Honking for Hugs #CareNotCOVID

With the restrictions on visitors, several communities across the country have gotten creative showing appreciation for patients and residents by coordinating “Honk for Hugs” events in a reverse parade fashion.

Forest Hills Care and Rehabilitation, Broken Arrow, OK

The Forest Hills Care and Rehabilitation team in Broken Arrow, OK participated in two community parades, which allowed the patients and residents to see friends and family from a safe distance.

Let’s recognize the team:

Rachel Blanchard DOR
Dianna Sunday PT
Rebecca DeVilliers OTR
Chelsea Holmes OTR
Shannon Pinson SLP
Kelsey Farragher SLP
Saundra Fite PTA
Tara Stephenson PTA
Katie Forler PTA
Candice Ertman PTA
Michelle Kellam COTA
Kimberly Luu COTA

Cottonwood Creek Healthcare Center, Richardson, TX

Cottonwood Creek Healthcare Center in Richardson, TX held a Honk for Hugs event with patients and residents. The patients and residents had so much fun!

CareCore at Westmoreland, Chillicothe, OH

CareCore at Westmoreland’s therapy team in Chillicothe, OH decorated and had patients participate in a “Honk for Hugs” event where the community showed how much they cared for the facility patients and residents.

Let’s recognize the team:

Angie Nartker PT
Kelly Davidson SLP
Crystal Steele PTA
Amanda Karr PTA
Jill Burton COTA
Penelope George PTA/DOR

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.” 

1 https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf


Implementation Strategies: Trauma-Informed Care During the COVID-19 Pandemic

The COVID-19 pandemic introduces unique considerations related to patient-specific care plans, the execution of trauma-informed care (TIC) and the implementation of protocols to prevent disease transmission allowing for the continued provision of quality care.  In order to incorporate TIC, each patient’s unique history, specifically those relevant to the current environmental demands, should be addressed with strategic care planning. 

Interdisciplinary teams must help alleviate the unintended consequences of social isolation and source control strategies (i.e. face mask use) while in pursuit of infection control.  Now, more than ever, we must be familiar with our residents and newly admitted patients, their histories, potential triggers and preferences in order to develop and employ patient-specific TIC successfully. 

Consider the following strategies:

  1. Determine the health literacy of each resident/patient and provide education concerning infection control and prevention at their level of understanding to the diminish potential for new trauma
  2. Adapt protocols as necessary and modify care plans accordingly to prevent re-traumatization.
  3. Provide patients reassurance as often as necessary that protocols in place are in their best interest.
  4. Address needs for a sense of normalcy by developing new routines, roles, and habits. 
  5. Mitigate the psychosocial effects of isolation through creative implementation of activities to promote socialization and engagement.
  6. Utilize technology to facilitate connections with family and friends, when possible.

There are no shortages of avenues for success with TIC, but communication is critical for them all.  At its core, TIC requires communication with the patient and their designated representative for historical knowledge and care plan updates. It takes each member of the interdisciplinary team offering specific insight resulting from their familiarity with the patient, to develop a thorough and comprehensive care plan for the individual that accomplishes preventing traumatization or re-traumatization.  Do not diminish the explicit value each member brings as their contribution may very well be the one to enable positive patient outcomes. 

Strike Out Against Potentially Devastating Brain Attacks

Learn the three types of risk factors for stroke. While you may not be able to change them all, there are still ways to stack the odds in your favor.

Non-modifiable risk factors

• Age    

• Gender    

• Race/ethnicity

Modifiable risk factors

• High blood pressure                                   

• Lack of exercise

• Smoking                                                                  

• Diabetes

• High cholesterol                                                     

• Atrial fibrillation

• Sickle cell disease                                                   

• Obesity

• Alcohol abuse                                                         

• Drug abuse

• Presence of other cardiovascular disease

Harder to change or possible indicators

• Obstructive sleep apnea                                        

• Migraine

• Certain infections                                                   

• Gum disease

• Blood markers like factor V Leiden, lipoprotein(a) or others

Stroke Awareness and Prevention

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.

Care Matters Spotlight: Leisure Village Achieves 100% Clinical Ladder Champion Level I Facility

Reliant’s Clinical Advancement Ladder was created to recognize therapists who have a high level of expertise in an area of clinical practice. Therapists may specialize in one of many tracks including cardiopulmonary, dementia, dysphagia, geriatrics, neurology, orthopedics, or wound care. Therapists emulate Reliant Rehabilitation’s core principles while providing mentorship and education to fellow therapists, as well as exemplary patient care that leads to successful outcomes. Since its launch one year ago, we have over 120 therapists across the country who have earned the status of Champion Level I.

