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LEADERLTCODF: QMs to return to traditional survey processCaralyn Davis, Staff Writer

The Division of Nursing Homes at the Centers for Medicare and Medicaid Services (CMS) is preparing for surveyors in the traditional survey process to begin using the Quality Measure (QM) reports in survey activities, said CMS officials at the March 1 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF). The three QM reports that surveyors hand to nursing home administrators when they come in for survey will be the same three that were previously used under MDS 2.0: the Facility Characteristics Report, the Facility Level Report, and the Resident Level Report.

While these three reports will track the new MDS 3.0-based QMs, they will not include “every single QM that will be part of the main set,” said officials. “The new QM list is much

If wrinkles must be written upon our brows, let them not be written upon the heart. The spirit should not grow old.

— J A M E S A . G A R F I E L D

W W W . A A N A C . O R G

Facilitate Successful Outcomes by Addressing Undetected or Unmanaged Dementia, Delirium and DepressionKim Warchol, otr/l, President of Dementia Care Specialists, a CPI Specialized Offering

Introduction

My heart belongs to our elders living with Alzheimer’s and related dementias (ADRD). It is my life mission to enable these individuals, along with the businesses and people that serve them to thrive! I have been practicing as an Occupational Therapist since 1989 with most of that time spent specializing in dementia management. I have attended numerous continuing education events related to cognition and aging and I have advanced training in the Cognitive Disabilities Model (CDM) by Claudia Allen, OTR/L. After receiving extensive education, I implemented this knowledge as an Occupational Therapist in long-term care (LTC) environments. I then began creating interdisciplinary dementia training programs and acting as a consultant to LTC operators and providers who desired to establish innovative dementia living environments and programs. The trainings and the care model I developed were based upon strong theoretical

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2 A ANAC LTC LE ADER 3 .6 . 2012

shorter than it used to be. There were some that we figured the surveyors didn’t need to spend their time on. And mostly those were the ones about immunizations for flu shots and pneumonia vaccine shots. So we eliminated them.”

In addition to redesigning the forms so that the language “matches the QMs themselves,” CMS is changing the thresholds that surveyors use to identify topics for survey. The thresholds will now be “nationally based instead of based in your state,” said officials. “So where there is a threshold over that ‘magic’ percentile, it used to just compare your home to other homes in your state. We decided to go with the national comparison since we have it available. So

for an item, say it is pressure ulcers, surveyors would be paying attention to that in the sample if it is nationally triggered.”

CMS also is changing two survey forms that the facilities have to complete:

•Form CMS-802, the Roster Sample Matrix, which is used in the traditional survey; and

•Form CMS-672, the Resident Census and Conditions of Residents, which is used in both the traditional survey and the Quality Indicator Survey (QIS). Note: The revised form CMS-672 is the only change pending for the QIS, said officials.

CMS will incorporate the redesigned survey process tasks and the revised forms into Appendix P and the Exhibits, respectively, of the State Operations Manual. When these changes are finalized, CMS expects to issue a survey-and-certification memorandum that will include the draft final manual changes as an attachment. CMS doesn’t yet have “an exact date” when these survey changes will occur, said officials.

“It won’t be released until sometime in April. It could even drag on a little longer than that.”

Other issues tackled in the ODF include:

Errata document has errors

On Feb. 29, CMS posted an Errata Document for the MDS 3.0 RAI User’s Manual version 1.08, which goes into effect April 1. Officials announced that the Errata Document contains some errors and a revised version is pending at press time. (Check “Need to Know”

QMs to return to traditional survey process, continued from page 1

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“We decided to go with the national comparison since we have it available. So for an item, say it is pressure ulcers, surveyors would be paying attention to that in the sample if it is nationally triggered.”

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3 A ANAC LTC LE ADER 3 .6 . 2012

on the AANAC home page or the MDS 3.0 Training Materials website.) Of the existing Errata Document, pages 1 – 4 are accurate and can be referred to for educational purposes. The chart on these pages discusses the RAI Manual issues and the resolutions that CMS is making. However, pages 5 – 11, which comprise the corrected RAI Manual pages, are inaccurate and will be changed when CMS issues the revised Errata Document.

In addition, “we will likely have additional errata documents periodically as items are identified or as there are items that we need to clarify,” said officials. “For any corrected pages, they will be indicated by (R) at the bottom of the page in the footer area. So you can

simply replace the page in your manual if there are any updates.”

Expedited determination notices

CMS has simplified the expedited determination processing by developing one set of notices that providers will use for both traditional fee-for-service Medicare patients and Medicare Advantage (MA) patients. The new Notice

of Medicare Non-Coverage (NOMNC) and the new Detailed Explanation of Non-Coverage (DENC) “are based on existing notices that have been combined so that they can be issued to both original Medicare beneficiaries and Medicare Advantage enrollees,” said officials.

QMs to return to traditional survey process, continued from page 2

“For any corrected pages, they will be indicated by (R) at the bottom of the page in the footer area. So you can simply replace the page in your manual if there are any updates.”

