CMS revising 3.0 timeline
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1. E mail address Required for electronic subscriptions Q Payment enclosed OU Please bill me Q Please bill my organization using PO Q Charge my Q AmEx QO MasterCard QO VISA QO Discover Signature Required for authorization Card Expires Your credit card bill will reflect a charge to HCPro the publisher of PPSA For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Nursing Continuing Education Exam January March 2009 A service of PPS Alert for Long Term Care Accreditation statement HCPro Inc is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation Credit designation statement This educational activity for three nursing contact hours is provided by HCPro Inc Directions gt Fill out your contact information in the space provided gt Complete the exam by circling the letter that corresponds to the correct choice for each question The questions are based directly on content from the January March issues of PPSA and you may refer to them as you take the exam gt Return all four pages of the exam to us by May 1 2009 To qualify for three continuing medical education CME credits you must answer at least 80 of the questions correctly2. After reading this article you will be able to gt State the definition of a restraint according to the State Operations Manual gt Name the regulation limiting restraint use in long term care facilities gt Explain why reducing restraints in long term care is important for resident care gt Discuss strategies for reducing restraint use Operating a restraint free nursing facility may seem like an unattainable goal but it has been a reality at one Pennsylvania nursing facility in recent years The Partridge Tippett Nursing Facility which is part of the United Methodist Homes Wesley Village Campus in Pittston PA has been restraint free for the past seven years according to staff members As a result the facili ty has experienced fewer falls and residents have a better 2009 HCPro Inc overall quality of life says Patt Vitale RN director of nursing services at Partridge Tippett Reducing restraints has been one of the great success stories in long term care during the past two decades according to a CMS report issued in November 2008 The percentage of nursing home residents physically restrained daily declined from 21 1 in 1991 to 5 in 2007 according to the report However many long term care facilities are still using some physical restraints believing restraints are neces sary for resident safety Restraints can endanger residents and are not proven to reduce falls according to CMS Using unnecess
3. She suggests that the spokesperson tell the media you are investigating a problem rather than refus ing to comment If you slam the door on the media they ll run away with the story Marshall says Develop strong internal communication and antici pate negative coverage so you can prepare a response Soden says For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2009 PPS Alert for Long Term Care Page 5 Be honest and up front about the situation No comment just prolongs the life of an issue in a news cycle she says Answering five star questions With all the attention the five star rating system has received nursing facilities may already be fielding calls from the media about their star ratings When the rating system was unveiled in Decem ber United Methodist Homes explained how the rat ings were calculated why the organization s facilities received their ratings and what they are doing to im prove Soden says We also explained our organization s take on the rat ing system and why the star ratings don t make for a complete picture of our facilities and services she says You can read an article United Methodist Homes posted on its Web site about the rating system at www unitedmethodisthomes org news viewarticle asp a 3079
4. The American Health Care Association AHCA has posted information about the five star rating system on its Web site at www ahcancal org including quality talking points and myths and realities about the rating system When the five star rating system was released some nursing facilities were contacted by members of the me dia before they had seen their ratings says Lyn Bentley MSW director of regulatory services at AHCA One rea son AHCA posted the information was to help nursing facility staff members who may not be experienced in dealing with the media A director of nursing or administrator s business is get ting people to care for people says Donna Doneski director of public affairs at AHCA who helped assemble Questions Comments Ideas Contact Associate Editor Emily Beaver Telephone 781 639 1872 Ext 3406 E mail ebeaver hcpro com 2009 HCPro Inc some of the information posted on the Web site Doneski says she hopes the information will also be useful to con sumers who may be trying to evaluate information about a nursing facility CMS says consumers should visit nursing facilities in person but that suggestion may be difficult to find among the other information about nursing home rat ings on the agency s Web site Doneski also recom mends that consumers visit www longtermcareliving com for information about selecting a nursing home For more details about AHCA s efforts to w
5. is not considered a skilled service b can be reimbursed in addition to the daily rate c is not reimbursed in addition to the daily rate d can only be reimbursed if the resident is receiving another skilled service February 2009 11 Which of the following beneficiary notifications is not mandatory for SNFs under any circumstance a SNF Advance Beneficiary Notice ABN b Notice of Exclusion from Medicare Benefits NEMB c ABN for Medicare Part B services d A generic notice CMS 10123 12 Issuing an ABN gives a resident the right to a appeal to a fiscal intermediary Fl for the demand bill process b an expedited review through a Quality Improvement Organization QIO c continue to receive skilled care covered by Medicare d remain in the nursing facility 13 Issuing an expedited determination notice EDN gives a resident the right to a appeal to an FI for the demand bill process b an expedited review through a QIO c continue to receive skilled care covered by Medicare d remain in the nursing facility 14 When Medicare Part A services are ending but the beneficiary will remain in the facility for custodial care or therapy which of the following notices would a facility issue a ABN or ABN G b SNF ABN denial letters and EDN c NEMB d The SNF is not required to issue any notices 15 When therapy is no longer medically necessary for a resident but the resident s family wants to continue therapy under private pay w
