2. Edward A. Klik, Jr. Denise A. Park, RN Kristopher S. Pattison, RN, RAC-CT Optimizing Nursing Department Operations June 16, 2016 2 with Leonard Quimby, NHA

3. Agenda Arnett Carbis Toothman LLP (ACT) Optimizing Nursing Department Operations Evaluating the Nursing Department Manage Quality, Decrease Cost, and Support Reimbursement Benchmarking Operational Performance Questions 3

4. Arnett Carbis Toothman LLP (ACT) Nearly 75 years of experience Over 275 team members in 9 locations Leadership team comprised of more than 30 partners Work with entire health care delivery system Regional firm with offices located in PA, OH, and WV ACT company affiliations: – ACT Wealth Advisors – Total Practice Management – Walker Benefits 4

5. Optimizing Nursing Department Operations 5

6. Evaluating the Nursing Department 6

7. Let’s Begin with Human Resources – Vacant positions – Results of exit interviews – Review of job descriptions 7

8. Evaluating the Nursing Department Discipline Specific Job Descriptions – Last updated – Pertinent to current responsibilities 8

9. Evaluating the Nursing Department Orientation Program – Discipline specific – Policies and procedures – Competencies 9

10. Evaluating the Nursing Department Interview Staff – Administrative RNs & LPNs – Clinical RNs & LPNs – Certified Nurse Assistants – Unit Secretaries 10

11. Evaluating the Nursing Department Interview Questions – Roles and responsibilities – Tools for success – Longevity – Likes and dislikes – Change 11

12. Evaluating the Nursing Department Other services that may have an impact on the delivery of resident care – Social Services Department – Activities Department – Pharmacy Services 12

13. Evaluating the Nursing Department Social Services Department – On call – Extended hours – Involvement with the admission process 13

14. Evaluating the Nursing Department Activities – Weekend programs – Evening programs – Centralized programs – Volunteers – Extended behavioral unit support 14

15. Evaluating the Nursing Department Pharmacy services – Number of deliveries – Times of deliveries – On-call services 15

16. Evaluating the Nursing Department Recruitment Opportunities – Hiring process Application kiosk Walk in interviews Turn around time 16

17. Evaluating the Nursing Department Recruitment Opportunities – In house Nurse Aide Training – Partner with local Nurse Aide Training programs – Shared staff pool 17

18. Evaluating the Nursing Department Recruitment Opportunities – Job fairs and advertising – Flexible scheduling – Baylor program 18

19. Evaluating the Nursing Department Staff Retention – Structured orientation with competencies – Mentoring programs – Shift differentials – Positive recognition – Regular staff meetings “Special” guests 19

20. Evaluating the Nursing Department 20

21. Evaluating the Nursing Department “Specialty” Units and Staffing Structure Behavior or Dementia Units – Activities involvement Skilled Rehabilitation Units 21

22. Evaluating the Nursing Department 22

23. Manage Quality, Decrease Cost, and Support Reimbursement 23

24. Learning Objectives Understanding how quality is presented to the public (Five-Star Rating) Understanding Medicaid reimbursement system (Pennsylvania Case Mix) Understanding of how reimbursement and quality are interrelated in the current system 24

25. What Makes up the Ratings? Health Inspections – Based on outcomes from the most recent State health inspection year and outcomes over the prior 2 years – Includes complaint surveys with deficiency findings Staffing – Number of hours of care provided on average to each resident each day by nursing staff Quality Measures – 11 different measures impact the rating – Information is collected by the nursing home for all residents on the Minimum Data Set (MDS) 25

26. Health Inspection Scores are calculated using a points value for deficiencies cited based on the scope and severity of the deficiency 26

27. Health Inspection Points are reassigned if not cleared during the revisit – 50% of the total points are added if not cleared on the second visit – 70% by the third visit – 85% by the fourth visit Points are then totaled for each survey year based on the time in which the deficiencies were identified – Current year weight is 1/2 (50.00%) – last year 1/3 (33.33%) – and third year is 1/6 (16.66%) 27

28. Health Inspection CMS posts cut-points tables monthly that establish the cut-points for each star level by state – Top 10% = Five Star – Middle 70% = Two, Three, Four Star Approx. 23.33% in each group – Bottom 20% = One Star The Health Inspection rating is the base for the overall Five-Star Rating for each facility 28

