audit, tax, and consulting - arizonaleadingage.org speaker ppts for posting... · multiple data...
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WEALTH ADVISORY | OUTSOURCING | AUDIT, TAX, AND CONSULTING
Investment advisory services are offered through CliftonLarsonAllen Wealth Advisors, LLC, an SEC-registered investment advisor
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LeadingAge Arizona May, 2018
CMS Data Complexity – Can You Manage It?
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Outline
Data provided to CMS and data sources
5 Star Quality Rating (most data ends up here)
5 Star domains and improving performance
Managing 5 Star data
Stepping Back from the Detail and Complexity
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Multiple data sources provided to CMS
MDS process – MDS 3.0
Billing process – UB04
Annual health survey – CMS 2567
Payroll Based Journal Entry – PBJ section of CASPER
Medicare Cost Reports
OSCAR and CASPER systems OSCAR – Online Survey Certification and Reporting
CASPER – Certification and Survey Provider Enhanced Reports
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Who uses the data
Very small percentage of consumers use the information on NH compare and they often do not know how to interpret it Hospitals
ACO’s
Competitors
Attorneys
Media
Insurance companies
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Aggregated Data Sources
Nursing Home Compare
Nursing Home Data Compendium
Individual SNF Data Sources
CASPER system
PEPPER Report Program for Evaluating Payment Patterns
Electronic Report
PS&R report Provider Statistical and Reimbursement
System
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PS&R Report – Medicare Reimbursements
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PS&R Report – Medicare Reimbursements
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PS&R Report – Medicare Reimbursements
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PEPPER Report – Investigate Outliers
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PEPPER Report – Investigate Outliers
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PEPPER Report – Investigate Outliers
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PEPPER Report – Investigate Outliers
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PEPPER Report – Investigate Outliers
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5 Star Rating- Why should you care
Majority of aggregated data provided resides here –Data collection and parsing by CMS will continue
Medicare payment is shifting from PPS (prospective payment system) to value based reimbursement 90% of all fee for service (FFS) to be tied to quality by 2018 (not just long term care FFS)
2% withholding on SNF PPS rates begins 10/1/18 – redistribute 50-70% to top SNFs
CMS goals Improve health care
Reduce spending
Improve care experience for the consumer
Bundled and alternative payment programs require minimum of 3 star rating
Quality + Value SNF Bed Reduction
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History
2008 Five-Star Nursing Home Quality Rating System added to the Nursing Home Compare website.
January 2013 Bundled Care Payment Initiatives Announced
August 2014 NY Times Article “Medicare Star Ratings Allow Nursing Home to Game the System”
October 2014 CMS made announcement about changes to Staffing and Quality Measure domains of Five-Star
February 2015 Implementation of those changes announced in 2014
July 2016 5 New Quality Measures added to Five-Star Rating including claims based ratings
November 2016 Payroll Based Journal Entry submission required with an early 2018 roll into 5 star rating expected
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5 Star Rating Components
Health Inspection Measures based on outcomes from State health inspections
Staffing Measures based on nursing home staffing levels
Quality Measures Measures based on resident-level quality measures (QM’s)
Overall The rating system features an overall quality rating of one to five-stars based on facility
performance in the 3 domains mentioned above. Each domain has its own five-star rating and they are calculated together for an overall rating.
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5 Star Calculation
Step 1
Start with the health inspection (survey) five-star rating
Step 2
Add one star to Step 1 if the Staffing rating is four or five stars AND greater than the health inspection rating
Subtract one star if Staffing rating is one star
The overall rating cannot be more than 5 stars or less than one star
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Calculation continued
Step 3 Add one star to Step 2 if Quality Measure rating is five stars
Subtract one star if Quality Measure rating is one star
The overall rating cannot be more than five stars or less than one star
Step 4 If the health inspection rating is one star, then the overall quality
rating cannot be upgraded by more than one star based on the staffing and quality measures.
Step 5 If the nursing home is a special focus facility (SFF) that has not
graduated, the maximum overall quality rating is three stars.