6. RRS Healthcare Consulting Services in San Diego To submit a question contact Associate Editor Emily Beaver at ebeaver hcpro com e A resident had horrible excruciating pain once dur ing the observation period She was given a medi cation and the pain was relieved without recurrence during the observation period Does the result of the intervention affect the coding of the pain in J2a pain frequency and J2b pain intensity Would it be coded 0 no pain because it was relieved promptly A No the result of the intervention does not affect the coding of pain The question you must answer is whether there was pain during the observation period If the answer is yes code the frequency in J2a and the high est intensity the pain reached in J2b even if it reached that intensity only once during the observation period The RAI User s Manual states Code the highest inten sity of pain that occurred during the observation period in J2b Code for the presence or absence of pain regard less of pain management efforts p 3 141 In the ex ample provided J2a would be coded 1 pain less than daily and J2b would be coded 3 times when horrible or excruciating e If a person ambulates in the hall only once in the seven day lookback period for G1 activities of daily living ADL is it coded as 8 activity did not occur since it didn t occur the three or more times necessary to as sign a code A No If it happened ev
7. resident s time not for the therapist s time Note The 25 rule applies only to Medi care A residents p 3 188 e have a resident who was in the facility on Part A for 12 days and converted to Medicaid on day 13 which was yesterday No one realized that the assessment reference date ARD hadn t been set for the five day assessment I m confused about how to handle this Illustration by David Harbaugh She just coded all the residents ADLs and forgot all the subtasks 2009 HCPro Inc AW Because the resident has been discharged from a Part A you cannot do the assessment now and you cannot bill the default rate in this situation In other words the facility will receive no payment for the stay The 2009 PPS final rule made this clear and reiterat ed the following five circumstances under which a facil ity may bill the default rate in the absence of a required RAI as outlined in the Provider Reimbursement Manual gt The stay is less than eight days within a spell of illness gt The SNF is notified on an untimely basis or is un aware of a Medicare Secondary Payer denial gt The SNF is notified on an untimely basis of the revo cation of a payment ban The beneficiary requests a demand bill gt The SNF is notified on an untimely basis or is un aware of a beneficiary s disenrollment from a Medi care Advantage plan If the resident had not been discharged from Pa
8. that s 24 correct answers out of the 30 questions gt Upon successful completion of the exam we ll e mail you a certificate that you may use for display and documentation of three CME credits Name E mail Nursing license number Telephone Facility Fax Address city state ZIP January l Nursing facilities must be able to immediately identify delirium in residents because g a delirium is over detected among nursing home residents b the condition cannot be reversed c delirium is a manifestation of a more serious condition such as dehydration or an adverse reaction to medication d delirium is easy to detect 2 Under the MDS 2 0 nursing facilities assessed residents for delirium by what means a Structured cognitive assessments b Unstructured observations c Resident interviews d Nursing facilities did not complete delirium assessments under the MDS 2 0 3 Under draft versions of the MDS 3 0 how will nursing facilities assess for delirium a Using structured cognitive assessments b Interviewing residents c Reviewing residents medical records d All of the above 4 What kind of assessment must be conducted so nursing facility staff members can complete the confusion assessment method CAM under the MDS 3 0 a Unstructured staff observations b Family member interviews c Structured cognitive assessments d The Mini Mental Status Exam A service of PPS Alert for Long Te
9. to it says Marshall If any of your residents knit caps to donate to home less shelters or send care packages for troops overseas telling their story can show the public that your residents are still vibrant members of the community E Five star update Members of three long term care industry associations met with CMS in January to discuss their concerns about the five star rating system released in December 2008 The American Health Care Association AHCA the Ameri can Association of Homes and Services for the Aging and the Alliance for Quality Nursing Home Care met with Thom as Hamilton director of the survey and certification group at CMS Hamilton was willing to clear the agenda to listen to the industry groups concerns says Lyn Bentley MSW direc tor of regulatory services at AHCA who was involved in the meeting CMS plans to form four work groups which will include some industry advocates to identify ways to improve the rating system Bentley says The groups will focus on quality measures QM staffing surveys and consumer satisfaction CMS will determine which issues can be resolved quickly and which must be addressed over the long term she says One major problem is that the rating system uses informa tion from QMs to rank facilities something QMs were never intended for Bentley says As a result a facility that admits many postsurgical patients may be penalized under the rat ing sys
10. touch with members of the media about long term care industry news and making your staff members available as expert sources This can help you build relationships with reporters and reporters may appreciate getting a lead on a story she says Working with the media In 2008 Soden helped United Methodist Homes get television news coverage for a vow renewal ceremony for residents a gallery opening for art created by young children in a United Methodist Homes day care and a certified nursing assistant who received an Excellence in Caregiving award from the Central New York chapter of the Alzheimer s Association One of Soden s rules about working with the media is never invite reporters to events that aren t truly unique or interesting If you invite members of the media to dull or routine events they may not show up when you have a great one When you invite the media to your facility make it as easy as possible for reporters to get the information they need Soden says She takes the following steps when enlisting media coverage for special events 1 Send out a press release well in advance of the event with basic information e g who will be there the contact information of your facility s media represen tative and the event s purpose importance and date and time Also tell the press whether they can get photographs or video footage 2 Ask members of the media to let you know whether they ll be comin
