Ch 10 - Long-Term Care - Comparative Him Alternate Health Care

Front 1

For referred outpatients, the hospital provides diagnostic or therapeutic services, but it does not

Back 1

take responsibility for evaluating or managing the patient's care.

Front 2

Hospitals that meet the standards

Back 2

of the Joint Commission, HFAP, or DNV are deemed to meet the Conditions of Participation.

Front 3

According to the Joint Commission, the records of patients receiving continuing ambulatory care services must

Back 3

contain a summary list of known significant diagnoses, conditions, procedures, drug allergies, and medications.

Front 4

When a resident, as part of his or her medical education, participates with a teaching physician in providing a service,

Back 4

the resident is usually paid a salary by the hospital , and the teaching physician is reimbursed by Medicare.

Front 5

Charges for ancillary services, such a laboratory and radiology charges, are usually captured

Back 5

through the hospital chargemaster.

Front 6

According to the American Hospital Association (AHA), a hospital must maintain at least

Back 6

six (6) inpatient beds and care must be readily available for the patients who stay an average of 24 hours or more per admission.

Front 7

Acute and chronic illnesses can both

Back 7

be treated on an ambulatory basis.

Front 8

The level of service provided determines the

Back 8

selection and reporting of an appropriate code, which in turn determines the amount of physician reimbursement.

Front 9

Often independent contractors rather than employees.

Back 9

Occupational therapists

Front 10

Residents who need constant oversight and supervision in activities of daily living.

Back 10

Permanent residents receiving nonskilled care

Front 11

Responsible for assessing the therapeutic recreational needs and preferences of each resident and developing an individualized program.

Back 11

Activities staff

Front 12

A periodic, resident centered inspection that gathers information about the quality of service furnished in a facility to determine compliance with the requirements of participation in the Medicare and Medicaid programs.

Back 12

Standard survey

Front 13

Make arrangement for adaptive equipment, clothing, and financial assistance.

Back 13

Social services

Front 14

Designed to care for residents diagnosed with conditions such as Alzheimer's.

Back 14

Permanent residents, special care

Front 15

In some states, can assume responsibilities to lessen the load of licensed nursing professionals.

Back 15

Certified medication technicians

Front 16

Residents receive frequent skilled care from licensed professionals.

Back 16

Permanent residents, skilled care

Front 17

Provide daily care needs to long term care residents.

Back 17

Nursing assistants

Front 18

Ability to bathe, dress, groom, transfer and ambulate, eat, use speech, languages, etc.

Back 18

Activities of daily living

Front 19

Predominant licensed caregivers in the long term care setting.

Back 19

Licensed practical nurses

Front 20

Residents length of stay is less than 100 days.

Back 20

Short-term residents

Front 21

Physical presence in the long-term care facility is limited.

Back 21

Licensed physicians

Front 22

Clinically relevant information about an individual that identifies specific problems and forms the basis for individual care planning.

Back 22

Care area triggers

Front 23

Coordinate long-term daily care and hold supervisory positions.

Back 23

Registered nurses

Front 24

Short stay to provide relief to primary caregivers of the frail elderly.

Back 24

Respite care

Front 25

What are the two primary agencies that regulate long-term care facilities?

Back 25

The Centers for Medicare and Medicaid Services at the federal level; Medicaid at the state level.

Front 26

What are the primary reimbursement categories and pay sources for care of residents in long-term care facilities?

Back 26

Medicaid;

Medicare Part A for up to 100 days per spell of illness in skilled nursing facilities;

Medicare Part B for services such as physicians' visits and durable medical equipment;

Managed Care;

Commercial insurance;

Private pay.

Front 27

Who determines how long-term-care facilities are reimbursed under the Medicaid program?

Back 27

The individual state agency through state legislation.

Front 28

What are the three categories for which ratings are provided in the Five-Star Rating System for nursing homes?

Back 28

Health inspections, Nursing home staffing, and Quality measures.

Front 29

What is the single most important content characteristic of a care plan in a long-term care facility that is subject to federal regulations?

Back 29

Care plans must be individualized to the residents' care needs, strengths, and individual performances. Standardized care plans that do not list the caregiver's daily care responsibilities for the individual resident are not considered as resident centered and may present both legal and regulatory compliance problems in the event of a negative care outcome.

Front 30

List common electronic software applications in long-term care.

Back 30

*Electronic physician orders, medication, and treatment records, either within the facility or provided by the off-site pharmacy service *Electronic financial information (census, payroll, billing, cost-reporting data)

*Electronic MDS system, care area triggering system, and care plans

*Integration of care plan with nurse aid assignment

*Electronic interdisciplinary progress notes

*Electronic assessment templates

*Electronic tracking of incidents/accidents, infections, and other significant events.

