Documenting the Picture for Skilled Need During a Health Care Emergency and Beyond

​During times of pandemic and national emergency, when flexibilities or waivers are allowed by CMS, supportive documentation is crucial to justify the need for our skilled care. Throughout the public health emergency, many providers have utilized the available waivers for SNFs, including “skilling in place.”  With use of these waivers the following should be considered:

  1. Physician involvement, skilled nursing notes, and therapy evaluations and treatments should demonstrate medical necessity and skilled interventions relative to specific patient care needs. ​
  2. A signed physician certification will not suffice; the documentation needs to clearly support the order. 
  3. ​The patient assessment, physician documentation,  justification for the reason why the patient should be skilled in place versus discharged to the hospital, and hospital notes that document rationale for not admitting a patient or discharging early should all be obtained and recorded.
  4. Consistent and thorough documentation related to the care being delivered and why the particular care being provided is appropriate to the patient’s diagnosis, illness, or condition should be included.
  5. Strong facility processes, ongoing communication, and frequent medical record spot checks are the most effective ways to ensure that your records can best support the patient-centered care that is provided through the health care emergency and beyond. ​

After the emergency declaration is rescinded, it is very likely that CMS, either through the Office of the Inspector General (OIG) or contractors, will look to ensure that Medicare dollars were spent appropriately without fraud, waste or abuse. ​ When evaluating the use of the waivers, it is important to focus on CMS’ goal to take “aggressive actions and exercise regulatory flexibilities to help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19).” ​ Documentation will be critical to explain the rationale for the use of the waivers as well as clinical decision making for application.

In conclusion, a thorough interdisciplinary treatment record is crucial to support the specialized services provided during this health care emergency. ​ As we continue to provide excellent resident-centered care, we should ensure that we demonstrate the complexity, sophistication, and medical necessity of the services that we provide in our documentation. ​Documentation is paramount to fortify defensibility following this pandemic and to ensure our residents continue to have access to quality care.

CMS Releases Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results

CMS released a memorandum addressing COVID-19 survey activities, enhanced enforcement, and engagement of Quality Improvement Organizations (QIOs).  CMS also released a state-by-state report on COVID-19 cases for residents and staff along with numbers of infection control focused surveys completed. The memorandum includes guidance related to

  • Focused Infection Control Nursing Home Surveys and CARES Act Supplemental Funding 
    • States that have not completed focused infection control surveys in 100% of their state’s nursing homes by July 31, 2020 will be required to submit a corrective action plan outlining the strategy for completion of these surveys within 30 days. 
    • Access to CARES Act allocations will be impacted by state performance on completing the nursing home infection control focused surveys. 
  • COVID-19 Survey Activities 
    • Requiring states to implement the following COVID-19 survey activities. States that fail to perform these survey activities timely and completely could forfeit up to 5% of their CARES Act allocation, annually. 
  • Expanded Survey Activities 
    • Emphasizes Nursing Homes Re-opening Recommendations, which indicates that once a state has entered Phase 3 of the reopening process, states may use their discretion as to whether and how they decide to expand survey activity beyond the current survey prioritization.
  • Enhanced Enforcement for Infection Control Deficiencies 
    • For all infection control deficiencies at a scope and severity of D or above, CMS will impose a directed plan of correction that will include the use of root cause analysis. 
  • Support From Quality Improvement Organizations (QIOs) 
    • Nursing homes can take advantage of weekly National Nursing Home Training that focuses on infection control, prevention and management to help prevent the transmission of COVID-19.Nursing homes can locate the QIO responsible for their state here

Read the memo from CMS here.

COVID-19 Data and Inspection Results Available on Nursing Home Compare

The Centers for Medicare and Medicaid Services (CMS) initiated posts of COVID-19 nursing home data which will be updated weekly.

In addition, results of targeted inspection surveys and reports are available on Nursing Home Compare. CMS plans to post the results of the inspections monthly as they are completed.

