HP Enterprise Services
Summary Report of LTC Facilities Reviewed
July 2013
Tracking Number E20130222
Prepared August 2013
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Contents
July
Contents
Overall Summary for Long Term Care
Health Services
Introduction – Long Term Care Unit ..................................................................................................................... 4
Volume ............................................................................................................................................................ 4
Quality ............................................................................................................................................................. 5
Validation rate and Reconsiderations ....................................................................................................... 5
Training ........................................................................................................................................................... 5
Audit variations – July 2013 ............................................................................................................................ 6
Introduction ..................................................................................................................................................... 6
Findings .......................................................................................................................................................... 6
Analysis by Risk Category ........................................................................................................................ 7
Areas of Concern ...................................................................................................................................... 8
Statistics by RUG Classification...................................................................................................................... 9
Level of Care Statistics ................................................................................................................................. 10
PASRR Level II Statistics.............................................................................................................................. 10
Recommendations ........................................................................................................................................ 11
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July 2013
Health Services
Overall Summary for Long Term Care

The Long Term Care (LTC) Unit completed sixteen Minimum Data Set (MDS) audits during the month
of July 2013. The mean validation rate for the providers audited during the month was 89.44%. The
threshold during an audit is currently 80%.


The LTC Unit received one requests for reconsideration of audit findings in July.
The validation rate and minimal requests for reconsideration indicate that LTC continues to be
successful in helping providers achieve compliance with Indiana Health Coverage Programs (IHCP)
rules and regulations.
The purpose of the LTC review is to ensure that the IHCP is reimbursing for the appropriate RUG
classification as demonstrated by the MDS version 3.0 and supporting documentation.
Changes to the MDS audit frequency were implemented January 1, 2010. The LTC auditing team also
performs Level of Care (LOC) and Pre-Admission Screening Resident Reviews (PASRRs) of LTC
residents.
The following risk criteria are used in selecting nursing facilities for audit:
Audit every nursing facility (NF) at a minimum of once every three years based on the following criteria:

Low-risk provider
○ Previous audit score of 90 – 100% – audit at a maximum of every three years

Medium-risk provider
○ Previous audit score of 80 – 89.9% – audit at a maximum of every two years

High-risk provider
○ Previous audit score of 79.9% or lower – audit every four to 12 months
The Office of Medicaid Policy & Planning (OMPP) reserves the right to perform additional MDS audits
as deemed necessary at any time.
The objectives of the HP LTC audits are as follows:

Determine whether residents continue to have needs requiring NF placement in accordance with
State LOC criteria defined by 405 IAC 1-3-1 and 405 IAC 1-3-2.


Ensure all services recommended by the Level II assessments are provided.

Verify that the MDS responses that impact the RUG score are accurate and supported with the
appropriate documentation within the assessment reference period.
Determine whether IHCP is reimbursing the provider for the appropriate RUG-III classification,
reflective of resident needs.
NFs may be notified up to 72 hours prior to the scheduled case mix/LOC/PASRR audit. The LTC
auditing team conducts an entrance and exit conference to apprise the facility staff of the nature,
purpose, and sequence of events of the audit, as well as the audit results. The auditing teams are
available throughout the audit to address facility questions and concerns. These (The) auditing teams
consist of qualified professionals, including registered nurses and licensed social workers. These team
members may be qualified mental retardation professionals (QMRP) or designees.
The facility is responsible for ensuring that all resident medical records are complete, up-to-date, and
available to the auditing teams. Facility staff will also need to assist the LTC auditing team with resident
observations. Documentation in each resident’s medical record must support all notations made on the
MDS form.
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July 2013
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Health Services
Introduction – Long Term Care Unit
The LTC Unit performs retrospective service provision and case-mix auditing functions. The LTC staff
members conduct on-site audits of Medicaid-certified LTC facilities. Oversight is provided for the
Division of Aging (DA) and the Office of Medicaid Policy and Planning (OMPP). In addition the LTC staff
members assist providers in achieving compliance in documentation and billing, as well as helping
ensure the health and safety of the Indiana Health Coverage Programs (IHCP) members.
Volume
Figure 1 illustrates the number of audits completed by month. For the period of August 2012 through
July 2013, HP completed 179 audits.
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July 2013
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Quality
Validation rate and Reconsiderations
The LTC Unit has a respected presence in the provider community, as evidenced by the relatively small
number of requests for reconsideration (refer to Table 1) and overall validation performance (refer to
Table 2). Less than 2% of audits resulted in facilities requesting reconsideration of audit findings.
Following each case mix audit, nursing facilities receive final results electronically with instructions for
how to request informal reconsiderations for reviewed records that failed to support. Facilities may
request reconsideration of audit findings for specific records within 15 business days of receiving their
initial findings from HP. The reconsideration request must include specific audit issues that the facility
believes were misinterpreted or misapplied during the audit. It should be noted that MDS supporting
documentation that is provided after the audit exit conference shall not be considered in the
reconsideration process.
Table 1 Reconsideration requests
Reconsiderations
Number Received
July 2013
# of Initial Audit
Findings Upheld
1
1
Table 2 Monthly validation rate statistics
Validation Threshold,
per IAC
80%
Audit Timeframe
Average Monthly
Validation Rate
August 2012–July
2013
88.4%
Training
LTC auditors discuss with providers audit decisions and provide education throughout the audit
process. Providers have shown appreciation for these discussions.
The LTC Unit plans to continue to conduct Supportive Documentation Guidelines (SDG) training via
virtual room throughout 2013 and encourage LTC providers to reference the IHCP website for future
training information.
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Audit variations – July 2013
Introduction
The Audit Variations report provides information on nursing facilities (NFs) that demonstrate a variation
between their previous case-mix audit validation rate and the current validation rate.
NFs that exceed the 20% error threshold rate as outlined in the Indiana Administrative Code (IAC)
receive a 15% Administrative Component Corrective Remedy penalty applied for one quarter. The
Nursing Facility is required to respond to a Validation and Improvement Plan (VIP). All unsupported
worksheets are reclassified, and the NF is subject to a Case Mix audit within 12 months.
Findings
The LTC unit completed sixteen Case Mix audits in July 2013. The Case Mix audit validation rate
average was 89.44%. The variation by gain or/loss percentage was 32% to -29%.



