Reg's Blog

Senior and Post-Acute Healthcare News and Topics

SNFs: Five Compliance Issues to Pay Attention To

I don’t write a lot on compliance issues. Given the scope of my firm’s practice in this area, maybe I should.  My practice focus is more strategic, policy, research  and corporate development while compliance is the purview of another Sr. Partner and it is our largest practice area (by full disclosure, this practice area is headed by my wife).  In a recent meeting, we reviewed the list of common/current compliance issues, engagements, and information and speaking requests and determined that five compliance issues bear illustration via a post here.  These are not in order of importance but their appearance represents issues of current magnitude or issues where we see clients potentially putting themselves “behind the 8 ball” by not addressing the requirements properly.

  1. Emergency Disaster/Preparedness Plan: In December of last year (2013), CMS issued a proposed rule that will significantly update the requirements for providers to address all elements of Emergency Preparedness (storms, earthquakes, active shooters, infectious disease outbreaks, etc.).  While final Conditions of Participation are forthcoming as comment periods were extended, providers who have yet to start on a path toward compliance will find themselves startled by how lengthy and daunting the route toward compliance is. This process is a complete revamp of anything prior.  Attached via link is the CMS Preparedness checklist: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_Provider.pdf   Clearly, the larger the organization the greater the length of time and preparation required to complete the plan.  As of this writing, the significant majority of the providers we connect with regularly are not in compliance and worse, haven’t started a process toward compliance and/or, haven’t paid attention that this new requirement is forthcoming.  Note: This requirement applies to virtually all providers that participate in Medicare and Medicaid including hospitals, home health organizations, hospices, and yes, Assisted Living Facilities if the same receive resident care funding via Medicaid waiver programs (Home and Community Based Services).  Anyone wishing additional info. or templates on this requirement, contact me directly via a comment to this post with a valid e-mail address or via the contact info. on the Author page of this blog.
  2. CPR/Advanced Care Planning: In October of 2013, CMS issued new survey guidance to SNFs and State Survey Agencies requiring that all SNFs provide CPR to residents who wish resuscitation and that each SNF have a program and process in-place to assure adequate trained individuals, the communication and education of residents regarding the availability of CPR and the rights of residents to execute Advance Directives including no-code orders.  Effectively, CMS has said that a facility must provide residents access to CPR if desired, 24 hours per day, 365 days per year and no longer will “no code” policies suffice or “911 policies” be permitted.  This regulation went into effect 30 days after it was published though we are just beginning to see enhanced enforcement.  For SNFs there are many nuances to consider including the issues around resident transportation, activities outside of the facility, etc.  As the SNF, without a complete discharge or transfer to another provider for specific care (hospital, ER, etc.) is still responsible for the care of the resident, CPR trained individuals must be available (and the SNF must assure availability) when residents are transported to physician visits, on therapeutic (recreational) outings, etc.  Again, as with the Emergency Preparedness requirements, we continue to see a large number of SNFs unaware of this requirement and not in compliance by the documentation and trained staff requirements across the resident care continuum.  The original CMS memo on this issue is here : http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-01.pdf
  3. QAPI: I have written about this topic in an earlier post ( http://wp.me/ptUlY-fa ) and posted a PowerPoint from a presentation I did last fall on the Reports and Other Documents page of this site.  While CMS has not yet set a hard date for SNFs to be compliant with a QAPI program, one is forthcoming.  Like the Emergency Preparedness requirement, QAPI is not a simple “paperwork” fix.  Meeting the requirement takes time and requires commitment fromf the entire organization plus an enhanced engagement from residents (via input), families/loved ones, and community.  Additionally, with pay-for-performance forthcoming (competitive bidding/Quality Measures), facilities that are not actively engaged in a QAPI effort are today, behind and falling further behind.  Illustratively, we have clients that have had their proverbial compliance Bacon “saved” by having a fully functional QAPI program in-place (QAPI minutes, data, etc. were used to show surveyors that issues were addressed, monitored and continued to be monitored – particularly QIS friendly).  The take-away is that SNFs need to get on their QAPI journey now and build, build, build!  Again, anyone needing additional resources that aren’t on this site or direction, feel free to contact me via comment or e-mail (on Author’s page).
  4. Care Transitions: SNFs that aren’t actively monitoring any and all transitions of their residents to other providers, especially hospitals, are placing themselves at- risk; competitively and from a reimbursement perspective.  While the latter has yet to arrive, it is coming as CMS will, under ACA mandated pay-for-performance rules, begin to reduce Medicare payments for SNFs that re-hospitalize and hospitalize unnecessarily, Medicare residents.  Additionally, as bundled payment models expand and ACOs increase, SNFs that cannot control their transitions are at competitive risk; the risk that they will be precluded from various alliances, ACO models, etc. In May of 2003, CMS issued enhanced survey guidance for hospitals via updated interpretive guidelines on discharge planning, focused on re-admission reductions.  In order for SNFs to continue to garner referrals and position themselves for competitive success in the near future (and survival), a focus on care transitions is paramount.  Attached is the link to Interact – a good resource for transition monitoring and reductions tools: http://interact2.net/
  5. Medicare Therapy Billing: This issue is on the OIG’s radar, in their 2014 work plan and forward on the audit agenda for CMS.  SNFs that ignore this issue are asking for potential significant problems including False Claim Act exposure (it is illegal to bill Medicare for services not medically necessary).  SNFs need to have an audit step engaged, periodically reviewing claims against the MDS, the careplan, nursing documentation, etc.  If an SNF is using a contract therapy provider, this audit step is even more critical.  Remember, SNFs cannot cede liability for fraudulent acts committed as a Part A provider to a contractor.  Additionally, most therapy contracts we see (virtually all) limit the therapy company’s liability (indemnification) for rejected claims to the cost of the therapy billed to the SNF. In other words, while the entirety of the stay or large portions thereof are deemed non-payable to the SNF by CMS (or a CMS auditor), the SNF will recover from the therapy provider, the cost of therapy billed to the SNF for the stay – the rest of the RUG revenue is gone!  In short, SNFs cannot nor should ever allow, their therapy contractors immunity from routine outside audits of their care provision, their MDS coding, their documentation, etc.  This is a big and growing compliance risk area for SNFs and knowledge and simple systemic audit tools are a big step toward keeping this risk low.  For additional insight on this area and resources, contact me directly via e-mail or post a comment on this article.
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June 19, 2014 - Posted by | Skilled Nursing | , , , , , , , , , ,

2 Comments »

  1. Reg, One issue I see is that of SNFs skilling patients who are not appropriate. Example, 93 year old male lung CA with mets to the brain and near death.

    Joseph S. Killian Chief Executive Officer Hospice of Southwest Ohio 7625 Camargo Road Cincinnati, Ohio 45243 513-770-0820 Office 513-382-6688 Cell

    Comment by Joe Killian | June 19, 2014 | Reply

    • Joe:

      Absolutely a problem. I wrote a post about this issue a month or so ago (http://wp.me/ptUlY-gA). The concept of Skilled to Death or SNFs skilling patients that should be hospice because a) they want the revenue and census and/or b) families are told that they won’t have to pay for any care in the SNF or “inpatient” setting unlike under the Hospice benefit, where they’d be responsible for the room and board component. This practice is a danger area for SNFs as it is full of potential False Claims Act peril. Thanks for the comment!

      Reg

      Comment by Reg Hislop III | June 19, 2014 | Reply


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