Long Term Care: Nursing Facilities The settings, Levels of care and caregivers

What are the three Type of settings for Long Term Care
Freestanding Nursing Facilities
Freestanding Skilled Nursing Facility
Skilled Nursing in Hospitals
Explain Freestanding Nursing Facility
Permanent residence for long term nursing
Long term Care Facility, Intermediate Care Facility
(ICF), Nursing Home
Explain Freestanding Skilled Nursing Facility
Certified wholly in Part A Medicare SNF provider
Explain Skilled Nursing in Hospitals
SNF Unit area within hospital for postacute care of Medicare Beneficiaries
SNF Facility Wing structure on Hospital campus, licensed for skilled nursing care
Give the five types of care for Long Term Care
Nonskilled care (custodial)
2. Special Care- Alzheimer’s
3. Skilled Care permanent Residents
4. Skilled Care- Short-Term Patients
5. Respite Care
Explain Nonskilled Care (Custodial)
provides oversight and supervision of ADLs (Activities of daily living) as frequently as monthly to as infrequently as annually
Skilled care not needed on a daily basis
Explain Special Care Alzheimer’s
Patient needs are more behavior oriented rather than medically oriented.
Explain Skilled Care -Permanent Residents
skilled care from licensed professional frequently
combination of nursing & restorative professionals
Physicians visit their patients several times per week to montly
Explain Skilled Care – Short-Term Patients
Less that 100 days
intent to discharge
may be categorized as subacute
skilled care for treatment for specific condition
goal is rehabilitation to discharge patient home or to a lower level of care
Explain Respite Care
Relief to primary caregivers
overnight to several weeks
meals, general supervision, necessary medications, safe environment, socialization.
Caregivers for Nursing Facilities
Physicians, Nurses, Nursing Assistants, Certified Medication Technician (CMT), Social Services, Recreation Therapist, Independent Contractors for various services.
What are the CMS requirements for Nursing Facilities Social Services
Requires that facilities with 120 beds or more employ a full-time social worker
Explain Recreation Therapist in Nursing Facilities
licensed or credentialed individual are required in some states
Give some examples for independent Contractors for various services
Lab, x-ray, Rehabilitation (physical, occupational, speech therapy) Respiratory Therapy, Registered Dietitians, Pharmacists
Explain Comprehensive Resident Assessment
Is used to evaluate patient outcomes in the federal LTC
must be completed for ALL residents of Medicare/Medicaid certified facilities, hospice and short term/respite patients who may stay in the facility longer that 14 days.
a) most be completed within 14 days of admission
b) or after if any significant change in condition
1. is not self-limiting(resolves itself)
2. impacts on more than one area of health status
3. requires interdisciplinary review & revision of care plans e.g. pressure ulcer, change in anxious mood
c)must be assessed on at least an annual basis thereafter quarterly reviews on physical, mental, psychosocial
Explain Resident Assessment Instrument (RAI)
Is the instrument & process to completing the comprehensive Resident Assessment
What are the four components of the RAI
1. MDS (Evaluate care trends)
2. Triggers (pressure sores got worse)
3. RAP (Resident Assessment Protocol)
4. Utilization Guidelines (time plan for the next RAI based on the annually, quarterly etc.
Explain MDS
Minimum Data Set is a core set of screening, clinical and functional status elements that forms a standardized means in medicare/medicaid certified facilities. Evaluate care trends for identify problems e.g. pressure sores, UTIs
How many months are supposed to be keep in the resident’s active clinical record of RAI data assessment and where is require the Electronic data to be submitted
15 months/ to the State and each state sends it to the federal government.
What are the MCS timeliness of the Care Plan for long term care
The care plan must be completed within 7 days of the comprehensive resident assessment.
What are the federal regulation for Long Term care for discharge/transfer?
Home health care is intented for
Homebound (the patient cannot leave the home to get health care) patients who require skilled services medicare is stringent for this requirements
Who accredits home health agencies ( HHA )
1. Joint Commission using Comprehensive Accreditation Manual for Home Care
2. CHAP ( Community Health Accreditation Program)
What are the forms required to be completed by HHA for Medicare beneficiaries
CMS 485 HH certification and Plan of Care
CMS 486- Medical Update of patient Information review update & recertify plan at least every 60 days
CMS 487- Addendum to 485 used when additional space is needed.
