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By Cathy Fratello

PointRight began assisting customers in California with QASP in 2017 but the QASP program has been around for over 5 years. The impetus came from our relationship with California Association of Health Facilities (CAHF) and an effort to help both their members and our customers manage their performance in this state-based quality program.

QASP Best Practices

Get Educated about QASP

Succeeding in QASP requires a true understanding of what drives the program and how these elements effect your daily, weekly and monthly activities. The QASP program is updated regularly and it is critical to know how these changes impact quality outcomes.

Learn from MDS Coding Errors

Coding the MDS accurately and appropriately is the foundation to successful QASP performance. Exploring the learnings behind coding errors and drilling down to root causes can help avoid these errors in future and identify opportunities for improvement.

Create a QASP Routine

Create a cadence for the team that impacts QASP to check in on performance, coding errors, learnings, etc. Ask these questions: Is the MDS accurate? Why is a resident triggering? How can your team be proactive? How can I drill down to the root cause?

What is QASP?

Let’s take a moment to define the program. The State of California’s Quality and Accountability Supplemental Payment (QASP) Program encourages and incentivizes Skilled Nursing Facilities (SNFs) to implement quality improvement programs focused on a core set of performance metrics. SNFs are motivated and financially rewarded based on set qualification criteria, including significant improvements in outcomes and high performance on QASP metrics.

Have the Right QASP Tools

If managing MDS submissions is at the heart of QASP performance, having a reliable tool to verify coding accuracy is key. To ensure a proactive resident focused approach, PointRight offers a core set of Data Integrity Audit (DIA) tests that highlight QASP quality metrics. This allows for education on why a resident may have triggered an alert and an opportunity to catch coding errors.

Our QASP solution includes quality measure analysis with drilldowns to the resident level, as well as program and eligibility information. View real-time, simplified insights within a highly intuitive user experience and simplified workflow. Feedback from our customers indicates that this interface eliminates manual data aggregation and analysis. 

QASP Takeaways

What I’ve learned over the last few years from working with our QASP customers is that the more you truly understand the QASP program and engage with your program management tools, the better your outcomes. In fact, facilities using PointRight QASP analytics achieved an average total payment that was 21% higher than non-PointRight facilities. PointRight clients outperformed on all the individual elements that make up QASP payments.

Cathy Fratello
Cathy Fratello, National Business Development Executive

 

If you’d like to see for yourself, you can request a demo and see our QASP tools in action.

Filed Under: Blog

Cesar GoulartBy Cesar Goulart, CIO

For decades, companies behind large, integrated transactional systems such as Enterprise Resource Planning (ERPs), Electronic Health Records (EHRs) and Managed Care Applications have disseminated the notion that having all data in one database brings multiple benefits. At the transactional level, this argument is supported by benefits ranging from infrastructure cost avoidance to higher data integrity and fewer data governance issues. When it comes to analytics platforms, the “one database” model is extremely limiting for organizations and does not produce the benefits seen at the transactional data level.

As someone who has been managing health information technology for over 20 years, it’s important to me to explain why the “one database” argument loses its validity when applied to analytics platforms across multiple industries. What remains is an obstacle to adoption of advanced analytics (descriptive, predictive and prescriptive) resultant from the lack of data in sufficient volumes, with the necessary level of standardization, technology and focused research.

Infrastructure Costs

Transactional data is usually represented in highly normalized relational databases optimized to support online transaction processing. Very often “reporting” databases, Operational Data Stores and Data Warehouses are created to support data and analytics initiatives. PointRight’s analytic initiatives center around using multiple datasets and sources to research and create advanced analytics solutions that further clinical, financial and operational objectives in the post-acute space.

Technology has evolved to a point in which modern advanced analytics platforms can be cloud-hosted in highly cost-effective multi-tenant environments. This allows companies to build affordable, powerful and focused analytics services leveraging multi-tenancy to achieve results not possible in traditional transactional single tenant environments.