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“The new NOMNC combines and will replace the current Notice of Medicare Provider Non-Coverage form CMS-10123, which is issued to original Medicare beneficiaries, and the Notice of Medicare Non-Coverage form CMS-10095-NOMNC, which is issued to MA enrollees. It retains the form number of the current original Medicare notice, which is the CMS-10123, and takes on the name of the MA notice, which is Notice of Medicare Non-Coverage or NOMNC,” they explained. “The new DENC combines and will replace the Detailed Explanation of Non-Coverage form CMS-10124, issued to original Medicare beneficiaries, and the Detailed Explanation of Non-Coverage form CMS-10095-DENC, issued to MA enrollees. The new DENC retains the form number of the current original Medicare Detailed Explanation of Non-Coverage, which is CMS-10124. The requirements for issuing these notices have not changed.”

The new CMS-10123 and CMS-10124 forms have been posted on the CMS FFS ED Notices page. (They are also available in the “What’s New” section of the AANAC home page.) Providers can start using the new forms immediately, but must implement them by no later than May 1. Providers can send questions to the e-mail box revisedabn_odf@cms.hhs.gov. “Please include NONMC in the subject line,” said officials.

MDS 3.0 coding advice

An ODF caller asked whether MDS 3.0 item A2400 (Medicare stay) should be coded for residents who have Medicare as a secondary payer. “The answer is yes, you do need to complete this,” said officials. “We will work on updating the manual to clarify the directions.”

Another caller asked about the rules for coding co-treatments in section O400 (therapies) in relation to home visits, offering this scenario: The occupational

QMs to return to traditional survey process, continued from page 3

1 A ANAC LTC LE ADER 8 .30 . 2011

MDS 101An Introduction to

the RAI Process

A beginner’s resource from trusted MDS experts.MDS 101 was developed to provide a basic understanding of Resident Assessment Instrument (RAI) procedures and the MDS for anyone who needs to increase their familiarity of these critical tools.

Why MDS 101?

• MDS 101 is the perfect time commitment for busy professionals.

• Engage others involved in the assessment process and see results.

• Intensive glossary of common defi nitions, terms and acronyms.

• Understandable and applicable explanations of basic RAI conventions.

Purchase this course and many others in the AANAC online store. www.aanac.org/store

1.75 CEUs

Skilled Nursing Facility Consolidated Billing – (1.25 CEUs)

• Introduce elements of the UB – 04 that clinicians should be aware of.

• Examine the concept of consolidated billing in an SNF.

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• Identify strategies for ensuring that the SNF staff pay what is owed and do not pay if the service is excluded from consolidated billing.

Check out these other great MU training courses that help make you a Medicare master.

• The Prospective Payment System in a Skilled Nursing Facility – (1 CEUs)

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STEPStart by purchasing courses at the AANAC online store. Once you’ve completed consolidated billing, try another of our great Medicare University training modules and start making Medicare work for you and your residents.

The assessment process is a critical component of accurate care and facility reimbursement. Help other team members achieve results with a little help from the MDS experts you’ve trusted for years.

MDS 101 is the tool that you need.

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Empower Your Team to Deliver the Highest Quality Dementia Care

CPI’s Dementia Capable Care training from Dementia Care Specialists (DCS) empowers the entire team with a positive, person-centered approach like no other. Staff attitudes shift, confidence soars, and quality of life improves for residents and their families.

Learn more about this powerful training at crisisprevention.com/leader or visit Booth 24 at the 2012 AANAC Conference April 18–20 in Jacksonville, FL.

Also at the AANAC ConferenceJoin DCS president Kim Warchol, OTR/L, in the St. Johns room for her clinical session, Facilitate Successful Outcomes by Addressing Undetected and Unmanaged Dementia, Delirium, and Depression Thursday April 19, 8:15 a.m. to 9:30 a.m.

LT120

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foundations including the principles of person-centered care, and the CDM by Allen. Person-centered care emphasizes the importance of discovering and integrating life story and preferences. The CDM teaches how to discover and facilitate use of retained capacities and how to create the right fit or just right challenge at every dementia stage, through a compensatory approach.

Common LTC Challenges and the Relationship to Serving Individuals With Dementia

The prevalence of individuals with Alzheimer’s/dementia in our LTC communities is very high, and growing. Approximately 68% of nursing home residents and up to 67% of those living in Assisted Living Facilities have some degree of cognitive impairment related

to ADRD. But about 70% of those with Alzheimer’s are still living at home1, and we have seen many of these individuals in our short-term rehab beds.

LTC environments face many challenges every day including those related to revenue management, achieving quality care outcomes, and staff/customer satisfaction. What every leader needs to know is that many studies have shown a significant correlation between these problems and Alzheimer’s/dementia. Alzheimer’s/dementia is often identified as a root cause of many LTC common problems such as falls, weight loss, hospitalization, excess disability, aggressive behavior, and costs of care.The good news is, if we improve our interventions we can improve these outcomes, however if we continue to provide care in the usual manner, these Alzheimer’s/dementia related challenges and poor outcomes will continue to recur. The following identifies a few of the common problems and the study results which show the correlation to dementia.

