DADS notified contracted providers of changes to contract and fiscal compliance monitoring protocol in relation to negative billing. (Letter)

– (Published on the DADS site today, 6/18) DADS will hold the quarterly HCSSA stakeholder meeting this Friday, June 21, 2013, from 9 a.m. to 1 p.m. in the Public Hearing Room in the Winters Building, 701 W. 51st Street, Austin. Agenda (PDF)

–  DADS will hold a HCSSA Region 10 provider meeting on Tuesday, July 23, 2013, from 9 a.m. to 3 p.m. at the Educational Service Center – 19, Head Start MPC, 11670 Chito Samanietgo, El Paso. You may register here.

–  DADS will hold a HCSSA Region 7 provider meeting on Monday, July 29, 2013, from 9 a.m. to 3 p.m., in the Winters Public Hearing Rooms: 125E, 125W and 125C, 701 W. 51st. St., Austin. You may register here.

–  Effective immediately, DADS and the Board of Nursing have determined that providers participating in the LVN On-Call Pilot Program and those not participating are no longer required to enter data into CARE Screen 691.

–  DADS revised IL 13-26 to extend the deadline for compliance to November 1, 2013, when the Texas Home Living rule will be effective. Contact txhml@dads.state.tx.us with questions.

– Contract re-enrollment update excerpt:

IL 13-19 notified providers required to use EVV of the planned contract re-enrollment for all contracts subject to EVV requirements. On May 1, providers were sent documents necessary to re-enroll their contracts. Currently, the reports necessary to monitor EVV contract compliance are not available in the Santrax system. Some providers have expressed concerns about being subject to compliance requirements before those reports are available.

–  DADS will host five regional conferences for IDD waiver providers in July and August 2013. You may register here.

–  The Texas Center for Nursing Workforce Studies at the Texas Department of State Health Services asks all administrators and owners of licensed and certified home health and hospice agencies to complete a short survey in the summer of 2013. See the news alert page for details.

See the news page for more information about these and other alerts.

Public Notices and Correction

HHSC corrected a notice published in the May 31, 2013, issue in reference to the intent to submit a request to amend the CLASS Medicaid waiver. An excerpt:

In addition to the changes previously described in the public notice published in the May 31, 2013, issue of the Texas Register, employment assistance is also being added to the waiver as a service. Changes in the waiver will include the addition of the consumer directed services option for supported employment and a revision to the service definition of supported employment to clarify assistance available and specify integrated, competitive employment. Employment assistance is also being added to the waiver as a service. Point-in-time limits will be added based on the number of individuals that can be served in the waiver at a specific point in time. Service limits implemented December 1, 2011 will be removed.

HHSC intends to submit to CMS a request to amend the Texas Healthcare Transformation and Quality Improvement Program (THTQIP) waiver program, which would allow it to use either room under the overall waiver budget neutrality cap or unspent Delivery System Reform Incentive Payment (DSRIP) funds from Demonstration Year 2 or later waiver years, to count as a “credit” toward Upper Payment Limit expenditures made during two months in late 2011.

The other proposed amendment to THTQIP would allow it to use a small portion of DSRIP intergovernmental transfer funds (up to one percent or $10,000,000 per demonstration year) to use as 50/50 match to help monitor the DSRIP program. The final requested amendment would allow THTQIP to carry forward unallocated DSRIP funds into DY3-5 to fund state priority initiatives. For more information about each entry, see the Texas Register.

Adopted Rules

• On DADS’ Behalf

HHSC adopted amendments to §90.3, Definitions; and §90.42, Standards for Facilities Serving IID, in Chapter 90, ICF/IID, which increase medical professional service options, clarifies that the term “health care professional” includes a physician, licensed nurse, physician assistant, podiatrist, dentist, physical therapist, speech therapist, and occupational therapist, and other changes. See the Texas Register for more information

–  “[Nursing home management] business arrangement violates the federal Nursing Home Reform Act, CANHC argued. The reform act says that every Medicare- or Medicaid-certified nursing facility must be directly overseen by a governing body that appoints an administrator, and the administrator must be ‘directed by and answerable to’ the governing body alone.” – McKnight’s

– CDC report: “The occupancy rate for nursing homes was steady at 82% between 2000 and 2011, according to the most recent national health report from the Centers for Disease Control and Prevention. The CDC compiles the annual review to comply with the Public Health Service Act.” – McKnight’s

–  “Long-term care providers should be cautious adopters as Medicaid managed care programs grow in scope and number, according to a new report and toolkit from the American Health Care Association…Only 16 states currently have Medicaid managed care in place for long-term services and supports, but this number will increase to 27 as the Affordable Care Act is fully implemented in 2014, the AHCA analysis states” – McKnight’s

Charting by exception is the single most problematic form of nursing charting. Charting by exception is a tool used for residents who require little to no nursing intervention or care.   This type of charting, if not done correctly, will leave the facility subject to allegations of RUG review errors.  Reviewers scrutinize nurse charting to determine if it supports flow sheets and checklists.  Since MDS 3.0 requires clearly documented comments, charting by exception will be a basis for allegations of RUG errors.

