Kenneth Daily, LNHA

1
State Budget, Survey Update 2011CMS Initiatives

• Kenneth Daily, LNHA
• President
• Elder Care Systems Group
• Kenn_at_qissurvey.com
• OHCA District II
• MVLTCA
• March 2011

2
District News

• CEUs for todays program is 2 hours
• Certificate of attendance
• Administrator and DON changes
• Need e-mail addresses
• Next meetings
• April 19
• Todays PowerPoint Slides will be post at our
  website
• www.mvltca.org

3
MVLTCA Golf

• 1st Annual Spring
• Golf Outing
• Dayton County Club
• April 28th
• 1PM
• Shotgun start _at_ 100PM

4

• "The Governor's Jobs Budget will transform
  Medicaid for Ohioans who rely on the program to
  lead healthy and productive lives, leading to
  better health, better care and cost savings for
  Ohio's taxpayers." - Greg Moody, Director, Office
  of Health Transformation

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Budget Details???

• Full implementation of the pricing system
• Direct care and capital will be cut from their
  current levels.
• Today 25th percentile plus 7 (based on 2003
  costs)
• Direct care will be set at 25th percentile
• Capital price will be set at the 25th percentile
• The "consolidated services payment" (bundling)
  will be folded into the direct care price.
• Total reduction to SNFs is gt425 million

7
Budget Proposal

• Leave days reduced from 30 to 15
• Leave day payments set at 25 of per diem rate
• Single point care coordination for all
  individuals coming out of a hospital (managed
  care)
• Details very sketchy at this point
• Bed tax will be increased to the 6 (max level)
  but this will reduce the rate to approx.
• 2012 - 11.38
• 2013 - 11.60

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Additional Proposals

• All AL waiver and PASSPORT rates reduced 3
• One line item of all waiver programs at ODJFS
• Payment set by setting and service
• HCBS waivers combined (PASSPORT, Ohio Home Care,
  Chocies, AL and Transitions Aging
• Self directed, single set of providers and
  enrollment criteria (person-centered)

9
Quality Add On

• Quality component of the price will be increased
  significantly
• Bed Fee component (6.25 per day) and the
  workforce development incentive payment (5.70
  per day) will be moved to the quality component
• New quality measures will be developed (Artifacts
  of Culture Change
• The system will be structured so that if any
  facility does not meet one or more of the
  measures, it will operate as an additional cut.

10
Est. Medicaid Reimbursement

• Current rates 177.50/day
• New rate 162.50/day
• 100 Bed facility loses about 400,000/ year

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Year 2011

• Demographics are moving quickly changing the
  American landscape
• 7000 Medicaid beneficiaries a day are added to
  the rolls
• Beneficiaries at 65 (Medicare statistically) do
  not a lot of health services.
• Spending begins at mid-70s and 80s that they're
  likely to need intensive and expensive health
  care.

13
Where Does CMS See LTC

• Push for alternatives is tremendous
• Each alternative must offer government and
  citizens greater value than in the past
• Last year more than 3.2 million nursing home
  residents
• 13 Under 65 67 65-84, 20 85
• More than 50 cognitively deficits and require
  extensive assistance with ADLs
• Nearly 16,000 nursing facilities

14
Federal and State

• No FMAP extension 6/30/11 cliff
• MedPAC continues to ignore financial issues in
  our operations no COL
• Managed care
• Integration of dual eligibles?
• Forecast error adjustment possible for FY 13
  because RUGs IV was not a zero sum game

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Where are We Heading?

• For the past several years nursing homes have
  been under tremendous scrutiny

• Value
• Consumers
• Choice
• Culture change
• Financial viability

• Accountability
• Transparency
• Compliance
• Education
• Technology

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What is Culture Change?

• Culture change in long-term care is an ongoing
  transformation in the physical, organizational
  and psycho-social-spiritual environments that is
  based on person-centered values such as respect.

