Is your facility up to speed on the latest RAIUser’s Manual update for coding UTIs? For purposes of coding UTI in Section I2, the resident has to have significant lab findings to support the diagnosis of a symptomatic UTI. And people in most cases interpreted “significant lab findings” to be a positive urine culture and sensitivity, says Ron Orth, RN, NHA,CPC, RAC-MT, president of Clinical Reimbursement Solutions LLC in Milwaukee. But with the recent RAI Manual update, CMS is allowing the attending physician to determine the level of significant lab findings and whether to do a urine culture. Thus,the “lab finding could be a urinalysis or some other type of lab test -- a CBC, for example -- in order to make that affirmative diagnosis,”Orth says. “The MDS still says you code symptomatic UTIs,”such as a mental status change, urinary frequency,urgency, flank pain,etc., Orth says.

Important: Make sure the physicians provide some documented rationale in the clinical record as to the laboratory findings and whether a culture is warranted and supports a diagnosis of UTI,advises Jane Belt, MS,RN, managing consultant with Plante & Moran Clinical Group in Columbus, Ohio. The facility could obtain an explanatory statement as part of a telephone order, suggests Marilyn Mines, RN, RAC-CT,BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill. As an example, the statement might read: “Keflex 500 mg tid for 10 days for symptomatic UTI (concentrated,odorous urine) with abnormal U/A lab results.”

MDS 3.0 preparation will be heating up again in October.

That’s when the Centers for Medicare & Medicaid expects to publish the final MDS 3.0 data specifications,RUGs, RAP triggers and QIs/QMs, according to the agency’s new timeline. It will also publish the MDS 3.0 data elements, which includes admission, quarterly, swing bed and discharge MDSs. Also look for publication of the MDS 3.0 RAI Manual. MDS 3.0 implementation is set for Oct. 1, 2010.

Find out where these new requirements fit into the bigger picture.

If your facility hasn’t complied with the so-called “red flag rules” to detect and prevent identity theft, it may be wide open to serious problems if someone steals a resident’s personal financial information.

“The red flag rules apply to anyone who meets the regulation’s definition of a creditor,” which is an entity that provides services and charges for them later, says attorney Joanne Lax, with Dykema Gossett PLLC in Bloomfield Hills, Mich.

And that no doubt means your nursing facility.

What the rules require: Starting May 1, you need a written program to detect warning signs of identity theft, as well as “reasonable” policies and procedures to address and mitigate identity theft, according to the Federal Trade Commission, which oversees the rules. The facility also has to update the program periodically to reflect changes in risks related to identity theft, the FTC advises.

The consequences: The FTC can impose fines on entities found out of compliance with the red flag rules. As far as identity theft, a scenario where an unscrupulous staff person takes a resident’s financial information or Social Security number for personal use could also raise survey compliance concerns, as it constitutes misappropriation of property,says Lax. And that “is a reportable aspect of resident abuse under the Medicare/Medicaid requirements of participation for long-term care facilities.”

Identify Red Flags That Fit Your Facility

The federal regulations include an appendix that lists several possible “red flags,” notes attorney Scott Richardson, with Bradley Arant Boult Cummings, in Nashville, Tenn.“The regulations require that a committee be formed to consider a range of possible red flags and address how to detect and react” to them, he notes. But Richardson notes that “many facilities already have compliance teams, particularly HIPAA compliance teams, that are familiar with this area and can more easily take on this additional role.”

Red flag these examples: Some potential red flags that might apply in a long-term care setting include getting mail back marked “undeliverable” when sent to a resident’s given address, Richardson says. Or a resident or his representative may receive written correspondence from credit card companies or other financial institutions as if the resident had applied for consumer credit or a loan,when he hadn’t. Unexplained charges on a resident’s credit card can also be a potential sign that someone may have used the card number to order something online -- a scenario that has occurred in healthcare settings.

A red flag should also go up if someone’s medical records don’t match the person’s history or what he or family members relay to you. Also look for instances where a returning patient’s information doesn’t match what you have on file from his previous admission, suggests Richardson.

Focus on All the Rules and Regs

Whether lack of compliance with the red flag rules ends up leaving surveyors seeing red remains to be seen, unless the Centers for Medicare & Medicaid Services issues guidance on the issue, says attorney Joseph Bianculli, in private practice in Arlington, VA.

But nursing home providers should keep in mind that the red flag requirements are only one part of an interrelated system of privacy laws and regulations, including HIPAA. Some states have specific anti-identify theft laws. In addition, state elder abuse laws may also weigh into the compliance equation.