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Understanding the 5 star calculationCalculate the 5 Star Rating
Health Inspection rating is 3 Stars
Staffing Rating is 5 stars
Quality Measures Rating is 3 stars
What is the overall star rating?
What is the rating if Quality Measure rating is 4 stars and Staffing Rating is 4 stars?
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Five star sample comparison
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How and When does the data change
Health Inspection
New surveys and complaint visits – CMS 2567
2 year “Aging of Data” on an annual basis (frozen until 11/18
Staffing
CMS 671 and 672 – at annual survey in the past
PBJ – 45 days after end of fiscal quarter
Quality Measure data
MDS and UB04
Available Monthly in CASPER
Quarterly changes to Nursing Home Compare
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Surveyors already know where your trouble areas are
Understand resident issues that they are going to look for in specific charts
Facility can review issues ahead of time - you have access to all the same data they have in preparation for health inspection
Survey team knows how to dig deep into data, so you need to become skilled at this as well!
Data that survey team reviews prior to onsite visit comes directly from the MDS (Section F on Preferences and Section GG on Functional Abilities and Goals, for instance)
Foundation of the overall rating
Only non self reported domain
Star cut points updated monthly
Health Inspection Data
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Health Inspection Domain
All nursing homes that participate in a Medicare and/or Medicaid program are subject to an annual inspection.
This inspection occurs anywhere from 9-15 months from the exit of the last inspection (unannounced)
The health inspection rating is based on the two most recent standard surveys, results from any complaint investigations during the most recent two-year period, and any repeat visits needed to verify that required corrections have brought the facility back into compliance.
More recent surveys are weighted more heavily than older surveys
Change in Methodology Most recent survey cycle (cycle 1) has a weighting factor of 60%
The previous period (cycle 2) has a weighting factor of 40%
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Health Inspection Domain
Scored based on number of deficiencies tagged with a severity score
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Health Inspection Domain
CMS Five-Star health inspection ratings are based on the relative performance of facilities within a state
CMS compares facilities to each other within each state to help control for variation among states in the process
Facility survey rankings are determined as follows in each state
(moving target or “grade on the curve”!) 5 Stars only top 10% of facilities per state
4 Stars 23.33% of facilities per state
3 Stars 23.33% of facilities per state
2 Stars 23.33% of facilities per state
1 Star 20% of facilities per state
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Case Study – Health Survey
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State Cut Points - Health
Survey Score (Mar 2017) Number
Arizona 145 >60.667 38.667 23.333 9.333 <9.333
Delaware 45 >102.853 74 52 23.333 <23.333
Texas 1198 >153.167 76.667 44.667 16.000 <16.000
One bad survey is likely to take at least two years to resolve (still much better than previous 3 year weighting process)
A score of 23.332 in is 3 stars in TX, almost 2 stars in Arizona and is 5 stars in Delaware
Note variation and spread in each state and changing monthly which will raise the bar once again
SNF 2017 2016
Total
Weighted
Score
2018 Score
20 points
2018 Score
0 points
#1 0 90 36 12 0
#2 300 30 192 132 120
#3 100 390 216 52 40
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Case Study – Health Survey
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Ultimately the key is how you compare to your peers and market In some markets, CMS is more aggressive with deficiencies How many deficiencies are based on reported complaints? Be survey ready at all times and review with all staff
Group Rank
Deficiencies
2016 Score 2016
Deficiencies
2015 Score 2015
Deficiencies
2014 Score 2014
Weighted
Average
Score
Health
Inspection
Star Rating
Nursing Home 1 803 15 510 16 628 9 48 472.333 1
Average Peer Group 449.6 5.8 60 4.2 40.8 7.4 51.2 52.1334 3.2
City Average 783.0 10.21 252.83 10.65 171.67 13.41 159.14 214.73 2.18
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Improving Health Inspection Domain
Don’t wait for your survey “window” to open
Should be survey ready at all times
Mock surveys
Outside consultants to review nursing notes, MDS process, and interview residents
Teach all staff about survey expectations
Review previous survey results to determine patterns or facility weaknesses
Determine how long it will take to improve
New survey process still being adjusted
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Staffing Domain
There is evidence of a relationship between nursing home staffing levels and quality of resident outcomes. Expected hours – STRIVE study (2007) - previously CMS time study (1997)
Staffing domain based on two components Registered Nurse (RN) hours per resident day
Total staffing hours (RN+LPN+Nurse aide) hours per resident day
CMS 671 in past – now PBJ submission and quarterly change
Staffing rating is determined based on Reported hours/Expected hours*National Averages = Adjusted hours Reported hours is data from PBJ submissions
Assign a RUGs group to all MDS for residents in beds on last day of quarter
Sum the expected nursing times from the STRIVE staffing study
National average hours as determined by CMS (most recent is from April 2018 – may change quarterly)
Reported hours divided by expected hours times national average hours
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Staffing hours data source
Staffing data used to come from CMS forms 671 and 672
Filled out during your annual health inspection
PBJ will be used going forward
Who handles this and how is it checked for accuracy?