Available Links

Medicare COVID-19 Testing for Nursing Home Residents and Patients

The Centers for Medicare & Medicaid Services (CMS) instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes that provides recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID-like symptoms in an outbreak.

Medicare Advantage plans must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.

For the full Medicare Learning Network article, CLICK HERE.

CMS Releases FAQs on Nursing Home Visitation

The Centers for Medicare and Medicaid Services (CMS) issued a Frequently Asked Questions document on visitation for nursing home residents that provides clarifications and considerations including:

Visitation for compassionate care situations

  • CMS clarifies compassionate care situations are not exclusive to end-of-life situations.   An example is provided explaining a resident who was living with their family prior to being admitted to the nursing home may experience trauma due to the change in their environment and sudden lack of family.  Therefore, this may qualify as a compassionate care situation.

Outside visits

  • CMS encourages creative means of connecting residents and families including visitation outside of the facility while ensuring all actions for preventing COVID-19 transmission are followed.

Communal activities

  • Residents (without COVID-19 symptoms) may eat in the same room with social distancing.
  • Group activities may be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask.

Steps for reopening to visitors

  • Nursing homes should continue to follow CMS and CDC guidance for preventing the transmission of COVID-19 and follow state and local direction.
  • CMS does not recommend reopening facilities to visitors (except for compassionate care situations) until phase three when the following criteria are met:
    • No new onset of COVID-19 in the nursing home for 38 days
    • No staff shortages
    • Adequate supplies of PPE and essential cleaning and disinfection supplies
    • Adequate access to testing for COVID-19
    • Referral hospitals have bed capacity on wards and ICUs

Factors to consider regarding visitation

  • CMS encourages that any decisions to relax requirements or conduct creative alternatives within nursing homes be made in coordination with state and local officials after a careful review of facility-level, community, and state factors/orders.

To access the complete FAQs document from CMS’ Current Emergencies webpage, CLICK HERE.

A Picture is Worth a Thousand Words: Photos, Videos, & HIPAA

It has been said “a picture is worth a thousand words.”  That quote is so true in this COVID-19 era where friends and family must keep their distance from loved ones in nursing homes. The compassion and care that nursing home staff provide includes, now more than ever, the social wellbeing of residents and patients.  Sharing photographs and videos is a wonderful way to keep connected.  However, don’t forget Health Insurance Portability and Accountability Act (HIPAA) compliance still is required.

Photos or videos containing any portion of a resident’s or patient’s face are considered Protected Health Information (PHI). That doesn’t mean you cannot take and share photos or videos.  HIPAA allows use and disclosure of photos or videos when proper authorization is provided by the resident, patient, or responsible party.

To be HIPAA compliant, authorization documentation must include the following:

  • The purpose for using and disclosing photos or videos; for example, “to share with her daughter/son” 
  • The timeframe the authorization applies; for example, “to send to daughter/son while the facility is on lockdown”
  • Explanation that the resident, patient, or responsible party have the right to revoke the authorization at any time
  • Explanation that the health care provider will not condition treatment, payment, or enrollment or eligibility for benefits on the resident, patient, or responsible party signing the authorization
  • Signature of the resident, patient or responsible party

Thanks to all for keeping residents and patients safe and connected while remaining HIPAA compliant.

When Will We Begin Seeing Medical Review Audits Following the COVID-19 PHE?

While it is still unclear at this time when we will begin to see normal audit activity resume from traditional Medicare entities, some Managed Care companies have lifted their suspensions and may have resumed normal auditing practices as early as May 15, 2020. Humana released a memo on May 14, 2020 stating the following

“Given that health system capacity is opening up and procedures are increasing steadily, we will begin to resume some of the regular processes that we suspended on April 1, 2020, to support providers with the strain on the healthcare system posed by COVID-19 at the heart of the crisis…The first of these is for medical record requests for claim reviews, which we will resume effective May 15, 2020.