That’s why some legal experts advise healthcare organizations to focus on implementing an overall anti-identity theft effort. Such a program might include these strategies:

1. Always ask new admissions for a government-issued picture identification card to confirm who they are.

2. Compare the resident’s identifying and medical information to what you have on file from Medicare or Medicaid or hospital records. In one case, a hospital detected identify theft by noting that a patient had a different blood type from the blood type in the original record, notes attorney Robert Markette Jr., with Gilliland & Markette LLP in Indianapolis.

3. Set up a process to confirm guardianship status and HIPAA authorization in terms of identifying whom the facility can talk to about the patient, advises attorney Cynthia Stamer in Dallas. “Then the  organization should continuously monitor it.” This approach can head off a real-world scenario where a nursing home allowed a resident’s neighbors to serve as her personal representatives when an attorney had actually been appointed for that purpose. And some of the resident’s neighbors accessed her personal financial information -- and funds, Stamer relays.

4. Limit access to billing records. Some organizations keep these records separately, Stamer notes. Many facilities also authorize only certain personnel access to the information, Richardson points out.

5. Learn from past experiences with identity theft or attempted identity theft in the facility. The facility should make certain its red flag compliance plan addresses such instances to prevent them from happening again, stresses Richardson.

Providers share inside strategies.

Ask a group of nursing home providers who’s doing what to keep their residents, families, and staff happy, and the hands start flying. That’s what happened in an interactive presentation by Jennifer Pettis, RN, RAC-MT, C-NE, at the March 2009 American Association of Nurse Assessment Coordinators spring meeting. Here’s a rundown of what seems to be improving staff satisfaction for various nursing facilities:

1. Partner with local nursing schools. One participant noted her facility offers an extended orientation and preceptorship to nursing graduates of two local nursing schools. The new staff doesn’t come with “baggage” in terms of practices learned in other places. And now nursing staff wants to be preceptors, the AANAC attendee noted.

2. Groom your own professional staff. One facility offers tuition reimbursement for CNAs who want to go to nursing school or for LPNs who want to pursue an RN degree.

3. Reward everyone for a good survey. When a survey works out well,staff receives a jacket or shirt.

4. Offer inservices and gifts that really mean something to staff. That includes bonuses at holiday time or a dinner party for staff.

5. Provide a safety net for those in need. One facility has set up an employee foundation to which staff can make voluntary donations. Then staff members submit requests to use the funds for an employee in need ---for example, a staff person’s house burns down, or perhaps a staff member’s spouse passes away and the person can’t pay for a funeral.

6. Engage CNAs as peers. One facility uses consistent assignments in caring for residents. When a primary assignment becomes available, CNAs and other staff do the interviews to select someone who will be a good fit in caring for a resident.

Now for Improving Resident/Family Satisfaction …

AANAC conferees also weighed in with some simple -- and novel ways -- to meet resident and family needs.

7. Allow residents to bring their pets to live with them in the facility. One participant noted that this gave her facility a competitive edge as other facilities in the area had no-pet policies.

8. Meet with residents and families once a week to make sure everything is going OK. This approach can address small complaints before they snowball into a major complaint.

9. Implement hourly rounding. Staff checks with the resident each hour during the day and evening shifts to see if the person is in pain or has to go to the bathroom, etc. The facility has found that many times the resident’s or family’s request doesn’t involve a clinical issue; so they assign non-clinical people to help out with the rounding during busy times such as lunch. The residents view the approach as a sign that staff cares about their needs. The facility has also found that residents no longer have to put on their call lights to get their needs met.

10. Post the charge nurse’s name in the resident’s room each shift. The CNAs post the charge nurse’s name on a Velcro board each shift. The facility found this approach helps residents/families feel more in control and preempts them from having to repeatedly find out whom to talk to if they have a concern.

11. Implement a menu-style meal ordering system. In one facility, staff provides menus for the upcoming meal and takes the residents’ orders. The kitchen prepares the meal as the residents order them.

12. Require the first person to see a call light to answer it. That includes managers who aren’t qualified to provide clinical care. If the resident has a clinical issue, the non-clinical staff person tells the resident that his caregiver will be there in five minutes. But 50 to 60 percent of the time, the staff finds the resident wants something that anyone can do for him.

Use this as a handy QA checklist.

Talk about a roadmap to F tags: The revised survey guidance for F309 provides a checklist of what the Centers for Medicare & Medicaid Services expects nursing homes and hospices to be doing for Medicare beneficiaries on the hospice benefit.

Previously, “the hospice guidance was in Appendix P of the surveyor process, which would have told surveyors what to look at,” says attorney Paula Sanders. But now surveyors have a specific tag, F309, to cite if the facility isn’t in compliance, cautions Sanders, partner, Post & Schell in Harrisburg, Pa.