Problem: Falls

Studies show: about 3 out of 4 nursing home residents fall each year and falls result in disability, functional decline and reduced quality of life.2

Dementia Correlation: One of the identified key risk factors for falls includes many conditions associated with dementia such as cognitive impairment, impaired functioning and depression.3

Problem: Aggressive Behavior

Studies show: 24 – 95% of LTC residents display aggressive behavior. These individuals are more likely to receive psychotropic drugs and to be physically restrained, these behaviors compromise care, can create occupational injuries among nursing

staff, and can increased costs related to staff turnover and absenteeism.

Dementia Correlation: The most significant predisposing factor identified for Aggressive Behavior in LTC is cognitive impairment severity.4 This means the more advanced the stage of dementia, the more prevalent the aggressive behavior.

Problem: Costs of Care

Studies show a dementia correlation. The higher the dementia severity and/or functional dependence, the higher the direct and indirect care costs.5, 6

Problem: Hospitalization

Studies show a dementia correlation. Studies show people with Alzheimer’s disease and related dementias are hospitalized 3x more often than their peers without. Alzheimer’s patients were far more likely to be hospitalized for infections, pneumonia and falls (hip fracture, syncope, collapse).7

Addressing Dementia, Delirium and Depression, continued from page 1

Approximately 68% of nursing home residents and up to 67% of those living in Assisted Living Facilities have some degree of cognitive impairment related to ADRD.

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Jacksonville, FLApril 16 – 18 Preconference

April 18 – 20 Conference

Better Together:

Connecting Care and Assessment

Kim's session on addressing dementia, delirium and depression is just one example of the clinical sessions that we're providing at the 2012 conference.

Other choices include a session on pressure ulcer prevention and treatment or addressing and treating pain in LTC residents.

Join us and find out how AANAC can help you create positive results using your assessment skills.

Register today!

6 A ANAC LTC LE ADER 3 .6 . 2012

Addressing Dementia, Delirium and Depression, continued from page 5

Understanding the Root Cause of These Problems

As seen above, it is evident that unidentified and/or undermanaged dementia is a common denominator and root cause of these and many other problems. But in addition to dementia, residents in LTC often experience delirium or depression, which also have an impact on cognition and therefore impairs function, health and safety. Let’s review “the 3 D’s” and identify some of the key differentiating factors.

Dementia

Dementia is a broad clinical term meaning impairment in mental functions such as thinking, reasoning, and memory to such a severity that it interferes with a person’s ability to function and live independently. First the individual will experience changes in IADL’s such as driving, cooking and money management. As the disease

advances the person will have problems performing basic ADL’s such as eating, bathing, mobility and dressing. There are both reversible and irreversible/progressive dementia types. However, the most common classification in the

elderly is chronic and progressive dementia and that includes Alzheimer’s disease, which is the most common form in our elders. Other chronic progressive dementias include vascular dementia, lewy-body dementia and fronto-temporal dementia.

Dementia progresses through rather predictable stages. At each dementia stage, there are retained abilities that must be identified and utilized, and there are losses that must be compensated for during care. With this compensatory

care approach, those living with dementia can achieve their best ability to function in all activities including ADL’s, mobility and leisure, at every dementia stage.

Delirium

Delirium also causes changes in cognition that can impact on function and safety. However delirium is often treatable, especially if recognized early. If the underlying health issue can be resolved (such as a UTI infection), cognition may reverse back to normal, or at least demonstrate improvement. Delirium often presents differently from dementia with a couple key differences being (a) the onset is more abrupt, and (b) the hallmark cognitive deficit is impaired attention.

Depression

Depression is a broad term used to represent many mood disorders. Unfortunately depression is common in the elderly for many reasons including emotional distress and medication reactions. Depression is common in those with Alzheimer’s/dementia. Depression not only impacts on mood but can also impact cognition. Depression can be treated and if successful, mood and cognition can improve. Depression presents differently from dementia, with three differences

being, the person with depression (a) may have more “don’t know” or “don’t want to” responses, (b) may have decreased energy and (c) may have impaired appetite or sleep problems.

In summary, nurses, therapists and others must be able to identify indicators of dementia, delirium and depression so treatment including non-pharmacologic and pharmacologic can be initiated quickly. While keeping in mind the important fact that cognitive

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Delirium often presents differently from dementia with a couple key differences being (a) the onset is more abrupt, and (b) the hallmark cognitive deficit is impaired attention.

7 A ANAC LTC LE ADER 3 .6 . 2012

dysfunction related to dementia is chronic and progressive, and cognitive dysfunction related delirium and depression may be fully or partially reversible, the same basic “compensatory care approaches to optimize function and safety” apply to all.

