MDS Focused Survey Results in CT

We had our first MDS Focused Survey in a CT facility on Mon and Tues 7/27 and 7/28/15.

Here is a synopsis:

When the surveyors entered the facility, they first checked the posted staffing/census and the most recent survey posting.

The two surveyors handed us a copy of the Focused Survey Worksheet.

The surveyors did ask that we identify the private pay residents on the worksheet with a “P”.

The surveyors also requested from the facility:

1)      A list of all admissions and readmissions in the last 90 days of their entrance into the facility. Include name, room number, date of admission and/or readmission, where they came from, date of discharge, and where they were discharged to. From this data, the surveyors wanted to know who was a current resident in the facility.

2)      A copy off the floor plan

3)      18 months of staffing/census. Make sure your staffing sheets are updated daily!

4)      Location and extensions of key personnel

5)      Within 24 hours, a completed 671 form

6)      Policies and procedures:

a)      RAI/MDS Policy 

b)      Staffing and Scheduling

7)      Lap tops/computers for both surveyors.

There were no MDS findings.

We had a problem with staffing not being updated from the weekend.

Unfortunately, everything was fair game and they did find some issues: missing weekly weight; incomplete I/O; no AIMS.

MY opinion: very poor knowledge of RAI directives and the MDS.

Connecticut MDS Focused Survey Information from Murtha Cullina, LLP

From DPH quarterly meeting, as reported by Murtha Cullina, LLP to their clients in a memo dated July 1, 2015:

Barbara Cass disclosed there would be approximately 6 MDS Focused Surveys for 2% to 2 1/2% per year.in a quarterly  meeting at DPH.

Barbara Cass, Lori Griffin, Karen Gworek and Connie Green have been trained to perform the MDS focused surveys.  They must be completed by Sep 30, 2015.

The national association shared the following additional information: (1) a major focus of the survey is compliance with F356 - §483.30(e) - Nurse staffing information; (2) noncompliance results in automatic CMPs and if CMP meets the threshold, loss of Nurse Aide Training Program; (3) CMS is identifying the centers to receive this survey; (4) CMS is adamant that no information about training, surveyor focus, etc., may be shared with either individual centers or with associations; and (5) some state affiliates have heard that CMS has indicated the state agencies will receive no additional funds for completing these focused surveys.

Last week, a facility underwent the first MDS focus survey in Connecticut. That provider shared the following details about the survey. The surveyors requested the following:
1. a tour of the building and a floor plan;
2. MDS policies and procedures as well as the staffing policy;
3. admission/discharges for the last 90 days (with admissions broken down
by long-term and short-term);
4. A&Is for all falls with injuries;
5. the facility worksheet form that was sent via blast fax within 1 hour;
6. interviews with staff focusing on the number of staff on the floor and
resident to staff ratio.
The provider reported that the survey team focused on skin issues. They reviewed 10
records and were in the building for two days. The facility expects one MDS related tag

and two non-MDS tags.

Important Payroll Based Journal Action Items

Important PBJ Action Items (posted 07/24/2015)

- View PBJ Training Modules for an introduction to the PBJ system and step by step registration instructions. Four training sessions will be available beginning July 27th on QTSO e-University, select the PBJ option. (https://www.qtso.com/webex/qiesclasses.php)

- Obtain a CMSNet User ID for PBJ Individual, Corporate and Third Party users, if you don't already have one for other QIES applications. (https://www.qtso.com/cmsnet.html)

- Obtain a PBJ QIES Provider ID for CASPER Reporting and PBJ system access. Registration will be available beginning Aug. 4th. (CMS QIES Systems for Providers page)

- PBJ Corporate and Third-Parties must use the current form based process to register for a QIES ID. The MDS forms will be updated to include PBJ and will be available Aug. 4th. The forms are available under the Access Request Information / Forms section on the right side of the page. (https://www.qtso.com/)

- Review the PBJ Data Specifications and Errata for the October 1, 2015 release appearing in the Downloads section at the bottom of the page. (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html)

- In an effort to serve you better, we are offering a vendor ListServe. This information will be used to contact you with important news, updates, and conference call information. (https://www.qtso.com/vendor/post.php)

- The CASPER Reporting and PBJ systems will be available on October 1, 2015. A user will be able to submit XML files or manually enter staffing and census data for work performed on or after October 1, 2015. (CMS QIES Systems for Providers page)

From https://www.qtso.com/vendorpbj.html

MDS Focused Survey results NC

No deficiencies

MDS/Staffing Focused Survey Results: North Carolina

Three citations:  D,E,B
Missed Sig Change after LTC resident hospitalized and returned for skilled care with new catheter and two new pressure ulcers.
MDS inaccurate for 6 of 8 residents (primary issue:  Pre-populating from previous MDS)
Did not have 18 months of the staffing sheets required by F356.  Facility kept 12 months at a time.

