Speaker 1 (00:02):
Welcome to the Post-Acute Point of View podcast, our discussion hub for healthcare technology in the out-of-hospital space. Here we talk about the latest news and views on trends and innovations that can impact the way post acute care providers work. We'll also dive into how technology can make a difference in today's changing healthcare landscape for home and facility-based workers and the people they care for. Let's dive in.
Lois Bowers (00:35):
I'm McKnight Senior Living editor Lois Bowers, and I'll be your moderator today. As you know, surveys affect every aspect of a senior living provider's business, from occupancy to financial performance to staff workload. And now I'd like to introduce today's speakers. Janet Feldkamp is a partner in the Benesch Law Healthcare Practice Group at Benesch Law. She focuses her practice in healthcare law, including long-term care survey and certification, state and federal regulation, physician and nurse practice, and fraud and abuse.
She retains active licenses as a registered nurse and a nursing home administrator. Robert Moore is director of strategy and portfolio management with MatrixCare LPC. He began his long-term care career as a CNA and has been a registered nurse for more than 15 years. During his time in nursing, he's been a telemetry unit staff nurse, a unit manager, and MDS coordinator, a director of nursing and quality assurance, a business analyst and a product manager. I know all of you are eager for the presentation to begin, so let me now turn the microphone over to our speaker so they can get started. Janet and Robert, please take it away.
Robert Moore (01:46):
Excellent. Thank you very much. We are so grateful to be here with you today. Let's get right into memory care citations. So we know that throughout this presentation there are going to be discussions surrounding the top citations. And one of the key areas to focus on is memory care. Memory care is at the top of focus and we want to ensure that every resident has a thorough cognitive assessment.
As of January 1st, 2023, Medicare pays approximately $266 per assessment. This is an assessment that is available to be provided by a physician, nurse practitioner, clinical nurse specialist, or physician assistants. And these cognitive assessments can be provided via office or outpatient, private residents or care facility, rest home or via telehealth.
The CMS cognitive assessment wants to ensure that the care plans that are in place address functional limitations and that the care planning for the patients with cognitive impairment are in place and regularly updated. The key areas to focus on are dementia, including Alzheimer's disease at any stage. This cognitive assessment is available and can be given For CPT code 99483. This has replaced the interim HCPCS code of G0505.
Janet Feldkamp (03:21):
So hello, this is Janet. I'm going to be doing a variety of things. Rob and I are going to go back and forth, but those folks that have joined for AL, don't worry because when you really think about care in the post acute care sector, although we may be referencing some CMS citations and a variety of other things, the underlying care aspects in the post acute care environment, the concepts translate both the AL as well as the NIF and SNIF. So that's what we're going to be doing.
And also, as you probably are well aware, many states, the surveyors are cross-trained with between the SNIF, NIF stuff as well as the AL. And oftentimes the surveyors will be thinking SNIF. And you're like, no, no, no, we're in the AL. But the underlying professional care standards, the expectations of quality of care and particularly in the dementia care environment are very much the same because you can pretty much transfer in many situations the thoughts that occur, pardon me, in dementia care and AL right into that SNIF and NIF.
The residents are often very similar and many times the care is as well. And so when the surveyors are building on the SNIF side, they're going to look at a number of things, but we really need to be thinking about more so what kinds of things we're going to be doing. And we're going to talk about critical element pathways. And for the folks that actually understand what critical element pathways are in the SNIF world, really where we're going to go is we're going to utilize these tools that can also be accessed by assisted living individuals if you go to the CMS website.
And what is a critical element pathway? A critical element pathway is this tool that about 20 plus of these are provided in the survey tools that are out there on CMS's website. And what it is, it's a pathway that is looked at by the surveyors when they come. And again, there's things like observations over various shifts and there's multiple questions. There is resident family and resident interviews along the way, staff interviews, there's questions and answers.
And you can utilize these not just for knowing what the surveyors will come and do, but to look and actually deal with what kinds of policies and procedures you should have, should you, when you're dealing with the dementia and there has been a situation in which there was some concern about the dementia care or whatever, utilize these as learning tools. So just because they happen to be SNIF tools doesn't mean that you have to use them that way. So when the surveyors are coming in, so think about this, they're going to be looking at appropriate dementia care provided, person-centered care.
