You Are Here:Home/Today in Long-Term Care
The way the nurse assessment coordinator (NAC) is tracking pressure ulcers may have changed, but that doesn’t mean the nursing team’s care process should.
As part of its annual October updates to the RAI User’s Manual, the Centers for Medicare & Medicaid Services (CMS) made some changes to how pressure ulcers are referred to and how they are coded.
First and foremost, the RAI manual has broadened the scope of its terminology, to include pressure injuries rather than just pressure ulcers.
Visitors to nursing facilities often say, “What is that noise I keep hearing? It is so loud!” For those of us who work in the facilities, we get so that we hardly notice it. You know, of course, that “that noise” is the nerve-rattling sound of personal alarms.
COVID-19 can spread like wildfire. In some facilities, the number of suspected or confirmed cases has surged from zero to fifty or more seemingly overnight. Here are three steps that nurse assessment coordinators (NACs) can take to mitigate the risk of severe COVID-19 spread among residents:
Do COVID-19 surveillance on an independent track
The Centers for Disease Control and Prevention (CDC) recommends that nursing homes that have no suspected COVID-19 residents actively screen all residents upon admission and at least daily for fever and symptoms of COVID-19 in order to immediately isolate symptomatic residents and implement transmission-based precautions. Note: This is consistent with April 2 and March 13 guidance from the Centers for Medicare & Medicaid Services (CMS) and should be done in conjunction with similar recommendations for screening staff, as well as all visitors to the facility, to ensure comprehensive surveillance.
If presumptive or confirmed COVID-19 residents are identified in the facility, the CDC recommends that providers monitor symptomatic residents “(including documentation of temperature and oxygen saturation) at least 3 times daily to … identify and quickly manage serious infection” and also to “consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any with new symptoms.” Note: This guidance is partially in Key Strategies to Prepare for COVID-19 in Long-term Care Facilities and partially in the Interim Additional Guidance.
In the March 13 revised Quality, Safety, and Oversight (QSO) memo QSO-20-14-NH, the Centers for Medicare & Medicaid Services (CMS) advised nursing homes to restrict all visitors except for compassionate-care situations and to “cancel communal dining and all group activities, such as internal and external group activities.” Adjusting to these changes has been difficult for every nursing home resident, but social distancing is especially hard for residents with dementia who wander and are eased by group activities.
“That’s not who these people are,” acknowledges Teepa Snow, MS, OTR/L, FAOTA, founder and CEO of Positive Approach to Care, a global dementia care services and products company based in Efland, NC. “Nurses are being asked to do the impossible with the inadequate.”
While physicians and physician extenders may be willing to prescribe an antipsychotic medication as an emergency measure in an acute or emergency situation as allowed under F758 (Free From Unnecessary Psychotropic Meds/PRN Use) in Appendix PP of the State Operations Manual, giving residents with dementia antipsychotics to make them immobile not only increases their risk of adverse events, such as cerebrovascular accidents (CVA) and even death, it also increases their risk of respiratory symptoms, including shortness of breath—one of the primary symptoms of COVID-19, points out Snow. “Providers may also consider taking away wheelchairs and other mobility aids. However, doing that puts residents with dementia at greater risk for falls and fall-related injuries, potentially resulting in a trip to the emergency department where they may be exposed to SARS-CoV-2, the virus that causes COVID-19.”
• Recommendations for State and Local Officials: CMS is providing recommendations to help determine the level of mitigation needed to prevent the transmission of COVID19 in nursing homes. The recommendations cover the following items:
o Criteria for relaxing certain restrictions and mitigating the risk of resurgence: Factors to inform decisions for relaxing nursing home restrictions through a phased approach.
o Visitation and Service Considerations: Considerations allowing visitation and services in each phase.
o Restoration of Survey Activities: Recommendations for restarting certain surveys in each phase.
In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications. These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1. This will allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM ones and thereby inform their future payment models.
The changes to the technical data specifications that support these modifications are contained in the Errata v3.00.4 which can be accessed in the file: MDS 3.0 data specs errata (v3.00.4) Final 04-30-2020 in the Downloads section below. Supporting materials including the 1.17.2 Item Change History report and the revised 1.17.2 Item Sets can be accessed in the file: MDS 3.0 Final Item Sets v1.17.2 for October 1 2020 zip also posted in the Downloads section below.
