Alternative Chapter 10, 12, 13
Who determines how long-term care facilities are reimbursed under the Medicaid program?
The individual state agency through state legislation
Developed by an interdisciplinary team, the _____ includes measurable objectives and timetables to meet a resident’s medical, nursing, mental, and psychosocial needs.
The ______ (is/are) a core set of screening and assessment elements, including common definitions and coding categories forming the foundation of the comprehensive resident assessment of residents in a long-term care facilities, such as skilled nursing facilities (SNF)
minimum data set
Which of the following provide(s) structure for assessing social , medical, and psychological problems by providing a systemized method of reviewing key components of the minimum data set and directing caregivers to evaluate causes, interrelationships, and particular strengths that affect development of the care plan?
Care area assessment process
When a care area is triggered, the long-term care interdisciplinary team documents the outcome of the assessment process for that particular care area and _____
their decision regarding care planning for a particular problem or need
Medicare Part A coverage is limited in that a long-term care resident must first qualify with a minimum of a ____ hospital stay
The duration of skilled nursing facility Medicare Part A coverage is limited to the need for daily skilled care up to a maximum of ____ days per spell of illness.
The resource utilization group (RUG) that applies to a given resident is based on ____
the minimum data set
The phrase “private pay” in the long term care setting denotes payment by ____
the individual or family
In long-term care, CPT codes are used most commonly to bill for:
Medicare Part B Services
Which of the following is a facility in which the majority of patients are regarded as permanent residents?
Which of the following would initiate a complaint investigation in response to a hotline call concerning alleged abuse or neglect?
The state licensing agency
According to federal regulations, the care plan should be completed within ______ of the comprehensive assessment.
An agreement between the HMO and CMS to provide services to Medicare beneficiaries under which the health plan receives a monthly payment for enrolled Medicare members and must then provide all services needed is called a(n) ______
CMS provides free software for entering and transmitting MDS assessment data. This software is called ____
Ability to bathe, dress, groom, transfer and ambulate, toilet, eat, use speech, languages, etc.
Activities of daily living
Clinically relevant information about an individual that identifies specific problems and forms the basis for individual care planning
care area triggers
A periodic, resident-centered inspection that gathers information about the quality of service furnished in a facility to determine compliance with the requirements of participation in the Medicare and Medicaid programs
A person-centered philosophy that creates a more home-like environment for residents of a nursing facility
culture change movement
Residents who need constant oversight and supervision in activities of daily living
Permanent residents receiving non skilled care
Designed to care for residents diagnosed with conditions such as Alzheimer’s
Permanent residents, special care
Residents receive frequent skilled care from a licensed professional
Permanent residents, skilled care
Residents length of stay is less than 100 days
Short stay to provide relief to primary caregivers of the frail elderly
Physical presence in the long-term care facility is limited
Coordinate long term daily care and hold supervisory positions
Predominant licensed caregivers in the long term care setting
Licensed practical nurses
Provide daily care needs to long term care residents
In some states, can assume responsibilities to lessen the load of the licensed nursing professionals
Certified medication technicians
Make arrangements for adaptive equipment, clothing, and financial assistance
Responsible for assessing the therapeutic recreational needs and preferences of each resident and developing and individualized program
Often independent contractors rather than employees
True or False: Standard surveys of long-term care facilities are unannounced and conducted at least every fifteen months
True or False: Contracted providers, such as physical therapists, bill Medicare directly for their services to residents in a skilled nursing facility
True or False: Long term care patients are commonly called residents
True or False: Most LTC facilities are accredited by the Joint Commission
True or False: Substantial noncompliance and substandard quality of care findings at a long term care facility can result in fines up to $10,000 per day
True or False: A care area may be triggered by data entered on the minimum data set (MDS) and, if so, the interdisciplinary team must document the outcome of their assessment process for that care area
True or False: When federal and state laws conflict, the facility is required to follow federal law
True or False: In long-term care facilities such as nursing facilities, records are generally audited for completeness only at the resident’s death or discharge
True or False: Resource Utilization Groups (RUGs) compromise a case-mix methodology based solely on diagnosis and procedure codes submitted on Medicare bills.
