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Mississippi Hospital Association Group Discussion Swing Bed

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Mississippi Hospital Association Group Discussion Swing Bed Powered By Docstoc
					   Effective Management
              Of
  Critical Access Hospitals
Swing Bed Utilization in CAHs

                                 August 7, 2003
                    Vicksburg Convention Center
                          Vicksburg, Mississippi


                     Mary Guyot, RN, BS, CRRN
                       mguyot@stroudwater.biz


             STROUDWATER ASSOCIATES
STROUDWATER ASSOCIATES

            Financial Incentives Are Plentiful
        Majority of the SB patients are Medicare = increased
         proportion of “cost-based” acute care payer mix = increased
         overhead cost allocation

        More volume reduces the average cost per unit of service by
         spreading the high fixed costs over more patients

        Decreased cost/unit of services = more money in your
         pockets for non-Medicare patients = increased revenue

        With new CAH SB payment methodology it’s like getting
         paid acute rate for skilled level of care

                                                                       2
STROUDWATER ASSOCIATES
        Overview
           Section 1
                History of Skilled Care Beds
                SNF vs Swing: What Is The Difference?
                Swing Bed Regulation
                Skilled Medicare Benefits for the Beneficiary
           Section 2
                Why Have Swing Beds
                     Other than Financial Benefits
           Section 3
                Physician’s role
                Physician Billing
                                                                 3
STROUDWATER ASSOCIATES
        Overview (cont’)
           Section 4
                Promoting SB Programs
           Section 5
                Sample Skilled Care Needs
           Section 6
                Medicate Documentation Requirements
           Section 7
                Medicare Compliance
                     Remaining survey ready


                                                       4
Session One


 History ofSkilled Care Beds
 SB Regulations
 Skilled Beneficiary Medicare Benefits

                                          5
STROUDWATER ASSOCIATES


        History of Skilled Care Beds
           Crunch to get patients out of the hospital!!!




                                                            6
STROUDWATER ASSOCIATES




                           SB
                                SA
                         SNF




                                     7
STROUDWATER ASSOCIATES

          SNF vs SWING:
          What is the Difference?
                                                         LTC       Hosp.     Rural      CAH
                                                         SNF       Base      Swing      Swing
                                                                    SNF
    Certificate of Need (CON)                                    Depends on the State
    Distinct Part Unit                                    X           X
    Specified Nursing Staff Allocation                    X           X
    LTC OBRA Regulations                                  X           X      Partial    Partial
                                                                 Differs by
    Licensed as a NH
                                                          X        State
    Cost Base Reimbursement                                                               X
    Reimbursed under PPS                                  X          X         X
    Skilled Admission & Continued Stay Criteria           X          X         X          X
    Average Length of Stay (ALOS)                       60-100     12-14       9          9
    Short Form MDS for Payment Purpose                    ?X         X         X
    Day-14 MDS (long form) for Payment and QA Purpose     X          ?X


                                                                                                  8
STROUDWATER ASSOCIATES

         Swing Bed Regulations
        The Social Security Act permits certain small hospitals to enter into swing
         bed agreement where the hospital can use its beds as needed to provide acute or
         SNF care

        Swing beds are not required to be in a distinct part unit

        Does not require OBRA Surveys under Long Term Care Regulation but must
         be in compliance with basic standards

        The Act provides for payment for post-hospital SNF care furnished by a rural
         hospital that has swing-bed approval

        Presently CAHs may have no more than 25 beds with a maximum of 15 beds
         used for acute care
              Does not prevent you from having more than 10 beds for skilled level of care



                                                                                              9
STROUDWATER ASSOCIATES

         Swing Bed Regulations (cont’)
        FYI: Non-CAH Rural hospital with 50 to 100 beds may
         only have a skilled bed LOS of 5 days if there is a NH SNF
         bed available within 50 mile radius
         Note: In the calculation of bed counts, the hospital may
         exclude:

         a) Units of special nature (e.g.: ICU, newborn), where
         beds are not available for swing bed use

         b) Beds in separately certified “ distinct part” SNF and NFs,
         and beds in a distinct psychiatric or rehabilitation unit.


                                                                         10
STROUDWATER ASSOCIATES

         Rural Non-CAH Hospital (cont’)
        The hospital must have a written “availability agreement with each
         SNF in the geographic region (excluding those Medicare
         participating SNFs unwilling to enter into such agreements). The
         agreement must specify that:
             a. The SNF will notify the hospital of available beds
             b. The hospital agrees to transfer the patient to a SNF within
              5 weekdays (excluding weekends and holidays) of the
              availability date unless the patient’s physician certifies that the
              transfer is not medically appropriate; and
             c. In the event of multiple SNFs with available beds, the
              patients will choose the SNF to which he or she will be
              transferred. The transfer must occur, however, within 5
              weekdays from the day the first bed becomes available.

