Approximately 45% of hospital admissions from skilled nursing facilities could have been avoided if telehealth care were available, according to the Centers for Medicare & Medicaid Services.

The agency also said that 19% of hospital transfers originate from SNFs, which the Medicare Payment Advisory Commission asserts can unnecessarily expose seniors to falls, delirium, infections and adverse medication interactions.

The Reducing Unnecessary Senior Hospitalization (RUSH) Act of 2018 seeks to cut those numbers by providing emergency telehealth care.

“The RUSH Act presents a great opportunity for government to step back and allow innovation to solve a problem which has restricted access to care at nursing homes for decades,” said Rep. Adrian Smith (R-NE), one of the bill’s sponsors.

Another sponsor, Rep. Diane Black (R-TN), a registered nurse who has worked in long-term care settings, said these changes will be especially beneficial in isolated, rural parts of the country with limited access to care.

“Medical innovation and technology is at the forefront of today’s healthcare system, and it is vital that the Medicare program embrace advances in emergency medicine to ensure that quality, affordable care remains available to our nation’s seniors,” Black said.

Other bill sponsors include Joe Crowley (D-NY), Morgan Griffith (R-VA) and Ben Ray Luján (D-NM). Industry advocates, including Health IT Now Executive Director Joel White, applauded the bill’s introduction.

“The RUSH Act will bring Medicare fee-for-service into the 21st century by allowing value-based contracts with medical groups who provide high-quality, on-site emergency care facilitated by a telehealth connection,” White said. “This should help stem the flow of patients from nursing home to hospital by treating patients in place.”

The House also affirmatively included clinical nurse specialists in the bill.

The legislation, which expands nursing education grants to include education programs for clinical nurse leaders and combined registered nurse and graduate degree programs, provides more accessibility to education, said Amy Stewart, BSN, RN, AADNS Curriculum Development Specialist.

Specific to long-term care, “the bill extends loan repayment and scholarships for geriatric care education through fiscal year 2022,” she added.

The bill addresses care concerns related to the nation’s most vulnerable populations, including the elderly. It also acknowledges the need for specialized education to improve the quality of care for them.

“For long-term care, this means assistance in obtaining specialized geriatric education so that nurses can positively impact care of the residents,” Stewart explained.

Overall, the goal of the legislation is to support advancement of nurses and the nursing workforce.

The IMPACT Act of 2014 requires the development of quality measures and skilled nursing facilities to report quality data. Drug Regimen Review with Follow-Up for Identified Issues is a new quality measure that will start to be gathered Oct. 1, 2018, and will impact reimbursement beginning FY2020.

This measure continues to reflect Centers for Medicare & Medicaid Services goals of reducing adverse events in nursing homes and reducing the use of unnecessary drugs. There are three new Section N items on the MDS beginning October 1, 2018 to capture this quality data for measurement.

Two of the items will be gathered with the initial MDS including “Did a complete drug regimen review identify potential clinically significant medication issues?” and “Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?”

The third question will be answered on the Discharge from PPS assessment. “Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the admission?” CMS estimates 10 extra minutes of MDS nurse time. This measure looks at if providers were proactive to potential or actual clinically significant medication issues during a skilled stay.

It is important for sta to understand the definitions. Medication reconciliation makes sure that everyone has the most accurate and current list of medications: Looking at name, dose, frequency and route.

Please send your payment-related questions to Patricia Boyer at ltcnews@mcknights.com.

Currently, ACOs can have up to six years without taking on risk, while being granted waivers from certain federal requirements. The new proposal would shorten that window to two years for basic plan participants. The proposal also would offer greater rewards for ACO physicians using tele-medicine.

Officials said the new “Pathways to Success” program is a stride toward “greater accountability” and “new flexibilities.”

They projected it would save the Medicare program $2.2 billion over 10 years.

“The time has come to put real ‘accountability’ in accountable care organizations,” CMS Administrator Seema Verma said during the unveiling Aug. 9. “Medicare ACOs do not currently face any financial consequences when costs go up, and this has to change.”