Data Governance

Many problems created by multiple “sources of truth” at the transactional level can be avoided by having ERPs, EHRs and other large transactional systems store the bulk of transactional data. Because, by design, analytics platforms ingest controlled copies of transactional data, they are never the “source of truth” for anything other than the derived data elements presented as valuable insights and not present in the source transactional systems.

Analytics vs. Reporting

While well integrated transactional systems are perfectly capable of meeting an organization’s basic operational reporting needs, the availability of standard data in large scale environments with focused research allows for a deeper understanding of underlying datasets. This makes it possible for the development of adjusted measures (risk, population geography, etc.), meaningful benchmarks and accurate prediction of important outcomes. In most cases, this is simply not possible with the “one database” approach.

More specifically, a transactional system gives you reporting, which is really like looking in the rearview mirror. To be able to look through the front windshield, to be able to compete in a value-based environment, this is simply not sufficient. Cloud-based, software as a service (SaaS) analytics platforms, leveraging machine learning and AI quickly and cost effectively add capabilities out of reach for most organizations, even large well funded companies. Issues including lack of data standardization, small data samples, insufficient funding and resources all impede the development of high-quality predictive and prescriptive analytics.

Integrated Transactional Databases and SaaS Analytics Platforms – The best of both worlds

 Organizations do benefit from keeping transactional level data in as few databases or repositories as possible. Increasing the level of integration and consistency of transactional data should always be part of the technology strategy. When it comes to analytics, especially advanced analytics, leveraging SaaS platforms in mission critical areas delivers unique value without the downsides associated with multiple transactional data sources. With the spread of AI, the ability to quickly deploy data-driven initiatives, products and services is becoming a condition to “play” in most industries. Having run large enterprise-wide analytics programs in healthcare, and now leading technology at PointRight, this CIO can emphatically say that the ‘One Database’ model has a role and combining SaaS analytics platforms creates unique capabilities that are better together.

 

About the Author:

Cesar Goulart, Chief Information Officer

Cesar Goulart is passionate about the potential of technology-enabled change in the healthcare industry. Cesar is a seasoned IT leader with over 20 years of experience in Health Information Technology.  More

Filed Under: Blog

Jennifer Gross
Jennifer Gross, Senior Healthcare Specialist

By Jennifer Gross, BSN, RAC-CT, CPHIMS

As with most things that happened before COVID-19, it seems like the MDS item set updates for October 1, 2020 (FY 2021) happened in the mists of the far-away past.  In fact, it was just December 20, 2019, and even in my webinar on upcoming MDS changes back in February, I warned that things could change. Little did I know how much! To briefly recap the original plan, it included the elimination of Section G and addition of Section GG to OBRA item sets, as well as additional items related to high risk medications, social determinants of health, and numerous updates to existing MDS sections.  These updates were all put on hold by the Centers for Medicare and Medicaid Services (CMS) on March 27, citing stakeholder concerns about the changes.

While this delay gave skilled nursing facilities (SNFs) one less thing to think about as the impact of the pandemic hit facilities hard, October 1 brings with it a new Fiscal Year – and with the Patient Driven Payment Model (PDPM) approaching its first birthday, at least some changes were to be expected.  CMS announced the revised update (v. 1.17.2) on May 15.  While not the major change originally planned, this update will potentially have a significant impact on how your SNF manages the MDS assessment process – depending on what state you’re in.

MDS Updates – Know Your State’s Plan

Here’s the gist: Effective October 1, states will have the option to collect PDPM data on OBRA Comprehensive and Quarterly item sets.  This data collection will enable the states to compare PDPM case mix classification with their current RUG-based case mix grouper, so that they can develop future PDPM-based Medicaid models.  What this means from a practical standpoint is that the MDS items that are used for PDPM calculation will be added to the OBRA item sets.  This includes Section GG, the primary diagnosis in Section I, and surgical procedures in Section J.