                                                                                    11
STROUDWATER ASSOCIATES

         Rural Non-CAH Hospital (cont’)
        A hospital licensed for more than 49 beds may be eligible
         for SB approval for fewer category if it consistently
         utilizes staff for fewer than 50 beds, in which case they
         can use the swing bed at lib

        Likewise, a hospital licensed for more than 99 beds may
         be eligible for approval in the 50-99 category given the #
         of beds the hospital staffs for. In this case, the 5-day rule
         would apply.

        Note: CMS may require you to show the # of beds the
         hospital is operating, staffing schedules, and census
         information for the previous 12 months.
                                                                         12
STROUDWATER ASSOCIATES

        Rural Non-CAH Hospital (cont’)
       Q: What is considered my geographic region?

       A: The determination is based on existing transfer
        practices or if not in place, it consists of an area that
        includes all SNFs within 50 miles of the hospital (unless
        the hospital can demonstrate that the SNFs are
        inaccessible to it’s patients)




                                                                    13
STROUDWATER ASSOCIATES


        Medicare SB Qualifying Stay
           Enrolled in Medicare Part A (see next slide)

           Has days available to use (see next slide)

           Three consecutive day qualifying stay in acute care
            hospital (3 midnights) within the last 30 days

           Has skilled needs and such are related to the condition
            which was treated or arose during the qualifying stay

                Physician and staff documentation to support the skilled needs

                                                                                  14
STROUDWATER ASSOCIATES
         Medicare Benefits:
        Enrolled in Medicare Part A
             Has days available to use
                  100 days total for skilled care per spell of illness
             First 20 days at 100% and day 21 to 100 is 100% minus a basic
              daily rate – payable by secondary insurance or self pay
             These days are accumulative for the same or different condition in a
              consecutive stretch of days
        Spell of Illness:
             Must have 60 days with no Medicare Part A services (Acute Care or
              Acute Rehab, SNF, Psych hospital, LTC Hospital) for the 100 days
              to re-apply
             This still holds even if the patient has a brand new condition such as
              a stroke on day 1 and a hip fracture on day 35



                                                                                       15
Session Two


   Non-Financial Benefits   of Swing
   Bed Utilization


                                        16
STROUDWATER ASSOCIATES

        Why Have Swing Beds?
           For Starters:
                To manage the acute care bed utilization
                   CAHs presently must maintain an average LOS of 96 hrs or
                    less and a 15 acute care bed limit
              Improved care
                   Opportunity to identify patient needs to assure a safe and
                    sustainable return home
                   More time for training, demonstration, return demonstration,
                    education
                   More time for family education
                   Extra time to put post-acute discharge plan in place
                   Increased patient/family satisfaction (“not thrown out”)

                                                                                   17
STROUDWATER ASSOCIATES

        More Good Reasons
        For Swing Beds
            Increased in-house services for the community
                Physicians are less reluctant to discharge patients to a skilled
                 level of care when in-house
                Increase patient’s willingness to go to a skilled level of care
                 while meeting their needs for a longer inpatient stay
                Allows for local residents to return to their community
                 hospital for medical and/or physical rehab skilled needs after
                 receiving care in non-community hospitals


            Helps to manage your Nursing Hours/Patient Day
             (NHPPD) with less drastic fluctuation in the census
                                                                                    18
STROUDWATER ASSOCIATES

        Benefit of Your SBs to
        Urban Hospitals Without Skilled Bed
         PPS hospitals reimbursed with a DRG system

         If they provide services for less than the fixed PPS
          payment, they may keep the difference

         Need to have good resources for skilled care to
          prevent delayed discharges from the DRG bed


                                                                 19
STROUDWATER ASSOCIATES

         Benefit of Your SBs to
         Urban Hospitals With Skilled Beds
        Skilled Units in PPS hospitals are paid under a PPS system
         called Resource Utilization Group (RUG)

        A per diem RUG rate is one of 26 pre-determined possibility
         depending on a limited number of resources used
             Cost of caring for the patient may be more than the RUG rate
             Open to discharge sites who can meet the skilled needs and are not
              limited by the cost
             Prevents “bottleneck” in their SNF
             Allows increased family involvement for support and training when
              patient is closer to home
             Decrease burden on the family (travel, cost of gas…)

                                                                                   20
STROUDWATER ASSOCIATES
     Benefit of Your SBs to Urban Hospitals
     With Acute Rehab Unit and No Skilled Unit
        ARUs are also now paid under a PPS system
             Payment rate is per discharge such as DRG depending
              on the Case Mix Group (CMG) for each admission
             Paid on a per discharge basis
             Benefit from having discharge resources for skilled care
              to prevent extended LOS


        ARU admission and continued stay criteria requires
         a need for PT and OT x 3 hrs/day
             Referral to them may not be appropriate based on need
              or tolerance so need resources or,
             Patient still needs IP therapy but less than 2-3 hrs  21
Session Three


