex • B0100-Comatose • I2100-Septicemia • I2900 – Diabetes Mellitus included in diabetes string • I4900 – Hemiplegia/Hemiparesis • J1550D – Internal bleeding • K0700A – Portion of total calories and K0700B – Average Fld per day with feeding tube

27. RUG Classifications Clinically Complex • M1040A – Infection of foot • M1040B – Diabetic foot ulcer • M1040C – Other open lesions on foot • M1040F – Burns • M1200I – Application dressings to feet, impacting strings with skin conditions of foot • N0300 – Injections – impacting diabetes string

28. RUG Classifications Clinically Complex • O0100A, 1 or 2 – Chemotherapy • O0100C, 1 or 2 – Oxygen therapy • O0100I, 1 or 2 – Transfusions • O0100J – Dialysis • O0600 – Physicians’ examinations • O0700 – Physician orders

29. RUG Classifications Impaired Cognition • B0700 – Making self understood • C0200 – Repetition of three words • C0300A, B, C – Temporal orientation – year, month, week • C0400A, B, C – Recall • C0700 – Short-term memory OK • C1000 – Cognitive skills for daily decision making

30. RUG Classifications Behavior Problems • E0100A – Hallucinations • E0100B – Delusions • E0200A – Physical behavioral symptoms directed toward others • E0200B – Verbal behavioral symptoms directed toward others • E0200C – Other behavioral symptoms not directed toward others • E0800 – Rejection of care presence and frequency • E0900 – Wandering presence and frequency

31. Nursing Restorative Program • H0500 – Bowel toileting program • H0200C-Current toileting program or trial • O0500 A, B, C, D, E, F, G, H, I, J – Restorative nursing care

32. Activities of Daily Living (ADL) Assistance • G0110A, 1 & 2 • G0110B, 1 & 2 • G0110I, 1 & 2 • G0110H, 1 • Included in coma string impacting extensive services count in clinically complex and impaired cognition • Documentation of these ADLs requires 24 hours/7days within observation period.

33. Supportive Documentation Guidelines (SDG) MDS 3.0Effective for assessments dated October 1, 2010, or after

34. Overall Documentation Instructions • Supportive documentation must be dated during the assessment period. • Each page or individual document must contain the resident identification information. • Corrections/Obliterations/Errors/Mistaken Entries: At a minimum, the audit teams must see one line through the incorrect information, the staff’s initials, the date the correction was made, and the correct information.

35. MDS 3.0 C0200 – Repetition of three words C0300A, B, C – Temporal orientation – year, month, week C0400A, B, C – Recall Minimum Documentation Standards BIMS Codes are sufficient. MDS will be considered source document. Additional Information for SDG MDS 3.0

36. MDS 3.0 D0200A-I, 2 – Resident Mood Interview (PHQ-9) Minimum Documentation Standards Resident Mood Interview (PHQ-9) symptom frequency codes are sufficient. MDS will be considered source document. Additional Information for SDG MDS 3.0

37. MDS 3.0 D0500A-J, 2 – Staff Assessment of Resident Mood (PHQ-9-OV) Minimum Documentation Standards Documented examples demonstrating the presence and frequency of clinical mood indicators must be provided during the observation period. Additional Information for SDG MDS 3.0

38. MDS 3.0 I2900 – Diabetes Mellitus I4300 – Aphasia I4400 – Cerebral Palsy I4900 – Hemi-plegia/Hemiparesis I5100 – Quadriplegia I5200 – Multiple Sclerosis Minimum Documentation Standards Diagnosis was active during look-back period. Active diagnosis signed by the physician within the past 60 days (plus 10-day grace period permitted by 410 IAC 16.2-3.1-22(d)(2) Additional Information for SDG MDS 3.0

39. MDS 3.0 O0500, A, B, C, D, E, F, G, H, I, J – Restorative Nursing Care Minimum Documentation Standards Documentation during the observation must include the five criteria for restorative nursing care. Additional Information for SDG MDS 3.0

40. Resources • For auditing questions, call HP Enterprise Services Long Term Care Unit at (317) 488-5062. • For more information, including bulletins and copies of Supportive Documentation Guidelines, go to http://www.indianamedicaid.com. Click Bulletins to access bulletins for updates and copies of the Supportive Documentation Guidelines.

41. Q&A