Monthly Summary Report of HP Indiana CaseMix / PASRR Audits

Background -

Every month in Indiana, the HP LTC Unit conducts on-site audits of Medicaid-certified long-term care facilities with oversight provided for the Division of Aging and the Office of Medicaid Policy & Planning. The purpose of the LTC review is to ensure that the IHCP (Indiana Health Coverage Program) is reimbursing for the appropriate RUG classification as demonstrated by the MDS version 3.0 and supporting documentation. The LTC auditing team also performs Level of Care (LOC) and Pre-Admission Screening Resident Reviews (PASRRs) of LTC residents. The frequency of the audits was changed approximately 3 years ago and is determined according to the nursing facility's risk criteria.

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HP LTC Audit Objectives -

Determine whether residents continue to have needs requiring NF placement in accordance with State LOC criteria defined by 405 IAC 1-3-1 and 405 IAC 1-3-2.
Ensure all services recommended by the Level II assessments are provided.
Determine whether IHCP is reimbursing the provider for the appropriate RUG-III classification, reflective of resident needs.
Verify that the MDS responses that impact the RUG score are accurate and supported with the appropriate documentation within the assessment reference period.

2012 Average Monthly Validation Rate - 90.6%

Validation Threshold, per IAC (Indiana Administrative Code) - 80%

Nursing facilities that exceed the 20% error threshold rate as outlined in the IAC receive a 15% Administrative Component Corrective Remedy penalty applied for one quarter. The facility is required to respond to a Validation and Improvement Plan (VIP). All unsupported worksheets are reclassified, and the facility is subject to a Case Mix audit within 12 months.

December 2012 Findings -

The Case Mix audit validation rate average was 91%. Five areas of concern emerged from December's audits with the elements having 20% or greater inconsistency with the MDS data transmitted by the nursing facility.

K0700A Percent Caloric Intake Through Parenteral/Tube Feeding
O0500G Dressing/Grooming
O0700 Physician Orders
O0600 Physician Examinations
O0400D2 Respiratory Therapy - Days

Nursing Restorative issues reappeared on the list this month. At least one of the ten elements comprising Nursing Restorative has appeared in the Areas of Concern for eleven out of the last twelve months and for ten straight. Physician Orders remains on this list for the fourth consecutive month. It has appeared here 9 months in the last twelve.

December 2012 Percentage of Records Fully Supported by RUG (Resource Utilization Groupings) Classification -

Extensive Services - 93%
Special Rehabilitation - 97%
Special Care - 83%
Clinically Complex - 92%
Impaired Cognition - 96% (September had been 76%)
Behavior - 0%
Reduced Physical - 88%

PASRR -

Eight residents were referred for Level II’s -

One resident with a diagnosis of cerebral palsy was referred, no evidence an ID/DD Level II was ever completed, although a Level II for Mental Illness was completed 11/1/2007.
Five residents had a diagnosis of Depression, with ongoing psychotropic medication administration.
Two residents had diagnoses of Depression and Anxiety, with medication administration and exhibiting symptoms.

Requirements that will continue to be reinforced -

The Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual for Physician Orders.
That RUGgable diagnosis has two parts, physician signature within 70 days and “Active” meaning documentation within the 7 day time frame of the direct relationship of the diagnosis to the resident’s current status.
MDS 3.0 requires individualized, measureable care plans for nursing restorative and evaluations completed in the 7 day assessment time frame.
Emphasis will be placed on residents who do not participate in the BIMS (Brief Interview for Mental Status), who may still achieve a Resource Utilization Group (RUG) for impaired cognition reasons. Those MDS items require examples within the 7 day assessment time frame. Residents who RUG for the BIMS, must have evidence that the interview took place within the assessment time frame.

Social Service remains an important factor in achieving a successful HP audit. Timely, descriptive, accurate documentation is essential for the Case Mix component. Proper screening and referrals are necessary for PASRR compliance.

Does your nursing facility need assistance preparing for your HP audit? Do you feel that your Social Service department could benefit from an outside audit before the actual one? Do you know if you are in compliance with the required QMRP consultation for your ID/DD residents? Is your current Social Service or QMRP consultant not achieving your desired results? Contact Simmons Healthcare Consulting, LLC, at julie@simmonshc.com or 260-894-1417 and we'll discuss efficient, cost-effective solutions.

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