MDS/Staffing Focused Survey Results: MA

Done in MA in June by regular surveyors, not from the complaint unit:  Three citations.  MDS coding error, missed fall.  Staffing posted did not include facility name,  resident who went to hospital had discrepancy in MOLST form at hospital and wishes for end of life when readmitted.  Their MDS Worksheet #1 did not contain a line for antipsychotics.  *update:  provider called back and form did have line for antipsychotics. It was the same form.

MDS Focused Survey Results Virginia

 Resident Assessment- facility failed to ensure accurate MDS Assessments for 4 of 10 residents

                   2 was for a foley, 1 re-entry assessment was not done,  fracture was not coded on 2 

                           assessments on 1 resident

       

 Quality of Care- facility failed 2 anchor catheter tubing for 2 residents and 1 resident did not have

                   a medical diagnosis for a foley

Quality of Care- facility failed to ensure an atmosphere free from hazards because 1 resident

                           had his catheter tubing wrapped around his ankle 

Staffing- the facility failed to post the daily staffing sheet on Day 1 of the survey

MDS/Staffing Focused Surveys: Citations for Posted Employee Hours

Reports are coming in on citations for not posting your staffing data.  I have one report of a citation,  from an annual survey, that staffing data did not include the hours worked.  Note it is a requirement to post actual hours worked, so make sure to go back and correct it as things happen over the course of the day.  Also note this annual survey was heavily centered on MDS/Staffing issues.  It was in PA. When surveyors get training, they tend to cite what they just heard about.   Virginia seems to be using the two surveyors who were trained last year do to the MDS surveys.  MA is using their complaint department.

Here is the regulation:

F356  Nurse Staffing Information—

•The facility must post the following information on a daily basis:

–Facility name,  current  date, census

– Total number  and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident  care per shift:

•Registered nurses.

•LPN/LVN

•Certified nurse aides.

•Data must be posted

–In a clear and readable format.

– In a prominent place readily accessible to residents and visitors.

•Must, upon request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

•Must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Virginia: MDS Focused Surveys have Started

The two surveyors are Karen Kanody and Tina Wells.  They are the ones trained for the pilot.  They are in Tidewater now.  It is likely they will do all five.  They are from Rodney's region in the West.  Look for them over the coming weeks.  It is also likely they will just line them up and get them done all in a row.  If you get one, let me know and I will post it here.  When we get the results of this one,  I will post it here.  The survey agency director is still out, and Rodney is the acting director until further notice.

Skilled Nursing Facility Billing for Changes in Therapy: Improvements are Needed

Skilled Nursing Facility Billing for Changes in Therapy: Improvements are Needed (OEI-02-13-00611)

CMS introduced three types of therapy assessments to more quickly capture when beneficiaries start therapy, end therapy, and decrease or increase therapy. However, we found that SNF billing for changes in therapy increased only slightly. In addition, SNFs used assessments very differently when decreasing therapy than when increasing it, costing Medicare $143 million over 2 years. Further, SNFs frequently used the new start of therapy assessment incorrectly. For example, SNFs often used a start-of-therapy assessment but billed for no therapy during the stay.

• Read Full Summary http://oig.hhs.gov/oei/reports/oei-02-13-00611.asp
• Read PDF Report http://oig.hhs.gov/oei/reports/oei-02-13-00611.pdf

MDS/Staffing Focused Survey Reports

From Ohio:  They are expecting 25
Two citations:  Administration for not having a specific policy that states who is responsible for each MDS section, completion of each CAA, development of each care plan & initiation of acute care plans as well as who is responsible for submission and completion of the MDS schedule. MDS accuracy for a discharge assessment:  We have a resident who fell within the facility and hit his head. The nurses notes stated guest had a bump on head order received to send to ED for eval. The discharge assessment was coded as a fall with injury. The resident readmitted 10 days later with a discharge summary that stated he had a subdural hematoma. The surveyor's stated the MDS nurse should have modified the discharge assessment upon readmission to state fall with major injury.

From Massachusetts:

This facility completed the MDS Worksheet by using a recent three month Casper Report.  They told the surveyors this, and the survey team said it was ok.  They asked for policies for MDS completion,  UTI, restraints, psychotropics but did not ask for pressure ulcer policies.  They got two citations:  One for a missed UTI on a PPS 14 day and one for not posting the daily staffing data.  When the survey team was asked what they needed for the "extensive assist of 2"  column, the team did not know.     You may be wondering how they got a UTI citation if they presented the Casper data on the MDS worksheet. The UTI triggered on a Sig Change/5 day and the surveyors saw that it also should have been on the 14 day.  

So far,  all reports are that it is two surveyors and it has taken two days. In Massachusetts the surveyors were from the complaint department.  

CMS Proposed Rule: Biggest Overhaul of Nursing Home Regulations since OBRA 87: Life changing

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 405, 431, 447, 482, 483, 485, and 488 [CMS-3260-P] RIN 0938-AR61 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule.

