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OIG Risk Areas: Sufficient
Staffing, Case Mix &
Psychotropic Medications
Presented by:
Irene Fleshner
Susan Whittle
Ken Burgess
Where We’ve Been & Today’s
Topics
Review of prior webinar topics
Mechanics of compliance programs
OIG Risk Areas to date
Today:
Sufficient Staffing – Irene Fleshner
Case Mix Reporting – Susan Whittle
Psychotropic Medications – Ken
Burgess
OIG Risk Area
Sufficient Staffing
What is Sufficient Staffing?
Federal & State requirements
CMS – Five Star
Budget
Resident/Patient needs
Staff preferences
Staffing Plan Considerations
Who do we care for - scope of
services, IVs, acuity level, behavioral
issues
Numbers – census, admissions
Model of care delivery – who does
what
Needs per shift - admissions, outside
appts.
Skill mix - role of licensed nurses –
RNs vs. LPNs
Staff competencies
Staffing Plan
Create a staffing plan
Build budget to support plan
Include budget dollars to cover call
ins, in-service training, shift report
Administrator and DON responsible
Communicate plan and rationale to all
staff
Implement Staffing Plan
Create schedule according to plan
Involve staff in development of
schedule
Allow flexibility in schedule for census
and acuity fluctuations – part time,
prn, on call
Schedule should not be static
Allow for real time review and
adjustment !!
Ask the question Do I have the right number of staff
with appropriate skill mix and
competencies available on this shift to
care for patients/residents?
Monitor Staffing
Have a system in place to regularly
review adherence to staffing plan
Schedule vs. actual
Hours over and under budgeted levels
Pattern of call ins
Communicate
Create a process for communicating
results of audit
Corporate
Staff
Continuous Improvement
Identify problems/ issues
Look for opportunities to improve
Develop improvement plan
Document
Document staffing plan philosophy –
do not include specific ratios
Document monitoring activities
Document reporting activities
Proper Reporting of Case Mix
OIG Risk Factor: “Upcoding”
Auditing and Monitoring
Case Mix
Review of RUG Assignments
Resident Case Mix
Assessment
Reporting
Evaluation
Auditing and Monitoring
Case Mix
Process
MDS Accuracy Review
Pre-/Post- Billing Claim Review
Trend Findings
Train and Educate
Auditing and Monitoring
Case Mix
MDS Accuracy Review by Clinician
Therapy Verification
ADL Score Verification
“Extensive Services” Review
Assessment Reference Data
Extensive Services
Special Care
Clinically Complex
Findings/Plan of Correction
Training Opportunities
Auditing and Monitoring
Case Mix
Pre-/Post- Billing Claim Review
Administrator As Team Leader
DON or Designated Clinician
Clinical Documentation/Medical
Records/MDS
DOR or Designated Therapist
Therapy Documentation/Therapy Logs
BOM or Business Office Designee
Patient Personal Information/SNF
Certification Verification
Pre-/Post- Billing Claim Review
Process
Patient Name/Payor Number
Admission Date/Dates of Service
Verification of Qualifying Stay
ARD Within Allowable Period
Rug Information = MDS Assessment
Therapy Minutes = RUGS Category
HIPPS Modifier Codes = MDS Codes
UB92 Diagnosis = MDS Diagnosis
Ancillary Services Billed = Medical Record
RUGS Level = Services Provided
Pre-/Post- Billing Claim Review
Process
Physician Certification/Re-certification
Certifications Completed Properly
Original, Not Stamped, Signatures
Signature Date = Certification Date (or
before)
Pre-/Post- Billing Claim Review
Process
Findings/Identification of Exceptions
Plan of Correction
Trend Data
Identify Training Opportunities
Pre-/Post- Billing Claim Review
Process
Frequency
Claim History
Pre-Billing
Post-Billing
Sample Size
Claim Hisotry
100%
Random Sample
OIG Risk Area: Psychotropic
Medications
OIG Focus:
Use of PP meds is consistent with Federal regs
/ standard of care
SNF responsible for quality of PPs use
No use as restraint / for convenience
PPs necessary per medical symptoms
No unnecessary PPs / other drugs
Gradual dose reductions with behavior
modifications unless medically contradindicated
Auditing/Monitoring for PP Meds
What are we looking for specifically?
The above items / issues
What information sources will we use
to look at those issues?
And who is looking on what schedule?
What will we do with the results of our
findings?
What Are We Looking For?
System to know who is on PP meds?
Documentation of symptom based
basis for PPs
Is documentation by proper interdisciplinary team – all aspects of
resident’s condition/care involved
Is documentation consistent with care
plan/medical records and updated
regularly
What Are We Looking For?
Documentation of ongoing efforts to
“dose down” with behavior
modifications, unless contraindicated
Is all of above regularly reviewed by
consulting pharmacist
Have system for regular updates to
care plan, med records, MD orders,
MARs, lab tests/lab results/followups
What Information Sources Do We
Examine to Test Those Issues?
Resident medical orders for PPs
Care plans
MARs
Nursing/social work/psychosocial notes re
symptom based reasons for use of PPs
System for recording/follow up of MD oral
PP orders / tracking lab orders & results /
reports of same to attending MD
What Information Sources Do We
Examine to Test Those Issues?
Facility incident reports, survey
results and QA Committee minutes to
detect failings in these systemss
Reports of consulting pharmacist re
same issues
AND who (by title) is handling each
task and on what defined, periodic
schedule
What Do We Do With The Results
of Our Audit?
Report same to facility administration
& QA Committee & Compliance
Officer / Committee
Revise applicable policies &
procedures to respond to detected
problems / Train re same (repeated)
Compliance Officer report to Bd of
Directors, including corrective
measures and how they are working