1. OHCA DISTRICT II LTC UPDATE Kenneth Daily, LNHA kenn@qissurvey.com

2. District News ■ CEUs for today’s program is 2.0 hours ■ 2016 we will: – Conduct the annual wage survey – Solicit for semi-annual scholarships – 50 th Anniversary Celebration

3. Golf Outing Annual Golf Outing Pipestone Golf Club August 25th Shotgun start @ 9AM

4. OHCA Events ■ OHCA Convention May 2-5 ■February 3 - 5 EFOHCA -- Activity Professionals Conference EFOHCA -- Activity Professionals Conference ■February 16 EFOHCA -- Therapy Conference EFOHCA -- Therapy Conference

5. Survey update from Region V ■Nationwide focus on infection control (F441), falls and accidents (F323), antipsychotics (F329) and quality of care (F309). ■Ohio had lowest number of deficiencies in the Region, but the highest daily fines in the Region. ■CMS Region V imposed a higher amount of fine than SA recommended 38% of time. ■MDS focused surveys ongoing. #1 cite is F278 for MDS accuracy. Nurse staffing posting (F326) also frequently cited. Results count in your 5 ‐ Star Rating. ■Dementia focused surveys will continue in 2016 and will no longer be identified as a “complaint” but results will count in your 5 ‐ Star Rating.

6. Focused Surveys ■MDS focused survey is on-going through FFY 2017 ■Dementia focused survey is expected to begin with surveyor training in Q1 ■Adverse event (medication errors) is expected to begin in 2016

7. Final Rules ■Life Safety Code – move to the 2012 code expected in Q1 –Increase inspection, testing and maintenance (ITM) ■Emergency Preparedness final rule is expected in 2016 –Extensive rule with all-hazard approach and includes risk analysis, communications, trainings and exercises

8. Federal Priorities ■Re-hospitalization ■Know your re-hospitalization rates –Reduce re-hospitalizations to less than 10 -12% –Review all of your rehospitalizations –Assume 100% were preventable –Develop robust transitions of care program –Arrange follow-up and communicate with primary care MD –Do follow-up calls to discharges to community within 24 hours and 3-5 days later

10. 5 Star Rating ■Managed Care & ACOs use to establish networks –CMS will waive 3 day hospital stay to qualify for SNF stay if SNF has 3 Star or greater rating for ■Hospitals in CCJR model (starting Jan 1st) ■Hospitals in Advanced ACO demonstration ■Adding measures in 2016 –Rehospitalizations, Discharge to community, Mobility in room for long stay residents, hypnotics and Change in ADL from admission to discharge ■IMPACT Measures –Potentially preventable Re-hospitalization during and 30 days after SNF discharge –Discharge back to community –Drug regime review (poly pharmacy) –Average cost per beneficiary during and after SNF discharge

11. Payroll-based Journal Entry ■ Staffing and Census data for feds voluntarily began 10/1/15 and will become MANDATORY July 1, 2016 – Determine level of staff in facilities – Report on employee turnover and tenure ■ Referred to as Payroll-based Journal – PBJ it will allow facilities to report the required category of work such as RN, LPN, STNA, therapist, etc.

12. PBJ

13. Staffing Data Collection ■ Rule implements the staffing data collection; requires submission of – Data submitted is similar to data submitted currently on CMS 671 and CMS 672 – Category of work of both contract and direct employees – Specify which employees are contract and direct – Info on start and end date and hours worked (meeting the statutory requirement for information on turnover and retention – Hours of care provided by each category of employees per day

14. Staffing Data Collection ■ Submission will be quarterly –Census Data Includes the facility’s census on the last day of each of the three months in a quarter ■ Submission will be a Required –Deadline for receiving the submissions is by the end of the 45th calendar (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter.

15. Methods of Submission ■ The PBJ system has been designed to accept two primary submission methods – Manual data entry - require an individual(s) at a facility to key in information about employees, hours worked, and census information directly into the PBJ User Interface – Uploaded data from an automated payroll or time and attendance system which will function very similarly to how MDS data are submitted currently ■ In addition, users can use both methods of these methods, for submitting data as needed

16. Gathering Employee Information ■ Staff members in direct care positions ■ Contracted / Agency employees in roles identified by CMS ■ Medical Professionals ■ Gathering Staffing Hours (Daily) – Manual Time Sheets & Excel Spread Sheet Tracking – Calculation of worked hours – Distribution of hours for direct vs indirect – “Reasonable Methodology” for allocation across Service Lines (AL, IL, SNF) ■ Time frames – should be daily to avoid memory issues ■ Auditable document TRAIL

17. Ohio Changes ■Medicaid Rebasing –Most significant revisions to pricing system since its creation in 2005 –Prices rebased using updated data –New grouper for determining case mix ■New quality incentive system (third since 2005) ■Further reduction of PA1/PA2 rate

18. Rebasing - The Get ■Existing law drives most changes - because reimbursement system is still in statute ■First increase in prices since SFY 2008 (prices declined SFY 2012) ■End result is about 6.7% increase in rates ($12+ per day) –2017 increase estimated at $78 million, now $139 million ■Average Rates by Peer Group –Estimates based on what we know now: ■Peer Group 1-L $194 ■Peer Group 1-S $195 ■Peer Group 2-L $191 ■Peer Group 2-S $195 ■Peer Group 3-L $177 ■Peer Group 3-S $180

19. RUGs IV ■Statute allows ODM to decide which grouper will be used ■After debate in legislature and discussion with provider associations, ODM chose 57 group, hierarchical model of RUG IV ■RUG IV results in higher direct care rates than if RUG III had been retained –Broader range of case mix scores under RUG IV than RUG III, which in turn means a broader ranger of rates ■SFY 2017 rate modeling so far uses historical case mix scores created by reprocessing old MDS data –Actual rates will be based on the average of the December 2015 and March 2016 quarterly RUG IV scores