One new NF validated at 100%.

Eight NF’s reflected a decrease in the validation rate from the previous audit, ranging from -1 to 29 percentage points.
One NF had no change at 96%.
Six NF’s validated higher than the previous audit. The validation ranged between 32 and 3
percentage points higher than the previous audit.
During July, two Case Mix audits were expanded; one provider’s validation rate at the conclusion of the
audit exceeded the threshold. The expanded portion of the audit resulted in an additional 8 hours of
audit time.
The team educated each facility about 450B & Level I requirements, as well as reviewed the SDG’s
regarding Activities of Daily Living (ADL’s), active diagnosis, impaired cognition and nursing restorative
elements.
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Analysis by Risk Category







Three Low Risk providers stayed Low Risk.
Four Low Risk providers became Medium Risk.
One Low Risk provider became High Risk.
Two Medium Risk providers became Low Risk.
Four Medium Risk providers stayed Medium Risk.
One High Risk provider became Low Risk.
One New provider became Low Risk.
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Areas of Concern
Ten Areas of Concern were statistically relevant upon analyzing data for the month of July 2013. These
elements had 20% or greater inconsistency with the MDS data transmitted by the NF, when at least 10
or more records were reviewed this month.
Table 3 Areas of Concern on the MDS 3.0 found during audits completed in July 2013.
Percent of
Element
Unsupported
Inconsis
tent
Records
# NF’s
75%
9
5
7
5
C1000
62%
29
8
14
6
O0500B
55%
6
4
5
4
C0700
54%
14
7
9
4
O0500F
53%
8
4
1
1
I2000
47%
9
5
2
1
O0500G
44%
15
9
8
4
I4900
38%
5
4
4
3
O0500H
EATING/SWALLOWING
38%
6
4
0
0
M1200A
PRESSURE REDUCING - CHAIR
34%
24
12
0
0
O0700
RUGs #
Not
NF’s
Supp
Element
Description
DECISION MAKING
AROM
SHORT TERM MEMORY PROBLEM
WALKING
PNEUMONIA
DRESSING/GROOMING
HEMIPLEGIA/HEMIPARESIS
PHYSICIAN ORDERS
oNursing Restorative, Diagnoses and Impaired Cognition have remained the top Areas of Concern.
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Health Services
Statistics by RUG Classification
This table summarizes monthly statistics for all facilities reviewed, including number of records reviewed
and the percentage of records fully supported. Resource Utilization Groupings (RUG) further breaks
down the statistics.
TOTAL
8/12
EXTENSIVE SERVICES
888
112
91
95
105
28
66
86
66
56
96
32
55
FULLY SUPPORTED
770
92
81
86
94
26
56
74
58
51
86
20
46
87%
82%
89%
91%
90%
93%
85% 86%
88%
SPECIAL
REHABILITATION
2,633
398
263
272
297
123
203
223
163
154
216
109
212
FULLY SUPPORTED
2,528
381
249
260
292
119
196
215
156
150
204
105
201
96%
96%
95%
96%
98%
97%
97% 96%
96%
SPECIAL CARE
811
101
96
97
69
35
67
75
61
68
63
37
42
FULLY SUPPORTED
654
73
78
87
61
29
51
55
52
55
49
27
37
81%
72%
81%
90%
88%
83%
76% 73%
85%
CLINICALLY COMPLEX
1,578
192
139
129
124
73
139
160
154
131
149
81
107
FULLY SUPPORTED
1,367
158
115
111
109
67
128
142
130
117
131
66
93
87%
82%
83%
86%
88%
92%
92% 89%
84%
IMPAIRED COGNITION
422
76
21
37
15
25
40
30
35
45
48
28
22
FULLY SUPPORTED
325
54
16
32
13
25
31
17
30
32
41
20
14
77%
71%
76%
87%
87%
96%
78% 57%
86%
BEHAVIOR
18
4
2
2
0
1
0
0
2
1
4
1
1
FULLY SUPPORTED
10
1
1
1
0
0
0
0
2
0
4
1
0
56%
25%
50%
50%
0%
0%
0%
0% 100% 100%
0%
REDUCED PHYSICAL
910
113
111
78
47
17
104
42
106
118
72
31
71
FULLY SUPPORTED
746
95
96
56
36
15
80
28
98
88
61
30
63
82%
84%
87%
72%
77%
88%
77% 67%
92%
RUG Category
%
%
%
%
%
%
%
9/12 10/12 11/12 12/12
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3/13
0% 100%
4/13 5/13
91% 90%
97% 94%
81% 78%
89% 88%
71% 85%
75% 85%
6/13 7/13
94% 84%
96% 95%
73% 88%
81% 87%
71% 64%
97% 89%
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Health Services
Level of Care Statistics
The Level of Care Statistics reports data for nursing facilities audited during the month. The number of IHCP
members, whose charts were reviewed is delineated into the following categories: total audited, those
having a Medicaid number, those not having a Medicaid number, those no longer in the NF, discharge
recommendations and those with Mental Illness (MI) or intellectual disability (ID) or those dually diagnosed
(MI/ID/DD) recommended for discharge. All residents present at the time of the audit were observed in the
course of the on-site audit.
TOTAL
FACILITIES Total
MA
REVIEWED Audited Residents Others
16
510
298
Res No
Longer in
NF
57
MI/ID/DD
No LOC
Recommend D/C Ref DMHA
136
0
0
PASRR Level II Statistics
The PASRR/Level II Statistics reports information for nursing facilities reviewed onsite during the reporting
month. Incorporated into the Case Mix audit is a PASRR component for current residents, whose charts are
reviewed, that includes review of Level I and review of the Level II, as applicable. The audit team requests
documentation from the nursing facility identifying residents that have a PASRR Level II due to MI/ID/DD.
The audit team compares the list provided by the nursing facility with the actual PASRR Level II documents
for verification of current status. Audit teams review the medical chart for compliance with Level II
recommendations for at least five residents with a Level II confirming MI, ID or MI/ID/DD. The LTC audit
teams also note if documentation on the active medical record indicates the need for a Level II, and when
one has never been completed, the audit teams will make referrals.
TOTAL
FACILITIES
REVIEWED
16