The Solution: Dementia Capable Care

Your goal as a leader should be to create an interdisciplinary dementia

capable workforce that is competent to implement interventions that promote positive outcomes. Dementia training is of course a vital piece, however a leader must establish several things before embarking on staff training because training is just a pillar of support of a quality model of care. Training needs to attach to the “why” and “how” of the model, or it will fail.

Key Components of a Highly Successful Dementia Care Model

The following are some of the key components of a successful dementia care model, phrased in questions the interdisciplinary leaders should answer, along with some of our recommendations:

•Component 1: Dementia Care Philosophy—What is it that you and your team believe/ what is your dementia care philosophy? Example, “Webelieveperson’swithAlzheimer’s/dementia have many retained abilities andwhencapitalizedon,canflourishateverydementiastage.”

•Component 2: Dementia Care Goals—What are your goals or objectives for dementia care? Example,“Tooptimizethe(a)function,

(b)healthandsafetyand(c)qualityof life and dignity of those with Alzheimer’s/dementiainordertoenable the person, and the business and people which serve them to thrive andprosper.”

•Component 3: Dementia Care Model Process and Training—What process components need to be in place to achieve stated goals, who does what, and what training is needed for that process to be supported for success? For example,

» “Evaluations should include a focus on discovering a resident’s dementia stage, key life story information, and indicators of depression or delirium.

Nursing may administer a brief functional cognitive screen such as the Global Deterioration Scale (GDS) and Occupational Therapy, upon receipt of a physician order, should administer the more in-depth CDM functional cognitive assessments to confirmtheAllenCognitiveLevel/dementia stage. Activities or social services should gather key life story routine and preference information.

» Care Plan and Care Delivery should incorporate the evaluation information above. The interdisciplinary team will collaborate to develop and deliver a plan of care to achieve the previously stated goals. Compensatory, person-centered care, based upon the person’s stage of dementia and their life story information is implemented by the entire team. Compensatory care means functional success in all activities is derived from how we:

Addressing Dementia, Delirium and Depression, continued from page 6

Cognitive dysfunction related to dementia is chronic and progressive, and cognitive dysfunction related delirium and depression may be fully or partially reversible, but the same basic “compensatory care approaches to optimize function and safety” apply to all.

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Addressing Dementia, Delirium and Depression, continued from page 7

° Change the environment to support and not hinder

° Change approach to gain understanding, trust and agreement

° Change the activity to the just right challenge level and to incorporate life story preferences

» Training is critical to give the interdisciplinary team the skills they need to competently and confidently carryouttheaboveactivities.”

•Component 4: Continuous Quality Improvement- How will you monitor the success of your dementia care and identify needs for improvement? You should immediatelyhaveaplantoanalyzeoutcomes data as it relates to those in yourcarewithAlzheimer’s/dementia.Minimally falls, aggressive behaviors, weight loss, activity levels, and hospitalization/re-hospitalizations,should be tracked. Outcomes should be benchmarked against

industry average and used to drive improvement activities.

•Component 5: Understand Your Return on Investment—How can you justify the time and financial investment in delivering high quality dementia care? The return onyourcommitmenttohighqualitydementia care and training can be seen in many ways including improved census,increasedtherapyutilizationand cost containment. Census can improveasadementiaspecializationprogram is marketed and there is

reduction in discharges related to poorly managed dementia. In addition, Occupational Therapy and possibly Speech Language Pathology and Physical Therapy will likely deliver increased services to the long-term stay residents under Medicare Part B billing, and the short-term rehab patients under Medicare Part A. In addition, costs of care can be reduced related to improved staff retention and reduction of spending on out of pocket care items such as weight loss supplements.

Summary

Currently there are over 5 million people in the US with Alzheimer’s disease and this number is expected to triple by mid-century if there is no cure or prevention. As this number rapidly grows, so does the request for innovative models of care to facilitate positive outcomes. The recently published Draft National Plan To Address Alzheimer’s Disease document, created as a part of the National Alzheimer’s Project Act (NAPA) that President Barack Obama signed into law on January 4, 2011, identifies their second goal as “Enhance Care Quality and Efficiency” and strategy number 2.A as “Build a workforce with the skills to provide high-quality care”. I hope you

will join us at the upcoming AANAC 2012 Conference to learn more about this very important topic and to network with others who share the mission of delivering dementia-capable care to enable those with Alzheimer’s/dementia in LTC to thrive! ●

References:1.Alzheimer’sAssociation,2011Alzheimer’sDisease

FactsandFigures,Alzheimer’s&Dementia,Volume7, Issue 2

2. Rubenstein LZ, Josephson KR, Robbins AS. (1994) Falls in the nursing home. Annals of Internal Medicine; 121, 442 – 51.

3. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention, 2001

4.VoyerP,VerreaultR,AzizahM,DesrosiersJ,Champoux, N, and Bédard, A (2005) Prevalence of physical and verbal aggressive behaviors and associated factors among older adults in long term care facilities. BMC Geriatr, 5, 13

5. Zhu CW, Leibman C, McLaughlin T, Scarmeas N, Albert M, Brandt J, Blacker D, Sano M, Stern Y. (2008) The effects of patient function and dependenceoncostsofcareinAlzheimer’sdisease.J Am Geriatr Soc.;56(8), 1497 – 503.

6.ZhuCW,LeibmanC,McLaughlinT,ZbrozekAS,Scarmeas N, Albert M, Brandt J, Blacker D, Sano M, Stern Y. (2008) Patient dependence and longitudinal changesincostsofcareinAlzheimer’sdisease.Dement Geriatr Cogn Disord., 26(5), 416 – 23.

7. Zhao Y, Kuo TC, Weir S, Kramer MS, Ash AS. (2008) HealthcarecostsandutilizationforMedicarebeneficiarieswithAlzheimer’s.BMCHealthServRes., 8,108.

The return on your commitment to high quality dementia care and training can be seen in many ways including improved census, increased therapy utilization and cost containment.

9 A ANAC LTC LE ADER 3 .6 . 2012

Q + A

A resident was admitted Feb. 14 and discharged the same day. He was in the building for only two hours. What assessments should we do? Do we get paid for day of discharge if the resident returned to hospital?

You would, at the least, need to complete the Entry tracking form and Discharge assessment for this resident. If the resident discharged home, you will also need a 5-day. However, if discharged back to the hospital on the day of admission, you would not do the 5-day, since the SNF will not be able to bill Medicare for that day.

Carol Maher, rn-bc, rac-ct

(cmaher0121@earthlink.net)

In the revised Section Q that will be effective April 1, there seems to be duplicate questions - Q0490 and Q0550A. Both seem to ask the same question: Does the resident or family prefer not to be asked about returning to the community? Why is this?

This is about the option offered to the resident to have the return to community question asked only on comprehensive assessments. When you are doing a non-comprehensive assessment, Q0490 prompts you to check the chart and see if the resident has requested that the return to community question be asked only on comprehensive assessments. If the answer is yes, then you skip the return to community-related questions—in fact you skip all the way to Q0600, referral. If the answer is no, then you go on to Q0500, Return to Community and ask that question, and you will also do Q0550, asking the resident about whether he or she wants to be asked about return

to community preference only on comprehensive assessments.

Rena R. Shephard, mha, rn, rac-mt, c-ne (RRS2000@aol.com)

A Part A patient is on IV antibiotics in our facility, and now he is also going for chemotherapy daily to the hospital. Do we get paid for those SNF days with the IV antibiotics and therapy?

As long as the resident returns before midnight each day, the SNF is reimbursed.

Ronald A. Orth, rn, nha, cpc, rac-mt

(raorth@clinicalreimbursement.com)

Our medical director is the physician for many of our residents. He wants his nurse practitioner do the admission histories and physicals and write initial orders, and then he will co-sign them. Is this acceptable?

F387 and F388 Frequency of Physician Visits define what is expected of physicians with regard to frequency, timeliness, and whether a physician must make the visit or can delegate to a physician extender. §483.40(c)(4) of F388 states: At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist. This establishes the expectation that the physician makes the first visit. Additionally, the physician

must make an actual “face-to-face” contact with the resident. There is no requirement for a face-to-face contact at the time of admission, since a physician is generally involved with the individual immediately prior to admission whether the resident is coming from a hospital or directly from home. However, the physician must visit within the first 30 days after admission, and then every 30 days thereafter for the first 90 days, after which visits are conducted every 60 days. That means your medical director must complete a visit within the first 30 days, his nurse practitioner can conduct the next visit on or before 60 days,

he conducts a 90-day visit, the nurse practitioner visits 60 days later, after which the 60-day visit cycle alternates between the medical director and the nurse practitioner. Read F387 and F388 details for physician visits at http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf.

Betty Frandsen, rn, nha, mha, c-ne

(bmacfran@gmail.com)

Regions of our State are using the QIS process, but our DOH field office survey teams have not been trained as QIS surveyors. We were told that we still might be surveyed using the QIS process. Can they do this?

To prepare for QIS implementation, each state selects an initial group of

continued on page 14

In regions where surveyors are not trained, it is still possible for a facility to undergo a QIS survey. This can happen if a QIS-trained team fills in at a different field office that has not been trained.

better together

At the 2012 AANAC Annual Conference you’ll reap the benefits of collaboration with peers and experts. You’ll develop strategies to ensure reimbursement efficiency and survey compliance. You’ll network with long-term care trailblazers, service companies and enthusiasts all gathered to promote your success in 2012. You’ll leave our conference with increased confidence in yourself and your abilities.

three dAys, four AmAziNg keyNote preseNtAtioNs:

Wednesday, april 18th

dANCe NAked—A Novel ApproACh to the Art of liviNgKris Radish, Author of Annie Freeman’s Fabulous Traveling Funeral

Radish will transform the way you look at living and dying. A champion of the nursing profession, Radish empowers attendees to connect the care and assessment of their own lives with the work they do.

thursday, april 19th

preveNtiNg elder Abuse ANd NegleCt: from the top dowN ANd bottom upDaniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN

Examine cost-effective methods for developing “forensic nurse” experts to improve a facility’s prevention strategies, assessment, documentation, and interventions around elder abuse and neglect. Learn techniques for training staff to improve documentation of injuries in the medical record to protect patients and your facility.