11. HA adjunct professor at the College of Mount St Joseph in Cincin nati Restraints can become dangerous if residents get trapped or tangled in them Krechting says MDS 3 0 question of the month a My automation vendor recently contacted me and told me the company will not be going for ward with producing new software for the MDS 3 0 What should do To read Regulatory Specialist Diane Brown s answer to this question visit www mdscentralonline com Click on the Ask Diane icon and then on the Diane Brown link above her picture Diane answered this question on January 26 If you don t see the answer on the page click on the Next Page link until you find January 26 Editor s note Do you have an MDS 3 0 question that you d like to submit Ask your question on the Ask Diane page at www mdscentralonline com 2009 HCPro Inc Physical restraints can lead to strangulation and death from asphyxiation loss of muscle tone and de creased bone density and loss of dignity among other problems according to CMS November 2008 report on restraints Falls that occur when residents are restrained often result in more serious injuries the report states Staff members at Partridge Tippett found that elimi nating restraints decreased falls Vitale says noting that the number of falls at Partridge Tippett is lower than the 1 5 falls per bed per year benchmark Eliminating restraints also improves residents w
12. HCPro An Integrated Approach to March 2009 Vol 12 No 3 the LTC Industry PPSALERT FOR LONG TERM CARE MDS 3 0 update CMS revising 3 0 timeline Agency aiming for October 1 implementation At the January SNF Long Term Care Open Door Fo rum amid industry rumors that this year s planned MDS 3 0 implementation would be delayed a CMS official said the agency is still pursuing an October 1 implementation However officials also stated that CMS will revise its orig inal MDS 3 0 timeline The agency is working aggressively toward the Oc tober 1 implementation date Mary Pratt director of the division of postacute and chronic care at CMS said at the forum That being said it is also important to mention that stakeholders have been expressing concern about the implementation of the MDS 3 0 which is currently scheduled for October 1 2009 Pratt said We ac knowledge that the time frame is ambitious and your comments and issues related to the implementation are under consideration IN THIS ISSUE P 3 Working with the media Telling your facility s story can show the community what the five star quality rating system doesn t measure p 6 Five star update Long term care industry associations are working with CMS to improve the five star rating system p 7 PPS Q amp A Rena R Shephard MHA RN RAC MT C NE answers questions about coding pain and ADLs and setting the ARD p 9 Reducing restrain
13. Pro Inc is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation The PPSA editorial advisory board members have signed a vested interest form declaring any commercial financial stake in this activity If you have any questions or concerns please contact customer service at 800 650 6787 Fax or mail your exam and evaluation by May 1 2009 to PPSA CE Exam P O Box 1168 Marblehead MA 01945 Fax 781 639 2982 Attn Kerry Betsold CE coordinator Page 4 Nursing Continuing Education Exam January March 2009
14. ary physical and chemical restraints can result in poor sur vey results for nursing facilities Partridge Tippett now serves as a training site for other area nursing facilities that want to reduce restraints Un derstanding Partridge Tippett s approach to eliminating gt continued on p 10 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 10 PPS Alert for Long Term Care March 2009 Restraints lt continued from p 9 restraints by creating a restraint reduction task force and adopting an interdisciplinary approach may help your facility reduce restraints Reasons to reduce restraints The 1987 Nursing Home Reform Act established resi dents right to be free from chemical and physical re straints imposed for discipline or convenience and not required to treat the resident s medical symptoms Long term care facilities that are found to use physi cal restraints not required to treat the resident s medical symptoms may be cited with F221 or with F222 for chem ical restraints not required to treat medical symptoms Beyond regulatory compliance there are several im portant reasons to reduce restraints including the seri ous risks physical restraints can pose for residents There are inherent dangers and people can die says Janie Krechting RN C BSN MGS LN
15. ccording to a June 2007 CMS memo issued to state survey agency directors Remove easily means that the manual method device gt continued on p 12 Tips for reducing restraints Even if your facility doesn t have a restraint reduction pro gram the following tips will help you reduce the use of re straints at your facility gt Start at the top Get your nursing facility s adminis tration to commit to reducing restraints at your facil ity says Patt Vitale RN director of nursing services at the Partridge Tippett Nursing Facility in Pittston PA After you have support from the top levels of your or ganization you can work on getting the entire staff to buy in gt Go less restrictive If your facility must use a restraint use the least restrictive method possible For example remove a restraint during meals or activities when direct supervision is available says Janie Krechting RN C BSN MGS LNHA adjunct professor at the College of Mount St Joseph in Cincinnati gt Make a team Forming a restraint reduction task force was one of the first steps Partridge Tippett took toward eliminating restraints The facility involved members of its nursing staff social services and therapy and activities departments in the task force gt Take it slowly Partridge Tippett eliminated restraints by evaluating one resident at a time and brainstorming ways to remove restraints gt Look for alternat
16. ce on F309 including new general and pain management investigative protocols with an effective date of March 31 The caller asked wheth er providers should observe the effective date or wait until CMS posts the materials Sheila Lambowitz director of the division of institu tional postacute care at CMS didn t have an immediate answer to the question know the pain material is out for review but we don t have a date Lambowitz said adding that providers should wait until CMS officially posts information Telling your facility s story in a five star era Now that consumers can access star ratings for nurs ing facilities on the Internet telling the public about your facility s special programs and unique benefits is more important than ever If your facility has tried to get your local newspaper or television station to cover a special event you know the challenges of getting media coverage fewer writers and reporters at many media outlets press releases that dis appear in the newsroom and staff members at your fa cility who are too busy to deal with the media Working with the media can help you tell your com munity about your nursing facility s award winning staff or creative activities program A long term care consul tant and the director of marketing communications and PR for a long term care organization explain strategies for building relationships with the media relaying your facili