Charting by Exception – the requirements.

To minimize allegations of RUG errors, each resident should have a well-documented resident health baseline and a detailed Plan of Care.  Proper charting by exception requires that a chart note directly address the Plan of Care and the documented resident baseline of health in all its elements.  This charting must be done for any change, no matter how minor.  Writing “resident doing well at this time” is not sufficient.

 If the facility is charting once a shift on an independent resident, the chart note must address every single aspect of the Plan of Care.  This means everything from diet to skin care must be addressed in the chart note. It also means any exception to a well-documented and established health baseline, no matter how minor, must be charted and must tie in to the Plan of Care. For a resident with far more care needs, charting by exception becomes overwhelmingly time consuming and almost impossible to achieve. 

When charting by exception isn’t charting 

Mr. B is a completely independent resident.  The previous 9 months of charting comprises a single entry, once per month that states “resident doing well at this time.”   Mr. B is found in his room crying.  The CNA talks to him for a few minutes and determines it is the anniversary of his Uncle’s death. The resident seems to calm down and the CNA makes no mention of the incident.  Two weeks later a chart note states “Resident doing well at this time” and maybe a few recorded vital signs.  Two weeks after that he leaves the facility unannounced and does not return.  The nurses call the police and a search ensues.  He is found several miles away attempting to board a bus and states to the Police, “No one at that place cares about anything, I just want to die.”

The resident’s family then institutes a lawsuit.  The facility is now in the position of having to prove they addressed this resident’s emotional well-being, health and safety.  With these chart notes as “evidence” the facility will have difficulty defending against this lawsuit. If an ARD happens at the same time and the MDS nurse codes for elopement that will cause allegations of a RUG error as well.

 Charting and Rug Errors

Charting by exception requires everything not in the documented and established base line to be charted.  In RUG reviews we have seen nurses charting that the Physician was in to see the resident.  This is not an exception to the baseline providing it is a normal “checkup” visit.  However, the MDS nurse does not see this note since it should not have been in a nurse note.  The MDS nurse, who did not reviewing nurse charting, does not give credit for that Physician visit and creating a potential allegation of a RUG error.  

Reviewers scrutinize nursing notes to determine the existence of a basis to support ADL and other “checklists” that are used for MDS coding claims.  If a nurse note claims “resident doing well” and another document indicates differently, that will be labeled a RUG error.  Any document that disagrees with another document in the resident chart is a basis for allegations of a RUG error.  All documentation in the resident chart must agree, meaning, the same thing is being charted on every document.  If a nurse charts, “resident limping, required assistance to chair” but on the same day PT wrote, “resident improving rapidly, requires no assist to chair”, a RUG error will be alleged because two documents give two outcomes.

Reviewers look for these elements of disagreement and find them.

MDS 3.0 requirements

MDS 3.0 requires that all items noted on the MDS have clear examples.  This does not mean putting a check in a box.  For example, if a resident has a base line including physical behaviors directed at others, MDS 3.0 requires there be documented examples of this behavior.   This means that although the baseline exists for these behaviors, the behaviors must be documented to support the MDS. Charting by exception poses risks to the facility in this scenario.

All MDS 3.0 documentation must have daily documentation supporting any frequency claims, programs such as toileting or physical therapy, behaviors, cognition and ADL.  A simple check box will no longer suffice.

To protect your facility from large recoupments, all nurses must be trained in charting by exception if it is used in the facility.  MDS 3.0 dictates much documentation must be available to reviewers.  Unless your nurses are charting correctly, those notes will become the basis for alleged RUG review errors.

Next week:  Three Ways to Prepare for RUG Reviews.

Public Notice

HHSC intends to submit to CMS a request to amend the Texas Healthcare Transformation Quality Improvement Program waiver program. An excerpt:

Effective September 1, 2013, the expenditures for STAR+PLUS enrollees for elimination of the 30-day spell of illness limitation will no longer be authorized. Under this policy, after 30 days of inpatient care has been provided, additional inpatient care will not be covered until the enrollee has been out of an acute care facility for 60 consecutive days. HHSC will continue to waive the annual benefit limit in STAR+PLUS.

Adopted Rules

HHSC adopted §355.8201, Waiver Payments to Hospitals, and §355.8202, Waiver Payments for Physician Services, to conform to the approved protocols for payment, clarify eligibility requirements, describe payment methodologies in greater detail, and other changes. See the Texas Register for more information.