The tricky part: knowing whether or not your state will be requiring these additional items starting in October.  On the MDS Vendor Call on June 11, CMS discussed the planned changes and released a Q&A document.  From the Q&A:

“States are responsible for notifying and educating their providers if implementing these changes. In addition, states are responsible for notifying the vendor community so vendors may make the required changes to their software products for their state providers. CMS will provide vendors with updated technical data submission specifications to allow the calculation of PDPM along with updated and new edits. CMS will not be providing vendors with a list of states opting to calculate the PDPM.”

In other words, there will be no communication from CMS regarding which states have opted to collect PDPM data.  While the states are responsible for communicating their plans to providers and vendors, the method of notification may vary from state to state.  Our recommendation: be proactive; October 1 always seems to arrive more quickly than we think it will.

Here’s what providers should do sooner rather than later:

  • Go to the source. Find out your state’s plan for FY 2021. Contact your State RAI Coordinator;  they are the go-to person in your state for MDS related questions and should be able to direct you to the information you need.  Be sure to download the current list of state contact information in the MDS 3.0 RAI Manual (Appendix B, in the Downloads section of the CMS web page).  If you haven’t already, sign up for your state’s email list so you will be alerted when an update is released.
  • Contact your Electronic Health Record (EHR) vendor. The vendors are already planning just as they do every year so that they can have their system updates ready to go live on October 1.  Reach out to your EHR’s account representative to find out if they have received notice that your state will be opting to collect PDPM data.  Your vendor may also have information on their website customer support portal or in regular blog posts and e-newsletters (just like PointRight does!).
  • When in doubt, you could err on the side of caution and assume that your state will be opting for the new item set. Begin to educate your interdisciplinary team on the proper coding of these items anyway. This will also reinforce the accuracy of your PDPM assessments.

If your state uses the PDPM MDS items…

If your state opts to use the PDPM MDS items, remember that this doesn’t necessarily mean that your Medicaid case mix system will change starting in October.  The process to switch Medicaid systems is a long and complicated one, and rest assured that the state will provide communication of any changes in enough time to address stakeholder comments and allow for adequate training. States will begin to collect PDPM data on the same MDSs that are being used to set RUG-based case mix.  This will help them to analyze the effect of PDPM on the current nursing home Medicaid population, and plan their rate setting accordingly.

Submissions Today Affect Medicaid Rates Tomorrow

Since your MDS data submitted now will affect your Medicaid rates in the future, accuracy is especially important.  Make sure you develop processes to collect PDPM related documentation on your long-term residents, and practice ahead of time in the following areas:

Section GG

Your CNAs and other direct care staff over all shifts will need to get accustomed to capturing the resident’s usual performance for the 3 days ending with the Assessment Reference Date.

Sections I & J

Begin to discuss with your physicians, nurse practitioners, and physician’s assistants about each resident’s primary medical condition as well as any recent surgeries that continue to require care related to the procedure.

Restorative Nursing Programs

Remember that restorative nursing programs play a role in PDPM as they do in RUGs. If this area has gone by the wayside in your center (or has never gotten off the ground), this may be a great opportunity to take another look at restorative for your long-term residents and get a renewed program in place.

Get Ready for Oct. 1 Today

The key take-away: Don’t delay!  We said this last year with the Medicare transition to PDPM, and it’s just as true today.  Proactive planning (or at least knowing what to expect) will save time and stress come October.

P.S. If you are in a state that doesn’t currently use a RUG-based case mix system for Medicaid, don’t automatically assume you’re off the hook for these MDS additions.  Your state just might decide to begin collecting PDPM data for analysis anyway, if their plan is to eventually transition to an MDS-based case mix system.  Find out what your state’s plan is just in case!

Claims vs MDS-based insights

Understand your data sources!
Download your guide to understanding claims versus MDS-based insights.

Get Your Guide

Jennifer Gross
Jennifer Gross, Senior Healthcare Specialist

 

More Resources from Jennifer Gross for MDS Professionals:

Author:

Jennifer Gross, BSN, RAC-CT, CPHIMS
Senior Healthcare Specialist, PointRight

Jennifer Gross’s experience in the nursing field includes work in psychiatric rehab and in long term care as a staff nurse, MDS coordinator, and as a consultant. Her role at PointRight is to support our clients in understanding the intricacies of the MDS, enabling them to maximize quality of care, identify residents at risk, and prevent decline.

