HP Enterprise Services
Summary Report of LTC Facilities Reviewed
July 2013
Tracking Number E20130222Prepared August 2013
HP Restricted / 1
Contents
July
Contents
Overall Summary for Long Term Care
Health Services
Introduction – Long Term Care Unit 4
Volume 4
Quality 5
Validation rate and Reconsiderations 5
Training 5
Audit variations – July 2013 6
Introduction 6
Findings 6
Analysis by Risk Category 7
Areas of Concern 8
Statistics by RUG Classification 9
Level of Care Statistics 10
PASRR Level II Statistics 10
Recommendations 11
HP Restricted / 2July 2013 Health Services
Overall Summary for Long Term Care
· The Long Term Care (LTC) Unit completed sixteen Minimum Data Set (MDS) audits during the month of July 2013. The mean validation rate for the providers audited during the month was 89.44%. The threshold during an audit is currently 80%.
· The LTC Unit received one requests for reconsideration of audit findings in July.
· The validation rate and minimal requests for reconsideration indicate that LTC continues to be successful in helping providers achieve compliance with Indiana Health Coverage Programs (IHCP) rules and regulations.
The purpose of the LTC review is to ensure that the IHCP is reimbursing for the appropriate RUG classification as demonstrated by the MDS version 3.0 and supporting documentation.
Changes to the MDS audit frequency were implemented January 1, 2010. The LTC auditing team also performs Level of Care (LOC) and Pre-Admission Screening Resident Reviews (PASRRs) of LTC residents.
The following risk criteria are used in selecting nursing facilities for audit:
Audit every nursing facility (NF) at a minimum of once every three years based on the following criteria:
· Low-risk provider
○ Previous audit score of 90 – 100% – audit at a maximum of every three years
· Medium-risk provider
○ Previous audit score of 80 – 89.9% – audit at a maximum of every two years
· High-risk provider
○ Previous audit score of 79.9% or lower – audit every four to 12 months
The Office of Medicaid Policy & Planning (OMPP) reserves the right to perform additional MDS audits as deemed necessary at any time.
The objectives of the HP LTC audits are as follows:
· 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.
NFs may be notified up to 72 hours prior to the scheduled case mix/LOC/PASRR audit. The LTC auditing team conducts an entrance and exit conference to apprise the facility staff of the nature, purpose, and sequence of events of the audit, as well as the audit results. The auditing teams are available throughout the audit to address facility questions and concerns. These (The) auditing teams consist of qualified professionals, including registered nurses and licensed social workers. These team members may be qualified mental retardation professionals (QMRP) or designees.
The facility is responsible for ensuring that all resident medical records are complete, up-to-date, and available to the auditing teams. Facility staff will also need to assist the LTC auditing team with resident observations. Documentation in each resident’s medical record must support all notations made on the MDS form.
Health Services
Introduction – Long Term Care Unit
The LTC Unit performs retrospective service provision and case-mix auditing functions. The LTC staff members conduct on-site audits of Medicaid-certified LTC facilities. Oversight is provided for the Division of Aging (DA) and the Office of Medicaid Policy and Planning (OMPP). In addition the LTC staff members assist providers in achieving compliance in documentation and billing, as well as helping ensure the health and safety of the Indiana Health Coverage Programs (IHCP) members.
Volume
Figure 1 illustrates the number of audits completed by month. For the period of August 2012 through July 2013, HP completed 179 audits.
Quality
Validation rate and Reconsiderations
The LTC Unit has a respected presence in the provider community, as evidenced by the relatively small number of requests for reconsideration (refer to Table 1) and overall validation performance (refer to Table 2). Less than 2% of audits resulted in facilities requesting reconsideration of audit findings.
Following each case mix audit, nursing facilities receive final results electronically with instructions for how to request informal reconsiderations for reviewed records that failed to support. Facilities may request reconsideration of audit findings for specific records within 15 business days of receiving their initial findings from HP. The reconsideration request must include specific audit issues that the facility believes were misinterpreted or misapplied during the audit. It should be noted that MDS supporting documentation that is provided after the audit exit conference shall not be considered in the reconsideration process.