Please confirm with your State Medicaid Agency if your State will be requiring the calculation of the PDPM payment codes on the OBRA assessments when not combined with a 5-day SNF PPS assessment.
CMS hosts varied recurring stakeholder engagement sessions to share information related to the agency’s response to COVID-19. These sessions are open to members of the healthcare community and are intended to provide updates, share best practices among peers, and offer attendees an opportunity to ask questions of CMS and other subject matter experts.
Call details are below. Conference lines are limited so we highly encourage you to join via audio webcast, either on your computer or smartphone web browser. You are welcome to share this invitation with your colleagues and professional networks.
This ZIP file contains resources for surveyors conducting initial surveys under the Long-term Care Survey Process (LTCSP).
05/14/2020 COVID-19 Focused Survey folder Updated the following:
• F-Tag Job Aid- changed font color of F761 to black. Removed asterisks from F885.
• Added updated F-Tag job aide to survey resources zip file.
05/08/2020 COVID-19 Focused Survey folder Updated the following:
• Summary of the COVID-19 Focused Survey for Nursing Homes Added to offsite survey activities-telephonic interviews of residents, representatives and families. Added review communication with residents, representatives and families. In the onsite survey activity section added in the interview section-information provided to residents concerning COVID-19. In the Facility Self-Assessment added Reporting to residents, families and representatives to priority areas. Added Reporting to CDC to priority areas.
• COVID-19 Focused Survey Protocol Added information about the review of F884 by CMS Federal Surveyors. Added ACO coding information to off-site prep. Expanded information under offsite and onsite activities.
• Entrance Conference Worksheet Clarified language under #9. Added #13 requesting information on facility’s mechanism for reporting COVID-19 to residents, representatives, and families.
• COVID-19 Focused Survey for Nursing Homes Added two critical elements (CE) and adjusted the CE order. #7 CE Reporting to Residents, Representatives & Families, #8 Reporting to CDC, and #9 Emergency Preparedness.
• F-Tag Job Aid- Added tags F884 and F885
The blanket waivers were updated on May 15, 2020.
Also Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19 was updated on May 15.
The update here is:
**Paid Feeding Assistants: CMS is modifying the requirements at 42 CFR §§ 483.60(h)(1)(i) and 483.160(a) regarding required training of paid feeding assistants. Specifically, CMS is modifying the minimum timeframe requirements in these sections, which require this training to be a minimum of 8 hours. CMS is modifying to allow that the training can be a minimum of 1 hour in length. CMS is not waiving any other requirements under 42 CFR §483.60(h) related to paid feeding assistants or the required training content at 42 CFR §483.160(a)(1)-(8), which contains infection control training and other elements. Additionally, CMS is also not waiving or modifying the requirements at 42 CFR §483.60(h)(2)(i), which requires that a feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN).
Summary of Changes to the Guidance:
Updated guidance to recommend that nursing homes:
Nursing homes and other long-term care facilities can take steps to assess and improve their preparedness for responding to coronavirus disease 2019 (COVID-19). This checklist should be used as one tool to develop a comprehensive COVID-19 response plan, including plans for:
The checklist identiﬁes key areas that long-term care facilities should consider in their COVID-19 planning. Long-term care facilities can use this tool to self-assess the strengths and weaknesses of current preparedness efforts. This checklist does not describe mandatory requirements or standards; rather, it highlights important areas to review to prepare for the possibility of residents with COVID-19.
CMS is delaying the release of the updated versions of the Minimum Data Set (MDS) needed to support the Transfer of Health (TOH) Information Quality Measures and new or revised Standardized Patient Assessment Data Elements (SPADEs) in order to provide maximum flexibilities for providers of Skilled Nursing Facilities (SNFs) to respond to the COVID-19 Pubic Health Emergency (PHE).
The release of updated versions of the MDS will be delayed until October 1st of the year that is at least 2 full fiscal years after the end of the COVID-19 PHE. For example, if the COVID-19 PHE ends on September, 20, 2020, SNFs will be required to begin collecting data using the updated versions of the item sets beginning with patients discharged on October 1, 2022.