This month, we would like to give a “shout out” to our therapy staff at Leisure Village Health Care Community in Tulsa, OK.  All the therapists at this facility have achieved Champion Level I on Reliant’s Clinical Advancement Ladder.  Congratulations team and “Way to Go!”

A group of people posing for a photo

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Pictured: (starting at the top then clockwise) Donna Miller, Colleen Weber, Jennifer Smith, Brittain Keifer, Christina Casey, Mike Larkins and (in the center) Director of Rehabilitation Ashley Howard

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.

COVID-19: Answering the Call

Because our patients and residents typically are older, often have underlying chronic medical conditions and live in a community together, they are at the highest risk of being affected by COVID-19. During this unprecedented time, our residents rely on the members of their interdisciplinary team to ensure that their health and safety needs are met.

With a team approach of collaboration, communication and demonstration of the value and essence of our skilled professions, we will answer the call to protect this vulnerable population in the pursuit of No Patient Left Behind. Whether it’s clinical considerations in the recovery wake of a COVID-19 diagnosis or ensuring they are supported to continue to attain and maintain the highest level of practicable function within this modified environment, nursing facilities are equipped to meet the needs of the residents who call our facilities home.

Each member of the interdisciplinary team – including therapy, nursing and administrative team members – has specific skills that can help meet the residents’ needs. Collaborative efforts to integrate each team member’s contributions allow for greater positive impact on the care provided.  Timely and effective communication of changes in function should be ongoing between nursing and therapy to identify emerging conditions and potential symptoms of COVID-19.  Each patient is unique and requires screenings relative to their specific diagnoses, history and risks. It is our imperative to ensure dignity, quality of life and the highest level of independence possible. Members of the care team have been empowered to own their distinct role in resident-centered advocacy, which ultimately leads to successful outcomes.

Any member of the interdisciplinary team can lead the advocacy efforts for each resident by observing changes in the resident’s ability, ensuring timely notification, developing a resident-specific plan of care and thoroughly planning for the next level of care. Care delivery must be adapted by team members to occur in bundled sessions with enhanced in-room treatment techniques. By working together, we can help curb the potential anxiety and psychosocial effects perpetuated by a world in pandemic and affirm that no patient is left behind.

Understanding How Stress Effects the Body

Learn more about how stress wreaks havoc with your body during Stress Awareness Month. Never underestimate the damage stress can cause. Check out our fun infographic for some great tips for reducing stress.

Notice these signs of stress:

  • Headaches
  • Heartburn
  • Muscle tension
  • Rapid breathing
  • Pounding heart
  • High blood sugar
  • Depression
  • Insomnia
  • Stomach ache
  • High blood pressure
  • Weakened immune system                           

Here’s how key body systems react:

Nervous System. When stressed, the body shifts its energy resources to fighting off the perceived threat. In what is known as the “fight or flight” response, the sympathetic nervous system signals the adrenal glands to release adrenaline and cortisol. These hormones make the heart beat faster, raise blood pressure, change the digestive process and boost glucose levels in the bloodstream.

Musculoskelatal System. Under stress, muscles tense up. Over time this can trigger headaches, including migraines and severe cramps.

Respiratory System. Stress can cause rapid and more labored breathing—or hyperventilation—which can bring on panic attacks.

Cardiovascular System. Acute stress causes an increase in heart rate and stronger contractions of the heart muscle. Blood vessels that direct the blood to the large muscles (including the heart) dilate, increasing the amount of blood pumped to these parts of the body. Over time, this can cause inflammation of the coronary arteries thought to lead to heart attack.

Endocrine System. With stress, the brain sends signals to produce “stress hormones.” When this happens, the liver produces more glucose, a blood sugar that would be available to give you more energy for “fight or flight,” but that otherwise can cause a diabetic reaction.

Gastrointestinal System. Stress may prompt you to eat more (or less) than normal. If you eat more or different foods you may experience heartburn or acid reflux. In addition, your stomach may have “butterflies” which can turn into nausea or pain, and your bowels might not absorb food properly resulting in constipation or diarrhea.

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.”