Poor sitting posture is a common problem in long-term care and has an effect on function and performance of ADL skills. Skilled Nursing Facilities strive for a restraint free environment, no recorded falls and eliminating the occurrence of skin breakdown at the facility level.  Committee meetings, QA teams and active walking rounds are a part of the daily operations in the SNF aimed at minimizing and eliminating the above listed clinical barriers to function.

Harmony continually discusses the significant clinical impact of accurate documentation. Accuracy is vital in developing the care plan, identifying changes in condition and attaining reimbursement that the SNF is entitled for services provided. The RAI Users Manual encourages the assessor to "engage direct care staff, from all shifts, which have cared for the resident over the past 7 days in discussions regarding the resident's ADL functional performance. Ask probing questions beginning with the general and proceeding to the more specific." It is with these discussions that inconsistencies can be identified, clarified and corrected. RUG's measure the resources utilized to provide care to the residents.

There are numerous ways to increase your Medicare Part A Revenue Medicare Part A Rate. Here are a few suggestions for increasing your facilities Medicare Part A Revenue:

Assessment Reference Date:

Positioning and Seating
 
Poor sitting posture is a common problem in long-term care and has an effect on function and performance of ADL skills.  The resident's ability to function in their environment is improved through good body alignment.  The primary goals of a positioning program includes improving body alignment, preventing or mitigating of the effects of pressure on existing pressure ulcers and improvement in ADL participation.  It is as important for caregivers to understand the unique situation of the identified patient at risk and document using and ADL flow sheet.  For example, one patient may tolerate sitting for 2 hours without skin compromise while another should be limited to 45 minutes out of bed. 
 
There are many factors to take into consideration when addressing positioning needs:
Is there abnormal tone contributing to poor posture and can it be normalized through treatment?
Is there muscle weakness contributing to poor posture and body alignment and can it be improved through treatment?
Can the patient get stronger?
Are there contractures contributing to positioning problems?
Can the contractures be reduced?
Is there any skin breakdown?
Is there adequate support of the extremities in the current seating system?
Does the patient have pain?
Does the patient have circulatory compromise?
Does the patient's position in the seating system vary throughout the course of the day or during specific tasks?
Evaluation and treatment of the above concerns are areas of specialty for a therapist versus the nurse or CNA.  This intervention meets the skilled criteria by definition and qualifies for coverage regardless of the patient's ability to demonstrate functional improvement.

Quality Indicators in a SNF Part II
 
Certain conditions impact the 5 Star Rating Quality Indicators, and it is essential to identify pertinent data in order to assess, paint a true portrait of the beneficiary, and care plan to reduce risk for recurrence.  Conditions coded on the OBRA admission assessment are stored in the database to compare to the next OBRA assessment. 
 
The primary use of the QI reports by facilities will be to:
Identify any potential areas of concern to focus quality assurance (QA)/quality improvement (QI) activities
Identify and select a resident sample for a QA/QI review.
It is important to determine why certain indicators triggered. If there is a documented clinical condition, then for example, dehydration may be an expected outcome. Ensure that clinical rationale reflects and care plans the risk/complication. Triggered indicators are not an indictment of facility mistakes and culpability rather they are a tool to evaluate systems and quality improvement programs.

The QIs/QMs and reports are not to be considered in isolation but should be used in conjunction with all pertinent information about a facility.

MANAGING LENGTH OF STAY 
 
Case management by the rehab staff is one of the primary factors effecting Medicare length of stay.  Generally, when a patient is admitted for short term rehab their underlying medical conditions stabilizes before they have reached their functional potential.  Therefore, although Harmony always teaches that nursing anchors all Medicare Part A skilled admissions, there are instances when the Rehab Department is the driving force behind the patients discharge plan. 
 
Medicare supports providing rehab services to help the patient achieve their prior level of function.  This should be thoroughly investigated and considered when discussing the patient's potential discharge and Medicare length of stay.  The following is a brief list of questions to consider before taking a patient off therapy:
Is the patient going home with an assistive device they did not previously use?  Does the patient have the potential to progress to a less restrictive device?
Are we asking caregivers to assist the patient with any of their ADL or IADL tasks that the patient was able to do before?  Does the patient have the potential to do these tasks on their own with further training?
If the patient is returning to an assisted living facility, did the patient utilize all of their services before or will they be using services that they previously did not?  Do they have the potential to resume their prior routine?
Even though the patient has assistance available (ALF, spouse, etc.) do they want to rely on their caregiver or are there activities the patient would like to be able to do on their own?
Does the patient enjoy making their bed every morning?
Would the patient prefer if other people did not wash their undergarments?
Does the patient like to make their own afternoon tea?
If yes is the answer to any of these questions it is clinically appropriate to investigate continuing the therapy program and further progress the patient to their highest functional ability.  It is important to update the therapy plan of care to include new goals specific to these higher functioning tasks and ensure that it documented that these goals directly relate to the patient's prior level of function and appropriate Medicare length of say. 

Nursing Documentation-ADL Coding:  The number of occurrences is a focus when coding Section G.  Many times Section G is undercoded as the MDS Coordinator notes assist on one shift alone and assumes that only one instance occurred.  When in fact, the aide may have interacted with the patient numerous times.  These are the occasions in which interview and investigative strategies are critical to ensure accurate coding.  This is indicated as patients may fluctuate from shift to shift, day to day.  There is great value both clinically as well as financially with accurate documentation of ADL status.  Clinically, it is important to have an accurate portrait of the patient in order to develop an appropriate plan of care.  Financially, the impact is significant when accounting for the resources utilized by the patient.