17. d plans or interventions congruent with the patterns For example the team would track a resident s toileting for a few weeks establish a pattern and then toilet the Relocating Taking a new job If you re relocating or taking a new lt 4 job and would like to continue receiving PPSA you are eligible for a free trial subscription Contact customer service with your moving information at 800 650 6787 PPSA Subscriber Services Coupon QO Start my subscription to PPSA immediately Options No of issues Cost Shipping Total PPS Alert for Long Term Care Q Electronic 12 issues 239 ppsae N A O Print amp Electronic 12 issues of each 239 ppsape 24 00 Order online at www hemarketplace com Sales tax see tax information below Be sure to enter source code NO001 at checkout Grand total For discount bulk rates call toll free at 888 209 6554 Tax Information Please include applicable sales tax Electronic subscriptions are exempt States that tax products and shipping and handling CA CO CT FL GA IL IN KY LA MA MD ME MI MN MO NC NJ NM NY OH OK PA RI SC TN TX VA VT WA WI WV State that taxes products only AZ Please include 27 00 for shipping to AK HI or PR HCPro 2009 HCPro Inc Mail to HCPro P O Box 1168 Marblehead MA 01945 Tel 800 650 6787 Fax 800 639 8511 E mail customerservice hcpro com Web w
18. ell being in other ways Mary Lou Langdon RN who is now a unit manager at Partridge Tippett says she re members working as a night shift nurse at a time when restraints were more common in nursing homes Some residents would stay awake all night trying to get out of their restraints Langdon says When residents are not restrained they are more comfortable sleep better and have a better quality of life she adds Trends in nursing home restraint use 25 21 1 2 20 oe Se as kd 5 15 mia og v aD 6 10 u uf 5 0 1991 1996 2001 2007 Calender year Source CMS For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2009 PPS Alert for Long Term Care Page 11 Steps to restraint reduction One of Partridge Tippett s first steps toward becom ing restraint free was to create a restraint reduction task force The task force which began 12 years ago included members of the nursing staff social services and therapy and activities departments Each week members of the task force would identify a resident who had restraints review his or her medical record and work together to identify ways to eliminate the restraints Langdon says Every member of the team is important say Partridge Tippett staff members Therapy depa
19. en once it occurred and 8 is not the correct code If the activity occurred only once or twice in the observation period the instructions are to code it 0 independent regardless of the level of 2009 HCPro Inc assistance required A higher level cannot be coded un til the ADL occurred at least three times See the defini tions in Chapter 3 of the RAI User s Manual A We are having a debate about how to calculate MDS minutes for group therapy The regulations say no more than 25 of therapy time can be in group thera py so we make sure that the number of therapy minutes doesn t exceed the number we get when we divide the total number of minutes in P1b by four Now we re told we re doing it incorrectly Please explain the process A To calculate the allowable 25 for group treatments simply multiplying the total number of minutes by 25 is incorrect The following formula which must be calculated separately for each therapy discipline i e phys ical therapy occupational therapy and speech language pathology can be used to calculate the allowable 25 for group treatments that can be counted on the MDS 1 Individual minutes divided by 0 75 total allowable minutes individual plus group minutes 2 Subtract individual minutes from total allowable min utes to determine the maximum number of group minutes available to the resident for the MDS The following are two examples of these calculations gt 250 i
20. g If you don t hear from anyone fol low up with a phone call 2009 HCPro Inc 3 Attend the event and identify residents who are will ing to be interviewed Make sure you have signed consent forms on file for any residents who are inter viewed or photographed 4 Give reporters a more detailed press release e g one containing the history behind an event and your contact information in case they have additional questions after the event 5 Soden also takes photos interviews residents and writes her own story for her facility s newsletter or Web site When you invite members of the media to your fa cility remember that you are inviting them into your residents home Your residents have the same expectation of privacy as you do at your home Don t volunteer residents for in terviews without their permission and make sure any residents who are interviewed have the required men tal capacity Soden says Responding to bad news At times your facility may have to respond to nega tive news coverage such as a story about a bad survey a lawsuit or a poor rating under the five star system Your facility or corporate organization should appoint one person as a media representative or spokesperson If you don t have a PR director your administrator might be the appropriate spokesperson Train staff members not to speak to the media and to refer any inquiries to the designated spokesperson says Marshall
21. g the seven day observation period of section P1b The limitation is that the resident cannot classify into the highest rehab resource utilization groups Rehab Very High and Rehab Ultra High using this projection regardless of the number of minutes projected The only way to classify into these two categories is by delivering the actual days or minutes required for the categories as entered in item P1 The instructions for completing section T are in Chap ter 3 of the RAI User s Manual It explains the process for projecting therapy days and minutes for the first 15 days of the Medicare stay The projection must be based on the treatment plan resulting from the evaluation The process is as follows 1 Look at the number of minutes days of therapy doc umented in section P 2 Based on the treatment plan project how much more therapy the resident is expected to receive from the day after the assessment reference date through day 15 3 Add the two together that s your projection Facilities should routinely audit the accuracy of pro jections by comparing them to the amount of therapy actually provided At times projected days minutes will not be delivered because the resident was too tired or got sick Most of the time the projection should be fairly accurate or it probably isn t being done correctly E Case study Taking away restraints one resident at a time A Continuing Education Learning Objectives