  1. Resuming pre-payment medical record claims review. As of May 15, Humana may begin to request medical records from your organization prior to issuing payment, consistent with our policy in place prior to the April 1 suspension.
  2. Resuming post-payment medical record claims review. Since April 1, Humana has not requested medical records in connection with our post-payment review process. Our post­ payment claims review team will now resume making requests for medical records as required, consistent with our policy in place prior to April 1.

Humana leaders will continue to monitor service volumes as well as the progression of the COVID-19 curve and recovery and will review our policies and procedures as necessary as this crisis evolves.”

Please be prepared to start seeing these requests again in the coming days and weeks and notify your Medical Review/Appeals department as soon as possible. It is highly possible that there will still be barriers to obtaining medical records timely and extensions may need to be requested. We are all in this together and are happy to assist in any way possible.

Updated MDS 3.0 Item Sets v1.17.2 and Technical Data Specifications

In response to State Medicaid Agency and stakeholder requests, CMS has updated the MDS 3.0 item sets (version 1.17.2) and related technical data specifications.  These changes will support the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1.  This will allow State Medicaid Agencies to collect and compare RUG-III/IV payment codes to PDPM codes and thereby inform their future payment models.

For more information, visit MDS 3.0 Technical Information page. Supporting materials including the 1.17.2 Item Change History report and the revised 1.17.2 Item Sets can be accessed in the file:  MDS 3.0 Final Item Sets v1.17.2 for October 1 2020 zip, also posted in the Downloads section of the MDS 3.0 Technical Information page.

Delayed: Release of Updated Versions of SNF Assessment Instrument

CMS has delayed the release of the updated versions of the Minimum Data Set (MDS) needed to support the Transfer of Health (TOH) Information Quality Measures and new or revised Standardized Patient Assessment Data Elements (SPADEs) in order to provide maximum flexibilities for providers of Skilled Nursing Facilities (SNFs) to respond to the COVID-19 Pubic Health Emergency (PHE).

The release of updated versions of the MDS will be delayed until October 1st of the year that is at least 2 full fiscal years after the end of the COVID-19 PHE. For example, if the COVID-19 PHE ends on September 20, 2020, SNFs will be required to begin collecting data using the updated versions of the item sets beginning with patients discharged on October 1, 2022.

For more information, visit CMS’ SNF Quality Reporting Program Training page.

CMS Releases Toolkit for Nursing Homes

CMS has released a toolkit to aid nursing homes, governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. Access the toolkit here.

The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency.

The toolkit is comprised of best practices from a variety of front line health care providers, governors COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalog of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

View the full press release from CMS here. The toolkit can be accessed here.

CMS Issues Guidance to Ensure the Safe Reopening of Nursing Homes

After President Trump revealed Guidelines for Opening Up America Again on May 18, the Centers for Medicare and Medicaid Services (CMS) announced new guidance for state and local officials to ensure the safe reopening of nursing homes across the country.  State leaders are encouraged to collaborate with the state survey agency and local health departments to develop a plan on how these criteria should be implemented.

CMS recommends that decisions on relaxing restrictions in nursing homes be made with careful review of the following facility-level, community, and state factors:

  • Case status in community
  • Case status in the nursing home(s)
  • Adequate staffing
  • Access to adequate testing
  • Universal source control
  • Access to adequate personal protective equipment (PPE) for staff
  • Local hospital capacity

Reliant’s Real Time Memo on this topic can be accessed here.

CMS’ guidance can be accessed here.

The Frequently Asked Questions (FAQ) document can be accessed here.

or questions or concerns related to this memo, please email the DNH Triage Team.

Connection Through Video Chat

As the country continues to take a proactive, preventative approach to reduce the spread of COVID-19, social distancing and visitor restrictions in long-term care challenge us to use alternative means for connecting patients, family members/responsible parties, and long-term care staff.  On March 13, 2020, the Centers for Medicare & Medicaid Services (CMS) issued Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised) stating:

“In lieu of visits, facilities should consider offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.)”1

When choosing to use video communication, the US Department of Health and Human Services provides guidance regarding which video communication platforms are safe to use and which are not. For example, FaceTime and Skype* are classified as non-public facing remote communication products while TikTok, Facebook Live, and Twitch are public-facing products.  Public-facing products are not acceptable to use. 