True or False: When the state agency receives notification of a complaint about a long-term care facility, the result is an investigation of the facility
True or False: The medical program for the indigent is called Medicare
Which of the following is a list of organizations that have deeming authority for home health care with regard to Medicare certification and the Condition of Participation?
The Accreditation for Commission for Health Care (ACHC) The community Health Accreditation program (CHAP) and the Joint Commission
Medical-surgical nursing, intravenous therapy, and restorative nursing care are ____
skilled nursing services
_______ is a data set that is a requirement under Medicare for home health
______ is the basis for home health reimbursement under Medicare
Under Medicare, approximately how often must a physician certify that home care is needed?
every 60 days
One of the criteria for receiving Medicare payment for home care is that the patient being served must be _____
_______ is a charitable organization that provides food services for those unable to leave the home:
meals on wheels
A wheelchair or hospital bed is an example of ______
durable medical equipment
In-home respite care______
Allows the primary caregiver to have some free time
Labor costs and transportation costs associated with home care visits are examples of _______
Software available from CMS which can be used for data entry, editing, and validation of OASIS data is called
The federal agency within the DHHS responsible for administering Medicare programs related to home health is the _______
Centers for Medicare and Medicaid Services (CMS)
The rule used as a basis of comparison for measuring quantitative or qualitative value is
A _______ is a record organized in sections according to patient care departments and/or disciplines
Physical therapy, occupational therapy, speech-language pathology, medical social services and respiratory therapy are all examples of various _____ that may provide services to home health patients.
True or False: Home health care is a service provided to recovering, disabled, or chronically ill patients who receive their treatment in their homes.
Medicare will only pay for home health care services for persons who are homebound.
True or False: A home care agency that opts to be surveyed for Medicare certification by the Joint Commission would be deemed to be in compliance with the Conditions of Participation upon accreditation by the Joint Commission
True or False: The Community Health Accreditation Program (CHAP) us responsible for the development of the OASIS data set and manages data collection using OASIS for home care providers nation wide.
True or False: The Accreditation Commission for Health Care (ACHC) has deeming authority for Medicare in home health, hospice, and DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies)
True or False: The home care patient’s physician must review, update and recently (if necessary) the plan of care at least every 6 months, a time frame referred to as the certification period.
True or False: The Outcome and Assessment Information Set (OASIS) is a data set that is used by Medicare for both payment and quality improvement purposes
True or False: An upcode occurs when the provision of care to a patient results in unusually high costs to the home care agency
True or False: A home health care agency’s payer mix is the ratio of various insurers and third party payers, such as government programs and commercial insurers
True or False: Home Health Resource Groups (HHRGs) are based on assessment data in three areas — Clinical, Functional, and Service Utilization
True or False: A physician must have a face to face encounter with the home health patient within 7 days prior to the start of home health care, or within 3 days after the start of care
True or False: Medicare-certified home health agencies are required to use OASIS-C for evaluating children and maternity patients
An associate or member of a particular business
A formal way of checking financial and other records
Lack of payment for services rendered due to failure to meet requirements or some other reason
Any happening that is not consistent with routine operations
Data set required of home health care agencies
End result or consequence; the patient’s health and functional status after a period of treatment
Assist patients who suffer from strokes or adverse effects of feeding tubes or endotracheal tubes; teach proper swallowing techniques and so on
Assist the patient to become independent with person care duties such as dressing, bathing and other normal activities of daily living.
Establish a home exercise and maintenance program for the patient, assisting with exercise routines and ambulating devices
Help patients and family members cope with a patient’s disease process through placement and involvement with community services; help find appropriate resources and make suggestions for long-range planning
Medical social services
Teach techniques to increase efficiency in the lungs, such as pursed-lip breathing, and safety precautions when using oxygen equipment in the home.