Friday, april 20th

Cms Address: Cms topiCs/mds updAteJohn Kane, Alice Bonner, PhD, RN, FAAN,

Thomas Dudley, MS, RN, Ellen Berry, PT (Invited)

CMS leadership provides the most up-to-date information on the new quality measurements, the MDS instrument, and much more in this

“can’t be missed” keynote address.

foCus oN frAud: stAyiNg out of the CrosshAirs Andrew Penn, Department of Justice, Rena R. Shephard, MHA, RN, RAC-MT, C-NE

Spotlight nursing home practices that result in major problems for providers and effective methods for avoiding these pitfalls. Understand the upcoming mandatory compliance and ethics program—with specified components to prevent and detect criminal, civil, and administrative violations.

april 18 – 20, 2012

2012 aanaC annual ConFerenCe & exhibition

Jacksonville

more opportunitiesmore keynotes

more time

Visit aanac.org/2012Conference to read the full keynote descriptions and join us in becoming better together.

jv_keynote_slick_PRINT.indd 1 1/10/12 8:38 AM

11 A ANAC LTC LE ADER 3 .6 . 2012

AANAC 2012 UPCOMING WORKSHOPS

TRAINING PARTNER MASTER TEACHER DATES CITY/STATE

2012 AANAC ANNUAL CONFERENCE

AANAC RAC-CT Certification Robin L. Hillier Apr 16 – 18 Jacksonville, FL

AANAC Medicare University Judy Wilhide Brandt Apr 16 – 18 Jacksonville, FL

AANAC C-NE Certification Jennifer Pettis Apr 16 – 18 Jacksonville, FL

AANAC RAC-CT Recertification Rena R. Shephard Apr 18 Jacksonville, FL

RAC-CT CERTIFICATION WORKSHOPS

Hill Educational Services Inc. Carol Hill Mar 12 – 14 Fultondale, AL

Judy Wilhide MDS Consulting Judy Wilhide Brandt Mar 13 – 15 Nashville, TN

LeadingAge New York (formerly NYAHSA) Sandy Biggi Mar 13 – 15 Utica, NY

Aging Services of Michigan Mar 13 – 15 Grand Rapids, MI

RRS Healthcare Consulting Services Rena R. Shephard Mar 13 – 15 San Francisco, CA

LeaderStat Lisa Hohlbein Mar 13 – 15 Chicago, IL

LeaderStat Lisa Hohlbein Mar 20 – 22 Cincinatti, OH

Pathway Health Services Judi Kulus Mar 20 – 22 White Bear Lake, MN

Harmony Healthcare International Jennifer Pettis Mar 20 – 22 Oakville, MO

Judy Wilhide MDS Consulting Judy Wilhide Brandt Mar 20 – 22 Atlanta, GA

Harmony Healthcare International Jennifer Pettis Mar 27 – 29 Seattle, WA

LeadingAge TX Ronald Orth Mar 27 – 29 Austin, TX

LeaderStat Lisa Hohlbein Apr 3 – 5 Indianapolis, IN

LeaderStat Lisa Hohlbein Apr 10 – 12 Dallas, TX

Pathway Health Services, Inc. Cynthia Perrault Apr 10 – 12 Westmont, IL

LeadingAge Iowa Deb Myhre Apr 10 – 12 Des Moines, IA

Harmony Healthcare International Jennifer Pettis Apr 10 – 12 New York, NY

LeadingAge NY (formerly NYAHSA) Sandy Biggi May 1 – 3 Rochester, NY

Harmony Healthcare International Jennifer Pettis May 1 – 3 Windsor, VT

MEDICARE UNIVERSITY WORKSHOPS

Harmony Healthcare International Jennifer Pettis June 4 – 6 Charleston, SC

The workshop schedule is subject to change and is updated regularly. To see a full AANAC Training Partner workshop schedule, visit aanac.org/workshops

12 A ANAC LTC LE ADER 3 .6 . 2012121212

One of the greatest features of AANAConnect is your ability to control over how you receive information. Unlike our previous list serve, you now have the option to select when, where and how your discussion messages are delivered. Want to know more about subscriptions and how to manage them? Read on...

What’s the difference between real time, daily digest, legacy, and no email subscription options?

• Real-time subscriptions mean that email messages arrive in your inbox as they are posted to the discussion group (typically within 1 hour of posting).