Front 31

Which of the following is a LTCH PPS reimbursement option for a patient stay that qualifies as a short stay outlier:

a. 100% of the cost

b. 120% of the MS-LTC-DRG per diem amount

c. Full MS-LTC-DRG amount

d. Blend of IPPS DRG amount and 120% of the MS-LTC-DRG per diem amount

e. All of the above are options

Back 31

e. All of the above are options

Front 32

Which of the following statements about long-term care coding and reimbursement is FALSE?a. CMS reimbursement to long-term care hospitals is based on the same methodology used to reimburse short-term acute care hospitals.

b. Long-term care hospitals are not permitted to report ICD-9-CM diagnosis codes for late effects as they have no bearing on the care being provided.

c. Selection of the correct principal diagnosis code is essential for accurate MS-LTC-DRG assignment.

d.Sections I, II, and III of the Official Coding Guidelines for Coding and Reporting not only apply to short-term acute care hospitals but also to long-term care hospitals.

Back 32

b. Long-term care hospitals are not permitted to report ICD-9-CM diagnosis codes for late effects as they have no bearing on the care being provided.

Front 33

Services typically provided at long-term care hospitals include:

a. cancer treatment

b. newborn care

c. pain management

d. all of the above

e. a and c only

Back 33

a. and c. only

(cancer treatment/pain management)

Front 34

What are some of the specific long-stay quality measures used in this system?

Back 34

activities of daily living, mobility, pressure ulcers, restraints, urinary tract infections, pain, and catheterization.

Front 35

What are some of the specificshort-stay quality measures used in this system?

Back 35

delirium, high-risk pressure ulcers, and pain

Front 36

activities of daily living (ADL)

Back 36

for purposes of the federal long-term care regulations, activities of daily living include the resident's ability to (1) bathe, dress, and groom; (2) transfer and ambulate; (3) toilet; (4) eat; and (5) use speech, language, or other functional communication systems (CMS, 2011); federal regulations include ADL as a component part of the quality of care requirements, and information concerning individual resident ADL capability is a significant portion of the monitoring information int eh minimum data set

Front 37

CAA resources

Back 37

"a list of resources that may be helped in performing the assessment of a triggered care area" (CMS, 2010, p.1-5)

Front 38

care area assessment (CAA) process

Back 38

a process that helps the assessor and clinician interpret and utilize MDSA data by focusing on key issues; components of the CAA process include care area triggers (CATs), CAA resources, and the CAA summary

Front 39

care area assessment (CAA) summary

Back 39

"(Section V of the MCDS 3.0) provides a location for documentation of the care area(s) that have triggered from the MDS and the decisions made during the CAA process regarding whether or not to proceed to care planning" (CAA, 2010, p.1-5)

Front 40

care area triggers (CATs)

Back 40

"specific resident responses for one or a combination of MDS elements; the triggers identify residents who have or are at risk for developing specific functional problems and require further assessment" (CMS, 2010, p1-5)

Front 41

care plan

Back 41

a documented plan developed by an interdisciplinary team that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment; a care plan must describe (1) the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and (2) any services that would otherwise be required but are not provided because of the resident's exercise of rights include the right to refuse treatment (CMS, 2011)

Front 42

case-mix reimbursement

Back 42

a long-term care reimbursement methodology designed to provide a mechanism for facilities to be paid in a manner that reflects the types of residents served and the types of services provided; the system is also designed to provide greater access to nursing facility beds for heavier care residents and to improve the quality of care for all nursing facility residents; payment is based on a specific methodology that considers direct care costs, care-related costs, administrative and operative costs, and property

Front 43

civil money penalties

Back 43

penalties or fines levied by the federal government against providers who are found to be in substantial noncompliance with federal regulations; these penalties may be as much as $10,000 per day

Front 44

comprehensive resident assessment

Back 44

as defined by the long-term care federal regulations, a comprehensive resident assessment describes the resident';s ability to perform daily life functions and significant impairments in functional capacity; specifically, it includes at least the following information: (1) medically defined conditions and prior medical history; (2) medical status measurement; (3) physical an mental functional status; (4) sensory and physical impairments; (5) nutritional status and requirements; (6) special treatments or procedures; (7) mental and psychosocial status; (8) discharge potential; (9) dental condition; (10) activities potential; (11) rehabilitation potential; (12) cognitive status; and (13) drug therapy (CMS, 2011)

Front 45

consolidated billing

Back 45

under Medicare, a skilled nursing facility is responsible for billing the entire package of care that residents receive during a stay, with certain specified exceptions such as physicians' professional services