The ____ provides care to the hospice patient in the patient’s place of residence (such as giving medications, dressing changes, reporting changes in patient’s condition) when hospice staff are not there
Mr. Jones has elected the hospice benefit. Upon election of the hospice benefit, Mr. Jones ________
waives standard Medicare coverage for services related to the terminal diagnosis
A hospice patient is admitted to a hospital for pain and symptom management. The hospice will be reimbursed for ______
general inpatient care
In a hospice situation, the _____ period ordinarily lasts about one year
Clinical measures taken to reduce the intensity of disease symptoms, rather than providing a cure for the disease are called
Which of the following statements is true concerning Medicare regulations regarding volunteers in hospice?
Volunteer hours must equal at least five percent of the patient care hours of paid employees and contract staff
Hospice care focuses on the needs of _____
both patient and the family
______ deals with the number of admissions, discharges, transfers and number of patients under the care of a hospice on a given day
Where is the majority of hospice care provided?
Patient’s place of residence
An individual is considered to be terminally ill if he or she has a life expectancy of _____ or less based on the physician’s clinical judgment regarding the normal course of the individual’s illness.
The National Hospice and Palliative Care Organizations (NHCPCO) _________
has staff available to answer questions or concerns regarding interpretation of NHPCO standards
When a Medicare patient revokes the election of hospice care, ________
the patient returns to standard Medicare coverage
The Palliative Performance Scale ______
assesses the patient’s physical, functional, and mental status
In hospice, coding additional ______ helps build a diagnosis database that can be used to evaluate not only the quality of care give, but also the components of various diagnosis groups.
Signs and symptoms
When coding, which would be more useful to hospice staff for internal evaluation of the quality of care provided to the terminally ill?
Urinary tract infection
The days of care reimbursed by Medicare at an inpatient rate (either general inpatient or respite) ______
can be no more than 20 percent of the total days of hospice care
Upon the death of the patient, the health information department may get numerous requests from insurance companies or attorneys to settle a claim or probate the patient’s estate. No information should be released without proper authorization from _____
the legal representative of the estate
Hospice routinely provide ________ services as part of the hospice benefit
Under Medicare, hospice payment rates are adjusted based on _______
the geographic location of the patient
Medicare reimburses hospice care on a _______ basis
A patient is at his or her place of residence and is receiving non-problematic care
Routine home care
A patient receives predominantly nursing care for a minimum of 8 out of 24 hours at his or her place of residence during a period of crisis
A patient receives care un a approved facility in a short-term basis (not more than 5 days at a time)
A patient receives care in an approved facility for pain control or acute or chronic symptom management
General inpatient care
True or False: Hospice care focuses exclusively on the needs of the patient as the unit of care
True or False: Under Medicare regulations, both the attending physician and the hospice medical director must certify that the patient is terminally ill
True or False: Hospice provide curative therapy rather than symptom management
True or False: No more than 50 percent of hospice care can be provided in the patient’s place of residence
True or False: The primary caregiver is the person designated to provide care for the hospice patient when hospice staff is not available
True or False: When a hospice patient is admitted to the hospital for pain and symptom management, the hospital is reimbursed by Medicare for the DRG and the hospice receives a reduced per diem payment for each day of the patient’s stay
True or False: The Affordable Care Act requires that hospice physician or nurse Practioner have a face-to-face encounter with a hospice patient not more than 15 days prior to the start of the hospice patient’s second benefit period
True or False: Volunteers may be paid at a lower hourly rate than other hospice employees
True or False: Medicare regulations permit certification of terminal illness with a life expectancy that is unknown and/or unspecified
True or False: A hospice program is licensed b the state in which its located
True or False: There is no voluntary accreditation organization with deeming authority for hospice programs and facilities
True or False: In addition to clinical staff, the interdisciplinary team includes a pastoral and other counselor who offers spiritual support and comfort
True or False: Hospice benefit periods are categorized as an initial 60-day period, a subsequent 60-day period, then a final 90 day period
True or False: By definition, the patient’s primary caregiver is also the patient’s legal representative
True or False: Hospice services require little out of pocket expense and paper work on the part of the patient and/or family