17
Culture Change is More Than

• Eden Alternative, Green Houses, Small Houses and
  Pioneer initiatives
• Or the superficial displays of culture change
• Having mailboxes and front doors yet no one
  knocks or takes seriously the privacy it is meant
  to offer
• Fin, fur and feathers
• Food line buffet
• Memory boxes
• Brag board
• All these efforts are important but these do not
  deliver culture change

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Steps in the Planned Change Process
Recognize the need for change
Diagnose and plan change
Formulate goals
Measure resultsMaintain change
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Overcoming Resistance to Change

• Education and Communication
• Participation and Involvement
• Facilitation and Support
• Negotiation and Agreement
• Manipulation, Co-optation and Coercion
• Promote Positive Attitudes Toward Change
• Empower Others to Act on the Vision
• Generate Short-term Wins
• Consolidate Gains and Create Greater Change
• Institutionalize Changes in the Organizational
  Culture

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Affordable Care Act
Provision Regulations Other
Disclosure of Ownership 2 Yrs After Enactment Reporting 1 Yrs After Final Reg.
Compliance Ethics Programs 2 Yrs After Enactment Evaluation 3 Yrs After Final Reg.
Quality Assurance Performance Improvement 2011 12/31/2011 Program Implemented 1 Year After Final Reg. Facility Submits Plan
Nursing Home Compare No Effective 1 Yr. After Enactment
Standardized Complaint Form No Effective 1 Yr. After Enactment
Staffing Data 2011 Reporting of Staffing Data 2 Yrs. After Enactment
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Affordable Care Act
Provision Regulations Other
CMPs 2011 Takes effect 1 Year After Enactment
National Independent Monitor No Implement Demo 1-Yr. After Enactment Demo 2 Yrs.
Notice of Facility Closure 2011 1 Yr. After Enactment
Culture Change IT Demos No 1 Yr. After Enact. Report to Congress 9 months After Demo
Dementia Abuse Prevention Training 2010/11 Specifies Trng. Requirement 1 Yr. After Enactment
Background Check No Discretionary State Participation Funded 2010 2012
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QA PI

• DO
• Involve all NH services
• Prove that priorities were identified and
  chosen for PI activities
• Focus on indicators
• Take actions to demonstrate improvement and are
  sustainable
• Maintain documentary evidence of its operation
  and be able to demonstrate this to CMS

• BE
• Developed, implemented, maintained
• Effective, ongoing, nursing facility- wide must
  that is both clinical and non clinical indicators
  of quality to be measured
• Data driven

23
Nursing Home Compare

• Currently averaging about 1.5 million hits per
  month

24
New Quality Measures

• Percentage of residents on a scheduled pain
  medication regimen on admission who self-report a
  decrease in pain intensity or frequency (short
  stay) JO0100
• Percent of residents experiencing one or more
  falls with major injury (long stay) J1800

• Percent of residents who self-report moderate to
  severe pain (short stay) JO0600
• Percent of residents who self-report moderate to
  severe pain (long stay) JO0600
• Percent of residents with pressure ulcers that
  are new or worsened (short-stay) M0800
• Percent of high risk residents with pressure
  ulcers (long stay) M0150

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New Quality Measures

• Percent of residents who have/had a catheter
  inserted and left in their bladder (long stay)
  H0100
• Percent of low risk residents who lose control of
  their bowel or bladder (long stay)H0300
• Long stay residents with a urinary tract
  infection I2300
• Physical therapy for new balance problem in long
  stay patients G0300O0400c

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New Quality Measures

• Percent of short stay residents assessed and
  appropriately given the seasonal influenza
  vaccine O0250
• Percent of long stay residents assessed and
  appropriately given the seasonal influenza
  vaccine O0250
• Percent of short stay residents assessed and
  appropriately given the pneumococcal vaccine
  O0300
• Percent of long stay residents assessed and
  appropriately given the pneumococcal vaccine
  O0300