Front 46

culture change movement

Back 46

a person-centered philosophy that creates a more homelike environment for residents of a nursing facility; culture change involves providing individuals with privacy and the ability to make choices similar to what they would experience were they living in their own homes

Front 47

federal survey

Back 47

a survey based on the federal long-term care requirements and using the federal long-term care survey procedures required for long-term care facility participation in the Medicare and/or Medicaid programs

Front 48

licensure survey

Back 48

a survey conducted by the state agency to determine long-term care facility compliance with state licensure laws

Front 49

minimum data set (MDS)

Back 49

a core set of screening and assessment elements, including common definitions an coding categories, that forms the foundation of the comprehensive resident assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid; the items in the MDS standardize communication about resident problems and conditions within facilities, between facilities, and between facilities and outside agencies (CMS, 2011); MDS data also serve as the basis for RUG assignment in the long-term care prospective payment system

Front 50

nursing facility

Back 50

an institution or a distinct part of an institution that provides skilled nursing care, rehabilitation services, or health-related care to individuals who because of their condition require services above the level of room and board; either a registered nurse for a license practical nurse is on active duty at all times; if properly licensed an certified, a nursing facility may receive reimbursement under the Medicaid program

Front 51

OBRA (Omnibus Budget Reconciliation Act) assessments

Back 51

a schedule of assessments performed for a nursing facility resident at admission, quarterly, annually, whenever the resident experiences a significant change in status, and whenever the facility identifies a significant error in a prior assessment

Front 52

quality of care

Back 52

a broad category of the long-term care federal regulations that requires a facility to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care; substantial noncompliance with quality of care requirements subjects a facility to potential civil money penalties and other punitive measures in the federal enforcement regulations

Front 53

quality of life

Back 53

a broad category of the long-term care federal regulations that requires a facility to care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life; substantial noncompliance with quality of life requirements subjects a facility to potential civil money penalties and other punitive measures in the federal enforcement regulations

Front 54

resident assessment instrument (RAI)

Back 54

an instrument that requires for completion the performance of a standardized assessment system, comprised of the MDS, CAA process, and utilization guidelines; this assessment standardized, and reproducible assessment of each long-term care facility resident's functional capabilities and identified medical problems (CMS, 2011)

Front 55

resident assessment protocols (RAPs)

Back 55

structured, problem-oriented frameworks for organizing MDS information and additional clinically relevant information about an individual that identifies medical problems and forms the basis for individual care planning (CMS, 2011); although RAP terminology is still in common use, CMS now uses the term care area assessment (CAA) process to describe this concept

Front 56

resource utilization groups (RUGs)

Back 56

a case-mix methodology based on data submitted on the MDS; RUGs are used to adjust per diem payments to SNFs under the Medicare PPS and to NFs under some stat Medicaid programs

Front 57

risk contract

Back 57

also known as a Medicare risk contract; a contract between an HMO and CMS to provide services to Medicare beneficiaries, under which contract the health plan receives a monthly payment for enrolled Medicare members and must then provide all services on an at-risk basis (Kongstvedt, 1993)

Front 58

skilled nursing facility

Back 58

an institutional or a distinct part of an institution that provides skilled nursing care or rehabilitation services; either a registered nurse or a licensed practical nurse is on active duty at all times; if properly licensed and certified, a skilled nursing facility may obtain a Medicare provider agreement and be reimbursed under the Medicare programs

Front 59

standard survey

Back 59

a periodic, resident-centered inspection that gathers information about the quality of service furnished in a facility to determine compliance with the requirements of participation in the federal Medicare and Medicaid programs (CMS, 2011)

Front 60

subacute care

Back 60

a transitional type of care that represents a level of service that is less intensive than traditional acute care but more goal oriented and resource intensive than what is generally regarded as skilled nursing care

Front 61

substandard quality of care

Back 61

one or more deficiencies related to participation requirements under 42 CFR 483.13, resident behavior and facility practices; 42 CFR 483.15, quality of life; or 42 CFR 483.25, quality of care; these constitute either immediate jeopardy to resident health or safety; a pattern of widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm (CMS, 2011)

Front 62

substantial compliance

Back 62

a level of compliance with the Conditions of Participation, such that any identified deficiencies pose no greater risk to resident health or safety than the potential for causing minimal harm; substantial compliance constitutes compliance with participation requirements (CMS, 2011)

Front 63

utilization guidelines

Back 63

CMS guidelines that provide instructions for when and how to use the RAI; these include instructions for completion of the RAI as well as structured frameworks for synthesizing MDS and other clinical information; the utilization guidelines can be used to evaluate a care area that has been triggered and to determine whether or not to continued to care plan for it