SUMMARY: This proposed rule would revise the requirements that Long-Term Care facilities must meet to participate in the Medicare and Medicaid programs. These proposed changes are necessary to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. These proposals are also an integral part of our efforts to achieve broad-based improvements both in the quality of health care furnished through federal programs, and in patient safety, while at the same time reducing procedural burdens on providers.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-17207.pdf

Report of MDS/Staffing Focused Survey from Alabama

There were no citations.  They made them fill out the MDS Worksheet #1.  It hadn't changed for this survey.  Here is the report:

The surveyors interviewed every nursing staff person working during the survey.  They came back at 6:00 a.m. to interview the night shift.  They asked questions like “Do you ever work short?”  What does management do about call offs?  If you work short does that affect resident care? Those types of questions.   Also they reviewed the last 18 months of our nurse staffing report.  Make sure that each day is completely filled out.  Then they reviewed a sample of MDS’s, care plans and assessments to make sure that everything is in order.  They will ask the administrator how we derived the hours worked for the form 671.  They also asked for many nursing policies and procedures.


If you have a focused survey, let me know and we can all benefit.  I will post it here.

Forbes article Aetna Buys Humana

Written by Dan Diamond, Forbes.com  entire Article

Aetna Buys Humana For $37 Billion, But Deal Doesn't Add Up

The big are getting bigger: Aetna AET -2.63% and Humana HUM -2.92%, the nation’s number three and number four health insurers by revenue, are merging.

Aetna will pay about $230 per share for Humana, in a $37 billion cash and stock deal, the largest-ever deal in the health insurance industry.

It’s also the latest major merger in an increasingly frantic health care marketplace. On Thursday, Centene CNC -7.99% announced that it was buying HealthNet for nearly $7 billion, and CVS last week bought the Target TGT -0.87% pharmacy business for $2 billion.

Aetna and Humana still need federal approval. But the combined company could become the nation’s number two health insurer, behind UnitedHealth Group … which had recently approached Aetna with its own offer to merge.

(And the other two big health insurers, Anthem and Cigna CI -0.46%, have alsotalked about merging.)

As health reporter Christopher Weaver cleverly framed it a few weeks ago,health insurers are playing a “Game of Thrones.”

But what crown are they after? And why are they merging now?

One common argument is that the Affordable Care Act is hurting health insurers, and pushing them to merge — but there’s limited evidence that the biggest players are struggling. While the ACA capped insurers’ ability to take profits, industry analysts have been fairly bullish on the sector.

“U.S. health insurers have successfully managed challenges from the rollout of the Affordable Care Act,” Moody’s declared in February, raising its outlook on insurers from “negative” to “stable.”

And as I wrote earlier this week, the ACA appears to have only helped major insurers, by driving millions of new customers into the market. Aetna and Humana have seen their stock valuations triple in the past five years, since the ACA was signed into law, and the other three major insurers also have seen huge gains.

Another proffered explanation is that deals like Aetna-Humana are about gaining greater efficiency.

“The complementary nature of our two companies provides us with a significant synergy opportunity, furthering Aetna’s efforts to increase its operating efficiency,” said Shawn M. Guertin, Aetna’s executive vice president and CFO, in a statement. “These cost efficiencies will support our efforts to drive costs out of the system and offer more affordable products.”

“Insurers are eager to reduce expenses and build scale that will help them face off against health-care providers that are bulking up,” the Wall Street Journalreported on Friday.

But Aetna and Humana already are giant, scaled entities. And economists aren’t buying the claim that insurer consolidation will lead to lower costs.

“These are already bigger companies,” says Martin Gaynor, a Carnegie Mellon economist and former FTC official. (We spoke last week, before the Aetna-Humana deal was consummated.) “It’s not clear to me, do they get any more scale economies from getting bigger?”

Consolidation among giant insurers “reminds me of the airline sector, and I don’t think there have been efficiencies gained there — and they have a more direct way of finding efficiencies, with the hub-and-spoke model,” Robert Town, a health care professor at the Wharton School, told me last week.

“Here, it’s a little less clear where they get those efficiencies,” Town added. “The economies of scale in insurance are relatively modest.”

In a post for the Columbia Journalism Review, industry watchdog Trudy Lieberman cited studies that larger insurers may end up hiking their prices, not lowering them. And as Bruce Japsen has written for FORBES, hospitals and doctors are worried that super-sized insurers could squeeze reimbursement and engage in anti-competitive behavior.

Perhaps the best rationale for health insurers’ deals is that it allows for greater diversification. For instance, Humana already serves about one-fifth of the nation’s 16 million Medicare Advantage patients, and that pool is expected to grow.

“Medicare Advantage is a coveted space,” Michael Bernstein, a partner at Baird Capital’s U.S. private equity team who focuses on health care, told Bloomberg in an interview last month. “To develop a similar scale in Medicare [for Aetna] would take a great deal of work and time, which would be bypassed by making that transaction happen.”

But economists see one more explanation: Amid health care’s merger mania, insurers are feeling psychological pressure to make deals of their own.

“I think they don’t know what else to do,” Town mused. “They’re not bending the cost curve.”

“Providers are saying, they might need to get bigger too,” adds Gaynor. So for insurers, seeking out deals “is insurance against unforeseen evidence … even though sometimes smaller is nimbler, it’s a better position.”

“In health care, bigger is not always better.”