We know that person-centered care, and whether we call them care plans or service plans or whatever we do in AL, they need to be identified as specific for that individual. How's the environment? How's the staffing? We have to have sufficient staffing. But most importantly, in special care environments such as dementia or even if you translate it into a respiratory care unit, do the staff possess the actual skills and competencies necessary?
Behavioral individuals, same kind of thing, our staff need to be well-trained, okay? Staff interviews, medical record reviews, care plans, all of that. And personalized and realistic goals. Those things are all the same in many ways. Documentation may be different, platforms for documentation and other things may be different, but we're going to really talk about the top 10 skilled citations. Again, don't worry, they're going to be translated into things that can be used for all of our colleagues, SNIF, NIF and assisted livings as well.
So let's move on. You can see that the top 10 citations have a number of different things. Reporting to NHSN, ugh, I don't even want to go back there, that was the top reported problem that was out there. There's a lot of reasons for that, but we're just going to buzz right past that for now. Infection control, accident hazards, quality of care, food and kitchen fun, always something interesting. And oh, one little tidbit that you didn't know many, many years ago, I actually was a surveyor and although I wasn't a dietician, I did the kitchen citations as well.
And that's what you see oftentimes when you have surveyors in who may not be, they may be social workers, they may be nurses, they may be sanitarians in some areas. So you're going to get a lot of variety there. ADL, activities of daily living care is the next one, and we're going to go through all of these. Comprehensive care plans, treatment and services to prevent pressure ulcers and any kind of skin integrity issues, labeling and storage of drugs and biologicals, always an easy one to cite and reporting of an alleged violation.
So we're going to keep moving. And we have a few things that I'm just going to highlight here. So on the nursing home side, you will see that there's active nursing homes, about 15000, a little more than that, and where we really are with that, we used to be about 18000, but I think when we now have higher assisted living, lots of wonderful assisted living providers out there, and so we've seen a lot of changes. We have less nursing homes. I think we're going to continue to see less nursing homes across the country.
This is with the 10 different regions and a little bit of tidbits there. But also want to talk a little bit about, in many states, there's civil money penalties for assisted living, but this is the civil money penalties issued by the federal government of CMS. We also know sometimes assisted living has civil money penalties, fines, and so do the nursing homes on the non-federal side because assisted livings are state only.
So if you have an interest in reviewing this, because there's a whopping amount of fines out there, you can go to the CMS, you can go out there and look for QCOR. And so just think about that. If you have a question about that, we can also provide a link for that at a later point. But Rob's going to move right on into F684 and talk about quality of care.
Robert Moore (10:12):
Thank you so much, Janet. F684 quality of care, being a previous director of nursing, we all understand that we are in this position or in that role to provide good quality care. So concerns which have caused or have a potential to cause a negative outcome. None of us want negative resident outcomes. We want positive outcomes.
So guidance for the end of life and hospice care, care and services provided need to meet professional standards, when it comes to that we also need to take a look at behavioral health and dementia care. Do the individuals that are caring for these residents, do they have the proper training and ability to care for these residents? That's one of the first things that if a surveyor comes into the facility they're going to be looking at is the continuing education there for those that are caring for these specific type of residents.
So that's something to keep in mind. Also, non-pressure related wounds. The arterial diabetic venous, are they receiving the proper care from a person that is appropriately trained to give that care? Many times when you're taking a look at hospice and end of life care, there can be discrepancies in who provides what piece and portion of care to that resident. Make sure that you have documented and outlined in your policies and procedures what exactly is being provided as far as care to that hospice resident by whom?
Janet Feldkamp (11:56):
And collaborate with the hospice as well because you're treating the whole person, aren't we?
Robert Moore (12:02):
Absolutely. Thank you Janet. F880, infection prevention and control. Big, big, big one here, team. Effective screening for symptoms. Quick response to symptoms, testing, isolation. We all know that infection has been a top item for many, many years. And then Covid came and really impacted our assisted livings, our independent livings, our CRCs, our SNIFs, and I think a heavier focus now today on infection, prevention and control is still out there.