Filed Under: Blog

 

By
Theresa Edelstein, MPH, LNHA
New Jersey Hospital Association

Pam Kaiser

 

By 
Pam Kaiser, MSN, RN
PointRight

As states are moving through the different phases of reopening, hospital groups are looking to the future, and many believe in that future looms a resurgence of the new SARS-CoV-2 (COVID-19). Hospital strategists are planning their way forward by addressing needs for the short and the long-term. Reviewing their plans can help Skilled Nursing Facilities (SNFs) establish their own strategies. 

Hospitals: Short-Term Strategies

The short-term takes a “lessons learned” approach. In other words, knowing what the outcome has been, what can be done differently or better in the future to improve?

Supply Chain & Testing

Not surprisingly, teams will make supply chain improvements and increase their stockpile of personal protective equipment (PPE). Understanding that availability of testing kits is a wildcard, they will establish testing and retesting plans to assist with cohorting patients and staff assignments. Based on the physical plant, they’ll establish COVID-19 positive units, COVID-19 negative units and if possible, a transitional unit to hold new admissions or potentially positive patients.

Coordination of testing between providers will have a significant benefit to transitioning patients to SNFs and residents to the hospital in an efficient way.  Being able to place patients in alternative care settings to quickly open Intensive Care Units beds without a pre-established communication process was challenging.

Regional Work Plans

Another approach involves creating a regional work plan that identifies predetermined COVID and non-COVID locations. Cohorting in this manner potentially reduces the use of PPE and testing. Patients would be less isolated and able to move about as able. Creation of a centralized information hub for care providers to share admission status, bed availability, staffing needs, test and PPE availability saves valuable time and resources.

Using a local approach follows similar preparations with hospitals and post-acute care providers (PACs) establishing communication plans to share capacity and ability to accept admissions, to cohort, to staff and to equip with proper PPE.

Technology

Leveraging technology to provide care and demonstrating a culture of safety gives hospitals a way to provide confidence to healthcare consumers. Using parking lot registrations, mobile check ins, and telehealth software allows for access to care in a way that reduces exposure. Confidence in safety and infection control practices will attract those patients that do require care during a pandemic.

SNFs: Short-Term Strategies

For SNFs, several of the hospital short-term steps apply; specifically, in the areas of supply chain improvements and an increased on-hand supply of PPE. With that, staff should be educated, trained and retrained on the use of PPE.

Just like hospitals, testing residents and staff is the only way to cohort and treat effectively in a manner that reduces the virus’ opportunity to spread. Additionally, dedicating a specific area for COVID-19 residents and a COVID-19 free area contributes to containment.

Establish Communication with Hospital Partners

To assist with opening hospital ICU beds, establishing a communication system now will allow you to inform hospitals if you are open for admission of COVID-19 residents on a daily basis. Assess the skills of your current staff and close any gaps before any resurgence happens. Many hospitals developed strike teams to bring their knowledge to the SNFs; reach out to your local hospitals for their current protocols so your team is well prepared to take their overflow. Work with other PAC providers to triage COVID patients/residents in the care setting best equipped to deal with that individual’s needs.  Also, if you have included a neighboring hospital in your disaster plan, be sure the hospital administration is aware, but consider looking to other PAC providers as potential discharge locations under the blanket waivers available.

Homecare & Telehealth

Happening already, the use of outpatient and ambulatory services to meet patient care needs will expand. Smaller core hospitals will provide inpatient care for only those patients that need the highest level of acute care. The move to this model will accelerate as telehealth use grows.

The focus will be on convenience and access to care in order to attract patients. To that end, virtual care and telehealth will be front and center. Current patient portals in hospital systems allow patients to communicate with providers, but hospitals will need to continue to innovate to improve market share.

