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Indiana FSSA Division of Aging Issues Updates to e450B Process
'Why' I Originally Chose to Work in Long-Term Care
ISDH Publishes Update to Advance Directives Brochure
CMS QAPI Material Rollout for Nursing Homes
National Nursing Home Week - Team*Care - 10 Simple Ways to Work as a Team

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Indiana FSSA Division of Aging Issues Updates to e450B Process


Indiana FSSA's Division of Aging is revising the e450B process.  The changes will be effective November 1, 2013.  A memo was published 10/14/13 which has some potentially valuable information for the staff who complete the e450B in your nursing facility. The memo can be found in its entirety here.  It includes not only the upcoming changes but also examples, a quick-reference table,  and reminders of the process.  

Indiana FSSA's Division of Aging Updates e450B Process - Simmons Healthcare Consulting, LLC - www.simmonshc.com - Providing Social Service, QMRP consulting to the long-term care industryThe Division of Aging will also be hosting several webinar/training sessions to review the changes along with an opportunity for questions and answers.  

Webinar Training Sessions (Registration is required) - 

An "In-Person" training session is scheduled for Monday, October 28 from 1P-3P at the Indiana Government Center South Auditorium (402 W. Washington St, Indianapolis).  Registration is not required for the Indianapolis session.  However, bring a printed copy of the 10/14/13 FSSA Memo for reference. The Division of Aging is also expecting to have a PowerPoint presentation available on the e450B website by the end of the business day 10/18/13.  It is recommended that it be printed and brought to the training session also.

Simmons Healthcare Consulting, LLC, provides Social Service, QIDP (QMRP) consulting services to the long-term care industry.  Our primary focus includes regulatory compliance, timely MDS 3.0 documentation completion, survey preparation, and behavior management.  Based in Indiana, we bring 19 years of 'hands-on' trusted experience to our valued clients.  Contact us today to discuss how SHC can assist your nursing facility to gain the results you need.

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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.

OMPP Changes in the Indiana #LTC 450B Process

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The potential for saving some trees is apparently on the horizon.  OMPP is changing the Physician Certification for Long-Term Care Services (450B) policy/process.  2 IHCP Bulletins have been released with the details.  One addresses acceptable signatures on the 450B form and the other change involves electronic 450Bs.  They can be found on this Indiana Health Coverage Program (IHCP) website link. Listed under #BT201248 and #BT201249, both have dates of 11/27/12.  Each Bulletin addresses different changes, so please read each one.  Training dates are being scheduled by the Division of Aging for January 2013.  As with any changes, it would be strongly recommended that the staff member(s) at your nursing facility responsible for 450Bs (i.e. Business Office Manager, Social Service, even Admissions Director) attend a training session.  If you have difficulty finding the Bulletins, contact SHC and we'll send you the information.