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Staffing by Title – Form 671
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Payroll Based Journal Entry (PBJ)
Major Change in staffing data collection implemented
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• Final Rule published August 4, 2015 in the Federal Register
• Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data
• Latest Release of PBJ Manual 2.4 on 9-26-17
• Data submitted, when combined with census information, is to be reported on the level of staff in each nursing home (different from the previous process using CMS-671 and CMS-672 forms)
• Originally required to report data to compute employee turnover and tenure – a new item (changed as of 3/19/17 to optional)
• Intent is to link daily payroll records to the CMS five star rating system
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• Staffing levels
• Turnover
• Tenure
• More in depth reporting
• Data must be verifiable and auditable
• Data collected more often than 671 / 672 forms
PBJ Key Objectives
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• From payroll data for employees
• From contracts / invoices for non-employees
• CMS may audit your data
• Tracked daily and uploaded quarterly to new PBJ system
• 671 / 672 still in place after PBJ starts
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Census Computed by CMS
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CMS is calculating your census based on MDS’s submitted Census is calculated daily, summed and averaged for the quarter
If there’s no Discharge assessment, CMS will count a resident in your facility for 150 days after the last MDS assessment - then exclude them
Inflated census will lower your HPRD, which may lower your Staffing Five Star rating
Studies have shown a correlation between missing Discharge Assessments and lower reported staffing HPRD
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Staffing Cut-points – National CURRENT
• One star rating given for the next quarter if:• Fail to submit PBJ data by deadline• Greater than 7 days in quarter reported with 0 RN staffing hours• Audit request is ignored or if major discrepancies found in audit
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Staffing Cut-points – Comparison to Previous
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Distribution of 5 Star Staffing Ratings
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• Overall distribution of Five Star Staffing Ratings will be approximately the same using PBJ data as it was prior
• Average National Hours Per Resident Day for Risk Adjusted Calculation
Previous New
– RN .7472 .3804– Total 4.0309 3.2285
• Significant change in calculation
– RN and LPN Administrative hours split
– Averages from latest PBJ data
– STRIVE time study breaks out LPN and RN hours differently so expected hours ratio is different
– RUGS distribution has likely changed recently
March 2018 Staffing Five Star Distribution:
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Comparison from Public Use Files
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Case Study #1 - Staffing
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HPPD Adjusted = HPPD Reported/HPPD Expected * National Average
Previous
Current
HPPD Reported Expected Adjusted
RN HPPD 0.90 1.30 0.52
LPN HPPD 1.40 1.10 NA
CNA HPPD 2.20 2.40 NA
Total HPPD 4.50 4.80 3.78
Star Rating 5 4
HPPD Reported Expected Adjusted
RN HPPD 0.55 0.70 0.30
LPN HPPD 1.75 1.50 NA
CNA HPPD 2.20 2.40 NA
Total HPPD 4.50 4.60 3.16
Star Rating 4 1
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Case Study #2 - Staffing
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What is the cost of each structure? Example: Can you increase by 1 star level if you replace one LPN with an RN?