   What   The Physician Needs To Know




                                         22
STROUDWATER ASSOCIATES

        Physicians Need To Know
              Benefits to physician, hospital and community

              Admission criteria related to skilled needs

              UR process to “swing” a patient

              Skilled care documentation requirement

              Physician Billing (probably first and foremost)

              Their role in promoting the service
                                                                 23
STROUDWATER ASSOCIATES
           Physician Billing
      8 Skilled (LTC) CPT codes
          AMA CPT 2002 Professional Edition (see next slide)
      Medical or Surgical Consultants use the acute care CPT codes for the
       first consultation (5 levels)
      If the consultant has initiated treatment and participates thereafter in
       the patient’s management, the “subsequent codes for NF” are to be
       used (see next slide)
      Same 3 CPT codes are used for hospital care and NF if not
       participating in the management but only doing follow-up
       consultations (see Follow-UP Consultation Code slide)
      Surgeon following the care of their patients are under the global fee


                                                                                  24
STROUDWATER ASSOCIATES
                  MS MS Physician IP Fee Schedule
                               Mississippi Physician Fee Schedule                               Follow-up Consultation Codes
                            Acute Care    Hosp.                             NF CPT
        Description                                      Description                 NF Rate
                            CPT Codes     Rate                               Codes
                                                  Annual assement                              Description CPT codes   Fee
  Initial hospital care
  (low complexity – 30                            (straight forward - low
                              99221      $59.99                             99301    $55.42    Low
                                                  complexity - 30minutes)
  minutes)                                                                                     Complexity   99261      $19.96
  Initial hospital care                                                                        (10 min)
                                                  Annual assement (mod.
  (moderate complexity –      99222      $99.72 to high complexity -        99302    $74.45
  50 minutes)                                     40minutes)                                   Moderate
                                                                                               Complexity   99262      $39.99
  Initial hospital care
                                                  Initial admission /                          (20 min)
  (high complexity – 70       99223      $139.12 readmission                99303    $92.53
  minutes)                                                                                     High
  Subsequent hospital                             Subsequent NF Care                           Complexity   99263      $59.67
  care (low complexity –      99231      $30.01   (low complexity - 15      99311    $27.71
                                                                                               (30 min)
  15 minutes)                                     min)
  Subsequent hospital
                                                  Subsequent NF Care
  care (moderate
  complexity – 25
                              99232      $49.38 (moderate complexity -      99312    $46.09       There are also 5
                                                  25 min)
  minutes)
  Subsequent hospital
                                                                                                  confirmatory
                                                  Subsequent NF Care
  care (high complexity –     99233      $70.38   (moderate to high         99313    $65.45
  35 minutes)                                     complexity - 35 min)                            consultation codes
  Hospital discharge (30                          NF discharge (30
  min. or less)
                              99238      $60.92 minutes or less)            99315    $52.39
                                                                                                  (2nd opinions)
  Hospital discharge                              NF discharge (more
  (more than 30 minutes)      99239      $83.55 than 30 minutes)            99316    $69.43
                                                                                                  99271 - 99275              25
STROUDWATER ASSOCIATES
                  MS LA Physician IP Fee Schedule
                  Louisiana (outside of New Orleans) Physician Fee Schedule                       Follow-up Consultation Codes
                             Acute Care    Hosp.                              NF CPT
         Description                                       Description                 NF Rate
                             CPT Codes     Rate                                Codes
   Initial hospital care                            Annual assement                              Description CPT codes   Fee
   (low complexity – 30                             (straight forward - low
                               99221      $62.27    complexity - 30minutes)
                                                                              99301    $66.39    Low
   minutes)                                                                                      Complexity   99261      $20.97
   Initial hospital care                            Annual assement (mod.                        (10 min)
   (moderate complexity –      99222      $103.36   to high complexity -      99302    $90.35
   50 minutes)                                      40minutes)                                   Moderate
   Initial hospital care                                                                         Complexity   99262      $41.37
                                                    Initial admission /                          (20 min)
   (high complexity – 70       99223      $143.70   readmission
                                                                              99303    $112.03
   minutes)
   Subsequent hospital                                                                           High
                                                    Subsequent NF Care
   care (low complexity –      99231      $30.94    (low complexity - 15      99311    $37.84    Complexity   99263      $61.52
   15 minutes)                                      min)                                         (30 min)
   Subsequent hospital
                                                    Subsequent NF Care
   care (moderate
                               99232      $51.09    (moderate complexity -    99312    $58.23      There are also 5
   complexity – 25                                  25 min)
   minutes)                                                                                        confirmatory
   Subsequent hospital                              Subsequent NF Care
   care (high complexity –     99233      $72.70    (moderate to high         99313    $79.99
   35 minutes)                                      complexity - 35 min)                           consultation codes
   Hospital discharge (30                           NF discharge (30
   min. or less)
                               99238      $65.08 minutes or less)             99315    $65.18      (2nd opinions)
                                                                                                   99271 - 99275            26
STROUDWATER ASSOCIATES
           Physician Billing (continued)