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New Quality Measures

• Percent of residents who were physically
  restrained (long stay) P0100
• Long stay residents with increased need for help
  with activities of daily living (ADLs) G0110
  Incidence of decline)
• Percent of residents who lose too much weight
  (long stay) K0300
• Percent of residents who have depressive symptoms
  (long stay) PHQ-9 score gt 5 D0200

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New Quality Measures

• Consumer Assessment of Healthcare Providers and
  Systems (CAHPS) Measures
• Initiative to develop standardized surveys of
  patients' experiences
• Consumer Assessment of Health Providers and
  Systems (CAHPS) Nursing Home Survey discharged
  resident
• Consumer Assessment of Health Providers and
  Systems (CAHPS) Nursing Home Survey long-stay
  resident
• Consumer Assessment of Health Providers and
  Systems (CAHPS) Nursing Home Survey family
  member

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Special Focus Facilities

• CMS uses a formula to identify 5 facilities in
  each state that qualify
• SC Letter with Policies Procedures
  (SC-10-32-NH)
• 18 months (3 surveys)
• List on the CMS website) and broken in to 5
  categories
• New additions
• Not improved
• Improving
• Recently graduated
• No longer participating in Medicare and Medicaid

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Special Focus Homes Compliance History

• SFFs NFs
• Total deficiencies at the D level or higher
  19.9 7.5
• Deficiencies at the D through F levels 15.8 7.0
• Deficiencies at the actual harm level (G-I)
  2.2 0.0
• Deficiencies at the immediate jeopardy level
  (J-L) 1.9 0.1
• Deficiencies cited -complaint investigations
  5.9 1.3
• Number of revisits 0.7 0.2

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Nursing Home Value-Based Purchasing Demonstration

• Objective Improve the quality of care furnished
  to all Medicare beneficiaries
• Four quality of care domains
• Nurse staffing (30 percent)
• Hospitalization rates (30 percent)
• MDS Outcomes (20 percent)
• Survey deficiencies (20 percent)
• Participants with the highest performance scores
  or the most improvement in their performance will
  be eligible for a payment.
• National expansion

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Performance Payments

• Budget neutral with respect to Medicare
• Improvements in quality must result in a
  savings pool that can be used to fund the
  payments.
• A participant will be eligible for a performance
  payment if it is either
• In the top 20 percent in overall performance or
• In the top 20 percent in terms of overall
  improvement

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Hospitalizations

• Includes potentially avoidable hospitalizations
• CHF, electrolyte imbalance, respiratory
  infection, UTI, sepsis for short stays also
  includes anemia for long stays.
• These are conditions that are prevalent in the
  nursing home population and considered to be
  sensitive to the quality of nursing home care.
• Includes hospitalizations that occur within 3
  days of discharge from the nursing home.

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Future Issues

• More an more alternatives being developed to
  steer resident away from nursing homes
• Managed care
• Care coordination for dual eligibles
• Home and Community based balancing
• MDS 4.0 (CARE Tool)

35
Interpretive Guidelines Revisions

• CMS Issued Changes to Appendix P
• Changed 3 Forms
• 672 Resident Census
• 802 Resident Roster
• 805 Resident Review
• Changed references from MDS 2.0 to MDS 3.0

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Appendix P Changes

• Temporary changes in survey process due to
• Temporary inability to run Quality Measure/
  Quality Indicator (QM/QI) reports
• Inability to select offsite sample and concerns
  based on MDS data

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Changes in Survey Forms CMS-802

• CMS-802 Roster/Sample Matrix
• Changes because of references to MDS 2.0 coding
• Separation of data
• Falls/Fractures
• Abrasions/Bruises
• Behavioral symptoms
• Depression

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Appendix PPChanges in Guidelines

• Remove refers to MDS 2.0
• Reference the CAA, ARDs timing and definitions
• Electronic storage
• Discharge assessments
• Install the QIS into Appendix P, and its E-forms
  into the Exhibits no comment period,
• Plan to issue this fall to coincide with release
  of new software