TxHmL and Local Authority Service Coordinators:

DADS informed TxHmL program providers of the requirement to complete a RN nursing assessment for all individuals in their program before a nurse or an unlicensed service provider can perform nursing tasks. (Letter)

–  DADS contracted with the NACES Plus Foundation Inc. to collect data for the 2013 Nursing Facility Quality Review. For more information, see the 2012 Nursing Facility Quality Review (PDF).

–  Registration is currently available for the Positive Behavior Management workshop in Austin, Texas, July 8 & 9, 2013, at the Commons Conference Center. Registration for the Denton workshop for August 1 & 2, 2013, is full. Visit KessJones.com to view a detailed agenda and to register.

See the news page for more information about these and other alerts.

As discussed last week, ADL’s are the major target for HHSC-OIG.  ADL’s are the source for most errors resulting in RUG write downs.  Not only did the facility lose money on incorrectly charted ADL’s they will also face large penalties after a RUG review. 

Charting ADL’s

 For most MDS nurses, ADLS are pieces of paper the CNA’s have scribbled some numbers on.  Ideally this number reflects both the Plan of Care and what care was really given.  Calculating an accurate ADL score for many residents is impossible to do using this system.  A single MDS coding mistake will cause a review error and a RUG write down.  Also, the practice of leaving charting until the end of the day or later can cost the facility a significant amount of money.

What really happens?

 As an example; your facility has a resident who generally requires no assistance, but on the morning shift the CNA moves the resident’s legs over the edge of the bed while the resident sits up.  The CNA charts 0 which reflects this resident’s independence.  However, the correct charting should have been 3, limited assistance.  This raises the ADL rate and the associated RUG.   Your facility just lost money.

This same resident is pulling on their socks but drops one; the CNA picks it up and puts the sock on for them.  The CNA charts 0 since the resident could have done it themselves.  This should be charted as 4, extensive assistance, 1 person assist. Your facility just lost money again and over a 90 day period, it adds up to a lot of money.  The real financial issues come into play during the MDS reporting period.

The MDS nurse reviews the ADL worksheets and notes the resident is charted as 0 on each shift.  The MDS nurse does not know that the LPN noted the CNA assisted the resident by putting on socks.  This will result in the allegation of a RUG error and reviewers will, by extrapolation, write down the entire resident RUG’s in that category.  Not only did you not bill for the correct services rendered, you will be subject to a substantial recoupment

How to protect yourself and realize better profit

The only way to prevent this serious financial loss and to verify quality of charting is to use a good software program such as MDSMax®.  Easy to use and inexpensive, it directs the CNA to correctly chart those easily forgotten ADL’s. It prevents the “prefilled” ADL worksheet (or worse), allows the manager to see real time charting and correct any issues immediately.   It also correctly calculates the MDS entries for each resident and appropriately documents the ADL’s for the resident’s chart.  Overall a package such as this will cut employment costs, boosts profits and correctly document ADL’s. 

ADL’s are the financial “bread and butter” for the long term care facility.  Don’t leave this important fiscal element to a few scribbled numbers on a piece of paper.

Next week – Charting by exception – the fast track to Review errors.

All ICF/IID:

DADS clarified the CMS Survey & Clarification Letter 13-11-ICF/IID, No Longer Certified Under Time-Limited Agreements, issued on February 8, 2013. An excerpt:

CMS eliminated the requirement for TLAs on May 16, 2012. Since the ACC was tied to the TLA, the ACC has also been eliminated. DADS will survey an ICF/IID on an average of every 12 months and at least every 15 months. The provider agreement will not have a termination date and will remain in effect as long as the ICF/IID complies with the terms of the agreement, including remaining in substantial compliance with the conditions of participation (COPs).

All NF Administrators:

This letter updates IL No. 13-17 and PL 13-12, Minimum Data Set 3.0 Section Q: Referral to the Community, NF Responsibilities, and Local Contact Agency Information, published March 27, 2013, to provide correct contact information for Local Contact Agencies. (Letter)

HHSC intends to submit to CMS a request to amend the CLASS Medicaid waiver to add the CDA services option for supported employment and a revision to the service definition of supported employment to clarify assistance available and specify integrated, competitive employment. See the Texas Register for more information.

–  On May 29, 2013, CMS re-posted the RAI Manual V1.10. Effective May 20, the new version omits six sections: Chapter 3 Section F; Chapter 3 Section J; Chapter 3 Section S title page; Appendix D; Appendix F title page; and Appendix H title page.

–  All home-delivered meal waiver requests must be received by 8 a.m. on Friday, June 14, 2013. See the news alert page for request rules.

–  All rate setting workbooks for common providers and Community Services-only providers must be received by 8 a.m. on Wednesday, July 31, 2013. See the news alert page for more information.

–  jRAVEN 1.1.7 is available.

See the news page for more information about these and other alerts.