The MSSP was established under the Affordable Care Act and launched in 2012. Many long-term care providers feel they are not given enough of the savings that are realized.

A government analysis of ACO performance revealed that CMS has spent an increasing amount on ACOs. This has occurred, in part, because 460 of the 561 ACOs in the MSSP program “are not taking on risk for increases in cost,” federal health officials said. They can reap bonuses but do not have to pay penalties if they do not create savings.

As part of the proposal, CMS has created a six-month extension for ACOs whose agreements are set to expire at the end of this year. CMS is accepting comments on it through mid-October.

The IRS will hold a hearing on the proposed regulation in its Washington, D.C., headquarters on Oct. 16.

“We will de nitely submit comments and will forcefully advocate our position,” said American Health Care Association President and CEO Mark Parkinson. “If we don’t prevail in the rulemaking process we intend to go to the Hill and seek legislative relief.

AHCA had hoped the Office of Management and Budget would allow its members and other for-profit skilled nursing providers to benefit from new deduction options. But the IRS said in early August that the SNFs cannot take advantage of the 20% business income tax deduction.

“The rule is inconsistent with Congressional intent. [It] was to provide tax cuts to job creators and those willing to put capital into the economy. We are both,” Parkinson told McKnight’s.

An estimate quoted by AHCA showed that an 80-resident facility operating with a 1% margin pays an estimated $32,256 in taxes annually, but it could save $6,451 with an advantageous interpretation of the new tax rule.

Examples of potential incidents include when a resident is the victim of a bad transfer, causing the resident to break a bone; medication errors that cause a negative or even fatal reaction; or when a resident is unattended for too long, causing them to fall and have an injury when attempting to get to the restroom on his or her own.

For a resident to win damages for negligence, the resident must establish that the care provided did not satisfy the duty of care. Also, the resident must establish this breach of duty caused the injury or damage.

Thus, any apology must be structured in a way that is not an admission of a breach of the duty of care that caused the injury to the resident.

If not carefully structured with the advice of the legal counsel who defends the facility and the insurance company that covers and pays the resident for any court awards of damages, the apology could become evidence used against the facility if the resident or resident’s family files a lawsuit.

There is a difference of opinions on whether an apology is a move that will increase the chance of a lawsuit, or will satisfy the resident and family, preventing a lawsuit. You must receive advice from your insurance company and your lawyer who specializes in defending these types of situations.

If they believe that an apology is a good practice, they will help you structure it and advise you how to present it. This is so it is less likely to be used against you as evidence or an admission in a subsequent lawsuit.

If the insurance company instructs you not to make an apology, refusing to follow its position could lead you to lose the insurance coverage.

Please send your legal questions to John Durso at ltcnews@mcknights.com.

The legislation in question is called the “filial support” law, which requires children to support their indigent parents, the Bismarck Tribune reports. It’s been in place since 1877, and at least two dozen other states have similar such laws on the books.

Shelly Petterson, head of the North Dakota Long Term Care Association, told McKnight’s that nursing homes are legally obligated under Medicaid to pursue collecting such debt. She added that operators only use the statue in circumstances where parents transfer income or assets to children and no longer qualify for Medicaid. “This is a complex issue and the suing of a child is a last resort,” she said.

But the adult children who receive the bills say they have no way to pay and are fighting in court. In one case, a family said it received a $43,000 nursing home bill six months after their father, a resident at Augusta Place in Bismarck, died. The nursing home’s attorney contends the Augusta Place resident’s family retained possession of his assets both before and after his death, adding that the family were given “numerous attempts to reasonably resolve” the conflict and “have a duty to support” their father after his passing.

Officials with Augusta Place declined to comment to McKnight’s for this story, since litigation was still ongoing.

While the outcome of the case is unclear, two state lawmakers are exploring ways to modify the statute.

