Nursing and Therapy Documentation: Optimizing SNF Regulatory Compliance and Quality Resident Outcomes

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Nursing and Therapy Documentation: Optimizing SNF Regulatory Compliance and Quality Resident Outcomes

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PDPM must be implemented by October 1, 2019. This resource will help you prepare.

Nursing and Therapy Documentation: Optimizing SNF Regulatory Compliance and Quality Resident Outcomes

Renee Kinder, MS, CCC-SLP, RAC-CT 
Liz Barlow, BSN, RN, CRRN, RAC-CT, DNS-CT


PDPM must be implemented by October 1, 2019. This resource will help you prepare.

 

With all of the regulatory changes taking effect between 2017 and 2019, communication across disciplines has become even more crucial. Facilities must work to align resident documentation across multiple departments, such as nursing and therapy, to not only improve quality of care, but protect themselves from an audit.

Most SNFs provide the care the resident needs at the appropriate time, but struggle with communicating and recording the care on the MDS in order to trigger a higher case-mix level and corresponding reimbursement. Nursing and Therapy Documentation: Optimizing SNF Regulatory Compliance and Quality Resident Outcomes highlights key areas of collaboration and communication that can ensure the full scope of resident care is documented and identified, letting the facility receive the payment it deserves.

This resource also provides access to downloadable tools and example documentation scenarios to help SNFs create an interdisciplinary team approach to their documentation processes.

Order today and learn how to: 

  • Align with MDS 3.0 documentation requirements 
  • Promote better collaboration between nursing and therapy skilled services 
  • Coordinate documentation to improve resident care 
  • Reduce your audit risk 
  • Strengthen reimbursement claims with comprehensive documentation 
  • Prove medical necessity and need for skilled care by practicing accurate documentation 


About the Authors:

Renee Kinder, MS, CCC-SLP, RAC-CT, is a speech-language pathologist and currently serves as director of clinical education for Encore Rehabilitation, where she oversees education and training programs for interdisciplinary team members related to Medicare regulations and evidence-based, interprofessional clinical programming. She recently served as a member of the CMS Technical Expert Panel aimed at PPS reform, resulting in the ANPRM for RCS-I.

Kinder is a member of the HCPro Editorial Advisory Board for PPS Alert for Long-Term Care and is the author of McKnight's Rehab Realitiesblog. She is a community faculty member for the University of Kentucky College of Medicine, and a member of the American Speech-Language-Hearing Association (ASHA)’s Healthcare and Economics Committee, where she serves as the RUC Alternate Advisor to the AMA's Health Care Professionals Advisory Committee. Additionally, Kinder maintains active membership in ASHA’s special interest groups for swallowing, neurology, and gerontology and currently serves as professional development manager for gerontology.

Liz Barlow, BSN, RN, CRRN, RAC-CT, DNS-CT, senior director of quality at RehabCare, is a Certified Rehab Nurse with over 25 years in long-term care. She started her nursing career in cardiac care and acute care rehab and soon found out that postacute care was her passion. She has worked in a variety of long-term care roles, including director of case management and national director of quality; from a therapy perspective, she has worked as a rehab director and vice president of clinical services. Her current role involves leading a team of therapists who educate and train on quality outcomes and care throughout the country in SNF therapy departments.

Barlow has presented at many professional organization conferences on LTC nursing and therapy topics. She currently serves on the Kentucky Board for Multiple Sclerosis and just completed a term with the Western Kentucky University Health and Human Services Board of Stakeholders.


Published: April 2018

Expected Page Count: 350 
Dimensions: 8.5” x 11”, Perfect Bound 
ISBN: 978-1-68308-704-5 

Table of Contents

  • Section 1: Introduction to Documentation and Long-Term Care 
    • Documentation Defined 
    • Electronic Charting 
    • Documentation and the MDS 
    • The MDS 3.0 Collaboration 
    • Section G: Functional Status 
    • Section O: Special Treatments, Procedures, and Programs 
    • Section I: Active Diagnoses 
    • Resident Falls 
    • Section J: Health Conditions 
    • Benefits of Nursing and Therapy Collaboration 
    • Optimize Care and Resident Outcomes 
    • Survey Success 
    • Positive Working Environment 
    • Benefits of Collaboration 
  • Section 2: Therapy Documentation 
    • Documentation to Support Skilled Therapy Services 
    • Five Criteria to Support Skilled Therapy Services 
    • Long-Term Goal Writing 
    • Short-Term Goal Writing 
    • Demonstrating Progress With Goal Achievement 
    • Daily Skilled Therapy Services 
    • Defensible Documentation Strategies 
    • Considerations for MDS 3.0 Documentation 
    • Considerations for Providing Therapy Under MDS 3.0 
    • Documenting Therapy Services 
    • The Plan of Care 
    • Completion of Section O, Item O0400 
    • Navigating the Medicare B Therapy Caps 
    • Exceeding the Therapy Cap 
    • Navigating the Threshold 
    • Internal Monitoring Program to Manage the Threshold 
  • Section 3: Understanding Functional G Codes 
    • Reporting G Codes Throughout the Episode of Care 
    • Choosing a G Code 
    • Choosing a Severity Modifier 
  • Section 4: The Appeals and Denials Process 
    • First Steps 
    • Redetermination: First Level of Appeal 
    • Reconsideration: Second Level of Appeal 
    • ALJ Level: Third Level of Appeal 
    • Appeals Council: Fourth Level of Appeal 
    • Judicial Review in U.S. District Court: Fifth Level of Appeal 
    • Just Remember 
  • Section 5: Nursing Documentation 
    • Documentation to Support Skilled ¬Necessity 
    • Documenting Direct Skilled Nursing 
    • Documentation Tips 
    • A Restorative Nursing Introduction and Philosophy 
    • Restorative Nursing as a Daily Skilled Service 
    • Criteria for Coding Restorative Nursing on the MDS 3.0 
    • Setting Goals for Restorative Nursing 
    • Documenting Restorative Nursing 
    • Evaluating Restorative Nursing 
    • Implementing a Restorative Nursing ¬Program 
    • The Nursing and Therapy Connection With Restorative Nursing 
    • Designing Restorative Programs 
  • Section 6: Improving Collaboration 
    • The Medicare Meeting 
    • RUG Huddle 
    • Prior Authorizations 
    • Therapy Screening and MDS 3.0 
    • Understanding the Nursing/Therapy Language Barrier 
    • Medicare Notice (BNI/ABN) 
    • QM as a Tool for Therapy and Nursing 
    • Five-Star Rating: Impact on Therapy 
    • Summary 
  • Section 7: Using Collaboration for Quality Results and Limiting Lost Revenue 
    • Assessment Window 
    • Scheduled Medicare PPS Assessments 
    • Unscheduled Assessments 
    • Combining Scheduled and Unscheduled Assessments 
    • Unscheduled Assessments Other Medicare Required Assessments 
    • Missed Unscheduled Assessment 
    • Compounding Effects of Early/Late Assessment 
    • Short Stay MDS