OIG Risk Areas: Sufficient Staffing, Case Mix & Psychotropic Medications

1. OIG Risk Areas: Sufficient Staffing, Case Mix & Psychotropic Medications Presented by: Irene Fleshner Susan Whittle Ken Burgess

2. Where We’ve Been & Today’s Topics • Review of prior webinar topics • Mechanics of compliance programs • OIG Risk Areas to date • Today: • Sufficient Staffing – Irene Fleshner • Case Mix Reporting – Susan Whittle • Psychotropic Medications – Ken Burgess

3. OIG Risk Area Sufficient Staffing

4. What is Sufficient Staffing? • Federal & State requirements • CMS – Five Star • Budget • Resident/Patient needs • Staff preferences

5. Staffing Plan Considerations • Who do we care for - scope of services, IVs, acuity level, behavioral issues • Numbers – census, admissions • Model of care delivery – who does what • Needs per shift - admissions, outside appts. • Skill mix - role of licensed nurses – RNs vs. LPNs • Staff competencies

6. Staffing Plan • Create a staffing plan • Build budget to support plan • Include budget dollars to cover call ins, in-service training, shift report • Administrator and DON responsible • Communicate plan and rationale to all staff

7. Implement Staffing Plan • Create schedule according to plan • Involve staff in development of schedule • Allow flexibility in schedule for census and acuity fluctuations – part time, prn, on call

8. Schedule should not be static Allow for real time review and adjustment !! Ask the question - Do I have the right number of staff with appropriate skill mix and competencies available on this shift to care for patients/residents?

9. Monitor Staffing • Have a system in place to regularly review adherence to staffing plan • Schedule vs. actual • Hours over and under budgeted levels • Pattern of call ins

10. Communicate • Create a process for communicating results of audit • Corporate • Staff

11. Continuous Improvement Identify problems/ issues Look for opportunities to improve Develop improvement plan

12. Document • Document staffing plan philosophy – do not include specific ratios • Document monitoring activities • Document reporting activities

13. Proper Reporting of Case Mix OIG Risk Factor: “Upcoding”

14. Auditing and MonitoringCase Mix • Review of RUG Assignments • Resident Case Mix • Assessment • Reporting • Evaluation

15. Auditing and MonitoringCase Mix • Process • MDS Accuracy Review • Pre-/Post- Billing Claim Review • Trend Findings • Train and Educate

16. Auditing and MonitoringCase Mix • MDS Accuracy Review by Clinician • Therapy Verification • ADL Score Verification • “Extensive Services” Review • Assessment Reference Data • Extensive Services • Special Care • Clinically Complex • Findings/Plan of Correction • Training Opportunities

17. Auditing and MonitoringCase Mix • Pre-/Post- Billing Claim Review • Administrator As Team Leader • DON or Designated Clinician • Clinical Documentation/Medical Records/MDS • DOR or Designated Therapist • Therapy Documentation/Therapy Logs • BOM or Business Office Designee • Patient Personal Information/SNF Certification Verification

18. Pre-/Post- Billing Claim ReviewProcess • Patient Name/Payor Number • Admission Date/Dates of Service • Verification of Qualifying Stay • ARD Within Allowable Period • Rug Information = MDS Assessment • Therapy Minutes = RUGS Category • HIPPS Modifier Codes = MDS Codes • UB92 Diagnosis = MDS Diagnosis • Ancillary Services Billed = Medical Record • RUGS Level = Services Provided

19. Pre-/Post- Billing Claim ReviewProcess • Physician Certification/Re-certification • Certifications Completed Properly • Original, Not Stamped, Signatures • Signature Date = Certification Date (or before)

20. Pre-/Post- Billing Claim ReviewProcess • Findings/Identification of Exceptions • Plan of Correction • Trend Data • Identify Training Opportunities

21. Pre-/Post- Billing Claim ReviewProcess • Frequency • Claim History • Pre-Billing • Post-Billing • Sample Size • Claim Hisotry • 100% • Random Sample

22. OIG Risk Area: Psychotropic Medications • OIG Focus: • Use of PP meds is consistent with Federal regs / standard of care • SNF responsible for quality of PPs use • No use as restraint / for convenience • PPs necessary per medical symptoms • No unnecessary PPs / other drugs • Gradual dose reductions with behavior modifications unless medically contradindicated

23. Auditing/Monitoring for PP Meds • What are we looking for specifically? • The above items / issues • What information sources will we use to look at those issues? • And who is looking on what schedule? • What will we do with the results of our findings?

24. What Are We Looking For? • System to know who is on PP meds? • Documentation of symptom based basis for PPs • Is documentation by proper inter-disciplinary team – all aspects of resident’s condition/care involved • Is documentation consistent with care plan/medical records and updated regularly

25. What Are We Looking For? • Documentation of ongoing efforts to “dose down” with behavior modifications, unless contraindicated • Is all of above regularly reviewed by consulting pharmacist • Have system for regular updates to care plan, med records, MD orders, MARs, lab tests/lab results/followups

26. What Information Sources Do We Examine to Test Those Issues? • Resident medical orders for PPs • Care plans • MARs • Nursing/social work/psychosocial notes re symptom based reasons for use of PPs • System for recording/follow up of MD oral PP orders / tracking lab orders & results / reports of same to attending MD

27. What Information Sources Do We Examine to Test Those Issues? • Facility incident reports, survey results and QA Committee minutes to detect failings in these systemss • Reports of consulting pharmacist re same issues • AND who (by title) is handling each task and on what defined, periodic schedule

28. What Do We Do With The Results of Our Audit? • Report same to facility administration & QA Committee & Compliance Officer / Committee • Revise applicable policies & procedures to respond to detected problems / Train re same (repeated) • Compliance Officer report to Bd of Directors, including corrective measures and how they are working