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Survey

• There has been a great deal of focus survey
  deficiencies by CMS, the press, Congress and
  consumers the past year
• More than 91 of all nursing facilities were
  cited for one or more deficiencies in 2007
• Nearly 18 of nursing homes were cited for harm
  and/or immediate jeopardy
• Quality of care, resident assessment and quality
  of life are most common

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REMEMBER SURVEY IS SURVEY

• Customer satisfaction
• Facility appearance and feel
• Residents with obvious unmet needs
• Personal hygiene and dress
• Assistive devices
• Restorative care
• Restraints
• Environment
• Resident and staff interactions
• Activities engaging and meaningful
• Dining experience
• Weights Skin Sheets
• Remember survey is about the basics

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CIRCLE OF LIFE
Assessment
Evaluation
Implementation
Decision Making
Care Planning
Decision making as well as determination of
avoidable and unavoidable
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Leading Deficiencies

• F323 Accident Hazards
• F371 Food Preparation
• F281 Professional Services
• F309 Quality of Care
• F279 Care Plans
• F329 Unnecessary Medications
• F253 Housekeeping and Maintenance
• F241 Dignity
• F514 Medical records
• F314 Pressure Sores

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Survey Priorities - MDS 3.0

• Assessment F272-278
• Care planning F279-282
• Discharge planning F284
• Social services F250
• Transfer/ discharge F201-204
• Resident rights F168

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Survey Priorities

• Abuse
• Investigative guidance for F223, F224, 225 and
  F226 from Appendix PP of the State Operations
  Manual
• Accidents F 323
• Dangerous Device Use
• Fall and/or Fractures
• Potential Accident Hazards / Bed Side Rails

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Survey Priorities

• ADLs and ROM
• Incidence over time of declines
• Positioning
• Bowel/Bladder Function
• Use of Catheter

• Behavioral/ Emotional
• Prevalence of Behavioral Symptoms Affecting
  Others
• Increase in Resistance to Care
• Symptoms of Depression

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Survey Priorities

• Resident choices
• Resident dressing
• Dignity
• Privacy
• Interaction With Others
• Investigative guidance for F155, F241, F242, and
  F246 from Appendix PP of the State Operations
  Manual

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Survey Priorities Priorities

• Pressure Sores F 314
• Medications F329, F332, F333
• Notification of Change F247
• Pain F309 etc.
• Resident environment F253

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Immediate JeopardyWorking Definition

• Any hazard (potential or real) for residents
• Safety issues that pose high risk for residents
• Any concern that is likely to cause serious harm
  to residents
• Accidents are no longer just unfortunate accidents

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Immediate Jeopardy

• Bed rails
• Disarming/ Deactivation of door alarm/ warning
  systems
• Dietary issues
• Paid feed assistants
• Unsupervised
• NPO orders
• Medications
• Inadequate monitoring of Coumadin/ excessive dose
  given
• Medication error causing death

• Abuse
• Failure to investigate abuse
• Resident to resident abuse
• Sexual assault by staff member
• Resident using illegal drugs
• Inadequate diabetic monitoring
• Lancets
• Resident Transfers/ Re-positioning
• Ignore Signs/ Symptoms of Serious Illness

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Immediate Jeopardy

• Accidents and supervision
• Falls
• Smoking near oxygen
• Smoking in bed
• Chemical within reach
• Elopements
• Hot beverage burn
• H2O temperatures
• Suicide attempt

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The QIS Process

• The Quality Indicator Survey process is a revised
  survey process that relies on two distinct
  phases supported by sophisticated computer
  software
• Completes resident sampling, standardized
  questionnaires, specific observations and
  record reviews
• Handles all data analysis and deficiency
  recommendations
• The software is a powerful tool allowing humans
  to make better and more informed decisions
• QIS goes far beyond the traditional survey
  process by its methodology i.e. quality of life
  initiatives

