Feeling the fire of SNF PPS rule

The final SNF PPS rule for FY2012 published this summer will cause all operational professionals to stop and think about their implementation plans for the changes in documentation and practice that occurred on October 1, 2011. These provisions will produce many changes for many people that must be identified by operational leadership in order to support staff with the proper processes as change is implemented.

The industry has had many warnings about the changes in the rehabilitation process and increased assessment activity, which would have been challenging enough. But now we see the entire picture: SNF PPS final rule, national training calls and a gigantic RAI Manual update on August 30-this all creates a global issue for facility management that will require focus, a study of changes, budget for training and systems to support assessment and documentation processes and true interdisciplinary planning for care. The facility management and staff need to prepare and monitor the changes as well as the data during the implementation period: October and November 2011.

Most changes that impact payment, practice and performance require a status evaluation of the current situation before changes are made. This is essential for each facility so that changes can be planned and honest performance evaluations can create the base for compliance and planning.

Believe me; the facilities will need it all. This is a big change for payment and process and, for some departments, a change in basic rules. It all began with the implementation of MDS 3.0 last year and the transmission of all assessment and payment data into the same server. A new RAI Manual was created and released beforehand containing fundamental changes in the definitions and the assessment process as well as rich care planning formats with data tracking to audit and evaluate the planning and documentation process of care delivery. Many teams were not prepared for these changes and have not adjusted their process. Payment went up with the changes to RUG-IV and many teams did not focus on documentation and outcomes even though the Centers for Medicare & Medicaid Services (CMS) was getting all of its data and billing files to review and compare.

So here we are in the fall of 2011 with a final PPS rule that brings another set of definitions and practice changes as well as the diminished payment rates. This is not just big-it challenges the entire operational and clinical team to communicate and problem solve to assure financial and clinical success. The scope of this change is comprehensive for most teams and requires focus, objective management and frequent budgeting to implement the requirements. Attention senior managers: That means you. You need to be aggressive to identify how these changes and requirements will impact your facility, staff and residents.

It’s not just about rates. The system is much more complicated. Risk management and compliance must be a focus as well as decision making about how and when services are delivered and documented.


The first step in understanding these changes is to secure the final SNF PPS rule as published in the Federal Register  and the October 2011 updates to the RAI Manual  for facility staff to review and summarize. The RAI manual has change documents showing the specifics of the changes for each chapter and section of the data set. Review those first with the interdisciplinary team (IDT) involved with the assessment and the operational team directing the assessment process. Do not delay in reading the changes to definitions and requirements. There are many changes including an entirely new requirement-the Change of Therapy Other Medicare Required Assessment-to review all therapy delivery during the entire covered Part A Medicare stay, seven days a week, and then do additional assessments if the RUG level changes during the stay. Start with the requirements and then decide which team members and processes need to be involved to meet the requirement.

However, the narrative in the final rule supports increased documentation and care planning processes for rehab services, so the two documents need to be cross referenced for discussion and problem solving. I suggest that different members of the IDT review the documents and prepare to discuss the specifics of the requirements as they impact the facility policies, procedures and service delivery. Be ready for some candid conversation and interdisciplinary problem solving as well as specific performance standards and evaluations. For example, how do we count minutes of therapy delivered to an elder by type of minutes and type of treatment? How is the rehab plan specific and effective treatment for the resident’s condition?

Administrators may need to observe the therapy department to see what techniques are being used and the level of accuracy of the records used for assessment and billing documentation. Don’t be afraid to have objective observation-the rules have changed. It’s all about accuracy and resident-specific planning and documentation. The final rule suggests therapists have timers to show exact minutes of treatment. The RAI Manual now has a specific quote about not rounding minutes of treatment to the next five-minute increment.

Start with the requirements and then decide which team members and processes need to be involved to meet the requirement.

Much focus has been placed on the decrease in daily rates. It is difficult to calculate, but the losses for individual facilities can be much higher than the 11 percent being published. I have clients that have calculated the payment losses and RUG declines to exceed 15 percent beginning with the October billing period. As overall payment and RUG distribution is important for fiscal security, facilities need to also consider some of the operational requirements like increases in numbers of data sets and changes in assessment schedules to diminish the days of the stay that are utilized for data gathering. There are many factors that can either have a negative impact on payment or increase the risk of payment denial or audit in this new process. Yes, this is dangerous! Your entire assessment and billing database are in the same server and the data needs to be consistent and support the claim. Look at your data, the submitted data on a case and the billing data to request payment. Is it accurate according to the requirements and does it support the claim and do the facility records on the case support the data?


Operational managers must monitor assessment activity by the week, month and season. The final rule also changes the basic assessment scheduling process, diminishing the number of duplicated days in assessment reference periods. This will impact the scheduling of all assessments with assessment reference dates (ARDs) on and after October 1 and will require time for the assessment office to change ARDs for their entire schedule.

Software performance and training are also important factors in assessment office efficiency as is proper hardware placement. Software updates need to be installed in the assessment office as soon as possible so that the edits and data processes in the new requirements can be operational in the facility system. These are large changes and delays can be costly.

The entire team must be aware of RUG distribution and the factors that create the payment levels for a Part A stay. This begins with the skilled service and ADL score for all RUGs and then payment can be increased by depression scores for nursing RUGs. ADL scores need to be accurate and documented in the medical record to support payment at the time of the billing or audit. No small task, but necessary at this time. Review your process-look for specific reference periods and shift-by-shift documentation. Do not use interviews as total documentation, even with notes. The ADL coding in Section G represents 24 hours a day during the assessment reference period and should support the resident’s need for skilled services. You have discussed this issue before, now you must move to accurate documentation to meet the requirements. This is an operational issue.

Large changes face the skilled nursing facility and it will take the entire operational, financial and clinical team to respond. Use the best problem solvers on your team and be very honest about performance, knowledge of definitions and documentation. Many staff members will need to participate, and management needs to take the lead to craft and direct the proper solutions for the facility. Leadership, communication and knowledge of the rules are the key to success.

Leah Klusch, RN, BSN, FACHCA, is Founder and Executive Director of The Alliance Training Center, Alliance, Ohio. As an educator and consultant, she has extensive experience presenting motivating programs for a variety of healthcare professionals. Klusch was named the NADONA Honorary Member of 2011 and was given the Education Award by ACHCA for 2011. Reach her at (330) 821-7616. Long-Term Living 2011 October;60(10):38-40

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