When video chatting, be mindful of the following:

  • Obtain proper authorization for use or disclosure from the resident/patient/responsible party.
  • Make reasonable efforts to ensure others, not authorized to participate in the video chat, cannot hear the discussions.
  • Ensure other patients are not in the background of the video chat to prevent unauthorized use or disclosure of that individual.
  • Confirm the party answering the video chat is the appropriate party before proceeding with discussions.
  • Be sure when ending video chat that it successfully ends so that other conversations or videos are not accidentally seen or overheard.

*FaceTime and Skype means of communication are not supported by HIPAA regulations outside of the current healthcare emergency. The Office of Civil Rights states:

“Health care providers may use popular applications that allow for video chats, such as FaceTime and Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.” 



CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program

On April 26, the Centers for Medicare & Medicaid Services (CMS) announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. The agency made this announcement following the successful payment of over $100 billion to health care providers and suppliers through these programs and in light of the $175 billion recently appropriated for health care provider relief payments.

CMS had expanded these temporary loan programs to ensure providers and suppliers had the resources needed to combat the beginning stages of the 2019 Novel Coronavirus (COVID-19). Funding will continue to be available to hospitals and other health care providers on the front lines of the coronavirus response primarily from the Provider Relief Fund.

Read press release here.

Access updated fact sheet here.

Will Your Documentation Stand Up in a Post-Pay Review Following the COVID-19 Pandemic?

The current SNF coverage decisions, under the COVID-19 Section 1135 Waivers, allow providers to render skilled services to LTC residents, considered “skilling in place.” It is important to note that the previous requirements for skilled care need as defined in Chapter 8, Section 30 of the Medicare Benefit Policy Manual remain unchanged.

The quality of our documentation should not change regardless of payer; however, when an 1135 waiver is evoked, extensive care should be taken to document the reasoning for the initiation of the Part A benefit (e.g., change in condition) and why the qualifying event (e.g., 3 day hospital stay or wellness period) was waived. According to CMS FAQs regarding the waivers, if “continued skilled care need…is unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her SNF benefits.”

Relation to the emergency may include:

  • early hospital discharge due to resource need or
  • avoiding hospital transfer due to exposure risk.

Documentation is our defense when under review—as we continue to provide care to our residents, educate nursing and therapy to demonstrate the complexity, sophistication, and medical necessity of the services provided throughout the episode of care. Our services have a positive impact on many areas of the patient’s life. It’s important that the work we do with each of them carries over onto paper to fortify defensibility following this pandemic and to ensure our patients continue to have access to quality care. 

Review the Medicare Part A waive memo here.

Review CMS FAQs for 1135 waivers here. (SNF Services may be found on pages 34-35)

AHCA Waiver Application Decision Making Flowcharts:

Medicare Beneficiary Chapter 8 Qualifications

As defined in Chapter 8, Section 30 of the Medicare Benefit Policy Manual, the following are required and should be considered when determining a patient’s qualifications for Medicare Part A coverage in the SNF setting:

  • The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 – 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;
  • The patient requires these skilled services on a daily basis (see §30.6); and 
  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

COVID-19 LTC Transfer Scenarios

CMS has provided supplemental information for transferring or discharging residents between skilled nursing facilities (SNFs) and/or nursing facilities based on COVID-19 status (i.e., positive, negative, unknown/under observation). In general, if two or more certified LTC facilities want to transfer or discharge residents between themselves for the purposes of cohorting, they do not need any additional approval to do so. However, if a certified LTC facility would like to transfer or discharge residents to a non-certified location for the purposes of cohorting, they need approval from the State Survey Agency.

A copy of the guidance can be found here

New Regulatory Reporting Requirements for COVID-19 Cases in SNFs

The Centers for Medicare & Medicaid Services (CMS) announced new regulatory requirements that will require nursing homes to inform residents and resident representatives of COVID-19 cases in their facilities.

