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.
HP LTC Audit Objectives -
Average Monthly Validation Rate - 90.5%
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.
January 2013 Findings -
The Case Mix audit validation rate average was 87.6%.
Five areas of concern emerged from January's audits with the elements having 20% or greater inconsistency with the MDS data transmitted by the nursing facility.
At least one of the ten elements comprising Nursing Restorative has appeared in the Areas of Concern for eleven out of the last thirteen months and for eleven straight.
January 2013 Percentage of Records Fully Supported by RUG (Resource Utilization Groupings) Classification -
Seven residents were referred for Level II's including -
Requirements that will continue to be reinforced -
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 email@example.com or 260-894-1417 and we'll discuss efficient, cost-effective solutions.