20. RUG III 44 vs. RUG IV 57 RUG III -44 OLD Medicaid ■ Index maximizing ■Some care delivered prior to admission impacted RUG ■Group –Dr’s orders and visits – Depression only recognized in Clinically Complex ■Behavior and Impaired Cognition had separate categories ■ADL range 4-18 RUG IV 57 New Medicaid ■Hierarchical version ■Only care delivered while a resident impact RUG group ■Only 2 or more Insulin order changes impact the grouper ■Depression recognized in Special Care High and Low as well as Clinically Complex ■Behavior and Cognition are combined in one grouper ■ADL range 0-16

21. Hierarchical Classification (Ohio Medicaid Classification) ■In the hierarchical approach, start at the top and work down through the RUG-IV 57 model; the assigned classification is the first group for which the resident qualifies. In other words, start with the Rehabilitation group at the top of the RUG-IV 57 model. Then go down through the groups in hierarchical order: –Rehabilitation (therapy) –Extensive Services (vents, trachs and isolation) –Special Care High (Coma, diabetic with 2+orders, COPD, weight loss, tube feeding) –Special Care Low (CP, Parkinson’s, MS, PU/ wounds) –Clinically Complex (O2, IVs) –Behavioral Symptoms and Cognitive Performance (BIMs <9, behaviors, wandering) –Reduced Physical Function ■RUGS scoring from 1.0 to 6.4889

22. Quality System 3 ■Old 20 measure system paying $16.44 goes away ■New 5 measure system –Funded through flat $1.79 reduction of each provider’s rate –Each of 5 quality indicators will be worth approximately 80 cents per day ■Indicators vary widely in difficulty of achievement ■Using 2014 data, ODM estimated only 5 centers would meet all 5 indicators

23. Measurement Period ■For state fiscal year 2017(July 1, 2016 rates), the period from July 1, 2015 and ending December 31, 2015 (all ready passed) ■MDS data will be included from the following: –Third quarter of calendar year 2015 –Fourth quarter of calendar year 2015 if available by June 1, 2016 ■For state fiscal year 2018 (July 1, 2017 rates) and thereafter, the calendar year immediately preceding the state fiscal year. –MDS data will be included from the following: –The first three quarters of the calendar year –Fourth quarter data will only be included if available by June 1

24. How Do I Achieve? ■Various data sources determine whether the indicators are met: – MDS data (pressure ulcers, antipsychotics) – Hospital claims data (potentially preventable admissions) –Cost report data (retention, PELI) ■ All data will not be compiled and analyzed until June 2016

25. Quality Indicator – Pressure Ulcers ■To earn 1 point, a facility must be at or below the target percentages for pressure ulcers for both short- and long-stay residents ■For state fiscal years 2017 and 2018, the rate will be at the 25 th percentile ■For state fiscal year 2019 and thereafter, the target will be the number at the 25th percentile in state fiscal year 2018. (Change) ■No point will be awarded if the facility has no data for either measure ■Estimated scores = Short term measure 0.00 and long term measure 2.9)

26. Quality Indicator – Antipsychotic Medications ■To earn 1 point, a facility must be at or below the target percentages for antipsychotic medication use for both short- and long-stay residents. ■For state fiscal years 2017 and 2018, the rate will be at the 25thpercentile ■For state fiscal year 2019 and thereafter, the target will be the number at the 25th percentile in state fiscal year 2018. (change) ■No point will be awarded if the facility has no data for either measure ■Estimated scores = Short term measure 0.00 and long term measure 8.7)

27. Quality Indicator – Preferences for Everyday Living Inventory (PELI) On the ODM Nursing Facility Cost Report the following question is included: ■Does the nursing center utilize the full or mid-level nursing home version of the Preferences for Everyday Living Inventory for all of its residents? ■1 point will be awarded if the facility replies yes ■No point will be awarded if the facility fails to answer the question

28. Quality Indicator – Potentially Preventable Hospital Admissions ■1 point will be earned if a facility’s actual hospital admission rate is at or below the risk-adjusted expected rate calculated for their facility ■Facilities with a score of 1.0 or less ■Data will be obtained from all hospital claims submitted to ODM – including crossover claims ■ODM estimate only 69 facilities will achieve????

29. Quality Indicator – Employee Retention ■To earn 1 point, a facility must be at or below the target rate of the75th percentile. ■For state fiscal years 2017 and 2018, the rate will be at the 75thpercentile ■For state fiscal year 2019 and thereafter, the target will be the number at the 75th percentile in state fiscal year 2018 ■No point will be earned if the facility fails to complete this section ofthe ODM Nursing Facility Cost Report

30. Calculation of the Medicaid Per Day Quality Payment Rate ■Step 1: Determine the number of Medicaid days delivered by each facility ■Step 2: Identify the total Medicaid patient days per facility ■Step 3: Determine the number of quality points earned by each facility ■Step 4: Determine the point days earned per facility by multiplying the Medicaid days by the number of quality points earned ■Step 5: Determine the number of point days for all facilities ■Step 6: Calculate the total quality funds to be paid by ODM for the fiscal year by multiplying $1.79 by the total number of Medicaid days (roughly $30,000,000)

31. PA1 and PA2 Patients ■Flat rate reduced from $130 to $115 effective July 1, 2016 ■PA1/PA2 records still excluded from case mix ■RUG IV estimated to increase PA1/PA2 patients by about 50% (1,600 ->2,400) ■RUG III used for PA1/PA2 billing through June 30, 2016 ■What does it mean to cooperate with the ombudsman?