from admission, and at least once every 60 days thereafter. A physician must certify the need for continued stay. The LTC facility must have physician orders for the resident’s immediate care and must periodically conduct a comprehensive assessment of each resident’s functional capacity (MDS). The MDS must be completed within 14 days of admission. The LTC facility must assess the resident quarterly and an annual assessment must be completed within 366 days after final completion of the most recent comprehensive resident assessment. The LTC facility must develop and implement a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Each resident must receive the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. The care must be performed by appropriate qualified persons. The LTC facility must ensure the resident does not develop pressure ulcers while in the facility; must reduce the risk of harm resulting from falls; and other patient safety/quality of care concerns. All documentation to support the appropriateness of continued stay must be available for review. In our audits of clinical LTC services, HMS requests and reviews the following documentation from providers (where applicable): Resident Assessment Instrument (MDS) Medicaid Patient Status Notification (Form 199) Form XIX LTC-9 and assessment document PASRR screening information Physician certification(s) Physician progress notes Physician orders Rehabilitative Plan and Treatment Notes (e.g., SP, PT, and OT) Nurses Notes History and Physical Discharge and Transfer Summaries Lab Reports Radiology Reports Interdisciplinary Team Notes Intake and Output Log Vital Sign Log Weight Records Treatment Sheets Therapy Re-evaluations (e.g., SP, PT, and OT) Form 161/Form 161B Form MED-54 Staffing Schedule if quality of care issues HMS incorporates the specialized review techniques described above into our automated, semi-automated, and complex review processes. We describe each of these processes in more detail below. Automated Review Process In our automated review process, an analyst will examine individual claims and various metrics concerning the audit population identified by DMA. Additionally, an internal QA process reviews the population according to the QA criteria
from admission, and at least once every 60 days thereafter. A physician must certify the need for continued stay. The LTC facility must have physician orders for the resident’s immediate care and must periodically conduct a comprehensive assessment of each resident’s functional capacity (MDS). The MDS must be completed within 14 days of admission. The LTC facility must assess the resident quarterly and an annual assessment must be completed within 366 days after final completion of the most recent comprehensive resident assessment. The LTC facility must develop and implement a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Each resident must receive the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. The care must be performed by appropriate qualified persons. The LTC facility must ensure the resident does not develop pressure ulcers while in the facility; must reduce the risk of harm resulting from falls; and other patient safety/quality of care concerns. All documentation to support the appropriateness of continued stay must be available for review. In our audits of clinical LTC services, HMS requests and reviews the following documentation from providers (where applicable): Resident Assessment Instrument (MDS) Medicaid Patient Status Notification (Form 199) Form XIX LTC-9 and assessment document PASRR screening information Physician certification(s) Physician progress notes Physician orders Rehabilitative Plan and Treatment Notes (e.g., SP, PT, and OT) Nurses Notes History and Physical Discharge and Transfer Summaries Lab Reports Radiology Reports Interdisciplinary Team Notes Intake and Output Log Vital Sign Log Weight Records Treatment Sheets Therapy Re-evaluations (e.g., SP, PT, and OT) Form 161/Form 161B Form MED-54 Staffing Schedule if quality of care issues HMS incorporates the specialized review techniques described above into our automated, semi-automated, and complex review processes. We describe each of these processes in more detail below. Automated Review Process In our automated review process, an analyst will examine individual claims and various metrics concerning the audit population identified by DMA. Additionally, an internal QA process reviews the population according to the QA criteria
ScopeOfWork-RAC.docx