Five-Star and QAPI Compliance Tips (Episode 7)

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Darcy Grabenstein: Hello from SmartLinx Solutions. In today's podcast, we'll talk about tips for regulatory compliance. Our guest today is Maureen McCarthy, president of Celtic Consulting LLC and the CEO and founder of Care Transitions LLP, a care coordination service provider. She is also the creator of the McCarthy Method, a documentation improvement system for ADL coding. She has been a registered nurse for 30 years with experience as an MDS coordinator, director of nursing, rehab director, and a Medicare biller. She is a recognized leader and expert in clinical reimbursement in the skilled nursing facility environment. Welcome, Maureen!

Maureen McCarthy: Thank you, Darcy!

DG: Can you tell us a little bit about the services you offer to the long-term care industry?

MM: Sure thing. Mainly, the service that we're most often getting requested these days is for quality improvement assistance. Whether it's Five-Star improvement reports or they're looking at the quality measure reports, and now with value-based purchasing coming down the pike and looking at re-hospitalizations, it's going to add a little bit more scrutiny into how facilities measure up to other facilities across the country.

We also work in clinical reimbursement, your state case mix, PPS managed care, as well as compliance auditing, MDS training for the interdisciplinary team, mock surveys, requirements of participation assistance, those types of things, QAPI plan development with requirements coming down the pike, facility assessments. We also help with [Payroll-Based Journal] PBJ assistance, with uploading and interpreting some of those files as well as billing and claims reviews, but the thing that makes us different than other vendors that are out there is that we help you fix the issues that you have in your building. It's not just reporting them back to you. We actually help to make a difference and get you to be independent and compliant all on your own.

DG: Wow. You do a lot. You cover it all, it sounds like.

MM: Thank you.

DG: Let's dive into our topic. I know in some of our previous conversations you said you often hear this question from your clients. "Why don't my Nursing Home Compare reports match what I see in the Five-Star reports?" What do you tell them?

MM: Basically, I tell them that we're probably looking at two different periods, as well as potentially two different populations, when we're looking at some of these reports. Some will just look at the Medicare Part A population, where some of your CASPER reports are looking at the whole house regardless of what the payer sources are. You're looking at some patients that are long-term versus patients that are considered short-term for some of these measures and, again, different periods of reporting and look-back periods, so don't expect those two reports to ever match.

You can use one to look at the other. You can use your current quality measure reports to look at what will come about in Five-Star because Five-Star is generally a lot further behind than the Nursing Home Compare or CASPER quality measure reports. That's what I usually tell our folks.

DG: What will happen to survey stars now that the Five-Star rating system is "frozen" — and I'm putting frozen with air quotes — as of November 28th? Supposedly it's going to be frozen for a full year until this new survey process is completed, but it probably will be more than a year, right? Likely not until 2019. What do you recommend LTC facilities do during these "dark days" as you've called it?

MM: I think that when you have your facility's data, as well as other facilities' data to compare yourself to, you can look at the trending directions with the number of tags in your state and what the surveyors are finding as they're coming around. Just because you're not able to see your specific results impact your Five Star, it doesn't mean that you won't see movement in some of the star measures. As the states compromise the star cut-point tables for each of the domains — and the survey star domains may change with what's considered Five Star versus four star, three star, or two — you may see some changes.

The reason I think that it's probably going to be a little bit closer to 2019 is that it will take a little bit of time for some of these surveys to be complete. If you have your survey on 11/25, it may not be finalized until 2019. If you have an informal dispute resolution and you're fighting any of the tags, that has to be finalized before the star process would even be posted. That's why I think it may also go into 2019.

DG: That makes sense. In our SmartLinx blog, back in November we mentioned that the Centers for Medicare and Medicaid Services, or CMS, will be moving to PBJ data for the source of staffing hours. When exactly will PBJ be used for staffing, and how do you think that will impact long-term care facilities?

MM: CMS hasn't said specifically when they're going to start to use that data, but we think it's probably going to be the spring of 2018. I think that that will have a significant impact on long-term care facilities. There are some facilities out there that are submitting PBJ data but not really analyzing what they're submitting. Then when this data is turned around to be used for Five Star and to influence your staffing numbers, you're going to want to make sure that information is correct.

For instance, if you have a facility where folks share many hats and they do many types of duties within their job description, you have to move that around. If you have someone who is covering for a supervisor and now they're doing direct care with the patients, that's got to get changed in the schedule before the PBJ data gets uploaded. The payroll person really needs to get together with the person who is the scheduler or one of the clinicians that's involved in the scheduling process to make sure that the data that you're submitting isn't significantly just from payroll, but it's been looked at, and people are allocated appropriately.

DG: Right, that's so important. I know that in our software we address that. We have capability to change assignments for a single person. You're right. That's so important.