        Hospital discharge or Observation discharge services
          performed on the same date as the nursing facility
          admission or readmission may be reported separately
              (American Medical Association CPT code manual 2002)



        An initial admission to a NF (code 99303) must include:
              A comprehensive history
              A comprehensive examination and
              Medical decision making of moderate to high complexity

                                                                        27
STROUDWATER ASSOCIATES
            Physician Documentation Needs
        Skilled services provided are congruent with the
         assessments
              Physician documented reasons for admission in:
                   Acute Care Discharge Summary OR
                   Abbreviated SNF H&P OR
                   A Copy of the Hospital H&P and an Admission Progress
                    Note
              The admitting information should include the following
                   Systems Review
                   Impression / Diagnosis
                   Plan of Care (Medical and/or Rehab)
                   Anticipated Progress
                   Anticipated Discharge Destination
                   Anticipated Length of Stay (LOS)
                                                                           28
STROUDWATER ASSOCIATES




          Sample form
          to be used as
         the physician’s
         initial progress
               note




                            29
STROUDWATER ASSOCIATES

            Physician Documentation Needs

        Q: How often can a physician bill for a skilled bed patient
         visit???


        A: According to CMS, a physician must see a skilled
         patient at least every 30 days but may see and bill for
         his/her visits as frequently as he/she feels it is necessary


        Note: Encourage physician to have good documentation
         and appeal denials


                                                                        30
Session Four


         Market Analysis
         Promotion




                            31
STROUDWATER ASSOCIATES
        Market Analysis
           Meet with your physicians – discuss their needs and
            explain what you can do for their patients
                Include the physicians from the specialty clinics
           Complete a market analysis of all potential referral
            sources
                Meet with them to identify their specific needs
                     Consider needs to determine the level of your program
           Complete a SWOT analysis of all other resources for
            skilled care in the area
                Identify your strengths and weaknesses compared to the
                 competition
           Explain the service to all hospital employees
                They can “make or break” your program
                                                                              32
STROUDWATER ASSOCIATES
         You’ve Got It, Flaunt It!
        Newspaper articles featuring:
             SB Service if new
             Discharge Planner
             Patient with a successful return home after post-acute care
        Add to list of posted services in the hospital
        Discuss the potential for return to their community hospital
         for post-acute care with the patient before transferring them
         out to urban hospital
        Work with the consulting and referring physicians to
         promote the expectation of referral back to the hospital for
         post-acute care (e.g. swing bed rehab following a joint
         replacement at another facility)
             Have therapists involved in meeting with orthopedics and
              neurologists

                                                                            33
STROUDWATER ASSOCIATES
        Promote The Availability
       Create or update your hospital marketing brochures listing the
        services you have
       Meet with the Case Managers / Discharge Planners of the
        potential referring hospitals
            Explain services, benefit to the patient, availability, ease of admission
             process
            Talk about success stories once you have them
       Telephone the family or send a card after transfer to remind
        them of the availability of skilled care program when tertiary
        hospital talks about discharging them to such
       Stay is frequent contacts with SW/CM/DP from the referral
        hospitals
       Tract ER patients that were sent to another hospital and
        communicate with patient/family
            Follow-up with the Case Manager/Discharge Planner from the
             receiving hospital                                                      34
STROUDWATER ASSOCIATES
     Maintain Relationships With Nursing Homes
      Nursing Homes can be a:
           Discharge planning resource for LTC
           Competition for the skilled beds (SB)
           Referral source for swing beds
                May not have Medicare certified beds
                May not have the staff needed for certain skilled level of care (e.g.: IV
                 therapy, wound debridment, therapy at the level to meet the patient’s
                 needs…)
                SNFs are not cost base hence may need to defer to you if cost is greater
                 than the RUG rate for the patent’s needs
      Respect the utilization of Medicare days
           Refer residents back to the NH from the hospital’s acute bed as soon as
            possible
           Refer the urban hospital to the NH SNF if you know the service
            needed can be met at the NH
           If LOS need is high, do not automatically keep the patient for 20 days
            before transferring them to the NH
                Do not refer to this unit as a “20-day unit” or a “20-day rehab”            35
Session Five


   Sample Skilled Care Needs



                               36
STROUDWATER ASSOCIATES

        Admission Criteria
          Admission criteria is not necessarily based on the diagnosis
           but rather on the skilled need(s) which may differ from
           patient to patient depending on the patient’s:
               Medical History
               Co-morbidities
               Age
               Physical stamina
               Pre-morbid condition
               Discharge plan
               etc…..
          Patient must have nursing skilled needs x 7 days/week
           and/or skilled therapy x 5 days/week