Previous
Current
HPPD Reported Expected Adjusted
RN HPPD 0.51 0.51 0.75
LPN HPPD 1.00 1.00 NA
CNA HPPD 2.40 2.40 NA
Total HPPD 3.91 3.91 4.03
Star Rating 3 4
HPPD Reported Expected Adjusted
RN HPPD 0.40 0.40 0.38
LPN HPPD 1.20 1.20 NA
CNA HPPD 2.40 2.40 NA
Total HPPD 4.00 4.00 3.23
Star Rating 3 2
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Improving your Staffing Domain
PBJ vs CMS 671
RN hours – what is the cost of increasing these to reach the next star level? Or cost savings to decrease one level?
Direct care hours overall – how much will you benefit from changes in staffing mix at each level?
Review Public Use Files to verify census computed by CMS
Review MDS process and CASPER reports to ensure that assessments are appropriate and timely
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Data from Quality Measure domain
Comes directly from MDS and UB-04 (claims)
MDS coordination and scoring consistency
Review analytics periodically with various staff
MDS controls a large amount of results
Money
Quality
Survey
Staffing
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Quality Measure Domain
Facility ratings for the quality measures are based on performance on 16 of the 24 QM’s that CMS posts on the Nursing Home Compare website
The QM’s use data from the Minimum Data Set (MDS), which each nursing home must submit as part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes
These measures address a broad range of functioning and health status in multiple care areas
For each measure points are assigned based on facility performance
Points range from 20-100 points per measure (325 – 1600 total range currently)
More points in this domain produces more stars
The QM’s are categorized according to a resident’s length of stay (short stay versus long stay (>100 days)) and according to the type of data captured on either the claim or the MDS
Claims based QM’s are all categorized in short stay measures
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MDS
Minimum data set Manual is 1330 pages of instruction on how to code it
Part of the RAI process Care Area Assessments (CAA)
Care Area Trigger (CAT)
MDS
Care plans
Over 1000 data points
25% error rate is standard
IDT
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MDS – Face Sheet
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MDS – Quality Measures Referenced
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MDS – Falls – How is a fall defined?
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MDS – Pain Assessment – Time dependent
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MDS - Mood
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MDS – RUGS and Depression
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UB-04
Claims based data comes from CMS form UB-04This is your bill for traditional Medicare part A services – both SNF and Hospital
The SNF does not submit all of the data to calculate Claims Based data
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Quality Measure Scoring
• Measures are Percentages of residents
• Imputed data if not enough for a specific SNF
• Rules related to scaling if some SNFs do not have all of the QMs
• Separate Technical Manual
• National targets for individual QM changes quarterly for point distributions based on rolling four quarters
• Point Total cuts may change annually (January 2017)
• Currently 325 – 1600 points available for the 16 measures (20/25 to 100 points per measure)
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Quality Measure Scoring
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Measure Type Number Scoring Method
Long Stay - Original 6 20 points per quintile
Short Stay - Original 1 20 points per quintile
Long Stay Physical Restraint 1 Top 3 quintiles – 100 points
4th
quintile – 60 points
5th quintile – 20 points
Short Stay Pressure Ulcer 1 Top 1/3 – 100 points
3 even lower groups - 25, 50 and 75 points
Long Stay Feb-15 2 Top 10% - 100 points
Middle 70% - 40, 60 and 80 points
Lowest 20% - 20 points
Short Stay Feb-15 1 Same as above
Short Stay Antipsychotic 1 20 points per quintile
Claims Based 3 20 points per quintile
Quality Measures Scoring Template (16 current measures over rolling 4 quarters)
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Case Study – Quality Measures
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Improving QM domain
Segregate the patterns of QM issues across all your units and/or facilities
Review others in your primary market area
Use technology
Accuracy? CASPER reports – current trending data
Nursing Home Compare – older data
QAPI
Correct staff who are well trained?
