Case Mix reimbursement operates on a weighted scale, the more resources needed to provide resident care, results in a higher CMI score and a higher reimbursement level. The Minimum Data Set (MDS) Assessment is used by states to collect objective data regarding a resident within specific timeframes, across multiple disciplines. When an MDS assessment is completed, a clinical score that reflects resident acuity is assigned. This clinical score, known as a Resource Utilization Group (RUG) level, correlates with direct care costs in a Case Mix reimbursement system.

Implementing systems that strengthen documentation of care provided and data capture in the MDS assessment, can have a significant impact on a provider’s Medicaid revenue.

Nurse staffing shortages have escalated nationwide to such an extreme level they are now labeled a staffing crisis. Skilled nursing facilities have implemented wait lists, declined new admissions, and even closed units as a result of the staffing crisis.

While the nation is currently gripped by the pandemic, long-term care providers will absorb the ripple effects of the staffing crisis for years to come. Industry experts anticipate providers will see declined reimbursement, as well as increased federal auditing due to use of PHE waivers. In addition, providers should expect to see Five Star rating reductions for survey non-compliance related to infection control surveys, with zero tolerance resulting in immediate jeopardy tags. Five Star ratings for staffing may see effects from burnout, vaccine mandates and other constraints placed on healthcare workers.

COVID-19 Vaccination Federal Mandate for Staff

COVID-19 has certainly taken taking its toll on the nursing home industry where staffing was a challenge even prior to the COVID-19 pandemic. The recent directive by the federal government that is mandating that all employees of skilled nursing facilities to be COVID-19 vaccinated on or about October 18th, 2021, (the estimated last day for final COVID-19 Vaccine shot on October 4, 2021) further compounds the staffing crisis and could result in significant negative ramifications to the clinical, financial, and operational performance of nursing facilities.

This new federal mandate comes shortly after the May 11th, 2021 regulation requiring nursing homes to report weekly the status of completed COVID-19 vaccinations for both residents and staff to Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN).

Skilled nursing facilities (SNF) began operating under the Patient-Driven Payment Model (PDPM) on October 1, 2019. Many current SNF employees have only been exposed to the Resource Utilization Group (RUG) model that was retired on September 30, 2019. The RUG model included therapy groups that ultimately trumped almost anything clinical being treated in the SNF. This may have resulted in minimum data set (MDS) assessments under the RUG model that didn’t include all diagnosis, condition and treatment information simply because it didn’t affect reimbursement.

The MDS assessment was originally created to assist SNFs with developing a comprehensive care plan for residents admitted to a SNF. In the 1990s, the MDS also became a payment tool under the RUG payment model. Consistent focus under the RUG model was on accuracy of therapy days and minutes captured on each MDS assessment. The number of days and minutes of physical and occupational therapy and speech-language pathology (SLP) services was ultimately the deciding factor regarding RUG and daily payment amount.

Have you ever felt like your life was an eternal boxing match? Every day you wake up, put your gloves on, and head out just to fight another day. I have felt this feeling many times throughout my life, but nothing has compared to this year of uncertainty and change. As I sit at my desk writing this article, the date is October 1st. Exactly one year ago today the company put on its' boxing gloves and went out to face PDPM. Our company spent over a year planning and preparing for that day and just as we were getting our arms around this new payment system, in came Round 2, COVID-19.

We barely had time to sit in our corner and catch our breath before putting the gloves on to go fight again. With this opponent, we did not have much time for preparation. There was a lot of trial and error and learn as you go. All of our teams bravely stepped up to this new opponent, and I was personally able to see the unwavering commitment from all of you. Six months into this pandemic, we are starting to see the light at the end of the tunnel. But just as we have had a moment to sit in our corner and catch our breath, here comes Round 3!

Deadline Looming for Mandatory Nursing Home Compliance Programs

Skilled Nursing Facilities have until November 28, 2019 to adopt and implement a compliance program that meets the elements set out by the Center for Medicare and Medicaid Services (CMS). Beginning on that date, state survey agencies will start assessing nursing homes’ compliance programs as an additional condition of participation in Medicare and Medicaid. Issued in 2016 as part of CMS’s revised Part 483 of Title 42 (“Requirements for States and Long Term Care Facilities”), the CMS compliance program elements are functionally identical to those from the Office of Inspector General for Health and Human Services (OIG).¹ Already the standard for effective compliance programs, the OIG elements are used to measure an organization’s culpability when federal fraud and abuse laws are violated. Specifically, the OIG considers “the existence of an effective compliance program that pre-dated any governmental investigation when addressing the appropriateness of administrative sanctions.”

Three new items have been added to Section N of the MDS, that will have a major impact on the policies and processes you have used in the past regarding medication reconciliation and administration.

• N2001: Drug Regimen Review (Assessed on Admission)
• N2003: Medication Follow-up (Assessed on Admission)
• N2005: Medication Intervention (Assessed on Discharge)

Although this new item may seem to be commonplace in your facility already, there are scenarios which frequently arise, that may interfere and render your processes inadequate. These fundamental concepts will be required for Medicare Part A covered residents but are considered a best practice for any payer source.