So ensure that staff is trained with the correct type and use of PPE. Those masks ensure that the N95 masks fit appropriately and that you have documentation surrounding the fit test and that zones are clearly defined so that upon entry into the facility, those zones are noted on paper as isolation and quarantine zones. Management of residents with dementia and wandering and tracking and trending, have those documents ready and available. And continuous to review process to monitor compliance through your QA and A, or your copy. I would always suggest that facilities have the infection prevention and control outlined in each one of those. Any additions from you on this, Janet?
Janet Feldkamp (13:31):
No, I think we can just kind of keep moving. You covered that well. So what do you expect when the surveyor related to infections? Well, we know that it's just been crazy over the period of time. Standard precautions, transmission base, how quickly you move those residents when someone has a communicable disease and all of those kinds of things. The infection prevention and control program that you have, and even if you're in assisted living, you really need to be having I'll just say a specialist, somebody that really is your expert.
One of the things that today I was on was with the Ohio Medical Directors Association and we had a long discussion among the team on there and a presentation on Candida auris and Candida auris is a fungus and it is very, very deadly. Go to the CDC, there's some wonderful things you can learn about Candida auris and it is making its way across the country and it can be deadly between 30 and 70% for infections because it is resistant and we won't go into that, but really know what's going on in the country, but also in your world.
It's very, very important to know what's happening in your state and your location along the way. Water management, we've seen a lot of legionellae, Legionnaires' disease, laundry services, antibiotic stewardship. So, if you're not monitoring your antibiotics and doing things appropriately, you'll have some issues there. Influenza, pneumococcal, and a whole bunch of immunizations along the way. But we have to make sure that they are really following the protocols as we go ahead and move forward.
So let's talk a little bit about the infection preventionist, because we know that this a highly cited tag sections and we know that a lot of facilities on the SNIF side during the pandemic had a sanction imposed that was directed plans of correction because they had a lot of issues with the infection control. But really important that we have in the infection control appendix PP, that is the interpretive guidelines for the nursing home side, had a lot of changes in October and a few more changes in February of 2023.
So you really need to be watching and reading many of these areas. And oh, by the way, when you're pulling up appendix PP as your SNIF, I put it on my desktop because when the changes come through with red and italicized actual font for the areas that were most recently changed, you will see many, many changes. But also with the infection prevention stuff, there is a critical element pathway that goes for seven pages. And it is really important that we look and watch and use those. And that critical element pathway number is CMS-20054, really important. And also six, and what the other thing is the critical element pathways and also in the interpretive guidelines for the SNIFs and NIFs, we have many cross references along the way, so be knowledgeable about what that is. But let's move on.
Robert Moore (16:54):
Thank you, Janet. Now we're going to take a look at F689, free of accident hazard supervision and devices. This is key, avoidable versus unavoidable. You need to be looking at things like where med carts are stored, where lifting devices are stored. Are there any issues with leaky water, drinking fountain? We all know that life safety comes in and can find things that we didn't even understand or acknowledge that was a potential risk.
So really understanding and identifying the risks, evaluate and analyze the risks and implement interventions across the board and monitor the effectiveness. This is a very, very highly tagged citation for accident and hazards. And when we take the deep dive into free of accident hazards, we understand that we all want a safe living environment for our residents and for our colleagues within the facilities. So ensure that this is part of your QA and A and copy process as well to just brainstorm, do a walkthrough of your facility and together as a leadership team, listen to the feedback of the aides, the CNAs, the nurses, what do they feel may be a risk because oftentimes they're going to be the ones that will call it out first and it ends up being not addressed. So take the time, do those walking rounds and really focus and listen to what the staff has to say.
Janet Feldkamp (18:39):
So let me pop in for one moment. So let's talk about what are the words they use with supervision? Adequate supervision, what is adequate supervision? And boy does it depend, doesn't it? And I think it's something that is really important that when you're looking avoidable versus unavoidable, when you're investigating, all of those things that making sure that you know the supervisory aspect of what was going on with this resident and do not forget to include that in your documentation related to your investigation of your accident.