                                                                          37
STROUDWATER ASSOCIATES


        Sample Skilled Needs Are:
          Infections requiring IV antibiotics
          Daily respiratory therapy requiring inhalation
           medications
          Unstable nutritional support requiring NG support
           for enteral feeding
          Erratic nutritional state in a diabetic requiring
           frequent insulin adjustments, nutritional
           modifications or intermittent IV hydration
          Patients undergoing radiation or chemotherapy
           and in need of IP program
                                                               38
STROUDWATER ASSOCIATES


        Sample Skilled Needs Are (cont’):
         Patients undergoing dialysis and in need of IP
         Complex wound care (multiple stage II, stage III
          or stage IV) with associated compromised
          medical conditions
         Patients with tracheostomies requiring frequent
          skilled care
         Patients requiring blood transfusions on an IP
          basis
         Patients requiring post surgical care

                                                             39
STROUDWATER ASSOCIATES


        Sample Skilled Needs Are (cont’):
           Patients requiring rehabilitation (PT, OT, ST)
               ADL Training
               Gait Training
               Swallow Eval and Training
               Strengthening for Safety Issue
               Vestibular training
               Etc…
           Patient requiring hydration
           Patients requiring instruction for proper care of
            specialized dressings or skin treatments
           Patients requiring teaching for care and maintenance of
            central venous lines, such as Hickman Catheters
           Patients requiring teaching for new ostomy care
                                                                      40
STROUDWATER ASSOCIATES
         Commonly Seen
         Diagnosis/Services Are:
        Neurologic: CVA
        Orthopedic:Amputations, Fractures, Hip and Knee
         Replacements, Multiple Trauma, Arthritis, Osteomylitis
        Pulmonary: Pneumonia, Tracheostomy, COPD
        Wound Management: Decubitus Care, Debridement, Burns,
         Skin Grafts, Cellulitis, Foot lesions with treatments
        Cardiac: Post-CABG, CHF, Endocarditis, Post CHF, Vascular
         Disorders
        Oncology: Chemotherapy, Pain Management
        Medically Complex: AIDS, Renal Failure, Diabetes, Post
         Septicemia, Ostomy Care, Blood Transfusions, IV
         Administration (Antibiotics, Hydration, Drip Medication, Total
         Parenteral Nutrition, Pain Management, Nutritional or
         Metabolic Disorders
                                                                          41
STROUDWATER ASSOCIATES
        Hospital Specific Admission Criteria
           Review level of nursing skills with present staff
           May want to administer a Nursing Skill Need
            Assessment
           May want to increase skills depending on the needs
           Agree on the type of patients you can safely care for
           Develop a P&P on Admission and Continued Stay
            Criteria which explains the types of patients the
            hospital can care for along with exclusions (e.g.:
            ventilator)
           Involve the physicians in the process
           Develop a Program that you can promote
               IP Therapy Services
               Staff training re: nursing rehab in certain specialties
                    Hip precaution, Stroke rehab etc..
                    Develop patient education packet etc…                42
Session Six


    Medicare Documentation Requirements



                                           43
STROUDWATER ASSOCIATES
              DOCUMENTATION…
        Under Skilled Care as for any other
         IP or OP program it is important to
         remember that:

             No Documented….


             Not Done ….


             Potentially not paid…
                                               44
STROUDWATER ASSOCIATES
            Skilled Care Guidelines for Medicare

           CMS Rules and Regulations have not changed
               Skilled Nursing is required 7 days/week or

               Skilled Rehabilitation Services is required at least 5
                days/week

               Services must be reasonable and necessary

               Skilled Services are ordered by the Physician

               Services are provided by a licensed professional

                                                                         45
STROUDWATER ASSOCIATES
              Documentation Needs
       D/C order and D/C summary from acute is required
       Admitting physician orders to include orders for the skilled need
       Nursing assessments and on-going progress notes
            Norm is nursing assessment q.24 hrs (vs q.shift)
            VS and wt as ordered (norm is for vs q/day or q. 4 and wt q. week)
       Nursing documentation by exception
            Needs to clearly support the skilled needs (treatments, teaching, level of
             assistance required, observations supporting the skilled needs…)
            Ideal is for a weekly synopsis of the progress (can be by nursing or case
             manager)
       Therapy assessments (if indicated) and on-going progress notes with re-
        assessment q. 7 days
       Physician’s on-going progress notes refers to the status of the skilled needs
        and benefit of treatments
            D/C summary should include the progress made in the patient’s functional level
                                                                                          46
STROUDWATER ASSOCIATES
            Physician Order Required:
    MD Signature          on therapy treatment plan
          Medicare allows for the professional therapist to develop a
           suggested treatment plan and to begin providing the services
           based on that plan prior to obtaining the physicians signature
           on the plan
          The physician’s verification of the suggested plan of
           treatment will be obtained w/in a reasonable amount of time
          However, a physician’s signature must be obtained before
           the facility bills Medicare for treatment he/she has approved