Give some key points from the Medicare COP for HHA
-HHA most ensure confidentiality of all patient identifiable information
-Must electronically report OASIS data
-Must include in the clinical record: Plan of Care, ID info. Name of physician, orders, progress notes, written summary AT LEaST every 60 days
Include availability of discharge
– Comprehensive assessment
-the initial assessment visit most be by an RN
What is the initial assessment timeliness
What is the initial assessment visit timeliness
within 48 hrs of referral or
within 48 hrs of the patient’s return to the home or
on the physician ordered start of care date
When is the assessment must be completed
no later that 5 days after the start of care
What are the timeliness for The Comprehensive assessment?
must be updated and revised as frequently as the patient’s condition warrants due to major decline or improvement, but not less frequent than every second calendar month beginning with the start of care(SOC), within 48 hours of return to home from hospital admission of 24 hrs or more.
What OASIS data must be incorporated into the HHA’s own assessment
Clinical record items
patient history
living arrangements
supportive assistance
sensory status
integumentary status
respiratory status
elimination status
neurological/emotional/behavioral status
equipment management
emergent care
data items collected at inpatient facility admission or discharge only
Clinical record review must be conducted…
at least quarterly and include both the active and closed records
Continuing review of clinical records must be performed for
each 60 day period to determine adequacy and continuation of services.
What are the Medicare requirements for Face To Face Encounter for Home Health patients
Face to Face Encounter most be documented with an eligible health care provider (certified provider or NPP) within 90 day period before or 30 days after the initiation of needed home health care services
Non Physician Provider e.g. Nurse practitioner
is the Outcome and Assessment Information Set that CMS requires HHA to use for purposes of outcome-based quality improvement (OBQI) and which forms the basis for a home health care prospective payment system.
What are the three types of measures most commonly used in quality work in OASIS
1. Structure – physical equipment and facilities such as using EHR
2. Process – how the system works- performing what is known to be clinically relevant and evidence based.
3. Outcome – the final product, results, stabilization, decline, or improvement
What are the OASIS data three important uses in the areas of:
-Patient assessment and care planning for individual adult patients
-Agency level care mix reports that contain aggregate statistic on various patient characteristics such as demographic, health, or functional status at start of care
-Internal HHA performance improvement
What data is not included in the OASIS
The vital signs which is included in the patient assessment
What is the OASIS timelines and requirements for data collection
must be collected within 5 days of the start of care
HHAs must “lock” the data for transmission within 30 after collecting the data.
Data must be collected when; transfer or discharge to an inpatient facility, recertification every 56 to 60 days and at discharge from the HHA
OASIS-C data collection time points
start of care
resumption of Care following inpatient facility stay
Recertification within the last five days of each 60-day recertification period
Other Follow-up
Transfer to inpatient facility
Discharge from home care
Death at Home
Home Assessment Validation and Entry (HEAVEN)
Stand-alone software system that enables an agency to computerize or enter OASIS data that have been recorded by clinicians using form that integrate the OASIS items into the agency’s assessment instrument
What are various Hospice Care Settings
The patient’s home, nursing units, hospital, SNF or as standalone facilities in the community
Define Hospice Care
Is a holistic approach for providing for the physical and emotional needs of the terminally ill and their family and significant others.
Define Palliative Care
(supportive not curative) is provided to make the patient comfortable and support the patient through the last stage of life.
Regulatory issues for Hospice Care Facilities e.g. SNF or hospitals
the facility is licensed by the state
States adopt Medicare’s COP for licensure
Most hospices do not seek accreditation, however now beginning to require to be Joint Commission accredited
Explain COP of participation for Hospices
-Are under Medicare Part A benefits
-The patient or Personal Representative sign a statement when electing the hospice benefit
-The physician and hospice medical director must document that the patient is not expected to live more than 6 months at the beginning of each benefit period.
-No out-of-pocket expenses for the patient
-Initial benefit period is 90 Days.
-May be renew for an additional 90 day period and then unlimited 60 day periods.
-Verbal certification must be obtained within 2 days after the benefit period begins and written certification obtain within 8 days.
Explain Medicare’s COP for hospice record content
-a record of all inpatient services the beneficiary received
-a copy of the discharge summary
-written plan of care which assesses the patient’s needs
-initial and subsequent assessments, Identification Data, the Plan of Care, authorization and election forms, Medical History, Services, Events, Evaluations, Treatments(not curative), Progress Notes, Informed Consents
What are the COP requirements for Hospices volunteer hours?
hospice should maintain a volunteer staff ratio equal to a minimum of 5% of the total patient care hours of all paid staff and contracted workers.
Advance Directives rules for hospice providers
What are the Face to Face visits Affordable Care Act (ACA) requirements for Hospice facilities
Requires a hospice physician or a hospice nurse practitioner to have a face to face encounter with a hospice patient prior to the patient’s 180th-day recertification and each subsequent recertification.
The encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period.
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