Following the PHE, CMS will announce training opportunities for providers via this webpage and announcements sent out via email distribution lists and posted on the Medicare Learning Network.
Memo # QSO-20-29-NH
Posting Date 2020-05-06
Fiscal Year 2020
• CMS is committed to taking critical steps to ensure America’s healthcare facilities are prepared to respond to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE).
• On May 8, 2020, CMS will publish an interim final rule with comment period. • COVID-19 Reporting Requirements: CMS is requiring nursing homes to report COVID-19 facility data to the Centers for Disease Control and Prevention (CDC) and to residents, their representatives, and families of residents in facilities.
• Enforcement: Failure to report in accordance with 42 CFR §483.80(g) can result in an enforcement action.
• Updated Survey Tools: CMS has updated the COVID-19 Focused Survey for Nursing Homes, Entrance Conference Worksheet, COVID-19 Focused Survey Protocol, and Summary of the COVID-19 Focused Survey for Nursing Homes to reflect COVID-19 reporting requirements.
• COVID-19 Tags: F884 and F885.
• Transparency: CMS will begin posting data from the CDC National Healthcare Safety Network (NHSN) for viewing by facilities, stakeholders, or the general public. The COVID-19 public use file will be available on https://data.cms.gov/.
Healthcare professionals were relieved when CMS agreed to make the Interim Payment Assessment (IPA) optional instead of a requirement. This meant that skilled nursing facilities (SNFs) could decide when or if they would complete these payment assessments. CMS anticipated that SNFs would perform IPAs during each Medicare Part A stay both to improve Medicare payment during the stays and to monitor patients’ clinical status. However, data shows that few IPAs are being completed.
One likely reason why: the complexity of the new Patient-Driven Payment Model (PDPM) makes it difficult to know when an MDS would improve the final payment. John Kane, CMS’s SNF Payment Team Lead, stated during one of CMS’s train-the-trainer sessions that there could be as many as 1,900 possible payment combinations per PPS MDS.
So how can you know whether an IPA would improve the Medicare payment? First, let’s consider the impact of CMS’s original plan to require the IPAs. CMS proposed that IPAs would be completed when there was a change in one of the first-tier classification criteria in any of the proposed payment components. For example, if the resident had been classified into the Major Joint Replacement category for the PT/OT component and their primary diagnosis changed to Medical Management, the IPA would have been required. Likewise, when a resident’s Nursing component category changed from Extensive Services to Special Care Low, an IPA would have been required. We are grateful that assessments are not mandatory in these circumstances, but they provide a useful starting point for understanding when an IPA could be financially beneficial.
In the SNF PPS Final Rule for FY 2020, CMS included the following table showing the FY 2020 federal unadjusted urban base rates for each of the six PDPM payment components:
To bill under traditional fee-for-service Medicare Part A, skilled nursing facilities (SNFs) must obtain appropriate, timely physician certifications and recertifications of posthospital inpatient extended-care services. The physician cert/recert policy did not change with the implementation of the Patient-Driven Payment Model (PDPM) on October 1, 2019.
However, the Centers for Medicare & Medicaid Services (CMS) did adjust the instructions in the Medicare Online Manual System to explain when providers need to obtain a new physician certification vs. when they should continue using the existing cert/recert to account for the interrupted stay policy that was implemented in conjunction with PDPM. This adjustment brought to light the fact that some SNFs may be counting calendar days instead of Medicare days to determine when certs/recerts are due—a practice that is incorrect CMS officials tell the American Association of Nurse Assessment Coordination (AANAC).
“The regulations at 42 CFR 424.20(d) state that the first recertification is required no later than ‘the 14th day of post-hospital SNF care.’ This would have the schedule track with the days of the stay (i.e., covered days) rather than calendar days,” explain officials. Note: Review the physician cert/recert section of the Code of Federal Regulations in the box at the end of this article.
“This also tracks with previous statements we have made comparing the recertification timeline with the variable per-diem schedule, and interrupted stays have similar impacts on both, as noted in response to FAQ 13.21,” say officials. Here is the FAQ excerpted from Patient-Driven Payment Model: Frequently Asked Questions (FAQs):
To access this resource, please login or sign up for a free 30-day trial membership.