                                                                            47
STROUDWATER ASSOCIATES
           Therapy Treatment Plan
         May be after consulting with the professional
          therapist
         May be in the form of a clarification order
         Must include the following:
                 Discipline to provide the service
                 Amount and intensity of the rehab therapy service
                 Modalities
                 Estimated length of time
                 Date, time, and signature of the Physician writing the order or
                  co-signing the order written by the therapist

         Faxed signatures are acceptable
                                                                                    48
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             CMS Transmittal # A-99-20
      We expect that review of the bill (i.e., UB-92) alone would not provide

     sufficient information in making a coverage determination
            Random postpayment reviews

            Continued demand bill reviews

            Focused medical review on “aberrant providers”

            Requests a hard copy version of each MDS (for PPS hospitals) and/or
             supporting documentation

      Instructions state that FI   is to consider all available information in
     determining coverage. This includes the medical record including physician,
     nursing and therapy assessments, daily documentation, and the beneficiary’s
     billing history                                                               49
STROUDWATER ASSOCIATES
       Therapy Skilled Needs
        Treatments must be:
            Reasonable and necessary
            Within accepted standards of practice to be a specific and effective
             treatment for the patient’s condition
            Services provided must be at the level of complexity and sophistication
             that only a licensed therapists can perform
            Amount, frequency, and duration of treatment must be reasonable
            Therapists should regularly reevaluate the condition and adjust the
             treatment plan as needed
        Documentation must include the following:
            Onset date of the problem
            Prior level of function
            Current level of function
            Reasons for noted changes
            Measurable goals
            Documentation of the patient’s progress (or lack of)
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STROUDWATER ASSOCIATES
         Licensed Skilled PT Needs
        Heat Treatments are only considered skilled if the patient’s condition is
         complicated by circulatory deficiency, areas of desentization, open wounds,
         or other complications
        Gait Training for a patient who’s ability to walk has been impaired by
         neurological, muscular, or skeletal abnormalities – must be expected to
         significantly improve the patient’s ability to walk (orders to “ambulate” to
         regain or maintain strength is not a skilled need)
        Ultrasound, Shortwave, Microwave Diathermy TX, ROM tests must be
         performed by a licensed therapist
        Therapeutic Ex. as part of an active treatment of a specific disease or lost of
         function (documentation to describe the degree of motion lost and degree to
         be restored) and why – what is the function one wants to return to?


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         Licensed Skilled OT Needs
        General: treatment concerned with improving or restoring functions
         which have been impaired or permanently loss or reduced by illness or
         injury (feeding, dressing, bathing, cooking…)
        Task-oriented therapeutic activities designed to restore physical
         function e.g., use of wood-working activities on an inclined table to
         restore shoulder, elbow, and wrist ROM lost as a result of burns
        Planning, implementing, and supervising of therapeutic tasks and
         activities to restore reality orientation (BI, psychiatric illness) and/or to
         restore sensory-integrative function (i.g., providing motor and tactile
         activities to increase sensory input and improve response for a stroke
         patient with functional loss resulting in a distorted body image)


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STROUDWATER ASSOCIATES
              Licensed Skilled OT Needs (cont’)
         Teaching of compensatory techniques to improve the level of
          independence in the ADL such as:
             Teaching a patient who has lost the use of an arm how to pare
              potatoes and chop vegetables with one hand
             Teaching an upper extremity amputee how to functionally utilize a
              prosthesis
             Teaching a new stroke patient new techniques to enable him to
              perform feeding, dressing and other ADL as independently as
              possible
             Teaching a patient with hip Fx/hip replacement techniques of
              standing tolerance and balance to enable him to perform functional
              activities as dressing and homemaking tasks
             Designing, fabricating and fitting of orthodic and self-help devices
              e.g., making a hand splint for a patient with rheumatoid arthritis to
              maintain the hand in a functional position or constructing a device
              which would enable an individual to hold a utensil and feed himself
              independently
                                                                                      53
STROUDWATER ASSOCIATES
         Licensed Skilled OT Needs (cont’)
        Note: Generally speaking, OT is not required to effect improvement or
         restoration of function where a patient suffers a temporary loss or a
         reduction of function (e.g., temporary weakness which may follow
         prolonged bedrest following major abdominal surgery) which could
         reasonably be expected to spontaneously improve as the patient
         gradually resumes normal activities – this would not be considered
         reasonable and necessary
        On the other hand: if the above patient has Parkinson which has now
         been exacerbated, the OT could treat for such as long as the physician
         has documented the Parkinson and how the patient is now less
         functional than previous

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STROUDWATER ASSOCIATES

         Licensed SLP Skilled Needs
      General: Services necessary for the diagnosis and treatment of speech
        and language disorders which result in communication disabilities and
        for the diagnosis and treatment of swallowing disorders (dysphasia)
        regardless of the presence of a communication disability
      Therapeutic services may include:
            CVA with dysphasia, aphasia/dysphasia, and dysarthria
            Neurological disease such as Parkinson or Multiple Sclerosis may
             exhibit dysarthria, dysphasia or inadequate respiratory
             volume/control
            Laryngeal carcinoma requiring laryngectomy resulting in aphonia
             may require therapy to develop new communication skills