22. hich of the following notices would a facility issue a SNF ABN denial letters b ABN or ABN G and EDN c ABN only d NEMB Page 2 Nursing Continuing Education Exam January March 2009 16 Under which of the following circumstances might an NEMB be issued a Part A services are ending but the beneficiary will remain in the facility for custodial care b Part B services are ending because they are no longer medically necessary or reasonable c All Part A and Part B services are ending d The beneficiary did not have a three day qualifying hospital stay 17 Transmittal 1106 states that Medicare contractors shall advise providers to use the to inform beneficiaries about the therapy caps a NEMB or a similar form of their own design b ABN ABN G c SNF ABN denial letter d EDN 18 Which of the following beneficiary notifications are issued for the expedited review process a SNF ABN denial letters and ABN or ABN G b SNF ABN denial letters and NEMB c SNF ABN denial letters only d A generic notice CMS 10123 and a detailed notice CMS 10124 19 Beneficiaries enrolled in the Medicare Advantage program a receive all of the same beneficiary notifications as those in the Medicare fee for service program b receive different notifications under the ABN process c receive different notifications under the expedited review process d are exempt from the beneficiary notification process 20 Which of the following is not one of the s
23. ives A low bed may work as an al ternative to a bedside rail Krechting says gt Learn from other facilities Partridge Tippett was identified as a training site for facilities that want to re duce restraints Look for nursing facilities with strong re straint reduction programs in your area Also your state may have a restraint reduction task force that can pro vide you with resources 2009 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 12 Restraints lt continued from p 11 material or equipment can be removed intentionally by the resident the same way it was applied by staff mem bers e g the resident puts down bedside rails rather than climbing over them The memo s clarifications of those terms were meant to be used in conjunction with the definition of physical restraints Creating individualized plans for each resident was a top priority in Partridge Tippett s restraint reduction program says Danielle Janeski NHA assistant ad ministrator at the facility The facility didn t take what Janeski calls a cookie cutter approach to eliminating restraints simply re moving a restraint and not following up with individu alized interventions Instead staff members would track residents patterns and formulate initial individualize
24. l distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 6 PPS Alert for Long Term Care March 2009 Five star lt continued from p 5 You can survey your customers with commercially produced surveys or create a survey program When you receive the results make an effort to work on areas your customers were unhappy with then survey your custom ers again Marshall says After you conduct a strong customer satisfaction sur vey include the results in gt Your facility newsletter or Web site gt Newspaper ads gt Flyers or handouts gt Presentations your staff members give during local speaking engagements gt Your facility brochure Changing perceptions about long term care Working with the media gives your facility an oppor tunity to educate the community about long term care Many people still hold ideas about nursing homes that are 20 years or more out of date Soden explains adding that she always has positive and timely sto ries to tell about events at United Methodist Homes facilities By telling their stories your staff members can be your best advocates in helping the public understand the value and role of long term care in your community she says Working with members of the media can help nurs ing facilities change the perception that nursing home residents are recipients of the community not givers
25. nager at Partridge Tippett says removing restraints improved the quality of life for residents by a allowing them to be more comfortable and sleep better b permitting them to move about the facility freely c giving them more dignity d giving them the ability to socialize with other residents 29 Which was the first step Partridge Tippett took toward eliminating restraints a Asking family members whether they approved of eliminating restraints b Asking residents whether they would like the facility to eliminate restraints c Conducting a customer satisfaction survey d Forming a restraint reduction task force that included members of the nursing staff social services and therapy and activities departments 30 Which of the following was not a strategy Partridge Tippett used to eliminate restraints a Finding meaningful activities for residents to engage in b Educating family members about the benefits of eliminating restraints c Removing restraints without following up with appropriate interventions d Tracking residents toileting patterns and toileting residents at appropriate times Evaluation 1 Did this CE activity relate to its stated learning objectives 2 Was the format of this CE activity easy to use 3 Did we avoid commercial bias in the presentation of our content 4 Will this activity enhance your professional development 5 How long did it take you to complete this activity include reading exam and evaluation HC
26. ndividual minutes divided by 0 75 333 allow able minutes 333 allowable minutes minus the 250 individual minutes maximum of 83 minutes per mitted for group treatments for this resident gt 300 individual minutes divided by 0 75 400 al lowable minutes 400 allowable minutes minus 300 gt continued on p 8 Correction A question in the January PPSA Q amp A incorrectly stated that a resident was admitted to the emergency room No vember 20 The question should have listed the date the resi dent was admitted to the emergency room as November 29 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 8 PPS Alert for Long Term Care March 2009 Q amp A lt continued from p 7 individual minutes maximum of 100 minutes per mitted for group treatments for this resident The RAI User s Manual states For groups of four or fewer residents per supervising thera pist or assistant each resident is coded as having received the full time in the therapy session For example if a thera pist worked with three residents for 45 minutes on training to return to the community each resident received 45 min utes of therapy so long as that does not exceed 25 of his her therapy time per therapy discipline during the 7 day obser vation period Remember code for the
