Care Matters Spotlight: The Power of Therapy by Kerry Frazier, Director of Rehab, Mineola, TX

Morgan Woods

Morgan Woods was a high spirited life-of-the-party kind of guy. He was always smiling, loved to dance and was an avid wood worker. Prior to his admit he lived in another SNF and was sent out to the hospital with symptoms of Altered Mental Status. He was treated for bacteremia and toxic metabolic encephalopathy and admitted to our facility to be evaluated by Hospice.

I know all of this because at admit, I spoke at length with his daughter, Temika, as she was really on the fence about either trying therapy or admitting to hospice. I explained the process therapy would follow and she decided to give us a chance, and let us see what we could do to help. 

At evaluation, he was bedridden with numerous bed sores, received nutrition via a PEG tube, and was unable to sit up or make purposeful movements. Over the past few weeks, nursing has worked hard to treat his ulcers and they have completely healed. Therapy began with small goals, such as sitting on the side of the bed, reaching out for objects, etc. As therapy progressed this is what we are able to share:

September 6, 2018

He stood in the standing frame for the first time. He fatigued very quickly and would not reach out to engage in any tabletop activity.
September 18, 2018

He took his first steps using a rolling walker and the assistance of two therapists. The week prior he took his first steps in the therapy gym with the assistance of three therapists.

October 17, 2018

He is now walking down the hallway with no assistive device and hand held assistance of two therapists.

Morgan has started tapping his feet and dancing in his wheelchair when we play his favorite music like Michael Jackson or Motown. He will reach out to play balloon toss and will flash you the best smile!
During all of this, he took his first bites of food and is now feeding himself and enjoying food daily. Morgan has worked hard and is making wonderful progress. His family is thrilled and so are we!We look forward to seeing him progress even further and one day be able to dance again!

No Patient Left Behind

No Patient Left Behind (NPLB) trains our therapists in interpretation of quality indicator reports and the impact of quality measure reporting to aid in the care of facility residents. This month we’ll look a little closer at the final element: Being an Advocate.

Reliant believes it is our moral imperative to do right by our patients and ensure dignity, quality, and the highest level of independence possible. Each care partner plays a role in the resident’s success and it’s important to remember, you don’t have to go to Washington to be an effective advocate for your patients. Advocacy starts at the facility level and means you’ll be the voice for the resident who can’t speak, the movement for the resident who isn’t independently mobile, or the reliable provider for the resident who needs reassurance.

From admission to discharge, your actions are contagious and by advocating for your patients through simple acts, others will want to be a part of that passion. There is purpose in what you do, never forget that!

Reminder Regarding Phase 2 and 3 Requirements For Participation

Last November, CMS issued a Temporary moratorium on imposing certain enforcement remedies for specific Phase 2 requirements. It was advised that this 18 month moratorium on the imposition of certain enforcement remedies be used to educate facilities about specific new Phase 2 standards.

• The following F-Tags included in this moratorium are:

• F655 (Baseline Care Plan); §483.21(a)(1)-(a)(3)

• F740 (Behavioral Health Services); §483.40

• F741 (Sufficient/Competent Direct Care/Access Staff-Behavioral Health); §483.40(a)(1)- (a)(2)

• F758 (Psychotropic Medications) related to PRN Limitations §483.45(e)(3)-(e)(5)

• F838 (Facility Assessment); §483.70(e)

• F881 (Antibiotic Stewardship Program); §483.80(a)(3)

• F865 (QAPI Program and Plan) related to the development of the QAPI Plan; §483.75(a)(2) and,

• F926 (Smoking Policies). §483.90(i)(5) While this moratorium is still active, providers should have these requirements in place now. In the same memorandum, CMS revealed changes to Nursing Home Compare (NHC) relative to survey and health inspection.

• Freeze on Health Inspection Star Ratings: Following implementation of the new LTC survey process on November 28, 2017, CMS held constant the current health inspection star ratings on NHC for any surveys occurring between November 28, 2017 and November 27, 2018.

• Availability of Survey Findings: The Survey findings of facilities surveyed under the new LTC survey process would be published on NHC, but not incorporated into calculations for the Five-Star Quality Rating System for 12 months. Link to full memorandum.