• Daily digest means you will receive one email each morning per discussion group that contains all of the previous day’s messages.

• Legacy subscriptions format the discussion group messages to appear in a text-only format that is easy to read on your smart phone or other handheld device. This is the only format that allows for direct reply, meaning you can use your email client “reply” button and do not have to go through the online interface. You can use this option on your regular email if you do not wish to use the online interface to post messages.

• No email means simply that—you will receive no messages in your inbox, but can log into AANAConnect to read messages posted to discussion groups.

Now that you know the basics of the different subscription options, you’ll need to know how you can modify them yourself to have complete control with the click of your mouse.

You can change your subscriptions and email delivery preferences at any time by:

• Clicking on the “My Subscriptions” link found in your discussion group emails

• Mousing over “Communities” in the top navigation of the AANAConnect site, then mousing over “View Discussions” from the drop-down menu and choosing

“My Subscriptions” from the sub-menu.

• From any “View Discussions” page you can click on the “Add/Change subscriptions” link in the upper right corner or the “My Subscriptions” link in the left navigation.

All communities to which you belong will appear in bold at the top of the list. You can change your preferences by clicking on the appropriate button. Be sure to click “Save” at the bottom of the page before moving on. ●

What’s new inActive Discussions this week on AANAConnect:

A ANAC LTC LE ADER 3 .6 . 2012

MDS Connection:

Thread Subject: ICD 10 implementation

Posted by: Judy Wilhide Brandt

I am looking for facility MDS coordinators to discuss, if

you will, the following:

1. Have you ever had any training on ICD-9? How do you

pick what you put in I8000? Does someone else pick

it? If so, what position? Do they know MDS coding

rules?

2. Have you had any training on ICD-10? Do you think you

need any? How do you plan to implement ICD 10 for

the MDS?

Have you ever seen an ICD 10 coding book, or anything

having to do with how ICD 10 is different from ICD 9?

Thanks, Judy

While the communities are great for answering questions

quickly, they are also great for people like Judy who

want to get a better understanding of what our members

are currently doing and how she can provide additional

services or information to help out. Share your experience

with Judy by clicking the thread subject above.

LTC Network:Thread Subject: Respiratory TreatmentsPosted by: Denise JohnsonIfalicensednursedoesanebulizertreatmentandfromset up to being completed takes 15 minutes or several tx a day totaling the 15 minutes, can it be counted as respiratory treatment. [I have heard that] it cannot be countedunlessthestaffpersonhashad“specializedtraining”.Cananyoneshedsomelightonthisforme?

Thanks... appreciate it.

Do you have a specially trained person on staff to perform the above activities? Has your facility found a way to solve the above situation? Share your experience / knowledge with Denise by clicking on the thread subject.

13 A ANAC LTC LE ADER 3 .6 . 2012

Coding TipWhen coding M0210: Unhealed Pressure Ulcer(s) the assessor would code “0” if the ulcer healed during the look-back period and was not present on prior assessment.

Treatment of Members PolicyAANAC has posted the Treatment of Members Policy on the website. If you need to access it, please click here.

FAQ referralDo you have a question you need answered NOW? Members of AANAC can go directly to the experts! Go to the FAQ section of the website. The answer may be right in front of you!

QMs to return to traditional survey process, continued from page 4

continued on page 14

therapist and the physical therapist take a Part A resident on a home visit. Can they both claim the full time that they are in the home doing treatments?

“Both PT and OT would be able to bill both codes the entire time of any treatment session, assuming they are each doing something for the entire time,” said officials. “If they’re both working the whole time and doing their own therapy discipline the whole time, then they would be able to code that whole time. However, let’s say a PT and an OT are together doing a transfer and one is just sitting there for half of it, then they would only be able to each code half the time.”

SNF PPS clarification memo pending

CMS plans to issue a formal clarification memo on SNF PPS issues, including the inactivation process and the rules for setting assessment reference dates for unscheduled assessments, soon after the agency’s March 6 – 9 MDS 3.0 National Conference training sessions, probably the week of March 12, said officials. (CMS also will preview these clarifications during the conference.) The memo will provide “formal substantiation of these policies,” they stated.

For example, one issue the memo will address is late change-of-therapy Other Medicare Required Assessments (COT OMRAs). A late COT OMRA occurs when

“the COT ARD is set for after day 7 but prior to the person being discharged from the Part A portion of their stay (i.e., a late assessment not a missed assessment),” said officials. “The general policy is that that you would bill default for the number of days that the assessment is out of compliance, that is, the number of

days beyond the COT ARD, day 7, that the assessment was completed.” This policy has some qualifications, and they will be addressed in the clarification memo as a formal statement of policy, added officials.

Good news for billers

As of Jan. 26, “SNF and swing-bed providers no longer need to report occurrence code 16 on their [Medicare Part A] claims to indicate the last day of therapy services” per Transmittal 2399 (change request, or CR, 7717), said officials. “It was a short-lived requirement, but after further, we decided we don’t actually need this.” Some providers might have thought they still needed to report occurrence code 16 until July 2, which is the implementation date of the transmittal. However, the transmittal “specifically states that, upon release of the instruction, you no longer need to complete that occurrence code,” they said. (Access the CMS transmittal here and the related MLN Matters article here.)