27. o treat the residents medical symptoms b residents right to be safe from harm caused by falls c nursing homes right to use physical and chemical restraints at their discretion d the right for family members to decide whether their loved one should be restrained 24 According to a 2008 CMS report on restraint use in nursing facilities nursing facilities a use more daily physical restraints than they did 15 years ago b use more daily chemical restraints than they did 15 years ago c use fewer daily physical restraints than they did 15 years ago d have completely eliminated restraint use 25 According to CMS restraints have not been proven to lead to a strangulation asphyxiation b decreased muscle tone c loss of dignity d decreased risk for falls Nursing Continuing Education Exam January March 2009 Page 3 26 Staff members at the iar Tippett Nursing Facility in Pittston PA found that after eliminating restraints falls at the facility a increased in number b increased in severity c decreased in number d did not change in number or severity 27 According to staff members at Partridge Tippett families should a dictate whether nursing facilities should restrain residents b receive education from the nursing facility about the benefits of not restraining residents c not be involved in care planning decisions d immediately accept a facility s decision not to use restraints 28 Mary Lou Langdon RN a unit ma
28. om or 978 750 8400 March 2009 PPS Alert for Long Term Care Page 3 the system that were caught in this freeze Lambowitz said adding that the last payment regulation for SNFs was made in July 2008 We have been moving forward on competitive bid ding for durable medical equipment and there is a reg ulation that is on hold pending a reevaluation But other than that we re not aware of anything that affects you directly Lambowitz said Dispelling 3 0 rumors CMS is working with the intention of giving providers updates on the MDS 3 0 and disseminating information to all stakeholders Pratt said The updates will be deliv ered through the open door forum listserv or posted at www cms hhs gov If you hear any other information please use those sites to verify any other announcements because those will be the official vehicles by which we send out the word on any updates on implementation Pratt said E Still waiting for pain tag Long term care providers are still waiting for revised guidance on F309 Quality of Care pain management A caller to the January 29 CMS SNF Long Term Care Open Door Forum asked CMS officials when the revised guidance on F309 the pain tag would be posted on the CMS Web site and whether the general investigative and pain management protocols would be effective March 31 CMS sent long term care surveyors a memo dated Jan uary 23 containing revised guidan
29. ork with CMS to improve the five star rating system see Five star update on p 6 Talking about satisfied customers One way to respond to questions about your facil ity s star rating especially if you didn t get five stars is with your customer satisfaction survey says Marshall gt continued on p 6 What CMS says about five star CMS gave long term care providers a preview of their rating under the five star quality rating system one week before the ratings were refreshed with the past two months of data on the Nursing Home Compare Web site in late Jan uary CMS officials said at the January SNF Long Term Care Open Door Forum Since the ratings have been refreshed with new data in February and March providers should have been able to preview their ratings before they were posted on Nursing Home Compare CMS also plans to open a Nursing Home Compare hotline the week before and after the ratings are updated so providers can ask questions about how their ratings were calculated officials said The hotline number is 800 839 9290 and providers can see their star ratings at www medicare gov nhcompare At the open door forum CMS officials said they expected to refresh the data February 26 Agency officials also confirmed that they have been speaking with stakeholder groups regarding the five star quality rating system For permission to reproduce part or all of this newsletter for externa
30. rm Care 5 How will assessors get the information they need to complete the CAM under the MDS 3 0 a By interviewing residents using clinical judgment and reviewing medical records b From the resident s doctor c From the resident s family members d From nursing facility staff members observations 6 How will assessors get the information they need to complete the CAM for residents who cannot be interviewed a By using old MDS 2 0 assessments staff interviews and chart review b From the resident s doctor c From the resident s family members d Nursing facilities do not have to complete the CAM for residents who cannot be interviewed 7 Negative pressure wound therapy is a a traditional wound care technique b wound care technique that uses a pump to apply a vacuum like pressure to heal wounds c wound care technique that requires frequent dressing changes d wound care technique that leaves wounds exposed to the open air 8 A nursing facility should use negative pressure wound therapy a after traditional wound care techniques have been unsuccessful b for any wound c for prolonged periods d on wounds with stable black eschar 9 Under the most recent drafts of the MDS 3 0 negative pressure wound therapy a is not considered a skilled service b cannot be reimbursed by any payer c can be recorded under skin treatments d is not included under skin treatments 10 Under Medicare negative pressure wound therapy a
31. rt A and was still in your facility on Part A a late assess ment could be completed with a current ARD and the default rate would be billed for all of the days out of compliance In this case the ARD would be set for today day 14 and the resource utilization group calculated by the as sessment would be effective today Thus the facility would bill the default rate for days one through 13 You can read about these regulations in the final rule at http edocket access gpo gov 2008 pdfle8 17948 pdf Editor s note Due to a production error in the February PPSA Q A4 part of Shephard s answer was omitted The question and complete answer are reprinted below e am trying to understand the projection in section T How can it be okay to bill for a category if the min utes haven t been provided Also if the projection shows that the resident will get enough minutes to reach the For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2009 PPS Alert for Long Term Care Page 9 Rehab Very High category why does the facility get paid at the Rehab High level A The projection which covers the first 15 days of the Part A stay allows the facility to be paid for the level of services the resident is expected to receive even though that level of rehab might not be delivered durin
