The purpose of a tool in long-term care is largely is to make sure that the information that is in each resident’s documentation is going to meet the requirements—whether regulation, guideline, or other. A tool is simply an easy way to go through a regulation (without having to read page after page), and apply it easily to the task at hand. (For example, a Quality Assessment and Assurance audit divides the regulation into pieces calling out what the surveyor will look at to make sure the facility is in compliance. )
Here are some of the most helpful tools available to you to prepare for survey, Medicare audits, and Additional Development Requests (ADRs), and best practices for how you should be using them.
CMS Critical Element Pathways
Critical Element Pathways (CEPs) were released by CMS to help facility staff prepare for the blended survey process. They outline exactly what surveyors will be looking for during their time in the facility. There are a number of CEPs that NACs should use before survey. These include:
- CMS-20052 Beneficiary Notice
- CMS-20058 QAA and QAPI
- CMS-20066 Activities of Daily Living
- CMS 20067 Behavioral
- CMS 20068 UTI
- CMS 20069 Communication-Sensory
- CMS -20070 Dental
- CMS-20071 Dialysis
- CMS-20072 General
- CMS-20073 Hospice
- CMS-20076 Pain Management
- CMS-20077 Physical Restraints
- CMS-20078 Pressure Ulcer
- CMS-20080 Rehab and Restorative
- CMS-20120 Positioning
- CMS 20125 Bladder
- CMS-20127 Accidents
- CMS-20131 Resident Assessment
- CMS-20132 Discharge
- CMS-20133 Dementia Care
Use CEPs in the way you would a check-off audit, determining whether all the components, processes, required documentation, and care plan entries are in place.
QA Audit Tools
The purpose of audit tools is to make sure everything that you think is and should be in each resident’s documentation is actually there. As a general rule, the person who knows the resident the least should perform the audit. This is because if you know a resident and his or her history, you can easily overlook missing information, unconsciously filling it in from your head, even if it’s not in the records. This is in part why surveyors are so effective at finding missing or incorrect information: they have no knowledge of individual residents and so they are answering “yes” or “no” based on information that’s strictly from the medical record documentation.
To adjust for this, ask social services to audit nursing records or nursing to audit dietary records. This will give the documentation fresh eyes. It will also help other team members to understand what different departments do and how difficult their roles are. This should give team members an appreciation of what the other departments have to do and get everyone to understand that no one has an “easy” job.
Medicaid and Medicare Audits
Particularly for states that use a Medicaid case-mix or a RUGs grouper, state reviewers verify that facilities are entitled to the payment they bill for. For example, if Mr. Smith was clinically complex (CC2), his record will be reviewed carefully not only for the major qualifying criteria, but also for indicators of a sad mood to ensure that it qualifies and matches the care plan. The RUG group will tell you what the MDS should be showing you. This means that by looking closely at the RUG score you should be able to identify the criteria that should be on the MDS. Some states with a Medicaid case-mix system will also have a document issued by the state (“Supplemental Documentation Guidelines”) that provides information required in the documentation to support the coding of particular MDS items. If the required documentation is not present in the clinical record, the reviewers will indicate that an error has occurred and it will be used to compile the error rate for the facility being audited.
To prepare for state auditors, perform your own audits in advance of the surveyors’ arrival. For example, use the state-specific “Documentation Guidelines” to determine whether the RUG coding is supported by the information in the medical record, or use any of the AANAC QA audit tools.
Additional Development or Documentation Requests (ADRs)
Additional development (or “documentation”) requests (ADRs) come from the jurisdiction-specific Medicare Administrative Contractor (MAC). Once a facility bills Medicare with a UB-04, MACs can make one of three decisions: (1) all services and documentation are approved and payment is sent; (2) documentation is insufficient and/or services are not okay and money is not sent or is requested to be returned; or (3) Part of the claim is correct and part of the payment is received.
If additional information is requested, the MAC will request specific documentation, such as the hospital History & Physical, the hospital Discharge Summary, the Continuity of Care or transfer form, physician orders, lab results, X-ray results, treatment records, medication records, therapy and progress notes, and/or discharge information if applicable for a specific time period. Typically, each department will be responsible for collecting documentation required from their department.
Keep in mind that the facility’s medical records team can help gather the documents, but it’s imperative to have a clinician review the documentation before it leaves the building. Typically, if your facility can provide sufficient supplemental documentation on the first attempt, your facility will fade a bit off of the MAC’s radar. If not, your facility will generally remain on the MAC’s radar. The information submitted must match exactly what the ADR specified. Be mindful of the billing dates so that the correct data will be included to support each MDS that has been submitted and billed. Sometimes the medical records needed will be in the prior month of the bill depending on the look-back periods for the submitted MDSs.
Use AANAC’s Responding to ADRs Tool, which outlines suggested processes to help you to formalize your team’s response to reviews.
Chapter 6 of the MDS Provider User’s Guide features MDS 3.0 Nursing Home Provider Reports. These can be accessed on the QTSO website, the same location where the MDS nurse submits reports. CASPER reports allow you to set the time frame and criteria—for example, previous citations, admissions, re-entries, error reports, and more. CASPER also provides the MDS 3.0 Validation Report, which flags both warnings and fatal errors that may prevent the submission from being accepted. It also informs you if something is found on the MDS that will impact SNF QRP Quality Measures. Lastly, the MDS Missing Assessment Report will flag any missed MDS assessments. (Facility software may also report and flag missing information on assessments.) The CASPER reports are an invaluable resource to the expert NAC, who will use them to verify the completeness and accuracy of the work submitted to CMS (https://qtso.cms.gov/providers/nursing-home-mdsswing-bed-providers/reference-manuals). Remember that surveyors have access to CASPER reports as well, so the NAC needs to know what the surveyors know before they walk through the facility door.
Tools help you make sure that everything is in place and accurate; by completing an assigned tool, you or other staff members are able to focus on specific items that may be missing or incomplete and could lead to survey citations and denials.
All audits should be submitted to the QAA committee for documentation purposes even if there are no concerning findings. Think of it like an insurance policy: if there is a problem identified during a survey or formal audit, the facility’s internal audit can be presented to indicate that the facility leaders are making efforts to double-check that documentation is supportive, complete, and correct. If you’re using the available tools to audit your facility, no findings by an auditor or reviewer should be a surprise.
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