On Feb. 1, the QIES Technical Support Office (QTSO) announced changes to the MDS 3.0 Quality Measure Reports in the CASPER Reporting application, including calculation updates/changes to the short-stay pressure ulcer measure, the long-stay pressure ulcer measure, and the long-stay weight loss measure. As a result, providers have been expecting the Centers for Medicare & Medicaid Services (CMS) to quickly release version 12 of the MDS 3.0 Quality Measures (QM) User’s Manual.

 

However, CMS doesn’t share that sense of urgency, planning to release version 12 “in the next couple of months,” said officials during the Feb. 14 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF). The methodology for those updated QMs “is not used in the public domain yet,” they explained to justify the agency’s delay in releasing new technical specifications.

 

In other manual news, providers also won’t get the draft version of the next update to the RAI User’s Manual for the MDS 3.0 quite as early as most hoped to help them prepare for the Oct. 1, 2019, implementation of the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS).

 

“We historically publish that manual more toward August,” said officials. “We do understand the need to be able to review [it for] the PDPM, so our goal is to have that published in May sometime this year.”

Many directors of nursing services (DNSs) have a hands-off approach when it comes to fee-for-service Medicare Part A and the MDS process, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “DNSs attend morning meetings and sometimes attend Medicare meetings, but they don’t really get involved because they count on their MDS staff to handle those processes.”

 

That approach works for the RUG-IV case-mix classification system, but when the Skilled Nursing Facility Prospective Payment System (SNF PPS) switches to the Patient-Driven Payment Model (PDPM) on Oct. 1, rehabilitation therapy will no longer drive Part A skilled care, says Harvey. “With PDPM focused on patient characteristics and skilled nursing services instead of therapy volume, nursing will become key to facility success in this new system, and as the supervisor of the nursing staff, the DNS will need to help lead the way.”

 

It’s important to note that working on PDPM isn’t just another task to add to the DNS’s plate, adds Harvey. “Getting paid appropriately is the focus of PDPM, but it ties back into quality of care. Much of what you will need to work on for PDPM will also benefit you on survey and your quality measures as well.”

 

Here are seven key steps a DNS can take to get out in front of PDPM:

Some residents require or request that their medication be crushed for oral administration. But not following CMS guidelines for crushing medications could result in a citation under §483.45(f)(2) F760 (Residents Are Free of Any Significant Medication Error). This citation could also occur in administering crushed medications via feeding tube. Facility leaders and the nurse administering the medications must first be sure that the particular medication can be crushed per manufacturer instructions. The Institute for Safe Medication Practices website can be a helpful resource in determining which medications should not be crushed.

These days, nursing homes face census pressures on multiple fronts. “Some issues are beyond the control of the director of nursing services (DNS),” says Carol Hill, MSN, RN, RAC-MT, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL. “For example, when census is low at the hospital and referrals simply aren’t out there or when you have trouble hiring staff because your local labor market is extremely tight, you can’t do much about it.”

 

However, no matter what outside forces are at play, a DNS still has the opportunity to maximize census, notes Hill. “On the positive side, it’s not a stand-alone endeavor that just adds one more job to the DNS’s task list. Boosting census requires looking at the total picture, so a lot of what you will do to improve census also will benefit your Quality Measures in the different programs, as well as your survey performance.”

 

The following steps can help providers get on the right track.

When the Patient-Driven Payment Model (PDPM) replaces RUG-IV as the case-mix classification system for the Skilled Nursing Facility Prospective Payment System (SNF PPS) effective Oct. 1, 2019, some SNFs may see their Part A length of stay temporarily increase, says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-CTA, president/CEO of Celtic Consulting in Torrington, CT.

 

“The skilled coverage rules for Medicare won’t change just because we are changing payment systems. However, 95 percent of SNF days are in rehab categories, and many providers have been so focused on obtaining the best rehab RUG score that they have lost sight of what the skilled coverage is,” notes McCarthy. “So length of stay may go up for a period of time as SNFs re-learn how to skill patients for nursing services and become comfortable with understanding when the need for skilled care ends if rehab is not involved.”