EXCEPTION REVIEW UPDATE Ohio Department of Medicaid TERRY

EXCEPTION REVIEW UPDATE Ohio Department of Medicaid TERRY MOORE, RATE SETTING, SECTION CHIEF - ODM DAN HIRSCHLER, PROGRAM MANAGER - ODM

EXCEPTION REVIEW SFY 2018 HISTORY, FINDINGS, STATISTICS

OHIO MDS EXCEPTION REVIEW RULES AND STATUTES Reference Ohio Administrative Code (OAC 5160 -3 -43. 4) Nursing Facilities: exception review process. Ohio Revised Code (ORC 5165. 193) Exception review of assessment data. .

MILESTONES 1 2 ODM contracted with Myers and Stauffer to conduct the Exception Reviews for Ohio providers Exception Reviews began January 8, 2018 in Columbus, Ohio 3 4 90 -100 Exception Reviews will be complete by June, 2018 It is anticipated that approximately 100 Exception Reviews will be conducted for FY 2019

Process Overview 1 2 3 4 Provider is notified 2 business days in advance of the schedule Exception Review Provider is then emailed a notification of estimated exception review date confirmation RN Reviewer will arrive in AM or PM RN Reviewer will provide an Entrance Conference detailing the Exception Review process 5 6 7 8 A resident record list including, ARD date, is presented to the facility liaison to retrieve medical records The review of supporting documentation associated to the RUG classification begins Once the Exception Review is completed an Exit Conference is conducted and findings are detailed Exception Review findings are communicated to ODM • ODM will submit a summary findings letter to the provider

Myers and Stauffer LC Contractor for OHIO DEPARTMENT OF MEDICAID TEENA WARD, RN REVIEWER 6

EXCEPTION REVIEW TIPS 1 2 3 Provide a private, quiet work space free of audio and video surveillance where an electrical outlet is available Provide a facility liaison to assist with retrieving supporting documentation as requested by the RN Reviewer Electronic or hard copy records or any combination is acceptable for review 4 5 6 If facility laptops are necessary, have readily available including log-in information for RN Reviewer ADL documentation will be needed on all requested records Provide facility policies including but not limited; protection of EHR, mattress policy, master signature log

EXCEPTION REVIEW STATISTICS 1 90 -100 Exception Reviews will be completed for FY 2018 2 Facility types include: • For profit, not for profit • Small (20+ bed) to large (>250 bed) • Single facility, multi-facility chain • State-wide (all corners of the state) 3 • • Average percent unsupported 15% Number of reviews expanded 17 / 34% Number of reviews under threshold 40 / 80% Number of reviews over threshold 10 / 20%

EXCEPTION REVIEW STATISTICS (Continued) 4 Number of reviewed records by RUG: • Rehabilitation 433 / 34% • Extensive services 61 / 5% • Special Care High 247 / 19% • Special Care Low 158 / 12% • Clinically Complex 141 / 11% • Behavioral Symptoms/Cognition 159 / 12% • Reduced Physical Function 92 / 7% 5 Number and percent of unsupported by RUG: • Rehabilitation 60 / 14% • Extensive services 4 / 7% • Special Care High 84 / 34% • Special Care Low 25 / 16% • Clinically Complex 33 / 23% • Behavioral Symptoms/Cognition 45 / 28% • Reduced Physical Function 12 / 13%

MDS ITEMS MOST MISUNDERSTOOD 1 2 3 4 Activities of Daily Living (ADL) Rule of 3 Section G COPD Section I Shortness of breath when lying flat Section J 1100 Diagnosis (esp. Quadriplegia) 7 -day vs 60 -day Section I Calories and fluid to support feeding tube/parenteral/IV feeding Section K 5 Mental Status (BIMS and Staff Assessment) Section C and B 6 Restorative nursing programs Section 0500 7 Z 0400 for interview items 8 Software inaccuracies

MDS ITEMS MOST UNDERSTOOD 1 Diagnosis in general 7 -day vs 60 -day support Section I 5 Insulin items Section N 0350 2 Pressure ulcers Section M 0300 6 3 Wound and skin problem items Section M 1040 7 Licensed therapy Section O 0400 4 Skin and ulcer treatment items Section M 1200 8 Respiratory therapy Section O 400 Special treatments, procedures and programs requiring administration documentation Section O

DOCUMENTATION MOST MISUNDERSTOOD 1 Documenting resident and staff interview findings 5 2 Documenting actual ADL frequencies for the late loss ADLs 6 3 Linking support related to diagnosis (such as medication, etc. ) 7 4 Validating degree of mental/cognition loss 8 • • • Making self understood Short-term memory Cognitive skills for daily decision making Treatment administration verification when service provided outside of facility Deleting resolved diagnosis from one assessment to the next (i. e. pneumonia) Need for Parenteral / IV Feeding must include hydration and/or nutrition documentation 7 -day Active diagnosis requirement

DOCUMENTATION MOST UNDERSTOOD 1 60 -day Diagnosis requirement 5 Insulin injections and orders 2 Fever (be sure to document baseline) 6 Therapy minutes and days (lacking in physician signatures) 3 Pressure ulcer staging and wound documentation 7 Behavioral symptoms - frequency 8 Respiratory therapy minutes 4 Other ulcers, wounds, and skin problems (remember to document that an open lesion is OPEN)

DOCUMENTATION PIT FALLS 1 Obliterations, write-overs, and illegible entries 5 2 Lack of documenting observation and interview findings 6 Lack of actual ADL frequency to apply the Rule of 3 7 Illogical dating for ARD, Z 0400, and Z 0500 3 4 Omission of ALL ADL key options required on the MDS (particularly option “ 8”) Lack of complete definitions for ADL key options (Self-Performance /Supported-Provided) Lack of complete definition for the four late loss ADLs (especially eating and toileting ADL) • • • 8 ARD 09/09/year Z 0400 09/19/year Z 0500 09/15/year Restorative nursing programs • • No actual minutes reported (check-off sheet) Combined programs Inadequate evaluation of program Lack of measurable interventions

GENERAL COMMENTS FROM FACILITY SURVEYS Reviewer was very organized, professional and extremely knowledgeable. Overall, the process went smoothly considering it was a new process for many of us. The reviewer was very informative and provided us with a lot of feedback and education. Reviewer was very prompt, professional and courteous. We appreciate her time & understanding that she gave when we asked questions. RN reviewer was very polite. Process was very well organized and timely. She took time to explain findings and offered suggestions for improvement. This being our first experience with this type of review was quite a learning experience. Provision of education very helpful.

GENERAL COMMENTS FROM RN REVIEWERS TEENA AND ROBIN • • • Facilities are warm and welcoming Work space is ready upon arrival and comfortable Facility staff are helpful and attentive Facility staff are eager to understand learn Facilities are organized and prepared

EMPOWER YOUR STAFF

Nursing RN, LPN Social Service STNA FACILITY DOCUMENTATION “A TEAM SPORT” Licensed Therapy Dietary Activities

FACILITY LEADERSHIP Administrator, Director of Nursing Social Service Nursing STNA Therapy Dietary Activities Educate, Educate Observe and Report Special Services Document and Communicate Lead, educate, document Key witness with eyes Physician order, plan of Often the first source of on the target treatment, minutes of service resident change! Document rendered and communicate

YOU BE THE EXPERT

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