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 Monitoring Case Mix Review of RUG Assignments Resident Case Mix Assessment Reporting Evaluation

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

16. Auditing and Monitoring Case 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 Monitoring Case 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 Review Process 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 Review Process Physician Certification/Re-certification Certifications Completed Properly Original, Not Stamped, Signatures Signature Date = Certification Date (or before)

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

21. Pre-/Post- Billing Claim Review Process 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