29. Staffing CMS study found evidence of a relationship between nursing home staffing level and resident outcomes. Rating based on two staffing measurers, each given equal weight – Total nursing hours per resident day (RN + LPN + nurse aide) Direct care staff hours (most recent complete pay period or 14 days prior to survey) – RN hours per resident day Taken from the 14 day schedule and CMS 671 given during each annual survey The CMS 671 includes RNs (F41), RN Director of Nursing (F39), Nurses with Administrative Duties (F40) 29

30. Staffing and Case Mix Case Mix Adjustment – This is done using the same case mix system that PA uses for Medicaid reimbursement in long-term care In Pennsylvania, each resident’s most recent RUG is assigned a numerical equivalent Case Mix Index (CMI) based on the MDS RUG The numbers for all residents are then averaged – In Pennsylvania - Two CMIs Total Facility CMI MA CMI 30

31. Staffing and Case Mix Case Mix Adjustment – Medicaid CMI Four picture dates – Creates a “snapshot” of acuity over the past quarter – February, May, August, November – Should represent the highest acuity for MA residents during the quarter – Total Facility CMI February 1 Picture date – Rebasing for MA rate setting Staffing Adjustment – Creates the “expected staffing” levels 31

32. Staffing Case Mix Adjustment – Both RN and Total Nursing hours are case mix adjusted – Hours adjusted = [Hours reported / Hours expected * National average hours] Payroll Based Journal impact – Reset National average – Cause adjustment of staffing stars quarterly 32

33. Staffing 33

34. Staffing 34

35. Quality Measures Quality Measures are calculated using the three most recent quarters of available data All measures are given equal weight and point values are summed 20 points for the worst, 100 points for best, 40, 60, 80 points for the quintiles in between – Better performance, higher QM points 35

36. Quality Measures Short stay measures – Less than or equal to 100 days – Qualifying assessment types = ADM, 5d, DRA, DRNA within the past 120 days – If a qualifying assessment is found, then the all assessments in the 120 days will be used Long stay measures – Greater than or equal to 101 days – If a qualifying assessment is found, then all assessments in the prior 275 days will be used 36

37. Quality Measures (Short Stay) Short Stay Measures – Percent of residents with pressure ulcers (sores) that are new or worsened Coding accuracy and timeliness on admission Covariate for BMI < 12 – Percent of residents who self-report moderate to severe pain Pain is reported frequent or constant with one episode of moderate or higher pain (pain scale 4 or higher). Any frequency of severe / horrible pain (pain scale 10) – Percent of residents who newly received an antipsychotic medication They were not admitted on an antipsychotic and now are 37

38. Quality Measures (Long Stay) Long Stay Measures – Percent of residents whose need for help with activities of daily living has increased Late loss ADLs (two coding points of decline) – Self-performance portion of the ADLs – Examples: from limited (2) to extensive (3) in two areas or from limited (2) to dependent (4) in one area – Percent of high risk residents with pressure ulcers (sores) Excludes Admission and 5 day MDS High risk (extensive assist bed/trans, comatose, malnutrition/at risk) Includes only stages 2-4 38

39. Quality Measures (Long Stay) Long Stay Measures – Percent of residents who have/had a catheter inserted and left in their bladder Excludes: Admission and 5 day MDS, Neurogenic bladder, obstructive uropathy Covariates: frequent bowel incontinence (prior MDS), pressure ulcers – Percent of residents who were physically restrained Any type of restraint Accurate coding 39

40. Quality Measures (Long Stay) Long Stay Measures – Percent of residents with a urinary tract infection Excludes Admission and 5 day MDS Must be coded on the MDS to trigger – Four specific criteria to claim, and ALL must be met Percent of residents who self-report moderate to severe pain – Excludes Admission MDS, or 5 day MDS – Pain is reported frequent or constant with one episode of moderate or higher pain (pain scale 4 or higher). – Any frequency of severe / horrible pain (pain scale 10) Covariate moderately or severely impaired decision making 40

41. Quality Measures (Long Stay) Long Stay Measures – Percent of residents experiencing one or more falls with major injury Lookback scan is 275 days from the last MDS Percent of residents who received an antipsychotic medication – Exclusions: Schizophrenia, Tourette’s, Huntington’s disease 41