Chart review of the 3 phases of implementation:

Phase 1: Implemented November 28, 2016 *indicates this section is partially implemented in Phase 2 and/or 3

• Resident Rights and Facility Responsibilities*

• Freedom from Abuse Neglect and Exploitation*

• Admission, Transfer and Discharge*

• Resident Assessment

• Comprehensive, Person-Centered Care Planning*

• Quality of Life • Quality of Care*

• Physician Services • Nursing Services*

• Pharmacy Services*

• Laboratory, radiology and other diagnostic services

• Dental Services*

• Food and Nutrition*

• Specialized Rehabilitation

• Administration (Facility Assessment- Phase 2)*

• Quality Assurance and Performance Improvement* – QAPI Plan

• Infection Control- Program*

• Physical Environment*

Phase 2: Implemented November 28, 2017

• Behavioral Health Services*

• Quality Assurance and Performance Improvement*- QAPI Plan

• Infection Control- Facility Assessment and Antibiotic Stewardship**

• Physical Environment- smoking policies*

Phase 3: Implementation November 28, 2019

• Quality Assurance and Performance Improvement*- Implementation of QAPI

• Comprehensive Person-Centered Care Plan: Trauma informed care

• Infection Control- Infection Control Preventionist*

• Compliance and Ethics Program*

• Physical Environment- Call lights at resident bedside*

• Training Requirements*

ICD-10 Updates!

Last month we proceeded with our series which dives into critical elements of PDPM by looking at ICD-10 coding. Due to updates provided by CMS we will take one more look at ICD-10 processes for PDPM.

During the open door forum on 11/29/2018, CMS validated information on the PDPM webpage indicating a new MDS item set will be active on October 1, 2019 which will guide the clinical category mapping for the resident. According to CMS’ training materials, new item set I0020B “What is the main reason this person is being admitted to the SNF?” allows for the primary SNF diagnosis to be entered when the response to I0020 “Indicate the resident’s primary medical condition category” is identified as 01-13. The training also provides detailed information about the new items for recording the patient’s surgical history using J2100-J5000. (As of 11/29/2018 CMS notes an error on the PDPM webpage resource New MDS Items which records I0020 as I0200).

It’s important to recognize that although this new item set replaces 18000A as the primary diagnosis mapping line, the codes entered in I8000 and identified throughout section I still require critical thinking and accuracy to ensure accurate reimbursement as these areas contribute directly to SLP comorbidities and conditions, nursing conditions and the non-therapy ancillary comorbidity score.

PDPM Patient Classification Fact Sheet

MDS Changes Fact Sheet

SNF Open Door Forum: 11/29/2018

In the last open door forum of the year, CMS provided the following information:

PDPM Webpage is now active. The site provides CMS created fact sheets, FAQ’s, training presentation, and resources specific to PDPM preparation CMS has created as PDPM specific email for questions or clarification needs.

• SNF VBP updates included clarification that providers incentive multipliers are available via CASPER reports. Phase I correction request review is currently in progress. Reconciled corrections will be updated via reports in the CASPER system. The Medicare Administrative Contractor (MAC) will directly apply the incentive percentage when making payment. More information is available on the SNF VBP webpage.

• SNF QRP data now posted on Nursing Home Compare. The next refresh will be in late January. Providers will receive preview reports 30 days prior. CMS directs any questions to the SNF QRP help desk.

• CMS indicated SNF QRP edit 3907 for discharge goal coding will be retired due to stakeholder feedback regarding its relevance; however, edit 3891, warning for discharge coding, will continue.

• CMS reiterated the resources available through the Civil Money Penalty Reinvestment Program (CMPRP). CMPRP is a three-year effort to reduce adverse events, improve staffing quality and improve dementia care in nursing homes.

PDPM Part 3: Function Scores Here, Function Scores There, PT, OT and Nursing Everywhere!

Unless you’ve slept through the second half of 2018, you’re aware this year introduced updates to Section GG (Functional Abilities and Goals) and are at least familiar with the concept that Section GG plays a role in the Patient Driven Payment Model (PDPM). Today, let’s break down exactly how important of a role Section GG it plays in PDPM and the importance of accurate data collection.

Physical Therapy, Occupational Therapy and Nursing case mix groupers will be directly impacted by Section GG scoring and the PDPM Function Score. Read the full article here so when PDPM officially launches, communication is streamlined and your assessment team is confident in their data.

Reliant’s Section GG Flow Chart

Reliant’s Section GG Reference

CMS PDPM Functional Scoring Fact Sheet