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MDS 3.0

Monthly Report of 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.

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.

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.  
  • C1000 - Decision Making
  • H0200C - Urinary Toileting Program
  • O0500G - Dressing/Grooming
  • O0500B - Active Range of Motion
  • C0700 - Short Term Memory Problem

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 - 
  • Extensive Services - 85%
  • Special Rehabilitation - 97%
  • Special Care - 76%
  • Clinically Complex - 92%
  • Impaired Cognition - 78%
  • Behavior - 0%
  • Reduced Physical - 77%

PASRR - 
Seven residents were referred for Level II's including - 
  • Four residents had a diagnosis of Depression, with ongoing psychotropic medication administration and symptoms noted.
  • Two residents had diagnoses of Depression and Anxiety, with medication administration and exhibiting symptoms.

Requirements that will continue to be reinforced - 
  • Utilization of The Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual for Active Diagnosis.
  • 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.

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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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.  

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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October HP LTC (Indiana) Monthly Summary Released - Is Your NF Prepared?

IHCP (Indiana Health Coverage Programs) has just released the October statistics for HP LTC Case Mix audits.  Each monthly summary can be found on their website here.  Several items should be of interest to Social Service staff - 

  • One of the expanded audits was due in part to PASRR
  • For October, the Behavior category was only fully supported at a rate of 50%
  • For October, Impaired Cognition was only fully supported at a rate of 87%
  • 13 residents were referred for Level IIs

Although the BIMS is considered a source document, there must be evidence that the interview was completed during the assessment period.  Residents who do not participate in the BIMS interview must have specific documentation during the time frame to validate their cognition.  There also must be documentation within the assessment period of any behavioral symptoms with specific examples.  

Does your Social Service staff keep a current PASRR list?  Have you reviewed those residents' Level II recommendations to ensure the recommendations have been implemented?  Has Social Service made Level II referrals for residents with significant changes as appropriate?  Need assistance with preparation?  Contact SHC and we'll schedule a visit to help your facility continue improving Quality of Life services to your residents.

CMS Releases Updated MDS 3.0 RAI User's Manual

The new updated MDS 3.0 RAI Manual and sample Item Sets, V1.09, effective November 7, 2012 can be downloaded from the CMS (Centers for Medicare and Medicaid Services) site here.  If you download the 'All Change Tables and Pages for Version 1.09', the changes are highlighted beginning on appoximately page 134 of the document.  As with any update, it's always a good reminder for Social Service and Activities staff to review their MDS/CAA/CP procedure.  Do you have an efficient process for completing your sections in a timely manner?  For Indiana staff, are you giving specific examples for behavioral symptoms?  Are you capturing relevant signs/symptoms of delirium?  Do you compare the current BIMS/PHQ-9 score to the previous score to track improvement/decline?  Are you utilizing the information gathered from the resident interviews to establish realistic care plan goals and interventions?  As always, if your department or facility needs assistance with the RAI process, contact SHC and we'll schedule a visit to help continue improving Quality of Life services.