How does the data in the Five-Star reports get updated? Can you talk about the difference between MDS-based versus claims-based measures?

MM: Sure. The MDS data is obviously clinical information that's directly coming out of the MDS. That gets updated each quarter, but the quarters are behind. We're waiting for third quarter of 2017 to come out and populate the Five-Star reports now.

The claims-based measures are only updated twice a year, and that's supposed to be done in April and October, at those two points in time. We didn't get the October updates yet to the claims-based data, so we're still waiting on that, and some folks with bated breath depending on where their quality measures fall. As we're looking at value-based purchasing and looking at re-hospitalizations in that program, as well as the Five-Star program and the Quality Recording program, looking at that data that's claims-based is just as important as looking at the data that's clinically based on the MDS.

DG: Right, right. I know we talked about using PBJ for staffing. How will switching to MDS data as the source for patient census impact a facility's Five-Star rating?

MM: We did have a few clients that had asked us to review their data when it first began to come out and they were looking at the census data related to the MDS's. We found that if folks are behind on completing discharge assessments, it could impact their census data. We had some folks that didn't get discharge assessments in their look-back period when the patient was leaving the facility, so it overstated the number of residents that they have in the building, and therefore it diluted the staffing number because it made it look like you had more residents in the facility than you actually had beds for. You've got to make sure you're keeping up on those discharge assessments because that will impact — and we found some facilities where the data didn't match, and they couldn't figure it out.

The best comment that I would have or tip that I would have for providers out there is to pull their Missed Assessments report. That's going to tell you the last assessment that was in there for a resident. If you see someone who's been gone out of your facility for quite some time, you may want to go into your system to look to make sure either you did a discharge assessment, or that it got accepted and it is on your validation report. You may have thought that it was in your batch to get submitted, and it may not have gotten accepted, therefore they're looking for that bookend to close out that person's story.

DG: Good tip, thank you. Maureen, as we all know the long-term care industry suffers from a really high turnover rate. CMS has mentioned several times that employee tenure and turnover are valuable measures of quality. Do you foresee CMS including these measures in the Five-Star rating at some point? Why or why not, and how soon?

MM: I'm not sure if they'll end up on the Five-Star rating, but I'm sure they will end up as some type of quality rating. They may go into the Nursing Home Compare site itself rather than just the Five-Star, but I know they were definitely interested in attrition rates. They could still get that information even though facilities don't have to specifically input that data. They're able to back into that and able to figure that out. I think it will be something that will be reported once the data is reliable, but I'm not sure it will be the Five-Star report where it will end up.

DG: Good point. They have a way of getting that information, don't they?

MM: Yes, they do!

DG: What's your advice to a facility that wants to predict its Five-Star rating?

MM: I think that the hardest piece to predict is going to be your staffing piece. It's looking at the Strive Test to determine the amount of time per patient day and per RUG category, and also risk-adjust the patients based on the prior quarter that just closed out. If you have a survey today, it would be looking for the most recent assessment for that patient through 12/31/2017, and risk-adjust the acuity based on the RUG-III system for that resident on that assessment and then looking at the staffing type. I think that's the most difficult part to predict when it comes to the Five-Star report.

Now your survey, it is what it is. You can have a facility that does a phenomenal job, and on any given day a surveyor can come in and find something wrong. You can have a facility that's sort of a little broken, trying to get back on their feet, and they can come in and not find any deficiencies, so that's a little bit harder to predict. When you're looking at your quality measures, that's probably the most common way to look at a Five-Star rating. That's probably using your CASPER reports to determine what that next quarter's going to be that's coming out on the Five-Star, and making sure that you're looking at your data real time. You should be looking at your quality measures every month, or at least every quarter, and looking at the quarter that you're in to see do you have any trends. Are you having any issues with, let's say, a policy? Do you need to tweak that piece because you're not getting the quality of the documentation or the care process that you need to improve that outcome?

DG: Yes, thank you. I agree. I would say at SmartLinx that our mantra is real-time data. We're all about using real-time data as accurate measures of your quality of service and your staffing.

I'm going to switch gears here. I know you also provide Quality Assurance Performance Improvement, or QAPI, services to long-term care facilities. Can you tell me where we've been regulatory-wise and where do you think we're going in terms of QAPI?

MM: Sure. Basically, we've always had the Quality Assurance, the QAA tag for our surveys, and now that's a lot more detailed. It makes sense when you think about it that we need to be proactive rather than reactive. When you're looking at a system that might not be performing to your satisfaction in a building and you go back and look at that system, you're looking at preventing something from happening. You don't react to something.

Let's say it's falls with major injury. Someone had the fall with major injury, then we did something about it, but what did you do before someone had a negative outcome or an adverse event? I think that's where we're looking more towards that QAPI piece is to prevent things, and identify trends, and looking at root causes, and that sort of a thing.