32. rtment members evaluate the resident s movement and find chairs the resident can sit in with out being restrained The activities department finds appropriate activities for residents because when they are engaged in an activ ity they enjoy they aren t focusing on trying to get out of their chair which may result in a fall One benefit to Partridge Tippett s approach was that many of the steps were inexpensive Vitale says The facility had to evaluate staffing time and purchase some equipment but it was able to eliminate many restraints by thinking of creative interventions Evaluating residents as individuals A key to identifying restraints and reducing their use is recognizing that what may restrain one individual e g a half bedside rail may not restrict another This requires evaluating individual residents says Krechting The Long Term Care State Operations Manual defines physical restraints as any manual method or physical or mechanical device material or equipment attached or adjacent to the resident s body that the individual cannot remove easily which restricts freedom of movement or normal access to one s body The manual defines chemi cal restraints as drugs used for discipline or convenience and not required to treat medical symptoms Freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control a
33. tem because its QMs show a high incidence of pain However it may be expected for residents to experience pain after surgery and doesn t necessarily indicate wrong doing on the facility s part Bruce Yarwood president and CEO of AHCA wrote CMS two detailed letters during summer 2008 expressing con cerns about problems in the rating system The rating system is having a broad effect on the long term care community Bentley says Many providers are strug gling to explain their ratings to families and staff members feel demoralized by poor star ratings One administrator who called Bentley said she lost two admissions because of her star rating even though the administrator believed her facil ity was excellent AHCA is encouraging providers to monitor their star ratings and ensure that the information used to arrive at the rating is accurate Bentley says Providers should also ask CMS questions such as why a recent survey wasn t included 2009 HCPro Inc For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 March 2009 PPS Alert for Long Term Care Page 7 PPS Q amp A Editor s note PPS Q A is written by Rena R Shephard MHA RN RAC MT C NE founding chair and executive ed itor of the American Association of Nurse Assessment Coordina tors and president of
34. teps facilities should take to ensure that all beneficiary notices are issued properly a Determining which staff members are responsible for issuing specific beneficiary notifications b Assigning responsibility for the beneficiary notification process to one person c Training more than one staff member to issue notifications d Inviting the staff members responsible for beneficiary notifications to daily Medicare meetings March 2009 21 The Long Term Care State Operations Manual defines a physical restraint as a clothing or material that restricts freedom of movement or normal access to one s body b any manual method or physical or mechanical device material or equipment attached or adjacent to the resident s body that the individual cannot remove easily which restricts freedom of movement or normal access to one s body c bedside rails chairs or lap belts that restrict freedom of movement or normal access to one s body d any device restricting freedom of movement imposed for the nursing facility s convenience 22 The Long Term Care State Operations Manual defines a chemical restraint as a drugs used for discipline or convenience and not required to treat medical symptoms b any antipsychotic drug c any sedative drug d drugs used in excessive dosage 23 The 1987 Nursing Home Reform Act established a residents right to be free from chemical and physical restraints imposed for discipline or convenience and not required t
35. thcare Chief Clinical Officer PointRight Inc Lexington MA Bonnie G Foster RN BSN MEd Ronald A Orth RN NHA Long Term Care Consultant Columbia SC RAC CT CPC President Cindy Frakes Clinical Reimbursement Solutions LLC Owner Milwaukee WI Winter Meadow Homes Inc Rita Roedel MS RN Topeka KS National Director of Clinical Reimbursement Extendicare Health Services Inc Milwaukee WI Rena R Shephard MHA RN RAC MT C NE PPSA Senior Advisor Founding Chair and Executive Editor American Association of Nurse Assessment Coordinators Julia Hopp MS RN CNAA BC Vice President of Patient Accounting Paramount Health Care Company San Antonio TX Steven B Littlehale MS GCNS BC Executive Vice President Healthcare Chief Clinical Officer PointRight Inc Lexington MA Mary C Malone JD Healthcare Attorney Director Hancock Daniel Johnson amp Nagle PC Richmond VA President RRS Healthcare Consulting Services San Diego CA Holly F Sox RN RAC C MDS and Staff Development Coordinator NHC Lexington West Columbia SC PPS Alert for Long Term Care ISSN 1521 4990 print 1937 7428 online is published monthly by HCPro Inc 200 Hoods Lane Marblehead MA 01945 Subscription rate 239 year PPS Alert for Long Term Care P O Box 1168 Marblehead MA 01945 Copyright 2009 HCPro Inc All rights reserved Printed in the USA Except where specifically encouraged no part of this p
36. ts A Pennsylvania nursing facility that has been restraint free for seven years offers insight into how to reduce restraint use New 3 0 timeline in the works Although officials said CMS planned to stick to the October 1 deadline for the new assessment system it will change the original timeline which had a March release date of the final MDS 3 0 form and RAI Users Manual In January many long term care providers noticed that CMS had re moved its MDS 3 0 implementation One of the things we re doing is looking at all of aa the moving parts and I m timeline from its Web site CMS identified some inaccuracies making sure that our work plans and timeline take everything into account Sheila Lambowitz with the timeline and is planning to revise it agency officials said at the forum We re evaluating the whole process and we ll let you know as soon as we can Sheila Lambowitz director of the division of institutional postacute care at CMS said when asked whether the agency still planned to re lease the final MDS 3 0 form in March Right now we re still moving forward Lambowitz said We just want to make sure we cover all the bas es and we address all the issues before we put a revised timeline back up there CMS will also reschedule some of the MDS 3 0 train the trainer events originally planned for this spring she said MDS 3 0 and RUG IV Long term care pro
