HP Enterprise Services
Summary Report of LTC Facilities Reviewed
Tracking Number E20110270
October 2011
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Contents
Contents
Overall Summary for Long Term Care
Health Services
Introduction – Long Term Care Unit ..................................................................................................................... 4
Volume ............................................................................................................................................................ 4
Quality ............................................................................................................................................................. 5
Validation rate and Reconsiderations ....................................................................................................... 5
MDS 2.0 – MDS 3.0 Comparison .............................................................................................................. 5
Training ........................................................................................................................................................... 5
Audit variations – October 2011...................................................................................................................... 6
Introduction ..................................................................................................................................................... 6
Findings .......................................................................................................................................................... 6
Analysis by Risk Category ........................................................................................................................ 6
Top Problem Elements .............................................................................................................................. 7
Recommendations .......................................................................................................................................... 7
Statistics by Class Categories ........................................................................................................................ 8
Level of Care Statistics ................................................................................................................................... 9
PASRR Level II Statistics................................................................................................................................ 9
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Overall Summary for Long Term Care
Overall Summary for Long Term Care

The Long Term Care (LTC) Unit completed nineteen Minimum Data Set (MDS) audits, during the month
of October 2011. The mean validation rate for the providers audited during the month was 89.9 percent.
The threshold during an audit is currently 80 percent.


The LTC Unit received two requests for reconsideration of audit findings in October.
The validation rate and minimal requests for reconsideration indicate that LTC continues to be
successful in helping providers achieve compliance with IHCP rules and regulations.
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October 2011
Health Services
Health Services
Introduction – Long Term Care Unit
The HP 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), helping providers achieve 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 audits completed by month. For the period of November 2010 through
October 2011, HP completed 212 audits.
Figure 1 Number of case-mix audits completed
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October 2011
Health Services
Quality
Validation rate and Reconsiderations
The HP 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 5 percent of audits result in facilities requesting reconsideration of audit findings.
Following each case mix audit, nursing facilities receive final results with instructions on how to request
informal reconsiderations for records that were reviewed and failed to support. 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. Facilities may request
reconsideration of audit findings for specific records within 15 business days of receiving their initial
findings from HP.
Table 1 Reconsideration requests
Reconsiderations
October 2011
Number Received
# of Requests Upheld
2
1
Table 2 Monthly validation rate statistics
Validation Threshold,
per IAC
Audit Timeframe
Average Monthly
Validation Rate
80 percent
Nov 2010–Oct 2011
86.3%
MDS 2.0 – MDS 3.0 Comparison
Comparative analysis was done of the validation rate before and after the advent of MDS 3.0. The 16
months prior to MDS 3.0 revealed an average validation rate of 91.1 percent. From October 2010 thru
October 2011 the rate was 86.6 percent.
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 has successfully
helped facilities achieve increased compliance thru educational training during audits, thru Virtual Room
online training and in conjunction with Myers & Stauffer trainings. In October, the HP LTC unit
completed one Supportive Documentation Guidelines (SDG’s) training in conjunction with Myers &
Stauffer. The LTC Unit also participated on the panel during PASRR training.
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Health Services
Audit variations – October 2011
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 percent error threshold rate as outlined in the Indiana Administrative Code (IAC)
receive a 15 percent Administrative Component Corrective Remedy penalty applied for one quarter,
have all unsupported worksheets reclassified, and are subject to a Case Mix audit within 12 months.
Findings
HP completed nineteen NF audits in October 2011. The Case Mix audit validation rate average was
89.91 percent. That is an increase of less than one percentage point over last month’s average.


Seven NF’s validated higher than the previous audit. The validation ranged between 3 and 47
percentage points higher than the previous audit.

Eleven NF’s reflected a decrease in the validation rate from the previous audit, ranging from 2-38
percentage points.
One NF audit was expanded. It had previously been Low risk. These results moved it into the High risk
group.
○ The elements at issue were Activities of Daily Living (ADL’s), Impaired Cognition (the Brief
Interview for Mood), Diagnosis, Respiratory Therapy, Physician Orders, Therapy and Nursing
Restorative.
Analysis by Risk Category







