Skilled Coverage / PHE / MA DPH / HHI Core Components Updated 1.19.2023 / Skilling Related to Quality Measures

Understanding skilled coverage criterion is always an area of opportunity.   

Attached and below are some tools and references to help guide you and the staff.

There are some time sensitive opportunities that require attention. 

Skilling patients improves care. 

HHI recommends assessing all patients triggered on quality measures and evaluate if they need skilled services under the Medicare Part A Coverage Criterion utilizing the COVID-19 Waivers.

What is a fever in a SNF? 

• It is a 2.4-degree Fahrenheit change from baseline. 

• If the nurses are not assessing the resident, how do they know the baseline temperature?  They will not be able to properly assess, appropriately care plan and render the highest quality of care for residents if they do not provide daily skilled observation and assessment.

Factors:

1. PHE Extended until April 2023:

a. COVID-19 Waivers allow for:

i. No 3 Night qualifying stay.

ii. No break in benefit period.

2. A patient that is exposed to COVID-19 requires daily skilled nursing to observe and assess for signs and symptoms of COVID-19.

a. This is a skilled service. (See attachment 1, page 2 yellow highlighted as Massachusetts DPH mandates observation on all exposed residents.) Many other states have this requirement as well.

b. Access Medicare Part A Benefits:

i. Admit to skilled MD Order.

ii. Medicare Certification Form completion.

iii. Daily Skilled notes. See Core Components, page 32 for COVID-10 Exposed Skilled Criterion.

3. Skilling Quality Measures

a. See attached updated HHI Core Components:

i. Ability to Move Independently Worsened (Quality Measures) -Page 4

ii. Antipsychotic Medication (Quality Measures) -Page 11

iii. Catheter (Quality Measures)-Page 18

iv. Falls with Major Injury (Quality Measures)-Page 41

v. Help with Daily Activities Increased (Quality Measures) -Page 47

vi. Pressure Sores (Quality Measures)-Page 77

vii. Urinary Tract Infection (Quality Measures)-Page 105

b. See below for skilling related to quality measures.  

i. Overview Quality Measures for Medicare Part A Coverage:

 HHI recommends assessing all patients that trigger for:

• Falls with Major Injury.

o   Management and Evaluation of a Care Plan

o   Observation and Assessment

o   Teaching and Training

• Pressure Sores

o   Inherent Complexity Skilled Nursing Services

• Catheters.

o   Management and Evaluation of a Care Plan

o   Observation and Assessment

• Urinary Tract Infections (UTI’s).

o   Observation and Assessment

• Antipsychotic Medication.

o   Management and Evaluation of a Care Plan

o   Observation and Assessment

• Help with Daily Activities Increased.

o   Teaching and Training

• Ability to Move Independently Worsened.

o   Teaching and Training

 ii. Details of Quality Measures for Medicare Part A Coverage:

Falls with Major Injury:

Skilled Nursing

• Overall management of care plan to ensure medical safety and promote recovery.

Skilled Therapy

• Evaluation, treatment, establishment of maintenance plan to maintain functional level and prevent falls.
• Is therapy involved? 
• Is therapy picking up patients under Medicare Part A?  (Waiver) 
• Any patient with a fall must be evaluated and treated by therapy.

Pressure Sores:

Any patients with multiple stage 2 pressure sores or 1 Stage III or worse, automatically skilled via Inherent Complexity.

Skilled Nursing

• Daily Skilled Nursing via inherent complexity of Treatment of Pressure Injury.
• Daily Skilled Nursing via inherent complexity of Multiple Stage 2 pressure injuries.
• Daily Skilled Nursing via inherent complexity of 1 pressure injury Stage III or worse.

Catheter:

Skilled Nursing

• Overall management of care plan to ensure medical safety and promote recovery.
• Daily skilled nursing to assess reason for catheter.
• Daily skilled nursing to establish a plan to removecatheter.
• Daily skilled nursing to observe, assess and identity for neurogenic bladder or obstructive uropathy.
• Daily skilled nursing to observe, assess and identity approved conditions for Catheter to remain in the bladder.

1. Daily skilled nursing to observe, assess and identity Urinary Retention that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible, and which is characterized by:

• Documented post void residual(PVR) volumes in a range over 200milliliters (ml);
• Inability to manage the retention/incontinence with intermittent catheterization; and
• Persistent overflow incontinence, symptomatic infections, and/or renal dysfunction.
  
  2. Daily skilled nursing to observe, assess and identity Contamination of Stage 3 or Stage 4 Pressure Ulcers with urine which has impeded healing, despite appropriate personal care for the incontinence; and

3. Daily skilled nursing to observe, assess and identity Terminal Illness or Severe Impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain.

Urinary Tract Infection (UTI):                

Skilled Nursing

• Daily Skilled nursing observation and assessment of signs and symptoms of UTI.  
• Daily skilled nursing to observe, assess and identity patient actually qualifies for diagnosis of UTI.
• Teaching and Training staff on proper peri care and catheter care to the direct care staff and residents as needed and assess competencies.
• Daily skilled nursing to observe, assess and identitythe resident if they experience increased confusion or behavioral issues in the absence of urinary symptoms. The assessment is to determine the causes and contributing factors prior to obtaining the Urinary Analysis (UA).
• Daily skilled nursing to observe, assess and identityincontinence.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via adequate hydration.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via Urology Consults for management of residents with chronic recurrent UTIs.
• Teaching and Training the staff on the McGeers UTI Criteria for determining UTIs and documentation of supporting symptoms.
• Daily Skilled nursing observation and assessment Ensuring that the UTI diagnosis is accurate.
• Daily Skilled nursing observation and assessment using evidence based criteria, such as McGeer, NHSN, or Loeb, to make the determination of a UTI during the last 30 days,
• Daily Skilled nursing observation and assessment of  Sign or symptom attributable to a UTI.
• Daily Skilled nursing observation and assessment of Significant Laboratory Findings in the medical record.
• Daily Skilled nursing observation and assessment of current medication or treatment for UTI in the last 30 days.