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• B0100-Comatose
• This item is used as an exclusionary item for
• Incidence of Decline in Late Loss ADLs
• Prevalence of Stage 1-4 Pressure Ulcers (High
  Risk)
• Prevalence of Stage 1-4 Pressure Ulcers (Low
  Risk)
• Lack of Corrective Action for Visual Problems
• Lack of Corrective Action for Auditory Problems

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• B0200-Hearing - Lack of Corrective Action for
  Auditory Problems
• 0300-Hearing Aid - Lack of Corrective Action for
  Auditory Problems
• B1000-Vision -Lack of Corrective Action for
  Visual Problems
• B1200-Corrective lenses - Lack of Corrective
  Action for Visual Problems

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• E0100A-Psychosis Hallucinations
• Exclusionary item for Prevalence of
  Anti-anxiety/Hypnotic Use.
• E0200A-Behavioral Symptom Presence Frequency
  Physical Behavioral Symptoms Directed towards
  Others
• Increase in Physical Abuse.
• E0800-Rejection of Care Presence Frequency

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• G0110A1-Activities of Daily Living (ADL)
  Assistance Bed Mobility, self performance
• Incidence of Decline in Late Loss ADL
• Prevalence of Stage 1-4 Pressure Ulcers (High
  Risk)
• Prevalence of Stage 1-4 Pressure Ulcers (Low
  Risk).
• G0110B1-Activities of Daily Living (ADL)
  Assistance Transfer, self performance
• Incidence of Decline in Late Loss ADLs
• Prevalence of Stage 1-4 Pressure Ulcers (High
  Risk
• Prevalence of Stage 1-4 Pressure Ulcers (Low
  Risk)
• Lack of Transferring Rehabilitation Progress.

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• G0110E1-Activities of Daily Living (ADL)
  Assistance Locomotion on Unit, self performance
• Locomotion Decline Since Admission
• Locomotion Severe Decline
• Locomotion Severe Decline.
• G0110G1-Activities of Daily Living (ADL)
  Assistance Dressing
• Dressing Decline Since Admission
• Dressing Severe Decline
• Dressing Severe Decline.

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• G0110H1-Activities of Daily Living (ADL)
  Assistance Eating, self performance
• Incidence of Decline in Late Loss ADLs
• Eating Decline Since Admission.
• G0110I1-Activities of Daily Living (ADL)
  Assistance Toilet Use, self performance
• Incidence of Decline in Late Loss ADLs
• Toileting Decline Since Admission.

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• G0400A-Functional Limitation in Range of Motion
  Upper Extremity
• Incidence of Decline in Range of Motion (ROM).
• G0400B-Functional Limitation in Range of Motion
  Lower Extremity
• Incidence of Decline in Range of Motion (ROM).

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• H0100A-Appliances Indwelling Catheter
• Prevalence of Indwelling Catheters.
• H0300-Urinary Continence
• Continence Decline Since Admission.

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• I2300-(Active Diagnoses Urinary Tract Infection
• Prevalence of Urinary Tract Infections.
• I2500-Infections Wound Infection
• Wound Infection.
• I6000-Psychiatric/Mood Disorder Schizophrenia
• Prevalence of Antianxiety/Hypnotic Use.

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• I8000A, 18000B, 18000C, 18000D, 18000E, 18000F,
  18000G, 18000H, 18000I, 18000J- Other current or
  more detailed Diagnoses and ICD-9-CM codes
• Prevalence of Dehydration
• prevalence of Stage 1-4 Pressure Ulcers (High
  Risk)
• prevalence of Stage 1-4 Pressure Ulcers (Low
  Risk)

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• J 1400 - Exclusionary items
• Dressing Decline Since Admission
• Dressing Severe Decline
• Dressing Severe Decline
• Eating Decline Since Admission
• Toileting Decline Since Admission
• Locomotion Decline Since Admission
• Locomotion Severe Decline
• Locomotion Severe Decline
• Continence Decline Since Admission
• Tube Fed and Losing Weight
• Lack of Transferring Rehabilitation Progress.