37. ty s message and responding to negative coverage 2009 HCPro Inc Building relationships with the media Establishing relationships with members of the media is important says Carol Marshall MA a long term care consultant in Fort Worth TX and author of an up coming HCPro book about customer satisfaction in long term care If you have a relationship with a reporter you ll have a friend when you want coverage of a special event or achievement and when you must respond to a bad sur vey an elopement or a lawsuit Marshall says You can establish a good relationship with the media by pitching feature stories sending quality news releas es and photos and responding to media inquiries in a timely way says Sarah Soden director of marketing communications and PR at United Methodist Homes a nonprofit organization that operates several nursing gt continued on p 4 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets contact the Copyright Clearance Center at www copyright com or 978 750 8400 Page 4 PPS Alert for Long Term Care March 2009 Five star lt continued from p 3 and long term care facilities in New York and Pennsyl vania Establishing your facility as a helpful resource will give members of the media confidence that you will pro vide them with honest information in a timely manner Soden says Marshall suggests keeping in
38. ublication may be reproduced in any form or by any means without prior written consent of HCPro Inc or the Copyright Clearance Center at 978 750 8400 Please notify us immediately if you have received an unauthorized copy For editorial comments or questions call 781 639 1872 or fax 781 639 2982 For renewal or subscription information call customer service at 800 650 6787 fax 800 639 8511 or e mail customerservice hcpro com Visit our Web site at www hepro com Occasionally we make our subscriber list available to selected companies vendors If you do not wish to be included on this mailing list please write to the marketing department at the address above Opinions expressed are not necessarily those of PPSA Mention of products and services does not constitute endorsement Advice given is general and readers should consult professional counsel for specific legal ethical or clinical questions current RUG system if it couldn t meet its date for the final rule CMS officials will evaluate that situation when they have a better idea of when the proposed rule will be re leased Lambowitz said Basically I can t tell you without my crystal ball exactly what date it will go out but we watch these things very carefully she said adding that she also couldn t answer questions about how interre lated the MDS 3 0 and RUG IV would be or how the 3 0 would affect state case mix payment systems One of the things
39. viders still don t have an answer as to when CMS will release the next iteration of the re source utilization group RUG system often referred to as RUG IV or how a new RUG system would interact with the MDS 3 0 gt continued on p 2 Page 2 PPS Alert for Long Term Care March 2009 MDS 3 0 lt continued from p 1 When asked by a caller whether CMS had an estimat ed time of arrival for RUG IV Lambowitz said changes to the RUG system will roll out in the SNF PPS regulation which would require proposed and final rules to be pub lished in the Federal Register Since the proposed rule requires a 60 day comment period before the final rule can be issued officials will aim to release the proposed rule in April in order to issue the final rule by July 31 she said But we do have to do significant work to do briefings through a whole series of internal and external stake holders including Office of Management and Budget so We can t you give you an exact date said Lambowitz Officials were also asked whether the MDS 3 0 would be moved or whether CMS would revert to using the Editorial Advisory Board PPS Alert for Long Term Care Group Publisher Emily Sheahan HCPro Associate Editor Emily Beaver ebeaver hcpro com Sandra Fitzler Senior Director of Clinical Services American Health Care Association Washington DC Steven B Littlehale MS GCNS BC Executive Vice President Heal
40. we re doing is looking at all of the moving parts and I m making sure that our work plans and timeline take everything into account Lambowitz said So we will be giving answers to those questions fairly soon but not today New administration new rules Providers may have heard that President Barack Obama s administration has established a moratorium on regulations put in place toward the end of former President George W Bush s administration and regula tions CMS put in place during the latter half of 2008 Lambowitz said The new administration will reevalu ate those regulations In terms of how they affect the nursing home indus try and your operations we really haven t had any SNF or long term care regulations that were moving through Online extra As the long term care industry awaits the MDS 3 0 we know you have plenty of questions about the new assess ment system We re tracking MDS 3 0 developments at www mdscentralonline com to keep you updated as soon as CMS releases news If you have a specific MDS 3 0 question visit www madscentralonline com and click on the Ask Diane icon to submit your question We ll notify you as soon as CMS releases the information you re looking for 2009 HCPro Inc For permission to reproduce part or all of this newsletter for external distribu ion or use in educational packets contact the Copyright Clearance Center at www copyright c
41. ww hcmarketplace com March 2009 resident prior to the usual time Janeski says This might help a resident avoid falling when traveling to the bath room and allow the facility not to restrain the resident Educating families and staff members Many nursing facilities are reluctant to eliminate re straints because they are afraid of lawsuits from residents family members Krechting says Educating residents families was one of the biggest challenges Partridge Tippett faced when implementing its restraint reduction program Janeski says Many families were concerned that their loved one wouldn t be safe Some residents had come to the nurs ing facility from a hospital where they were confined to a bed during treatment and families weren t aware their loved ones could be treated without restraints The facility met with family members and educated them about the benefits of removing restraints Eventu ally families began to like the idea that their loved ones could live free of restraints Janeski says Getting the entire staff to buy into the program is also important to the success of a restraint reduction program and buy in needs to start at the top Vitale says The commitment needs to begin at the admin istrative level where we re deciding this is the right thing do for our residents she says E Your source code N0001 Name Title Organization Address City State ZIP Phone Fax
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