I think that's the difference of what we're looking at, is that it's facility wide and it's not just clinical problems, like you mentioned before. Staffing turnover, that could be one of your performance improvement projects. Maybe that is something that's affecting your patient satisfaction and they want to have consistent staff and folks and faces that they know every day, so it's not always just those pieces that come up on the Five-Star quality measure reports. Look at your facility as a whole house, and find out what may be hindering your performance improvement.

DG: Sounds good, thank you. QAPI has five basic elements: design and scope; government and site leadership; feedback data systems and monitoring; performance improvement projects or PIPs; and systematic analysis and systemic action. That was a mouthful, wasn't it? What's one piece of advice you'd give to our listeners on each of these elements?

MM: I think when you're looking at design and scope, make sure that you're designing a program that fits the pace and the size of your facility. If you have 23 things on a performance improvement wish list, you may want to start with 4 or 5 of those rather than 10 things at once. I would just say when you're designing it and looking at the scope of what you're looking at, make it realistic for your building.

For governance, leadership, feedback, and that piece of it, looking at assigning the right person to be in charge of the program. They have to have enough autonomy over the staff that they can get performance improvement, but this is your chance to look at who's going to do what and who's in charge, and who's going to make the decisions, who's part of the QAPI committee, who's going to be your QAPI champion in the building who’s going to bring all this data together. When you have your meetings, I think that's the time to look at that.

When you're looking at feedback data systems and monitoring — so you've put something in place. You decided on which performance improvement projects you want to move forward with. You put something in place, making sure that you're feeding back to the system and all those folks who are interested in how we're going to improve. It's not just a management thing. You have to get this down to the front-level staff because everyone needs to be excited about the improvements and have the same buy-in. Then again, monitoring that to make sure it stays. Sort of like when you tell your kids to go clean their room. If you don't go back, that room's probably not going to be clean. Just like quality assurance, going back periodically to make sure you're still having that good outcome that you expected is going to be really important.

When it comes to Performance Improvement Projects, I think the biggest step there is making sure that you have an inventory list so that you know what projects you have going on and where you are with each one. I'm just starting this one. I'm in data collection with this one. I'm insuring with this one. This last one I think we're doing a great job on; we're just checking that twice a year rather than quarterly. I think that having that organization is really going to help when it comes to the Performance Improvement Projects and looking outside of that clinical scope.

Systematic analysis and action, my advice there would be to make sure that you've got the root cause of the problem, and making sure that you're going back far enough to address what the problem is and not just something that appears to be the problem. Many times you can go back and you don't really fix the problem, or it's fixed for a short period of time, but it's not fixed permanently. Sometimes it's because we don't really have what the issue was.

DG: All great advice, thank you. I have one more question. Can you give me an example of how you've helped a facility improve a specific process and how that impacted outcomes?

MM: Absolutely. Like I was mentioning before, making sure you get to that root cause. We had a group of folks that had issues with pressure ulcers. They end up doubling in one month and tripling in two months. For any facility, that's a significant change for them.

We went into the facility, and we tried to look at what was happening. We looked at the care process. We looked at what their policy was for pressure ulcer identification. We went through the whole gamut. It ended up that body audits were being done for the patients, turning and positioning schedules were assigned, care plans were updated, wounds were being identified.

It came down to the turning and positioning was not being performed every two hours, but that wasn't the issue. That wasn't the issue; it wasn't the root cause. No, the root cause: why are patients not being turned and positioned? The patients are not being turned and positioned because we don't have enough time to get to all of the patients that we have. Why do you not have enough time to get to all the patients we have? Because we have too many call-outs. Why do we have too many call-outs? Because the acuity was too high on the unit, so you go back to look at the acuity on the unit.

Sure enough, they had 21 folks on that unit who needed assistance to be fed. They were dependent for feeding. They also had 21 or 23 additional folks — it was 21 and 23 — who required Hoyer lift transfers to be able to transfer. The CNAs didn't have enough physical time in the day to do everything that they needed to do including the two-hour turning and repositioning. So we moved some of the long-term care residents who required a dependent amount of assistance from the CNAs onto other long-term care units. The call-ins dropped. The CNAs were no longer calling out. They weren't upset about their job. They felt good about what they were doing at the end of the day, and the pressure ulcers declined.

DG: Wow, that is a great outcome. It's like putting pieces of a puzzle together.

MM: That's exactly what it's like, Darcy. It's so much fun.

DG: Thank you, Maureen, for sharing your expertise with us today. It's all very important topics. To our listeners, thank you for tuning in. For more information on Celtic Consulting and its services, visit If you'd like to learn more about SmartLinx solutions and our fully integrated suite of workforce management solutions, including Payroll-Based Journal reporting, visit us online at

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