Table 1 Reconsideration requests /Reconsiderations / July 2013 / # of Initial Audit Findings Upheld /
Number Received / 1 / 1
Table 2 Monthly validation rate statistics /
Validation Threshold, per IAC / Audit Timeframe / Average Monthly Validation Rate /
80% / August 2012–July 2013 / 88.4%
Training
LTC auditors discuss with providers audit decisions and provide education throughout the audit process. Providers have shown appreciation for these discussions.
The LTC Unit plans to continue to conduct Supportive Documentation Guidelines (SDG) training via virtual room throughout 2013 and encourage LTC providers to reference the IHCP website for future training information.
Audit variations – July 2013
Introduction
The Audit Variations report provides information on nursing facilities (NFs) that demonstrate a variation between their previous case-mix audit validation rate and the current validation rate.
NFs that exceed the 20% error threshold rate as outlined in the Indiana Administrative Code (IAC) receive a 15% Administrative Component Corrective Remedy penalty applied for one quarter. The Nursing Facility is required to respond to a Validation and Improvement Plan (VIP). All unsupported worksheets are reclassified, and the NF is subject to a Case Mix audit within 12 months.
Findings
The LTC unit completed sixteen Case Mix audits in July 2013. The Case Mix audit validation rate average was 89.44%. The variation by gain or/loss percentage was 32% to -29%.
· One new NF validated at 100%.
· One NF had no change at 96%.
· Six NF’s validated higher than the previous audit. The validation ranged between 32 and 3 percentage points higher than the previous audit.
· Eight NF’s reflected a decrease in the validation rate from the previous audit, ranging from -1 to -29 percentage points.
During July, two Case Mix audits were expanded; one provider’s validation rate at the conclusion of the audit exceeded the threshold. The expanded portion of the audit resulted in an additional 8 hours of audit time.
The team educated each facility about 450B & Level I requirements, as well as reviewed the SDG’s regarding Activities of Daily Living (ADL’s), active diagnosis, impaired cognition and nursing restorative elements.
Analysis by Risk Category
· Three Low Risk providers stayed Low Risk.
· Four Low Risk providers became Medium Risk.
· One Low Risk provider became High Risk.
· Two Medium Risk providers became Low Risk.
· Four Medium Risk providers stayed Medium Risk.
· One High Risk provider became Low Risk.
· One New provider became Low Risk.
Areas of Concern
Ten Areas of Concern were statistically relevant upon analyzing data for the month of July 2013. These elements had 20% or greater inconsistency with the MDS data transmitted by the NF, when at least 10 or more records were reviewed this month.
Table 3 Areas of Concern on the MDS 3.0 found during audits completed in July 2013.
Percent of Element Unsupported / Inconsistent Records / # NF’s / RUGs Not Supp / # NF’s / Element / Description /75% / 9 / 5 / 7 / 5 / C1000 / DECISION MAKING
62% / 29 / 8 / 14 / 6 / O0500B / AROM
55% / 6 / 4 / 5 / 4 / C0700 / SHORT TERM MEMORY PROBLEM
54% / 14 / 7 / 9 / 4 / O0500F / WALKING
53% / 8 / 4 / 1 / 1 / I2000 / PNEUMONIA
47% / 9 / 5 / 2 / 1 / O0500G / DRESSING/GROOMING
44% / 15 / 9 / 8 / 4 / I4900 / HEMIPLEGIA/HEMIPARESIS
38% / 5 / 4 / 4 / 3 / O0500H / EATING/SWALLOWING
38% / 6 / 4 / 0 / 0 / M1200A / PRESSURE REDUCING - CHAIR
34% / 24 / 12 / 0 / 0 / O0700 / PHYSICIAN ORDERS
o Nursing Restorative, Diagnoses and Impaired Cognition have remained the top Areas of Concern.
HP Restricted / 11July 2013 Health Services
Statistics by RUG Classification
This table summarizes monthly statistics for all facilities reviewed, including number of records reviewed and the percentage of records fully supported. Resource Utilization Groupings (RUG) further breaks down the statistics.