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Session Three


     Swing   Bed Compliance




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         Swing Bed Compliance

     Federal Register: Appendix W
         Regulations and Interpretive Guidelines for
            CAHs
              Index: 485.608 – 485.643 (for CAH)



         Regulations and Interpretive Guidelines for
            Swing Beds in CAHs
              Index: 485.645 and 483.10-483.55
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         Swing Bed Compliance

     Survey Readiness:
             Hospital licensure and CAH eligibility
             Patient rights
             Admission, transfer and discharge rights
             Patient behavior and facility practices
             Quality of life
             Patient assessment
             Specialized rehab services
             Dental services
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STROUDWATER ASSOCIATES
         Resident’s Rights
    Survey Readiness:
        The patient has a right to be fully informed in language that he/she can understand of
          his/her total health status, including but not limited to, his or her medical condition



    Recommendation:
        Develop a “Patient Admission Packet” to include:
             Welcome to your skilled level of care……. Includes purpose and expected outcome
             Medicare coverage – Medicaid contact info
             Expectations (sample day – treatments, therapy – street clothing)
             Visiting hours
             Patient Rights ….
        CM/DP/SW to give and explain the packet to patient when discussing the change in the
          level of care
        Note the review of the packet and the discussion of advance directive in the initial SB
          progress note
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         Resident’s Rights (cont’)
      Survey Readiness:
              Notice of rights
              Right to refuse treatments, to refuse to participate in experimental research, and to
               formulate an advance directive
              Informed of Medicare and Medicaid benefits and what the patient is responsible
               both prior to admission and at the time of the service if it will affect their bill
              Choose a physician
              Participate in decision about treatment and care planning
              Have privacy and confidentiality
              Work or not work
              Have privacy and sending and receiving mail
              Visit and be visited by others from outside the facility
              Retain and use personal possessions
              Share a room with a spouse
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         Resident’s Rights (cont’)
      Survey probes:
          Is the staff keeping the patient informed?
          Is the information communicated in a manner that the patient can understand
          Is information available to the patient when they express concerns, raise
            questions and on an on-going basis
          Is there evidence in the medical record that the patient was informed of his
            rights
          Does the facility have written P&P on Advance Directives
          Is there documentation in the chart as to whether or not the patient has an
            advance directive and if so, is there a copy on the chart
          Does the facility educate staff regarding patient rights and advance directives
          Does the facility provide education for the community regarding individual
            rights under State law to formulate advance directives                           61
STROUDWATER ASSOCIATES
         Resident’s Rights (cont’)
      Patient or representative are involved in the development of the plan of
        care – survey to look for evidence of such through interview and chart
        review

          Options:
              CM/SW act as the liaison between the team and the
                 patient/family/S.O. and documents the conversations (patient’s
                 wishes, team’s plan…)
              Team meets on a weekly basis with patient/family (if they wish) to
                 discuss the progress and continued plan
                    Outcome documented on 1 page (include a synopsis of the progress
                     and on-going issues from every disciplines involved) – if this method
                     is used, it needs to serve as the weekly re-assessment – do not have
                     staff document the same info in 2 different places
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STROUDWATER ASSOCIATES

         Resident’s Rights (cont’)
      Privacy and Confidentiality
          Surveyed by observation and interview
              Personal privacy includes accommodations, medical treatment, medical
                records, written and telephone communication, personal care visits…
              Patient may approve or refuse the release of medical records except if
                transferred to another facility and / or required by law
          Note: Local residents frequently are afraid of lack of confidentiality in
            rural areas – ensure understanding of such by the staff

      Patient has the right to refuse work
          Note in chart if the patient is doing “work like activities” as part of
            his/her rehab or plan of care

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STROUDWATER ASSOCIATES

         Resident’s Rights (cont’)
      Mail:
          Patient must have mail delivered to him/her within 24 hrs of arrival and
            outgoing mail to the postal service w/in 24 hrs of regularly scheduled postal
            delivery and pick-up service
      Access and Visitation Rights:
          Facility may have reasonable hours of visitation
          Facility must provide another area to meet if a visitation would affect the right
            of the roommate
      Personal Property
          Encourage pictures etc…
      Married Couples
          Couples may share a room if medically approved and they so choose
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STROUDWATER ASSOCIATES
         Admission, Transfer & D/C Rights
     The facility must permit the patient to remain in the facility unless:
         Necessary for the patient’s welfare and/or the patient’s needs can not be met there
         Patient’s health has improved sufficiently and patient no longer needs the level of care
         Safety of other patients is in danger
         Health of other individuals in the facility would be endangered
         The patient has failed, after reasonable and appropriate notice, to pay for or to have paid
           (by MCare or MCaid) a stay at the facility
         The facility ceases to operate