New Protocols to be designed and implemented
Understand how the QM’s are risk adjusted with covariates
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Managing your 5 Star Rating
Understand where the data is coming from Self reported
Adjusted
Understand how to interpret the data
Identify the accuracy of the data Is the data on the website correct?
If not, can it be managed and fixed?
If yes, do root cause analysis to determine source of incorrect data
Determine what is actionable data What should priority be for making changes to protocols and training
Understand when and how fast you can make changes to your data
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Stepping Back from the Detail and Complexity
CMS value based measures are here to stay The 5 star rating will remain as the basis for reducing SNF beds
Data, Data, Data Analyzing and managing your data in real time is critical to future success
CMS will continue to require data to be electronically delivered
Patterns and outliers are key
CMS will continue to increase data collection Expect more new measures, new scoring, new segregation of star ratings
An increasing number of users will view your data Post acute services - most variable healthcare area in terms of cost and quality
More readily available data will raise the bar for post acute providers
Know what other users know about your organization
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Questions?
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MDS- is part of the U.S federally mandated clinical assessment of all residents in a Medicare or Medicaid certified nursing home. The process provides a comprehensive assessment of each resident’s functional capabilities and helps nursing home staff identify health problems
OBRA- omnibus reconciliation act of 1987. Changed the way nursing homes operated and have to report data to state and federal government. Driven by poor quality in nursing homes in Texas in the early 80’s
QM’s- quality measures. An item set from MDS data and Medicare claims data that measures standards of quality of care in nursing homes.
Short stay QM- an episode with cumulative days in the facility less than or equal to 100 days at the end of the target period
Long stay QM- an episode with cumulative days in the facility greater than or equal to 101 days at the end of the target period
CMS – Centers for Medicare and Medicaid Services
PBJ – Payroll Based Journal Entry used to collect staffing data for SNFs on a quarterly basis
ACO – Accountable care organizations are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to their Medicare patients (CMS Jan 2015)
UB-04- Medicare claim form for facility and ancillary billing for Medicare services
RAI – Is a comprehensive, standardized tool to assess residents in long-term care setting
QAPI- Quality Assurance (QA) is the process of meeting quality standards and assuring that care reaches an acceptable level. Performance improvement (PI) is continuously analyzing your performance and developing systematic efforts to improve it. (AHCA)
CASPER and OSCAR – systems used for statistical reporting by CMS
PEPPER report – Program for Evaluating Payment Patterns Electronic Report used to identify outlier areas of Medicare payments which may indicate errors
PS&R report – Provider Statistical and Reimbursement report used by SNF management to assess accuracy and completeness of RUGs days billed and Medicare reimbursements received for a given time period (also used in Medicare cost reporting)
Glossary of Terms
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Nursing Home Compare website
https://www.medicare.gov/nursinghomecompare/search.html?
MDS 3.0 users manual
https://downloads.cms.gov/files/MDS-30-RAI-Manual-V114-October-2016.pdf
5 Star Rating Technical User’s Guide
http://www.cms.gov/Medicare/Provider-Enrollment-and-certification/certificantandcompliance/FSQRS.html
Payroll Based Journal Long Term Facility Policy Manual (subject to v. 2.3 change)
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V22.pdf
MDS 3.0 Quality Measures User’s Manual
https://www.cms.gov/Medicare/Quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/downloads/MDS-30-QM-User’s-Manual-V80.pdf
State Operations Manual appendix PP
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
QAPI at a glance
https://www.cms.gov/Medicare/Provider-enrollment-and-certification/QAPI/downloads/QAPIataglance.pdf
Resources and References
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twitter.com/CLAconnectfacebook.com/cliftonlarsonallen
linkedin.com/company/cliftonlarsonallen
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CLAconnect.com
youtube.com/CliftonLarsonAllen
Carl Moellenkamp, CPA, LNHADirector – Consulting, HealthcareCliftonLarsonAllen, [email protected]