Value-based Contracting

Additionally, hospitals will get creative with contract renegotiations. As value based contracting gains wider acceptance, hospitals will look to partners that are prepared to go at risk. Whether with physician groups or other providers, hospitals are discussing how to weave quality outcome expectations and total cost of care goals into this new normal.

SNFs: Long-Term Strategies

For SNFs, the lingering negativity around care delivered and conditions in a SNF setting will be hard to overcome. Although progress has been made and stories of resilience and selflessness in the face of COVID are circulating, the pandemic and subsequent media coverage has cast a shadow over SNFs and the care delivered in those settings.

SNF Advocacy

Teams will need to continue to push for balanced reporting and legislation that address the needed changes to our healthcare delivery system. Activating residents and families to make the case for SNFs and the key role they play in the care of the frail and elderly can help raise public awareness. The gaps exposed during the pandemic point to the need to transform how we provide healthcare to our frail and elderly.

QAPI

SNFs should be ready to show how they drive quality through Quality Assurance Performance Improvement activities. Leveraging data can point towards areas of improvement and create opportunities to partner with other providers along the continuum in ways that reward quality outcomes. Collaboration on ways to be more efficient and to collectively drive down the cost of care is also essential. Successful collaborations are built on shared data, timely analysis and transparency.

The Bottom Line

SNFs who communicate strategically with their partners become providers that are ready to meet hospitals and health systems where they have the greatest need.

 

Authors:

Theresa Edelstein, MPH, LNHA
Senior Vice President, Partnerships Transforming Health
New Jersey Hospital Association

Pam Kaiser

Pam Kaiser, MSN, RN
Vice President, Clinical Resources Team
PointRight

Filed Under: Blog

Maria Arellano
Maria Arellano, RN, MS, Senior Healthcare Specialist

By Maria Arellano

Throughout history, world events have impacted society and significantly altered our daily life. World War II, for example, created an opportunity for women to work in factories and other traditionally male jobs and broke down long standing barriers out of dire need. When the war ended, it never really “went back to normal.” More recently, 9/11 significantly changed how the world travels and created new security protocols that have become second nature to us now. This too is not likely to ever return to “normal.”  

The global health emergency we all know as the COVID-19 pandemic certainly fits into this discussion and its impact on our society clearly was more of a smack in the face. Society implemented the necessary changes very quickly out of desperate need to prevent the spread of this mysterious virus, with the idea and hope that it would be short-lived and soon we’d get back to normal.

Getting back to “normal” is a common theme in the many video chats I’ve had with people over the last 4 months. But with the COVID cases falling and rising again, the anxiety and fear we all are experiencing are real and delays the return to “normal” anytime soon. I miss traveling, seeing my friends in person and hugging them when they’re down. I miss being able to get in the car and just go. Now it takes planning and careful evaluation whether it’s an essential trip or not.

This pandemic has also created some horrific experiences, including lost jobs or the loss of a loved one who died alone in the ICU or nursing facility. Both things that no one would ever want to go through.

Seeking Out Silver Linings

One approach to dealing with this situation has been to seek out all the silver linings and positive adaptations folks have made to address our current “normal.”  Personally, my backyard and garden have never looked so beautiful. It’s amazing what a little effort does to nurture my flowers and vegetables into magazine quality beauty and farmer’s market-like produce!  Women’s groups are sewing masks for those who might not be able to afford one and we’ve held parades and drive by parties to celebrate life changes and successes.

Professionally, I have been so impressed with innovations caregivers have made in the face of incredible shortages of PPE and staff, changing regulatory requirements and fierce media scrutiny. There are so many stories being told of the creative activities conducted in the hallways and in residents’ rooms, window visits to cheer up family members, and outdoor booths being built to allow for visits and hand holding, all while still maintaining precautions. Zoom care conferences and virtual visits with family keep the connections intact and allay the fears of many family members. We see signs of “Heroes Work Here,” and social media praises of the heroic and compassionate acts made by staff (#SNFStrong).

