Nursing Facility Utilization Review Stakeholder Meeting IG Audit Division March 14, 2016 O FFICE OF I NSPECTOR G ENERAL Texas Health and Human Services Commission Page 1
N URSING F ACILITY MDS 3.0 R EVIEWS AND T RENDS The Utilization Review Unit is performing reviews of MDS 3.0 assessments in FY 2016. • Previous reviews were conducted in FY 2014 and 2015. • Average error rates for reviews in FY 2014 and 2015 were 5.4% and 4.87%, respectively. • Nursing facility error rates ranged from 0% to 34.74%. Page 2
FY 2016 W ORK P LAN The Work Plan for the number of nursing facility reviews is FY 2016 Work Plan Progress based on availability of resources, historical outcomes, and other factors such as legislative mandates. * • FY 2016 plan is to review 235 nursing facilities in Texas. • 102 facilities have been reviewed as of the end of February. *Additional information is available on the IG Internet site (https://oig.hhsc.texas.gov/). Page 3
N URSING F ACILITY E RROR T RENDS FY 2015 Error Trends (Listed from high to low.) Unsigned Forms 5 4 11 Lack of, incomplete, or conflicting documentation 13 56 Missing forms, records, and/or LTCMI 14 Signatures don't match LTCMI No documented training/training out of date 15 Medical records not systematically organized or readily accessible BIM/RMI not within ARD/look-back period 36 Restorative Nursing - lack of plans, goals not 29 measureable, missing documentation Altered documentation 33 No M.D. visit or visit outside of ARD, or no diagnosis Page 4
N URSING F ACILITY E RROR T RENDS FY 2016 Error Trends (Listed from high to low.) Lack of, incomplete, or conflicting documentation 3 3 Signatures don't match LTCMI 4 4 Unsigned Forms 32 5 BIM/RMI not within ARD/look-back period 5 No documented training/training out of date Restorative Nursing - lack of plans, goals not measureable, 11 missing documentation, claims 7 days after ARD Missing forms, records, and/or LTCMI ST/PT/OT Utilization/Incorrect dates of therapy 18 16 Medical records not systematically organized or readily accessible Orders counted incorrectly Page 5
FY 2016 Q UARTER 1 REVIEWS AND DUE PROCESS % Forms Reviewed with RUG Changes 600 545 530 500 400 285 300 200 116 111 102 100 35.8% 20.4% 21.9% 0 Sep. 2015 Oct. 2015 Nov. 2015 Forms RUG Changes Page 6
FY 2016 Q UARTER 1 REVIEWS AND DUE PROCESS % RUG Changes Requested for Reconsideration 140 116 120 111 102 100 80 60 44 40 30 19 20 18.6% 39.6% 25.9% 0 Sep. 2015 Oct. 2015 Nov. 2015 RUG Changes Requests for Reconsideration Page 7
FY 2016 Q UARTER 1 REVIEWS AND DUE PROCESS 50 % of Onsite Review Decisions Upheld at Reconsideration 44 45 42 40 35 30 30 24 25 19 20 15 12 10 5 95.5% 80.0% 63.2% 0 Sep. 2015 Oct. 2015 Nov. 2015 Reconsidered Forms Decisions Upheld Page 8
FY 2016 Q UARTER 1 REVIEWS AND DUE PROCESS # Cases With Onsite Decisions Upheld at Reconsideration and Requesting Appeal Nov. 2015 1 Oct. 2015 0 Sep. 2015 2 0 1 2 3 Page 9
Linda Carlson Nursing Facility Program Manager 512-491-2065 Linda.carlson@hhsc.state.tx.us Page 10
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