Referrals for
new Level II’s MI Residents
13
ID Residents
120
18
MI/ID/DD
Residents
10
In nine of the sixteen NF’s audited this month, thirteen residents were referred for Level II’s for the
following reasons:
○ Two residents were referred for potential Intellectual Disability; One resident had a diagnosis of
Cerebral Palsy admitted one month ago from home without a Level II; the other resident had
diagnoses of Depression and Cerebral Palsy without a Level II; with ongoing psychotropic
medication administration and receiving psychiatric services.
○ Four residents had diagnoses of Depression, with medication administration two also had signs
and symptoms of Depression.
○ One resident had a diagnosis of Depression; with medication administration and receiving
psychiatric services.
○ One resident had diagnoses of Depression, Anxiety and Bi-Polar Disorder; with medication
administration and signs and symptoms.
○ One resident had diagnoses of Schizophrenia and Depression with medication administration.
○ One resident had a diagnosis of Schizophrenia; with medication administration and receiving
psychiatric services.
○ Two residents had a diagnosis of Psychosis with medication administration, only one was receiving
psychiatric services.
○ One resident had no diagnosis; with suicidal ideations noted and medication administration.
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Recommendations
1. The HP LTC unit will continue to emphasize the following requirements during provider audits and
training:
○ Utilization of The Center for Medicare and Medicaid Services (CMS) Resident Assessment
Instrument (RAI) manual for Active Diagnosis; that RUGgable diagnosis has two parts, physician
signature within 70 days and “Active” meaning documentation within the 7 day time frame of the
direct relationship of the diagnosis to the resident’s current status.
○ MDS 3.0 requires individualized, measureable care plans for nursing restorative and evaluations
completed in the 7 day assessment time frame.
○ Impaired Cognition elements (not BIMS) still require documentation of examples.
2. Encourage NFs to review the MDS 3.0 updates on the CMS website.
3. Encourage NFs to view the Long Term Care page of indianamedicaid.com, where the LTC team plans to
continue Virtual Room training on the Supportive Documentation Guidelines.
4. Continue to update the Long Term Care page of indianamedicaid.com with relevant topics and links
including the Monthly Reports.
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