True Definition of “Essential” Emerging

The true definition of essential workers is emerging and sheds new light on what is important and what deserves our priority. One of those groups of essential workers is healthcare workers, all of them – all disciplines, all departments, all settings. But I want to single out those who keep our nation’s long-term care facilities operating daily, as they deserve our respect and praise and OUR priority. Finally, we’re seeing their worth and contributions recognized in the media.

Power of Collaboratives

We’ve also seen the value that provider collaboratives established prior to COVID afford communities. These collaborations had a leg up on fighting this pandemic because they had pre-established communication and practice systems that supported a much more effective community response.

So, while we’re dreaming about the day we all return to “normal,” I’d like to start a list of things I’d like to see as the “new and improved normal” in our industry. 

My SNF Wish List for the New Normal

Wild innovation

Let’s keep problem solving or brainstorming as if our lives depended on it. Some of the most creative ideas for care delivery and activities during this crisis have come out of new ways of thinking. Thinking that isn’t held back by norms and regulations. Stay wildly creative then worry about the details later.

Recognition of essential workers

Now that we can clearly see who truly provides those essential services to our communities, let’s treat them accordingly. Let’s evaluate how we can provide them with adequate equipment to do their job. Show them that we recognize their value by paying adequate salaries so they don’t have to work two jobs to cover basic needs. Anyone notice that professional athletes and Hollywood stars, while entertaining, haven’t surfaced as “essential” in any way?

Care delivery system changes

Although efforts were already in the works to ensure the right care at the right setting, further exploration of creative staffing approaches and deeper integration of telehealth services must continue. In addition to helping manage during the quarantine, telehealth offers greater access to specialty providers, reduces potentially traumatic office visits outside the facility for frail residents or those with dementia and reduces the cost of transportation and staff time. I would also love to see the 3-day hospital stay requirement eliminated permanently. We tried this in the 1990’s, but it’s time to do it for real.  

More community care collaboratives

Further break down the silos by care setting and build collaboratives across providers. Hospitals and PACs can work together to build a community team that works together to improve the quality of care, holds each other accountable, shares best practices and resources, and communicates effectively. We’ve seen them do amazing things during this pandemic.

Family connections through technology

We’ve had the technology for a while, so why did it take so long to implement virtual care conferences? So many working families can’t attend care conference routinely due to work commitments. A quick 15-20-minute video conference call can easily be incorporated into the workday.  Long distance family members also can visit with their loved one using video conferencing. These connections add so much to the quality of life the resident’s experience. I know it has added to mine. I have monthly Zoom calls with my dear friend across the country. It’s become our normal and we’ll keep it up for sure!

Creative celebrations

Keep the yard signs and the drive by parades going! Let’s continue to howl at the same time every night or applaud healthcare workers at shift change and play music from our balconies to encourage those who may need an emotional lift. What a fun way to get the community involved to rally around its elders and the staff who care for them. 

What would YOU like to see become the new normal?

Share your thoughts on what the new normal should look like.

 

More Resources from Maria Arellano for Skilled Nursing and Post-Acute Professionals:

Maria Arellano

 

Maria Arellano, RN, MS, Senior Healthcare Specialist

Author:

Maria Arellano, MS, RN, RAC-CT
Senior Healthcare Specialist, PointRight

Maria has over 35 years’ experience as a registered nurse in the post-acute industry. Maria has served in a variety of roles directly in or supporting the long-term post-acute care sector including staff development, director of nursing and corporate consultant where she demonstrated regulatory excellence and exemplary quality outcomes. Previously she was a nursing home quality specialist with a quality improvement organization (QIO) and worked to enhance the quality of care for residents. Maria participated on CMS Technical Expert Panels as well as various committees and advisory boards throughout her career. She is focused on quality improvement, which fuels her passion for transforming data into knowledge and actionable insights.