Peterson said operators are open to that possibility.

“How do we protect, essentially, children from being responsible for potentially hundreds of thousands of dollars in bills they had no say in?” Sen. Erin Oban (D-Bismarck) told the Tribune.

The case in question is between Windsor Redding Care Center and the SEIU United Service Workers-West. Windsor Redding allegedly suspended and discharged a nursing assistant, despite one administrative law judge finding that the home had expressed “animus” toward the union. Plus, the home “unlawfully” suspended a merit raise program, the board said.

And despite it retroactively granting those raises to remedy the violation, the employer was obligated to maintain past timing of those pay bumps, the NLRB found, according to Bloomberg.

The state of California and federal government informed Windsor Redding in 2011 that they’d be making cuts to both Medi-Cal and Medicare reimbursements. It was around that time frame that the facility notified SEIU that it was suspending merit pay raises due to those cuts.

The NLRB found that the nursing home kept a list of employees who would receive retroactive raises if those cuts were ever rescinded. “However, the respondent refused the union’s demand to bargain over its decision, stating that, because raises are dependent on government reimbursement rates, it was following past practice by discontinuing raises due to the significant cuts.”

Those Medi-Cal cuts were undone in May 2012, with raises resuming. An administrative law judge dismissed the complaint from the union, for straying from its past practices.

“By deviating from its practice without affording the union an opportunity to bargain, the respondent violated the act.” As such, the board orders that Windsor Redding Care Center reinstate Angela Rowland to her former job or an equivalent position. Plus, it wants the nursing home to fully reimburse Rowland and other employees.

In fact, Columbus, OH-based Atrium, which operates facilities in Michigan, Ohio, Kentucky and Wisconsin, has already duplicated the Allendale model for three of its newest projects.

Conceptually, the $3 million Allendale project started in late 2013 and lasted nearly three-and-a-half years before opening in February 2017. The four-phase process included a 13,400-square-foot rehabilitation addition, as well as various building renovations that include a new therapy gym, chapel, physician office, staff training room and conference room.

Dodd Kattman, principal with MKM architecture + design, says one of the main priorities for designing Allendale was “to create a new way of providing nursing care” for Atrium.

Meticulous study went into developing a master plan that would reduce staff travel times to supply and utility rooms, furthering the goal of fostering more hands-on care for residents.

“It was a new concept, so planning took longer than normal and we had a non-traditional timeline for the project,” Kattman says. “We wanted to create an open environment where staff members have awareness of their surroundings and don’t have to travel down long corridors. By cutting down distance from supply rooms and resident rooms, it reduces footsteps and allows for a much higher percentage of direct resident care.” 

Allendale has the capacity for 60 skilled nursing and rehabilitation residents, with rooms arranged in small-home neighborhoods. Approximately half of available rooms are dedicated to short-term rehab patients, so the community now has the infrastructure to serve as a preferred post-acute provider organization, says Paul Gustafson, regional director for Atrium.

“The new rehab center has been a huge advantage for us – our transitional care volume has been through the roof,” he says.

“Grand Rapids is the largest managed care market in the state and this building has increased our managed Medicare referrals by 300%. And our 13-day average stay rate has proven attractive.”

Although he has no available data, Gustafson believes the efficient design has also reduced staff turnover and serves as a desirable place for prospective employees. “We have gotten amazing feedback from the staff,” he says.

The Allendale design also has another important purpose —enabling easy social engagement among residents, Kattman says.

“We are big believers that quality of life grows when people can create and maintain new relationships,” he says. “We are designing buildings that help to encourage and promote people engaging socially at their individual comfort level.” 

Lessons Learned

1 Building design that reduces the number of staff footsteps helps facilitate more direct care with residents.

2 Rehab infrastructure that minimizes short-term patient stays can grow referral volumes.

3 Strategic seating placement in common areas can increase resident social engagement.

1 While documentation doesn’t specifically affect payment, lack of it can hurt in other ways. 

“While bathing is not directly tied to reimbursement, it’s directly tied to quality outcomes, which can translate into higher census, resulting in higher reimbursement,” stresses Jessie McGill, RN, RAC-MT, curriculum development specialist for the American Association of Nurse Assessment Coordination.

