CMS COVID-19 Lessons from the Front Lines, Friday, May 22nd, 12:30 – 2:00 PM Eastern

The Wisconsin DHS has issued a Badger Bounce Back Plan. The plan identifies steps and criteria to guide the reopening of health care and other services in the state.

(i) symptoms; showing a downward trajectory in illnesses of a 14-day period;

(ii) cases, fewer and fewer positive tests over a  14-day period;

(iii) health care system; hospitals can treat patients without “crisis care” and there is robust testing;

(iv) testing; every Wisconsin resident with systems is able to get lab tests with results reported to public health within 48 hours of collection;

(v) contact tracing; every individual who tests positive is interviewed within 24 hours and their contacts are interviewed within 48 hours; and

(vi) protective equipment; all health care and public safety entities must have adequate protective equipment. 

1. To ensure that local hospitals and health systems have the capacity to handle COVID-19 patients through temporary expansion sites (also known as the CMS Hospital Without Walls initiative);
2. To expand at-home and community-based testing to minimize transmission of COVID-19;
3. To expand the healthcare workforce by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community or other states;
4. To increase access to telehealth for Medicare patients so they can get care from their physicians and other clinicians while staying safely at home; and
5. put patients over paperwork by giving providers, healthcare facilities, Medicare Advantage and Part D plans, and states temporary relief from many reporting and audit requirements so they can focus on patient care.

By John Fisher, JD, CHC, CCEP

Follow the links below to download from the CDC.

A coronavirus preparedness checklist for hospitals, including long-term acute care hospitals are available from the CDC.

Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings:

Strategies to Prevent the Spread of COVID-19 in Long-Term Care Facilities (LTCF):

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By Fisher, JD, CHC, CCEP

RUG System for Skilled Nursing Facility Reimbursement – Time is Running Out

It is currently anticipated that the RUG system, which is currently used to calculate reimbursement for Medicare Part A skilled nursing services, will be changed over the next year.  CMS is currently considering a new Resident Classification System that will completely change the way SNFs are reimbursed for their services.

Providers are getting glimpses of what may be included in the new calculation system.  CMS issued a draft sample worksheet using the RCS-1 system.  The stated purpose is to give providers a description of how the new system would work.  The worksheet gives a description of how a manual calculation would take place using the RCS-I methodology.

The sample draft worksheet that was issued by CMS is available here.  RCS_I_Logic-508_Final

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Wisconsin Prohibited Maneuvers and Techniques in Community Based Programs

Wisconsin Behavioral Health Lawyer

The Wisconsin Department of Health Services (DHS) as released a memo that specifies maneuvers or techniques that may not be used at any time in community based programs and facilities. DHS deems the prohibited maneuvers or techniques to “present an inherently high risk of serious injury and even death.”  Providers are directed by DHS to immediately discontinue the use of any of the listed maneuvers.  Prohibited maneuvers, techniques, and procedures that may not be used under any circumstances include:

• Any maneuver or technique that does not give adequate attention and care to protection
  of the head.
• Any maneuver or technique that places pressure or weight on the chest, lungs, sternum,
  diaphragm, back, or abdomen.
• Any maneuver or technique that places pressure, weight, or leverage on the neck or throat, on any artery, or on the back of the head or neck, or that otherwise obstructs or restricts the circulation of blood or obstructs an airway, such as straddling or sitting on the torso, or any type of choke hold.
• Any maneuver or technique that involves pushing into a person’s mouth, nose, or eyes.
• Any maneuver or technique that utilizes pain to obtain compliance or control, including punching, hitting, hyperextension of joints, or extended use of pressure points.
• Any maneuver or technique that forcibly takes a person from a standing position to the floor or ground. This includes taking a person from a standing position to a horizontal (prone or supine) position or to a seated position on the floor.
• Any maneuver or technique that creates a motion causing forcible impact on the person’s head or body, or forcibly pushes an individual against a hard surface.
• The use of seclusion where the door to the room would remain locked without someone having to remain present to apply some type of constant pressure or control to the locking mechanism.

DHS explains in the memo that the ultimate goal is to replace such interventions with trauma-informed systems and settings, positive behavior supports, and non-coercive intervention strategies. DHS promotes recovery and healing that is consumer-driven, person-centered, trauma-informed, and recovery-based.

In addition to describing measures that are completely prohibited, DHS states that restrictive measures that are not prohibited may only be used in emergency situations in which there is an imminent risk of serious harm to self or others, or as part of an approved plan. Situations in which the person’s behavior was foreseeable based on his or her
history are not considered an emergency.   Even restrictive measures that are not directly prohibited must be avoided whenever possible and may only be used after all other feasible alternatives, including de-escalation techniques, have been exhausted. When necessary, restrictive measures may only be used with the minimum amount of force needed, and for the shortest duration possible, to restore safety.

Facilities should review their policies and practices to assure compliance with the guidelines set forth in the memo. Additional staff training should be conducted to assure compliance with these standards.   Additionally, providers should become familiar with the changing standards of care and best practices focused on building skills and techniques to de-escalate and redirect behaviors that present safety concerns, and work earnestly to promote a trauma-informed culture of care.

By John Fisher, JD, CHC, CCEP

Personal Care Service Providers – Wisconsin Medical Assistance

Wisconsin Statute § 49.45(42)(d)3 describes the types of organizations that qualify to receive Medicaid reimbursement for “personal care services.”  Qualified entities include licensed home health agencies and other entities that are certified under section (2)(a)(11) to provide personal care services under section 49.46(2)(b)6j.  The DHS does not appear to have implemented regulations that specifically describe the criteria that “other entities” must meet in order to become qualified to receive reimbursement from Medicaid for the provision of personal care services.

The applicable provisions of section 49.45(2)(a)(11) do not contain specific criteria that “other entities” must meet but simply refers to the requirement that DHS promulgate rules establishing qualifications of providers.  The referenced statutory provision does not refer specifically to the requirements that “other entities” must meet in order to qualify to receive reimbursement for personal care services.

The requirements that must be met in order to become a licensed home health are more extensive than the personal care services entity.  However, becoming licensed as a home health agency will qualify you to provide and bill for personal care services directly.  It would also permit you to bill private pay patients for skilled nursing and other

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Nursing Facilities Are The First to Require Compliance Programs

The Patient Protection and Affordable Care Act of 2010 (PPACA) mandates compliance programs for most providers and requires the Secretary of Health and Human Services to publish regulations that establish the core elements for compliance programs.

Nursing facilities are the first providers to be mandated and must comply in 2013. However, CMS missed its statutory deadline of March 23, 2012 for issuing detailed regulations for nursing facility compliance programs. It is expected that these regulations and the requirements for other providers will be forthcoming now that the Supreme Court has opened the way for enforcement.  In the meantime, nursing facilities do not have precise guidance on compliance program requirements. 

Even though final detailed regulations have not been issued, providers should not wait to step up their compliance efforts.  There are many sources for guidance on how compliance should operate.  Providers will be required to certify that their compliance programs are effective in preventing and detecting criminal, civil, and administrative violations and in promoting quality of care.  Simply having a program in place is not enough.  The program must have sufficient operating history to demonstrate that it is “effective.”  Effectiveness reviews should be periodically performed to support the required certifications.