 

Filed Under: Blog

Maria Arellano
Maria Arellano, RN, MS, Senior Healthcare Specialist

By Maria Arellano

CMS announced plans for expansion of enforcement activities to improve provider accountability and sustained compliance of infection control practices in a June 1 CMS Memo. The memo also reinforced their expectations for state survey agencies and the timely completion of infection control focused surveys. CMS’ concerns about provider compliance with infection control practices is certainly not new, however, the emergence of COVID-19 certainly elevated that concern due to the serious threat to resident health and safety. Compliance concerns, lower than expected focused survey completion rates, and results from the federal reporting requirements prompted CMS to take an aggressive approach in its guidance.

I can’t help but wonder if this is akin to kicking someone when they’re down. 

Fifty-three percent of the nation’s nursing facilities have experienced a Focused Infection Control survey. However, the completion variability across states, ranging from 11-100%, certainly did not meet CMS’ expectations for the state survey agencies. CMS clearly indicated in the memo that states needed further direction to prioritize completion of focused infection control surveys in nursing homes.

States that have not completed 100% of their focused infection control nursing home surveys by July 31, 2020, will be required to submit a corrective action plan to their CMS location outlining the strategy for completion of these surveys within 30 days.  After the 30-day period, if States have still not achieved surveys in 100% of their nursing homes, their CARES Act FY2021 allocation may be reduced by up to 10%.  Subsequent 30-day extensions could result in an additional reduction up to 5%.  These funds would then be redistributed to those States that completed 100% of their focused infection control surveys by July 31.

SNFs Still Have Their Hands Full

I’m pretty sure skilled nursing facilities (SNFs) aren’t feeling sorry for the state survey agencies. SNFs still have their hands full either caring for residents with the virus or working diligently to keep it out. Not a task for the faint of heart!  In addition to the new extensive reporting requirements mandating weekly submissions of data to the CDC, facilities are also tasked with informing residents, their families or representatives if new occurrences of COVID are identified or 3 or more residents or staff show respiratory symptoms occurring within 72 hours of each other.

Additional Measures to Improve Accountability and Compliance

The memo builds on prior CMS actions by adding measures to improve accountability and sustained compliance of infection control practices. In addition to the enhanced enforcement, Directed Plans of Correction will be provided that aim to push for systemic organizational changes to achieve sustained compliance from the facilities. The memo also outlines the enforcement remedies for the following specific scenarios:

Non-compliance for an Infection Control deficiency when none have been cited in the last year (or on the last standard survey)

Nursing homes cited for current non-compliance that is not widespread (Level D & E) – Directed Plan of Correction 

Nursing homes cited for current non-compliance with infection control requirements that is widespread (Level F) – Directed Plan of Correction, Discretionary Denial of Payment for New Admissions with 45-days to demonstrate compliance with Infection Control deficiencies.

Non-compliance for Infection Control Deficiencies cited once in the last year (or last standard survey)

Nursing Homes cited for current non-compliance with infection control requirements that is not widespread (Level D & E) -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions with 45days to demonstrate compliance with Infection Control deficiencies, Per Instance Civil Monetary Penalty (CMP) up to $5000 (at State/CMS discretion)

Nursing Homes cited for current non-compliance with infection control requirements that is widespread (Level F) -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions with 45-days to demonstrate compliance with Infection Control deficiencies, $10,000 Per Instance CMP

Non-compliance that has been cited for Infection Control Deficiencies twice or more in the last two years (or twice since second to last standard survey)

Nursing homes cited for current non-compliance with Infection Control requirements that is not widespread (Level D & E) -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 30-days to demonstrate compliance with Infection Control deficiencies, $15,000 Per Instance CMP (or per day CMP may be imposed, as long as the total amount exceeds $15,000)

Nursing homes cited for current non-compliance with Infection Control requirements that is widespread (Level F) -Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 30-days to demonstrate compliance with Infection Control deficiencies, $20,000 Per Instance CMP (or per day CMP may be imposed, as long as the total amount exceeds $20,000)

Nursing Homes cited for current non-compliance with Infection Control Deficiencies at the Harm Level (Level G, H, I), regardless of past history.

Directed Plan of Correction, Discretionary Denial of Payment for New Admissions with 30 days to demonstrate compliance with Infection Control deficiencies. Enforcement imposed by CMS Location per current policy, but CMP imposed at highest amount option within the appropriate (non-Immediate Jeopardy) range in the CMP analytic tool.