RUG Category / TOTAL / 8/12 / 9/12 / 10/12 / 11/12 / 12/12 / 1/13 / 2/13 / 3/13 / 4/13 / 5/13 / 6/13 / 7/13EXTENSIVE SERVICES / 888 / 112 / 91 / 95 / 105 / 28 / 66 / 86 / 66 / 56 / 96 / 32 / 55
FULLY SUPPORTED / 770 / 92 / 81 / 86 / 94 / 26 / 56 / 74 / 58 / 51 / 86 / 20 / 46
% / 87% / 82% / 89% / 91% / 90% / 93% / 85% / 86% / 88% / 91% / 90% / 94% / 84%
SPECIAL REHABILITATION / 2,633 / 398 / 263 / 272 / 297 / 123 / 203 / 223 / 163 / 154 / 216 / 109 / 212
FULLY SUPPORTED / 2,528 / 381 / 249 / 260 / 292 / 119 / 196 / 215 / 156 / 150 / 204 / 105 / 201
% / 96% / 96% / 95% / 96% / 98% / 97% / 97% / 96% / 96% / 97% / 94% / 96% / 95%
SPECIAL CARE / 811 / 101 / 96 / 97 / 69 / 35 / 67 / 75 / 61 / 68 / 63 / 37 / 42
FULLY SUPPORTED / 654 / 73 / 78 / 87 / 61 / 29 / 51 / 55 / 52 / 55 / 49 / 27 / 37
% / 81% / 72% / 81% / 90% / 88% / 83% / 76% / 73% / 85% / 81% / 78% / 73% / 88%
CLINICALLY COMPLEX / 1,578 / 192 / 139 / 129 / 124 / 73 / 139 / 160 / 154 / 131 / 149 / 81 / 107
FULLY SUPPORTED / 1,367 / 158 / 115 / 111 / 109 / 67 / 128 / 142 / 130 / 117 / 131 / 66 / 93
% / 87% / 82% / 83% / 86% / 88% / 92% / 92% / 89% / 84% / 89% / 88% / 81% / 87%
IMPAIRED COGNITION / 422 / 76 / 21 / 37 / 15 / 25 / 40 / 30 / 35 / 45 / 48 / 28 / 22
FULLY SUPPORTED / 325 / 54 / 16 / 32 / 13 / 25 / 31 / 17 / 30 / 32 / 41 / 20 / 14
% / 77% / 71% / 76% / 87% / 87% / 96% / 78% / 57% / 86% / 71% / 85% / 71% / 64%
BEHAVIOR / 18 / 4 / 2 / 2 / 0 / 1 / 0 / 0 / 2 / 1 / 4 / 1 / 1
FULLY SUPPORTED / 10 / 1 / 1 / 1 / 0 / 0 / 0 / 0 / 2 / 0 / 4 / 1 / 0
% / 56% / 25% / 50% / 50% / 0% / 0% / 0% / 0% / 100% / 0% / 100% / 100% / 0%
REDUCED PHYSICAL / 910 / 113 / 111 / 78 / 47 / 17 / 104 / 42 / 106 / 118 / 72 / 31 / 71
FULLY SUPPORTED / 746 / 95 / 96 / 56 / 36 / 15 / 80 / 28 / 98 / 88 / 61 / 30 / 63
% / 82% / 84% / 87% / 72% / 77% / 88% / 77% / 67% / 92% / 75% / 85% / 97% / 89%
HP Restricted / 11
July 2013 Health Services
Level of Care Statistics
The Level of Care Statistics reports data for nursing facilities audited during the month. The number of IHCP members, whose charts were reviewed is delineated into the following categories: total audited, those having a Medicaid number, those not having a Medicaid number, those no longer in the NF, discharge recommendations and those with Mental Illness (MI) or intellectual disability (ID) or those dually diagnosed (MI/ID/DD) recommended for discharge. All residents present at the time of the audit were observed in the course of the on-site audit.
TOTAL FACILITIES REVIEWED / Total Audited / MA Residents / Others / Res No Longer in NF / Recommend D/C / MI/ID/DDNo LOC
Ref DMHA /
16 / 510 / 298 / 57 / 136 / 0 / 0
PASRR Level II Statistics