In addition, CMS will now require nursing homes to report cases of COVID-19 directly to the Centers for Disease Control and Prevention (CDC).

The CDC will be providing a reporting tool to nursing homes that will support Federal efforts to collect nationwide data to assist in COVID-19 surveillance and response.

For more information on the upcoming requirements for reporting, click here.

CMS Issues FY 2021 SNF Proposed Payment Rule

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for fiscal year 2021 that updates Medicare payment rates and the quality programs for skilled nursing facilities. If finalized, updates would take effect October 1, 2020.

For more information on proposals including a market basket increase, monitoring of the PDPM clinical diagnosis mapping, changes in SNF PPS wage index, and SNF VBP updates, review Reliant’s Real Time Memo.

Click for the SNF PPS CMS Fact Sheet and for the Proposed Rule.

Comments are being accepted until June 9, 2020.

Coronavirus Scams

There are increasing reports of scams and phishing attempts referencing COVID-19. These attacks many times appear as innocent emails looking for assistance or providing information regarding the COVID-19 crisis. Bad Actors are taking advantage of this crisis to prosper or do damage.  Their criminal actions are becoming more and more sophisticated and look very official as though coming from government agencies and health organizations.

It is critical to remain vigilant with all email correspondence and websites, but particularly those referencing COVID-19 updates, maps, donations, notifications etc.

To avoid becoming a victim, follow the guidelines below:

  • Never click on links or open attachments within unexpected emails.
  • If you receive a suspicious email appearing to come from a legitimate organization such as CDC, WHO, FEMA etc., confirm its legitimacy.  Make sure links direct you to the official site by hovering over the link.  Report suspicious email to your company’s Information Security Department.
  • If you visit a website or receive a pop-up window directing you to a phone number for support desk assistance, DO NOT call the number, instead contact your company’s Information Security Department.
  • Never share your password with anyone.

Trends noted to date include:

  • Malicious Websites – sites referencing coronavirus or COVID-19 in the URL. Thousands of new websites have recently been registered to distribute malware when the user accesses the site.
  • Spam – emails trying to grab your attention to sell information or goods now in high demand such as masks, hand sanitizers, COVID-19 drugs, etc.
  • Phishing – emails posing to be from legitimate organizations such as Center for Disease Control (CDC), the World Health Organization (WHO), Federal Emergency Management Agency (FEMA), etc. These emails contain malicious links, and some are collecting personal information.
  • Fake Charities – emails and websites asking for donations for studies, healthcare professionals, victims, or other activities related to COVID-19
  • Fake internal HR or IT communications such as coronavirus surveys pretending to be from your company’s HR or IT department – these sites are attempting to obtain your User ID and password or other personal information.
  • Fake notification of infection – beware of emails reporting you have been exposed to an infected individual, particularly ones asking for personal information to proceed.

 Always Think Before You Click.

Medical Review Audits Suspended

Reliant has worked closely with the National Association for the Support of Long Term Care (NASL) to raise awareness of the activity associated with Medicare’s medical review process during this pandemic, including pre-pay targeted probe and educate (TPE) activity and post-pay recovery audit contractor (RAC) reviews. At this time, Novitas, First Coast and CGS have suspended TPE activity until further notice. Our contacts indicate current pre-pay TPEs will be released and paid in the coming weeks.

According to an FAQ released on 3/30/2020, CMS indicates suspension of most Medicare Fee-For-Service (FFS) medical reviews during the emergency period due to the COVID-19 pandemic. The FAQ states that both pre-payment medical reviews such as the reviews for TPE and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractors (SMRCs) and Recovery Audit Contractors (RACs) are suspended for the duration of the Public Health Emergency (PHE).

The FAQ also notes that “no additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic.” Current post-payment review by the MACs, SMRCs, and RACs will be suspended and released from review as well. CMS is suspending these medical review activities for the duration of the PHE, but could conduct medical reviews “during or after the PHE if there is an indication of potential fraud.”