So expect surveyors to be on the lookout for the following for residents receiving the hospice benefit:

• “The plan of care reflects the participation of the hospice, the facility,and the resident or representative to the extent possible;

• The plan of care includes directives for managing pain and other uncomfortable symptoms and is revised and updated as necessary to reflect the resident’s current status;

• Medications and medical supplies are provided by the hospice as needed for the palliation and management of the terminal illness and related conditions;

• The hospice and the facility communicate with each other when any changes are indicated to the plan of care;

• The hospice and the facility are aware of the other’s responsibilities in implementing the plan of care;

• The facility’s services are consistent with the plan of care developed in coordination with the hospice (the hospice patient residing in a SNF/NF should not experience any lack of SNF/NF services or personal care because of his/her status as a hospice patient); and

• The SNF/NF offers the same services to its residents who have elected the hospice benefit as it furnishes to its residents who have not elected the hospice benefit. The resident has the right to refuse services in conjunction with the provisions of 42 CFR 483.10(b)(4), F155.”

Here’s what you never want to happen when caring for hospice patients.

Hospice care is increasingly finding itself in the hot seat, and so will your nursing home if it cares for residents receiving such services. You can, however, avoid known stumbling blocks that trip up efforts to coordinate hospice care and maintain survey compliance.

Problem No. 1. The facility and hospice physician orders don’t jibe. Suppose the nursing home attending physician writes a directive saying the resident should receive no lab tests or weights, says Harold Bob, MD, CMD, a hospice and nursing home medical director in Baltimore, Md. But then the hospice gets an order for either or both to verify the hospice patient’s continuing decline and eligibility. “The surveyor can interpret this as a violation of a directive,” Bob says.

Solution: The nursing home medical director can work with the physicians to make sure everyone is on the same page with the care directives and orders.

Problem No. 2: Nursing home and hospice caregivers aren’t on the same page in managing pain.

For example, Bob has seen a “mismatch in documentation” where “the hospice nurse writes a note in the chart saying ‘the patient had a 10 out of a 10 for pain, and only when I came did he get morphine.’ If a nursinghome surveyor reads that note -- the facility is going to get cited with actual harm and a CMP potentially.”

Instead: The nursing home and hospice should collaborate in assessing and treating pain -- and agree not to air their differences about care in the medical chart, Bob advises.

Problem No. 3: Providers don’t keep their eye on the hospice patient’s or family’s goals. Nursing home surveyors will likely hone in on instances where the nursing home and hospice are working against each other in providing care. As one example, nursing facilities sometimes tend to provide “aggressive” nutritional interventions to heal a hospice patient’s pressure ulcer, observes Joy Barry, RN, MEd, CLNC, principal of Weatherbee Resources Inc. in Hyannis, Mass. And that might be good, she says, if it’s the goal for care. “But you have to ask whose goals of care they are -- the patient’s, the family’s, the nursing home’s, a consulting physician’s, etc. -- and are those goals aligned with the hospice philosophy?”

The way out: Nursing home and hospice staff tend to get on the same “wavelength,” when they talk about a resident’s care in terms of what’s best for the person and what he and his family wish to do, says Bob. For example, if a treatment, such as a blood transfusion, can give a patient an extra week or two of quality life -- “and that time is precious to the patient and family” -- Bob believes the person should receive it.

Another example: “Sometimes hospices will administer oxygen or IV therapy for unconscious patients because the family feels a need to do something,” says Barry. “This type of treatment can help families avoid having regrets later that they did not do more to help the patient.”

In some cases, the patient may wish to come off hospice and pursue curative care, such as a new cancer treatment. Nursing homes and hospices should educate patients that they are free to go back on the hospice benefit at a later time.

Problem No. 4: The nursing home and hospice don’t have a standardized way to communicate. The nursing home should appoint a “go-to” person to handle specific hospice issues, advises Rachel Schmidt, a hospice consultant in Morganton, NC. Ditto for the hospice. For example, Seasons Hospice and Palliative Care appoints each hospice patient a nurse case manager who is responsible for the patient’s hospice care within the facility, reports Tim Simpson, RN, CHPN,VP of clinical services for the hospice in Des Plaines, Ill. The nurse case manager, who serves as the “point person” to the nursing home,meets with the nursing home’s DON and the staff nurse during each visit,and discusses the needs of the patient and family.

Good idea: Develop a system to notify the hospice of any changes that occur in the patient. Seasons Hospice puts a sticker on the resident’s chart to remind staff to do that, Simpson reports.