In other billing news, CMS officials reiterated that the fiscal intermediaries or Medicare Administrative Contractors (MACs) are the first ones providers should contact when billing problems crop up, not CMS central office staff. “The quickest way to get resolution to these issues is to immediately contact your contractor to alert them to situations that are occurring,” they explained. “You have to let them

In other billing news, CMS officials reiterated that the fiscal intermediaries or Medicare Administrative Contractors (MACs) are the first ones providers should contact when billing problems crop up, not CMS central office staff.

What You Need to KnowCheck out these latest updates from the “Need to Know” section of the AANAC homepage and find the information you need to get the job done right.

Errata Document for MDS 3.0 RAI User’s Manual v1.08 Released by CMS—Effective April 1, 2012

QTSO Reminds Providers April 1 Changes Require MDS 3.0 Software Updates: Contact Your Vendor

March 1 SNF/LTC Open Door Forum: Agenda and Call-in Information—UPDATED

14 A ANAC LTC LE ADER 3 .6 . 2012

AANAC Board of DirectorsCarol Siem msn, rn, bc, gnp Chair

Ruth Minnema rn, ma, c-ne, rac-ct Vice Chair

Carol Maher rn-bc, rac-ct Secretary

Peter Arbuthnot aa, ba, rac-ct Treasurer

Susan Duong, rn, bsn, nha, rac-ct, c-ne

Patrice E Macken, mba, rhia, lnha, rac-ct

Gail Harris, rn, bsn, rac-ct, c-ne

Joanne Powell nha, rhia

Diana Sturdevant ms, gcns-bc

AANAC Expert PanelAll articles published in LTC Leader are reviewed by a National Editorial Advisory Board to ensure the accuracy of the information we provide. AANAC is pleased to introduce you to our panel of volunteer reviewers who represent the best and the brightest in our field:

Jennifer Pettis rn, wcc, rac-mt, c-ne Chair, Harmony Healthcare International Topsfield, MA

Betty Frandsen rn, nha, mha, c-ne Nichols, NY

Robin L. Hillier cpa, stna, lnha, rac-mt President, RLH Consulting

Becky LaBarge rn, rac-mt Vice President, Clinical Reimbursement The Tutera Group

Deb Myhre rn, c-ne, rac-mt Nurse Consultant, Continuum Health Care Services

Ron Orth rn, nha, rac-mt Clinical Reimbursement Solutions, LLC, Milwaukee, WI

Andrea Otis-Higgins rn, mlnha, cdona, clnc, rac-mt CEO, Administrator, St. Andre Healthcare Biddeford, ME

Rena R. Shephard mha, rn, rac-mt, c-ne AANAC Executive Editor President, RRS Healthcare, Consulting Services, San Diego, CA

Judy Wilhide Brandt rn, rac-mt, c-ne Regional MDS/Medicare Consultant President, Judy Wilhide MDS Consulting, Inc.

surveyors for the QIS training. Training is scheduled over a four-week period, after which the team spends additional weeks conducting QIS surveys together. Next individuals complete a minimum of four additional QIS surveys of record, participate in a Train-the-Trainer Workshop, lead and facilitate classroom sessions, monitor and instruct the next student-surveyors during a mock survey, and complete a QIS compliance assessment of each surveyor-student. At this point individuals are ready to train other teams in their state. In regions where surveyors are not trained, it is still possible for a facility to undergo a QIS survey. This can happen if a QIS-trained team fills in at a different field office that has not been trained. This usually occurs if survey teams are understaffed due to vacancies, or if surveyors have a backlog of inspections because they have been surveying facilities that require intense survey team presence. It would be wise for key persons from your facility to attend QIS seminars and to share what they learn. Use the QIS forms for Quality Assurance activities to understand the process and be better-prepared. Access the QIS forms by visiting https://www.qtso.com/qisforms.html. Educational sessions on the QIS survey are available at the upcoming AANAC conference In Jacksonville FL.

Betty Frandsen, rn, nha, mha, c-ne (bmacfran@gmail.com)

●

Q + A, continued from page 9

QMs to return to traditional survey process, continued from page 13

know that you are receiving errors, especially with volumes of claims, so that they can submit these questions to our system maintainer so that they can be researched.”

If providers don’t receive responses from their contractors or need additional help in understanding the intent of specific CRs, then it’s time to contact CMS staff, particularly if a significant number of claims are involved so that CMS staff can determine if there is a national issue.

How to ask questions

Officials reminded callers that CMS provides a way “you can always ask questions.” The SNF/LTC ODF mailbox “is monitored frequently,” they noted. The address is snf_ltcodf-l@cms.hhs.gov. ●

15

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