     Survey probes:
         Is there good documentation as to the reason for discharge
         If to another like facility, is there documentation of why the needs could not be met there
         Sufficient preparation for discharge and safe transportation if going to another facility
         If the patient was in the facility greater than 30 days, they must have a written notice of
           discharge as soon as practical - see 483.12(a)(6) for content of notice - (deserves further
           research)                                                                                     65
STROUDWATER ASSOCIATES

         Patient Behavior & Facility Practice
     Restraints
         Need a P&P which identifies:
                 Examples of physical and medical restraints (including full bed rails)
                 That restraints are never to be used for convenience or discipline
                 There is a systemic process of evaluation and care planning prior to using restraints
                 Team to address the risk of decline if restraints are used
                 Care plan need and steps to prevent decline…..
         Need a P&P on Abuse (verbal, sexual, physical, mental) and Neglect
                 What it is, how to identify, process to use if such is suspected

     Survey probes:
         Review of complaints pre-site review
         On-site observation of staff treatments of patients, mis-appropriation of patient’s belongings
         If patient is temporarily separated - why, can the cause be removed etc…
         Personnel file review for pre-employment checks
         Was it reported to the administrator and the State
         What were the actions taken

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STROUDWATER ASSOCIATES
         Quality of Life
     Activities:
         The facility must provide for an on-going program of activities designed to meet, in
           accordance with the comprehensive assessment, the interest and the physical, mental and
           psychosocial well-being of each patient
         Must be directed by a qualified professional meeting the requirement (State certified, TR,
           OT/COTA, experienced (2 yrs w/in last 5 yrs) or by an individual on the facility staff who
           is designated activity director and who serves in consultation of the above list of
           professional

     Recommendations:
         Identify a key staff responsible to get assistance from a professional (as above), to
           develop and post a list of activities available for patients – review list and process during
           admission and PRN
              May develop a calendar of activities if the SB program is longer term
         Have a cart of activities available
         Include assessment of needs/wants in the nursing or SW assessment
         Add to care plan if a need was identified and ensure patient staff is assigned to such           67
STROUDWATER ASSOCIATES
         Quality of Life (cont’)
      Activity program survey probes:
           Are patients confined or choose to remain in their room have availability of activities
              and assistance with such as needed?
           Are the activities and supplies appropriate (interest and ability level)
           Do staff assist patients to ambulate as needed
           Activities are offered am, pm, eve and weekends
           Documentation of activities and outcome
      Note: Mostly becomes an issue if the patient is lonely, bored etc.. and they surveyors do not
         see that issue addressed
      Socials Services:
           The facility must provide medically-related social services to attain or maintain the
              highest practicable physical, mental, and psychosocial well-being of each patient
           Does not require a SW – can be a SW designee who is responsible to identify the
              medically related social services needed and makes arrangements for provision (see
              483.15g) for examples                                                                    68
STROUDWATER ASSOCIATES
         Patient Assessment
    Comprehensive Assessment
        See 483.20 for what needs to be included
        MDS is not a requirement

    Comprehensive (interdisciplinary) care plan: Most Common Citation
        Issues/actual or potential problems need to be identified and care planned as soon as
           possible after admission (includes problem, secondary to, objectives with time frame (as
           appropriate), action plan and documentation of outcome
        Services must meet professional standards of quality
        Services must be provided by qualified persons in accordance to plan of care
    A final discharge summary or recapitulation of stay is required
        Includes post-discharge plan of care

    Nutrition: Based on the assessment, the facility must ensure that the patient maintains
      acceptable parameters of nutritional status
        Measure by wt, lab values, observation
        Knowledge of risk factors                                                                    69
STROUDWATER ASSOCIATES
         Specialized Services
        Rehab Services:
            Therapy provided as needed for prevention and treatment
            Qualified staff (licensed, certified, or registered)
            Physician order required
        Dental Services:
            Oral assessment on admission and as needed
            Identified problems are remedied as much as possible (dentures, treatment
              of sores etc…)
            Referrals to dentist when urgent
            Assistance in making appointments as necessary as part of post discharge
              needs – does not have to be during SB stay if not urgent and patient is in a
              short term SNF stay

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STROUDWATER ASSOCIATES
       Resources:
         The following Centers for Medicare and
          Medicaid Services (CMS) website should
          be monitored for Swing bed updates
              www.cms.hhs.gov
         For billing questions, contact your Fiscal
          Intermediary
         For questions/clarifications regarding today’s
          presentation:
              Mary Guyot # 1-207-756-6090 x204
              E-Mail: mguyot@stroudwater.biz
              Web page: www.stroudwater.biz

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STROUDWATER ASSOCIATES

        The Name of the Game
        is Team Work…..




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