Residents without an Indwelling Catheter:

• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) A positive laboratory findings of at least 10₅ cfu/ml (100,000 colony forming units/mL) of no more than 2 microorganisms per voided specimen
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) At least 10₂cfu/ml (100 colony forming units/mL) of any number of organisms in a specimen collected via in and out catheterization. 
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms acute dysuria.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms acute pain.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms swelling.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms tenderness of the testes.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms tenderness of the epididymis.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms tenderness of the prostate.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms Fever (temperature of 100°F (38°C) or 2.4 degrees above the patient’s baseline temperature).
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms leukocytosis (>14,000 WBC/mm³).
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms of new or worsening Urgency.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms of new or worsening Urgency.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms of new or worsening Suprapubic Pain
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms of new or worsening Frequency.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms of new or worsening Gross Hematuria.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms of new or worsening Back or Flank Pain.
• Daily Skilled nursing observation and assessment (Residents without Indwelling Catheter) of signs and symptoms of new or worsening Urinary Incontinence.

Residents with an Indwelling Catheter:

• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of Fever.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of Rigors.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of Fever new-onset hypotension with no alternate site of infection.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of Leukocytosis.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of acute change in mental status.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of acute functional decline with no alternate diagnosis.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of new-onset suprapubic pain.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of costovertebral angle pain/tenderness.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of purulent discharge from around the catheter.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of acute pain, swelling, or tenderness of testes.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of acute pain, swelling, or tenderness of epididymis.
• Daily Skilled nursing observation and assessment (Residents with Indwelling Catheter) of signs and symptoms of acute pain, swelling, or tenderness of prostate.

Antipsychotic Medication:

Skilled Nursing Services

• Daily skilled nursing for overall management of care plan (medication management)  to ensure medical safety and promote recovery.
• Observation and Assessment
• Daily skilled nursing to observe, assess and identify Sedation. Antipsychotic medications pose tremendous risks for older adults and are linked with Sedation.
• Daily skilled nursing to observe, assess and identify Cardiovascular Changes. Antipsychotic medications pose tremendous risks for older adults and are linked with Cardiovascular Changes.
• Daily skilled nursing to observe, assess and identify Increased Fall Risks. Antipsychotic medications pose tremendous risks for older adults and are linked with Increased Fall Risks.
• Daily skilled nursing to observe, assess and identify Neurological/Extrapyramidal Side Effects.  Antipsychotic medications pose tremendous risks for older adults and are linked with Neurological/Extrapyramidal Side Effects. 
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via as behavioral management strategies and non-pharmacological alternatives such as activities. 
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via assessing the potential for cardiovascular risk by checking cardiovascular function prior to starting the medication.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via prior to starting a antipsychotic medication, the resident should have an electrocardiogram to identify the increased risk of cardiac arrhythmia with the use of an antipsychotic medication. 
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via using the smallest dose possible. 
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery when starting a resident on an antipsychotic medication, the adage of “start low and go slow”.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via stopping the medication or attempting a dose reduction at least once a year.
• Daily skilled nursing to observe, assess and identify Dystonia (spasms and muscle contractions).
• Daily skilled nursing to observe, assess and identify Akathisia (restlessness).
• Daily skilled nursing to observe, assess and identify Parkinsonism (rigidity).
• Daily skilled nursing to observe, assess and identify Bradykinesia (slow movement).
• Daily skilled nursing to observe, assess and identify Tremor.
• Daily skilled nursing to observe, assess and identify Tardive dyskinesia (jerky, irregular movements). 
• Daily Skilled nursing observation and assessment utilizing assessment instruments for evaluation of EPS, including the Abnormal Involuntary Movement Scale (AIMS) test or the Extrapyramidal Symptom Rating Scale (ESRS).
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via the usage and implementation of behavioral redirection.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via the usage and implementation of strategies like distraction.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via the usage and implementation of strategies like therapeutic conversation.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via the usage and implementation of strategies like activities.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via the usage and implementation of strategies like the simple application of personal attention.
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via the usage and implementation of strategies like application of personal attention and time that may alleviate behavioral disturbances that have previously resulted in a need for antipsychotic medication. 
• Management and Evaluation of a Care Plan to ensure medical safety and promote recovery via gradual dose reductions. 

Skilled Therapy

• Evaluation, treatment, establishment of maintenance plan to maintain functional level and prevent falls.
• Is therapy involved? 
• Is therapy picking up patients under Medicare Part A?  (Waiver) 
• Any patient with a fall must be evaluated and treated by therapy.
• All residents on Antipsychotic Medication are evaluated and treated by Physical and Occupational Therapy.
• When a resident is placed on an antipsychotic or anti-anxiety/hypnotic medication, include an analysis of the risk for injury if a fall occurs, since it is likely that one may follow the start of the medication.  While fall prevention strategies are beneficial, the likelihood of falling is dramatically higher for residents on antipsychotic and anti-anxiety/hypnotic medications.  The risk of falling should be weighed against the need for treatment with antipsychotic or anti-anxiety/hypnotic medications. 
  

I hope this information helps clarify the value of skilled coverage in a SNF.

As always, please feel free to call me at 617.595.6032

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