42. Take-Away Points Survey Redemption – Look forward - cannot erase the past (points) – Look at the past to help prepare for the future Staffing – How your organization staffs RNs within total nursing hours makes a difference – Consider using LPNs in nursing administration where possible to decrease cost, and increase “RN” rating 42

43. Take-Away Points Case Mix – Evaluate if your MA CMI reflects the higher acuity of the MA population – Evaluate whether your TF CMI reflects what is typically a lower acuity for the non-MA population Quality Measures – Work within the parameters set to capture items that impact RUGs without impacting the QMs – Use facility CASPER reports to monitor the 11 areas that impact Quality Ratings to set up performance improvement goals 43

44. Benchmarking Operational Performance 44

45. Benchmarking Operational Performance Key Performance Indicators – Census – Payor Mix Data – Admissions and Discharges – Medical Assistance Case Mix Index and Rates – Centers for Medicare and Medicaid Services Five Star Rating – Nursing Cost Per Day – Nursing Salaries Per Hour – Nursing Hours Per Patient Day – Staffing Patterns 45

46. Benchmarking Operational Performance How does my skilled nursing facility census compare to competitors? 46

47. Benchmarking Operational Performance How does my skilled nursing facility payor mix compare to competitors? 47

48. Benchmarking Operational Performance How does my skilled nursing facility payor mix compare to competitors? 48

49. Benchmarking Operational Performance How do my admissions compare to competitors? 49

50. Benchmarking Operational Performance How do my discharges compare to competitors? 50

51. Benchmarking Operational Performance How does my Medical Assistance Case Mix Index (CMI) compare to the PA statewide average? 51

52. Benchmarking Operational Performance How has my Medical Assistance Rate been historically trending? 52

53. Benchmarking Operational Performance How much of an impact does a.01 change in Medical Assistance Case Mix Index have on my Medical Assistance Rate? – Medical Assistance Case Mix Index has a significant impact on a PA skilled nursing facility’s quarterly rate – Typically ranges from $.75 to $1.25 for a.01 change – Example – a 120 skilled bed nursing facility that runs at 98% overall occupancy and 65% Medical Assistance occupancy could have the following impact: 120 beds X 365 days = 43,800 days 98% overall occupancy 43,800 days X 98% = 42,924 days Medical Assistance occupancy 65% 42,294 days X 65% = 27,491 Medical Assistance days 27,491 X $1.25 = $34,364 impact 53

54. Benchmarking Operational Performance How does my Nursing Cost Per Day compare to competitors? 54

55. Benchmarking Operational Performance How does my Nursing Cost Per Day compare to competitors? 55

56. Benchmarking Operational Performance How do my Salaries Per Hour compare to competitors? 56

57. Benchmarking Operational Performance How do my Salaries Per Hour compare to competitors? 57

58. Benchmarking Operational Performance How does my Five Star Rating compare to competitors? 58

59. Benchmarking Operational Performance How does my Five Star Rating compare to competitors? 59

60. Benchmarking Operational Performance What is my Excess Costs Due to Excess Hours per Patient Day? 60

61. Benchmarking Operational Performance How does my Staffing Per Bed compare to competitors? 61

62. Benchmarking Operational Performance How does my Staffing Per Bed compare to competitors? 62

63. Benchmarking Operational Performance In Summary: – Have we performed a self assessment of our nursing department? – How often do we benchmark to our competitors? – How closely do we monitor our census? – How closely do we monitor our MA CMI? – How closely do we monitor our CMS Five Star Rating? – How closely do we monitor Nursing Hours Per Patient Day? – How often do we evaluate mix of positions and staffing levels? 63

64. QUESTIONS? 64 Edward A. Klik, Jr. Partner l Health Care Services voice: 724.658.1565 l 800.452.3003 e-mail: ed.klik@actcpas.com Denise A. Park, RN Clinical Nurse Consultant voice: 724.658.1565 l 800.452.3003 e-mail: denise.park@actcpas.com Kristopher S. Pattison, RN, RAC-CT Clinical Nurse Consultant voice: 412.635.6270 l 800.452.3003 e-mail: kristopher.pattison@actcpas.com Leonard Quimby, NHA Chief Operating Officer Sr. Administrative Director Asbury Heights voice: 412.571.5129 e-mail: lquimby@asburyheights.org