It begins with knowing what to document, says Mary Madison, RN, RAC-CT, CDP, clinical consultant, LTC/Senior Care for Briggs Healthcare.

“Staff members involved in bathing any given resident should be recording when that event happens, albeit it on a paper flowsheet or on an electronic point-of-care kiosk,” she says. “Documentation of bathing shows that it was done and how often.”

Madison cautions that surveyors will look at the documentation to determine compliance with the Requirements of Participation (RoP), as well as honoring the resident’s preferences and choice.

Timing is everything. According to Betty Bogue, president and owner of Prevent Inc., the resident’s bathing preference should be documented on admission, quarterly and with a change in condition.

“The method of bathing must be determined, and it is imperative that care plan interventions be communicated to all caregivers,” she adds.

After bathing is complete, caregivers need to note the proper reimbursement codes for ADLS— such as bathing — that require weight bearing.

“This coding should be audited routinely to ensure it reflects the care plan directives,” Bogue says. As Madison reminds, “the RoP speak to bathing in terms of resident rights, proper care, privacy, confidentiality and dignity — all under the umbrella of resident-centered care and resident preference.”

2 Begin with a good resident assessment.

Madison advises each resident be assessed upon admission and then at specific intervals throughout their stay. Their preferences and right to self-direct their life in the facility include bathing frequency, time of day, and type of bath (shower, tub, sponge or bed). The evaluation also should include preferences around type of soap products and any special needs, such as mobility support, adds Bogue. And always note functional equipment needs, as well as clinical challenges that could impede bathing, such as falls, open wounds, anxiety, skin conditions and weight, she adds.

“Creating procedures to support bathing provides residents with a dignified, comfortable and safe process,” Bogue adds. “A process for residents who require partial or total assistance should be established for undressing, transporting, and the number of staff needed.”

3 Don’t underestimate resident preferences.

“The resident-centered care plan needs to clearly reflect what the resident’s preferences are for bathing,” says McGill. “Many of the benefits that may come from bathing are directly related to them. Do they prefer a warm whirlpool bath? Would they rather take a nice shower? What is the preferred temperature? The resident-centered care plan should answer these questions.

But the team also must make sure that the resident’s preferences are well communicated to the staff who will be performing the bathing activity. The resident’s choices must be honored with each bathing experience.”

McGill reminds staff to include these preferences in the baseline care plan developed within 48 hours of each admission.

“Bathing for some residents, especially those with impaired cognition, is not always a relaxing experience. So, working on consistency and following the resident’s choices in the bathing process will be a very important component, and can lead to a much brighter outcome for the resident,” she notes.

4 Successful bathing requires an adequate workforce.

“Staffing should be carefully monitored to ensure there are enough people to meet the needs of every resident admitted to and living in the facility,” says Madison. “Some long-term care facilities have designated bath aides for full baths while others assign the bath to the CNA with responsibility for the overall care of the resident on that shift.”

Meanwhile, Madison adds, other facilities have adopted the Universal Caregiver model so the staff member does all kinds of services — “bathing, feeding, housekeeping, whatever is needed for resident care,” she adds.

Finally, Madison strongly advises administrators pay close attention to staffing when it comes to the requirement for the facility assessment, or F-838.

“If there are 100 residents in a given facility, for example, there needs to be sufficient and competent staff in place to meet those needs,” she adds. “If all 100 residents want a shower or tub bath each day, staffing needs to be available to meet those preferences.”

Mistakes to avoid

Failing to perform and document resident assessments concerning bathing within the first 48 hours.

Overlooking resident preferences for types of bathing (shower, tub, bed or sponge).

Not providing adequate staff, or failing to train staff on bathing equipment.