Seven audits remained in the Low Risk category.
Three Low Risk providers became Medium Risk.
One Low Risk providers became High Risk.
One Medium Risk provider stayed Medium Risk.
Five High Risk providers were audited resulting in Low Risk for their next audit.
One High Risk provider became Medium Risk.
One New provider was audited and became Low Risk.
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October 2011
Health Services
Top Problem Elements
Twenty-two elements appeared with greater than 20 percent inconsistency with the MDS coding. These
elements resulted in 20 percent or greater unsupported where at least 10 or more records were
reviewed this month. The following analysis was completed on the Top Ten problem elements.
Table 3 Top Ten problem elements on the MDS 3.0 found during audits completed in Oct 2011.
Percent of
Element
Unsupported
Records
NF’s
38%
5
3
O0500E
TRANSFER
35%
6
3
O0500G
DRESSING/GROOMING
33%
9
5
O0500F
WALKING
31%
15
6
I4900
29%
11
6
O0500B
27%
3
2
I2000
PNEUMONIA
26%
37
16
O0700
PHYSICIAN ORDERS
25%
3
3
C1000
DECISION MAKING
23%
3
3
O0500A
PROM
20%
2
1
D0500E
APPETITE PROBLEMS
Element
Description
HEMIPLEGIA/HEMIPARESIS
AROM
oThe most pervasive issue appearing on the Top Problem Elements list is Physician Orders with
problems occurring in 16 out of 19 NF’s reviewed. Five of those sixteen NF’s had nine residents
records that were specifically unsupported due to Physician Orders. In the remaining 28 records
Physician Orders being unsupported did not negatively impact the RUG class.
Recommendations
1. HP will continue to emphasize the following requirements during provider training:
○ MDS 3.0 requires individualized, measureable care plans for nursing restorative and
evaluations completed in the 7 day assessment time frame.
○ Residents who do not participate in the BIMS may still RUG for impaired cognition reasons.
Those MDS items require examples within the 7 day assessment time frame.
○ 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.
2. Additionally HP will stress the CMS parameters for Physician Orders.
3. Encourage NFs to review the MDS 3.0 updates on the CMS Web site.
4. Refer NF’s to and continue to update the Long Term Care page of indianamedicaid.com with
relevant topics and links.
5. Encourage LTC providers to attend the Indiana Case Mix workshops provided by Myers & Stauffer.
6. HP will continue to schedule Virtual Room trainings.
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October 2011
Health Services
Statistics by Class Categories
The Statistics by Overall Validation Rate and Class Categories 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.
RUG Category
TOTAL 11/10 12/10
1/11
2/11
3/11
4/11 5/11
6/11
7/11 8/11
9/11 10/11
EXTENSIVE
SERVICES
1,262
75
151
113
92
70
77
104
143
102
80
144
111
FULLY SUPPORTED
1,105
63
137
104
85
63
69
85
122
89
70
119
99
88%
84%
91%
92%
92%
90%
90% 82%
85%
SPECIAL
REHABILITATION
2,155
77
82
93
165
168
160
256
276
152
249
280
197
FULLY SUPPORTED
2,022
71
74
91
148
156
153
238
255
147
230
271
188
94%
92%
90%
98%
90%
93%
96% 93%
92%
SPECIAL CARE
1,908
77
82
93
165
168
160
256
276
152
249
122
108
FULLY SUPPORTED
1,759
71
74
91
148
156
153
238
255
147
230
105
91
92%
92%
90%
98%
90%
93%
96% 93%
92%
CLINICALLY
COMPLEX
2,085
123
134
150
191
142
137
167
231
149
171
230
260
FULLY SUPPORTED
1,778
107
122
138
154
124
113
131
191
123
152
199
224
85%
87%
91%
92%
81%
87%
82% 78%
83%
IMPAIRED
COGNITION
662
33
43
62
40
64
43
42
61
49
59
75
91
FULLY SUPPORTED
510
20
32
54
31
42
34
31
48
44
45
53
76
77%
61%
74%
87%
78%
66%
79% 74%
79%
BEHAVIOR
25
0
2
6
2
4
1
1
2
0
2
2
3
FULLY SUPPORTED
17
0
2
5
2
4
0
1
1
0
1
0
1
0% 100%
50%
%
%
%
%
%
%
68% 100% 100%
83% 100% 100%
87% 88%
97% 92%
97% 92%
83% 89%
90% 76%
0% 50%
83% 89%
97% 95%
86% 84%
87% 86%
71% 84%
0% 33%
REDUCED PHYSICAL
1,268
131
98
109
135
92
82
114
156
84
93
118
56
FULLY SUPPORTED
1,045
123
85
85
107
76
77
101
106
79
74
87
45
82%
94%
87%
78%
79%
83%
94% 89%
68%
%
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94% 80%
74% 80%
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October 2011
Health Services
Level of Care Statistics
The Level of Care Statistics reports data for nursing facilities reviewed onsite during the month. The number
of IHCP members reviewed is delineated into the following categories: total audited, those having a
Medicaid number, those not having a Medicaid number, those no longer in NF, discharge recommendations
and MI/DD recommended for discharge.
TOTAL
FACILITIES Total
MA
REVIEWED Audited Residents Others
19
826
622
Res No
Longer in
NF
47
159
MI/DD
Recomm
D/C
No LOC
Ref DMHA
0
0
PASRR Level II Statistics
The PASRR/Level II Statistics reports information for nursing facilities reviewed onsite during the reporting
month. The audit team requests documentation from the nursing facility identifying residents that have a
PASRR Level II due to mental illness (MI) or mental retardation/developmental disability (MR/DD) or those
dually diagnosed (MI/MR/DD). The audit team compares the list provided by the nursing facility with the
actual PASRR Level II documents for verification. Also included are Level II referrals made by the audit
team.
TOTAL
FACILITIES
REVIEWED
19

Referrals for
new Level II’s MI Residents
33
MR/DD
Residents
263
MI/MR/DD
Residents
36
21
In twelve of the NF’s audited this month thirty-three residents were referred for Level II’s and the
reasons are:
○ One was referred to the local Diagnostic and Evaluation (D&E) Team. Documentation states MR
from birth with a dual diagnosis of mental illness.
○ Twenty had a diagnosis of Depression with ongoing psychotropic medication administration and
psychiatric intervention noted in the charts.
○ Eight residents were noted to have diagnosis of Depression and Anxiety, with medication
administration, symptoms, and some had ongoing Psychological services.
○ One resident has psychiatric consult every few weeks and is depressed about her cancer diagnosis
and a grandson who is on a waiting list for kidney transplant.
○ One resident has a diagnosis of Depression and Schizoaffective Disorder is on medication and
charting reflects resident is currently hearing voices.
○ One resident has a diagnosis of Schizophrenia, takes medication and has ongoing services.
○ One resident has a diagnosis of Anxiety, with ongoing medication administration and symptoms.
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