• J1400-Prognosis
• Prevalence of Stage 1-4 Pressure Ulcers (High
  Risk)
• Prevalence of Stage 1-4 Pressure Ulcers (Low
  Risk)

• J1550C-Problem Conditions Dehydrated
• Prevalence of Dehydration.

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• K0300-Weight Loss of 5 or more in the last month
  or a loss of 10 or more in last 6 months
• Prevalence of Weight Loss (Most Recent MDS).
• K0500B-Nutritional Approaches Feeding Tube)
• Prevalence of Tube Feeding
• Tube Fed and Losing Weight.

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• L Dental
• Cavity or Broken natural Teeth
• Broken or loosely Fitting Full or Partial Denture
• No Natural Teeth or Tooth Fragments
• Abnormal Mouth Tissue
• Obvious or Likely
• Inflamed or Bleeding Gums or Loose natural Teeth
• Mouth or Facial Pain, Discomfort or Difficulty
  with Chewing
• Unable to Examine
• None of the above were Present

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• M0210-Unhealed Pressure Ulcers
• Prevalence of Stage 1-4 Pressure Ulcers (High
  Risk)
• Prevalence of Stage 1-4 Pressure Ulcers (Low Risk)

66
MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• N0400B-Medications Received Antianxiety
• Prevalence of Antianxiety/Hypnotic Use.
• N0400D-Medications Received Hypnotic
• Prevalence of Antianxiety/Hypnotic Use.
• O0400B4-Therapies Occupational Therapy Days
• Lack of Transferring Rehabilitation Progress.
• O0400C4-Therapies Physical Therapy Days
• Lack of Transferring Rehabilitation Progress.

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MDS 3.0 variables used in QIS QCLI
calculations--listed by MDS item

• P Restraints Prevalence of a Daily Device.
• P0100B-Physical Restraints Used in Bed Trunk
  Restraint
• P0100C-Physical Restraints Used in Bed Limb
  Restraint
• P0100E-Physical Restraints Used in Chair or Out
  of Bed Trunk Restraint
• P0100F-Physical Restraints Used in Chair or Out
  of Bed Limb Restraint
• P0100G -Physical Restraints Used in Chair or Out
  of Bed Chair Prevents Rising)

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The QIS
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Stage I Samples

• Case-mix stratified sampling of residents is
  still required
• MDS Sample includes all residents with an MDS
  assessment within the past 6 months of the survey
• Census sample random sample of current
  residents (n40)
• Resident interviews and observations
• Staff and family interviews
• Record reviews
• Thresholds are broken into categories small and
  not small. Small would be when there are 35 or
  fewer residents
• Admission sample random sample of new
  admissions (n30)
• Record review
• Thresholds are broken into categories small and
  not small. Small would be when there are 9 or
  fewer residents
• Surveyor-initiated at surveyor discretion

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Resident Interview Observation

• Determine Interviewablity
• Multiple observations at various times of the day
  may be necessary to verify concerns
• The BIMS is being integrated into the QIS to
  determine Interviewablity
• Score gt or to 8, resident is interviewable
• Score lt or to 7 or 99, resident is non
  interviewable and set to family interview status

71
Tools Used by Surveyors

• Standards of Practice

• Facility Policy and Procedures
• Manufacturers Guidelines

72
Internet Resources

• www.qtso.com
• Quality Indicator Survey
• Process Tools and Resources
• Manual
• www.med-pass.com

73
QUESTIONS?
HAVE YOU HAD ENOUGH YET??
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Kenneth Daily, LNHA

• Elder Care Systems Group
• 1209 Dayton-Yellow Springs Road
• 143
• Fairborn, OH 45324
• Kenn_at_qissurvey.com
• Consulting and education firm focusing mainly on
  quality improvement, survey compliance, disaster
  preparation and facility management.