Robert Moore (19:15):
Oh, well said Janet. Well, well said. All right, now on to the F689 critical element pathway. So prior to surveyors entering the building, what are they going to be looking for? They are going to be reviewing the MDS and specifically the cause. Which one's triggered? Which ones are adequately documented in section B, those cause and what is the care plan? How are we focusing our resources to better the resident's safety related to these triggers?
Upon entry into the campus. Observation of all areas, those walking rounds. Smoking now includes electronic cigarettes. Note that, that is new. So it's not just smoking tobacco cigarettes, it is the use of electronic cigarettes as well. Through wandering and elopement, what are your facilities or campus's policies and procedures on elopement? When was your last elopement? Fall observation, entrapment safety, those bed rails, handrails. Are there sharp edges?
Once again, these items can be noted in walking rounds. Are people following the smoking areas that are designated for e-cigarettes and tobacco cigarettes? When you are doing the changing of linen, do you have a place documented where CNAs or nurses can document issues with sharp edges on handrails or side rails? Building an equipment, toxins and chemicals clearly labeled people, clearly labeled.
And water temperature. Make sure your logs are up-to-date. Surveyors very quickly pick up if the log is noted with the same color ink, the same handwriting. And start to question were these filled in last minute? And it will trigger them to do their evaluation in multiple different areas. Is lighting adequate and are assistive devices available per the physician orders? Key items here. And the critical element pathway, fall response, evaluate and monitor resident for 72 hours after a fall. Do you have documentation of this?
Do you have vital signs taken for the full 72 hours? Do you have interdisciplinary or progress notes completed? What were the circumstances? Was it witnessed? Was it unwitnessed? If it's unwitnessed, what are your policies and procedures surrounding evaluating risk for head injury because it was unwitnessed. Record circumstances, resident outcome and staff response. Notify the primary care provider and implement immediate interventions within 24 hours.
And where are you implementing those interventions or where are you documenting them? Ensure that they are going in the resident service plan or care plan because once again, if it's not documented, it's not done. Those fall assessments need to be updated after a resident has an incident such as a fall and continuous update of the plan of care. And monitor staff compliance and resident response.
Janet Feldkamp (22:32):
So before we move on, as a nurse attorney, I've spent so long, so many investigations related to things. So you brought up some excellent points, Rob here. Head injury. So let's say the person has fallen to the floor or is found on the floor. The resident says they have not hit their head. We know people have fragile vessels, maybe they're even on blood thinners, which is more obvious, but do you send them to the hospital, do you not?
When you notify the doctor, what do you say? How do you deal with it? What do you document? What is it when the family refuses to send them? So all of those kinds of things. But what are you doing for neuro checks and what are you documenting in your neuro checks? What if somebody goes to the ER and then returns and you stop your neuro checks?
Well, I'm going to tell you over the period of time, there's many times a very small, low level bleeds that happen. So if you have a policy on the amount of time your neuro checks should be done over whatever length of time, person goes out to the ER and comes back within that time, you should pick them back up for a little bit. Think about those things. So many things. But also think about when you are investigating, sometimes you have injuries of unknown source, right?
And so my general definition of that is not something able that the resident can tell you about, which is many of them, right, and that maybe those injuries may be unusual of nature or a pattern, but think about it, our seniors often bruise very slowly. I think every one of us who has a clinical background has seen something that somebody has a bruise on their knee or something that comes and you go back 72 hours, you find nothing.
Maybe you need to go back a little farther because they may end up with some kind of patellar knee fracture from an inappropriate transfer. Who knows what happens. But think critically as we're dealing with accident hazards because I will tell you, the accident hazard tag is very frequently cited and can be a serious one. And you can end up with actual harm citations or a serious state level citation. And whether you are in the nursing home or in the AL, an important thing to clearly understand.
Speaker 1 (25:06):
That concludes the latest episode of the Post-Acute Point of View podcast. We have a lot of guests and topics coming up that you won't want to miss. So be sure to subscribe to learn more about MatrixCare and our solutions and services, visit matrixcare.com. You can also follow us on LinkedIn, Twitter, and Facebook. Thank you for listening. Be well and we'll see you next time.