Nursing Homes cited for current non-compliance with Infection Control Deficiencies at the Immediate Jeopardy Level (Level J, K, L) regardless of past history

In addition to the mandatory remedies of Temporary Manager or Termination, imposition of Directed Plan of Correction, Discretionary Denial of Payment for New Admissions, 15-days to demonstrate compliance with Infection Control deficiencies.  Enforcement imposed by CMS Location per current policy, but CMP imposed at highest amount option within the appropriate (IJ) range in the CMP analytic tool.

 

QIOs Assistance

The memo did include some non-punitive actions by CMS as they leveraged the Quality Improvement Organizations (QIOs) to assist nursing homes in combating COVID-19 through such efforts as education and training, creating action plans based on infection control problem areas, and recommending steps to establish a strong infection control and surveillance program. Training can include working with staff on proper use of personal protective equipment (PPE), cohorting residents appropriately and transferring residents safely. The QIOs monitor compliance with infection control standards and practices in the nursing home.  Nursing homes can locate the QIO responsible for their state.

CMS June 4 Memo

CMS followed this memo up quickly with a June 4th Memo notifying facilities that facility survey data was now being reported on Nursing Home Compare. The zip file containing this information is on the Nursing Home Compare Home Page under the Spotlight section and provides PDF files of individual facility Statements of Deficiencies (CMS-2567) in a format difficult to review and provides no context for consumer analysis. Perhaps CMS was more interested in checking the box for completion rather than sharing quality information that consumers will understand. None of this focused survey data is currently being used in the Five Star calculations for Health Inspections.

Survey data from inspections conducted after March CMS memos highlighting the focused surveys are also available.

Negative Coverage of SNFs

SNFs are certainly getting the lion’s share of CMS scrutiny over COVID-19 and the media continue to add dramatic flair to the story. It is somewhat understandable as nearly half of all COVID related deaths were in SNFs, but SNFs aren’t the only providers dealing with COVID patients or prone to less than perfect infection control practices. Individual hospitals’ COVID related data is not shared publicly, nor are they scrutinized or criticized in the media for having deaths related to COVID.

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Many SNFs continue to struggle with basic PPE supply levels as nursing homes were not prioritized for government intervention to ensure adequate supplies. Some even had ordered supplies diverted to hospitals or to the national reserve supply. It is well known that SNFs serve the most vulnerable population with multiple comorbidities in a congregate living setting, so what did we as a nation expect when we deprioritized them for supplies and testing? We sent them to war with no armor, then publicly criticized their efforts.

Now, CMS adds more teeth to their enforcement efforts aiming to gain more sustained compliance by facilities. I wonder if this is the best approach. I believe facilities want to give the best care possible, but struggles happen. Many are working with limited supplies of personal protective equipment (PPE) and reduced resources due to staff illnesses and other COVID related impacts keeping them from work. The threat of further financial damage with hefty fines on top of all the negative hype in the media just may just push some of the most caring and hardworking folks right out of the industry. It hasn’t worked in the past. Perhaps a new approach by CMS might achieve different results.

 

More Resources from Maria Arellano for Skilled Nursing and Post-Acute Professionals:

Maria Arellano
Maria Arellano, RN, MS, Senior Healthcare Specialist

Author:

Maria Arellano, MS, RN, RAC-CT
Senior Healthcare Specialist, PointRight

Maria has over 35 years’ experience as a registered nurse in the post-acute industry. Maria has served in a variety of roles directly in or supporting the long-term post-acute care sector including staff development, director of nursing and corporate consultant where she demonstrated regulatory excellence and exemplary quality outcomes. Previously she was a nursing home quality specialist with a quality improvement organization (QIO) and worked to enhance the quality of care for residents. Maria participated on CMS Technical Expert Panels as well as various committees and advisory boards throughout her career. She is focused on quality improvement, which fuels her passion for transforming data into knowledge and actionable insights.

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