Table 11.2: Option 1. Provider Self-Assessment and Modified Department Audit Model Summary Appraisal Types Review Review Audit Approach Entry Funding Appraisal / Mandatory 6-month re-appraisal Outcomes Outcomes One category re-appraisal / Two category major re-appraisal Agree Disagree New Resident Provider completes R-ACFI and submits to Medicare (current rules apply) NA NA Validation Approach Can only be applied for a period of 12 months. R-ACFIs not reviewed are automatically approved. NA NA Three tiered From most recent of: R-ACFI appraisal start date or R-ACFI submission to Medicare. Validation Level 1 Basic data validation check Funding Downgrade Data Matching & Data algorithm check Approved OR Algorithm Audits checks facility R-ACFI against ACAT completed NSAF R-ACFI (new residents) Go to Time requirement applies current data modelling analytics and historical data to predict likely changes since Validation computer program NSAF R-ACFI was completed. Level 2/3 Validation Level 2 ROs use remote access to provider electronic clinical software system ‘partitioned sections’ to Funding Downgrade e-Review conduct e-Review. Approved OR (medium to longer ROs document their findings and provide a report for providers which provides the rationale for their Possible term possibility) decisions Level 3 Validation Level 3 New guidelines need to be developed for site reviews (assessed care need vs care provided and Funding Downgrade RO visit relevance to a review decision) to clarify: Approved the ROs R-ACFI review protocols compliance aspects of the RO role. A visit program may include: review of residents’ records observations of residents interviews with residents, staff, and families. Incongruences noted during direct observation of the resident should be used as a flag for further investigations to check the accuracy of the assessed care need. Interviews with informants (residents, families, staff, AHPs, GPs) could be used to inform on the accuracy of the assessed need. Appeals Provider can appeal as per current process to review outcome.
Table 11.2: Option 1. Provider Self-Assessment and Modified Department Audit Model Summary Audit Approach Appraisal Types Entry Funding Appraisal / Mandatory 6-month re-appraisal One category re-appraisal / Two category major re-appraisal Review Outcomes Agree Review Outcomes Disagree New Resident Provider completes R-ACFI and submits to Medicare (current rules apply) NA NA Validation Approach Three tiered Can only be applied for a period of 12 months. R-ACFIs not reviewed are automatically approved. From most recent of: R-ACFI appraisal start date or R-ACFI submission to Medicare. NA NA Validation Level 1 Data Matching & Algorithm Audits Time requirement computer program Basic data validation check Data algorithm check checks facility R-ACFI against ACAT completed NSAF R-ACFI (new residents) applies current data modelling analytics and historical data to predict likely changes since NSAF R-ACFI was completed. Funding Approved Downgrade OR Go to Validation Level 2/3 Validation Level 2 e-Review (medium to longer term possibility) ROs use remote access to provider electronic clinical software system ‘partitioned sections’ to conduct e-Review. ROs document their findings and provide a report for providers which provides the rationale for their decisions Funding Approved Downgrade OR Possible Level 3 Validation Level 3 RO visit New guidelines need to be developed for site reviews (assessed care need vs care provided and relevance to a review decision) to clarify: the ROs R-ACFI review protocols compliance aspects of the RO role. A visit program may include: review of residents’ records observations of residents interviews with residents, staff, and families. Incongruences noted during direct observation of the resident should be used as a flag for further investigations to check the accuracy of the assessed care need. Interviews with informants (residents, families, staff, AHPs, GPs) could be used to inform on the accuracy of the assessed need. Funding Approved Downgrade Appeals Provider can appeal as per current process to review outcome.
acfi_review_report_part_2_main_report.docx