Schedule Your Complimentary Analysis

In October 2016, the Centers for Medicare and Medicaid Services (CMS) published a final rule revising for Medicare and Medicaid requirements of participation (RoP) for nursing facilities. In the July 18, 2019 Federal Register, CMS proposed the rule that will reform some of the requirements that have been identified as “obsolete and burdensome regulations that could be eliminated and reformed to improve effectiveness or reduce unnecessary reporting requirements and other costs, with a particular focus on freeing up resources that health care providers, health plans and states could use to improve and enhance resident health and safety”. They proposed to delay implementation of some phase 3 requirements, which has a deadline of November 28, 2019. However, facilities are still waiting on CMS guidance.  

Let’s review the three major provisions in phase 3:

1. Quality assurance and performance improvement (QAPI) implementation;
2. Infection control;
3. Compliance and Ethics Program.

Quality Assurance and Performance Improvement:

CMS is requiring all LTC facilities to develop, implement, and maintain an effective comprehensive, data driven QAPI program that focuses on systems of care, outcomes of care and quality of life. Section 483.70 requires statement of responsibility for the program to be included in the obligations of the governing body. The rule also requires that facilities include abuse, neglect, and exploitation into the QAPI program.

In the proposed rule, CMS removed the prescriptive requirements of a QAPI program’s design and scope. This will allow facilities flexibility to determine how to best develop their QAPI program tailored to meet their individual needs and ensure the promotion of quality of care. The policies and procedures related to program effectiveness, data systems, and monitoring is still required however, CMS proposed to eliminate the specific details of what should be contained in the policies and procedures. Facilities are also still required to act for quality improvement, measuring success, and performance tracking however, CMS proposed to eliminate the prescriptive details of what the policies and procedure requirements should include.

Infection Control:

CMS is requiring facilities to develop an Infection Prevention and Control Program (IPCP) that includes an Antibiotic Stewardship Program and designate at least one Infection Preventionist (IP).

In the proposed rule, CMS removes the need to hire the infection preventionist, which will allow facilities to contract with an individual or another way to meet the requirement of the IPCP, “must have sufficient time at the facility to meet the objectives set forth in the facility’s IPCP.” Facilities must still meet the IPCP requirement but can still meet the requirements without adding additional personnel.

Compliance and Ethics Program:

This is a new section.  CMS is requiring the operating organization for each facility to have in effect a compliance and ethics program that has established written compliance and ethics standards, policies and procedures that are capable of reducing the prospect of criminal, civil, and administrative violations in accordance with section 1128I(b) of the Act.

In the proposed rule, CMS removed the need for a compliance officer, compliance liaisons, and reviewing of the facilities compliance program every year but rather review “periodically”.

With limited guidance from CMS, facilities are left to implement changes per their discretion.

Gina Tomcsik, Director of Compliance and Regulatory Strategy

If you were to Google the word ‘interrupt’, you will see the definition, “stop the continuous progress of (an activity or process); stop (someone speaking) by saying or doing something; break the continuity of (a line or surface); obstruct (something, especially a view).” For purposes of this blog, let’s use the definition “stop the continuous progress of an activity or process”. The activity or process we are talking about here is the Medicare Part A SNF stay.

Under RUG-IV, we utilize skip days when the resident’s stay is interrupted if, for example, the resident has to go to the hospital overnight for observation for less than 24 hours and past midnight.

The RAI Manual, V1.17 RAI Manual released May 20, 2019 provides detailed information regarding the new Interrupted Stay Policy under PDPM.

The Interrupted Stay is a Medicare Part A SNF stay in which a resident is discharged from SNF care (i.e., the resident is discharged from a Medicare Part A-covered stay) and subsequently resumes SNF care in the same SNF for a Medicare Part A-covered stay during the interruption window.  When a resident on Medicare Part A has an interrupted stay (i.e., is discharged from SNF care and subsequently readmitted to the same SNF within the interruption window after the discharge), this is a continuation of the Medicare Part A stay, not a new Medicare Part A stay.

The Interruption Window is a 3-day period, starting with the calendar day of discharge and including the 2 immediately following calendar days. In other words, if a resident in a Medicare Part A SNF stay is discharged from Part A, the resident must resume Part A services, or return to the same SNF (if physically discharged) to resume Part A services, by 11:59 p.m. at the end of the third calendar day after their Part A-covered stay ended. If both conditions are met, the subsequent stay is considered a continuation of the previous Medicare Part A-covered stay for the purposes of both the variable per diem schedule and PPS assessment completion.

Examples of when there IS an Interrupted Stay:

• If a resident is discharged from Part A, remains in the facility, and resumes Part A within the 3-day interruption window, this is an interrupted stay and no Part A PPS Discharge or OBRA Discharge is completed, nor is a 5-Day or Entry Tracking record required when Part A resumes.
• If a resident is discharged from Part A, leaves the facility, and resumes Part A within the 3-day interruption window, this is an interrupted stay and only an OBRA Discharge is required. An Entry Tracking record is required on reentry, but no 5-Day is required.

Examples of when there is NO Interrupted Stay:

• If a resident is discharged from Part A, remains in the facility, and does not resume Part A within the 3-day interruption window, it is not an interrupted stay. Therefore, a Part A PPS Discharge and a 5-Day assessment are both required (as long as resumption of Part A occurs within the 30-day window allowed by Medicare).
• If a resident is discharged from Part A, leaves the facility, and does not resume Part A within the 3-day interruption window, it is not an interrupted stay and the Part A PPS Discharge and OBRA Discharge are both required and may be combined (see Part A PPS Discharge assessment in Section 2.5 of 17 RAI Manual). Any return to the facility in this instance would be considered a new entry—that means that an Entry Tracking record, OBRA admission and/or 5-Day assessment would be required.

If the resident’s Medicare Part A stay ends and the resident subsequently returns to a skilled level of care and Medicare Part A benefits do not resume within 3 days, the PPS schedule starts again with a 5-Day assessment. If the Medicare Part A stay does resume within the 3-day interruption window, then this is an interrupted stay (see below).

• If the resident leaves the facility for an interrupted stay, no Part A PPS Discharge Assessment is required when the resident leaves the building at the outset of the interrupted stay; however, an OBRA Discharge record is required if the discharge criteria are met (see Section 2.5 17 RAI Manual). If the resident returns to the facility within the interruption window, as defined above, an Entry tracking form is required; however, no new 5-Day assessment is required.

Items A2400A–A2400C are not active when the OBRA discharge assessment indicates the resident has had an interrupted stay (A0310G1=1).

A 5-Day assessment is not required at the time when a resident returns to a Part A-covered stay following an interrupted stay, regardless of the reason for the interruption (facility discharge, resident no longer skilled, payer change, etc.).

• If a resident changes payers from Medicare Advantage to Medicare Part A, the SNF must complete a 5-Day assessment with the ARD set for one of days 1 through 8 of the Medicare Part A stay, with the resident’s first day covered by Medicare Part A serving as Day 1, unless it is a case of an interrupted stay.

In the case of an interrupted stay, that is, if a resident leaves the facility and resumes Part A within the 3-day interruption window, only an OBRA Discharge is required. An Entry Tracking record is required on reentry, but no 5-Day is required. If the resident was discharged return anticipated, no OBRA assessment is required. However, if the resident was discharged return not anticipated, the facility must complete a new OBRA Admission assessment.

Coding Instructions for A0310G1, Is this a SNF Part A Interrupted Stay?

• Code 0, no: if the resident was discharged from SNF care (i.e., from a Medicare Part A-covered stay) but did not resume SNF care in the same SNF within the interruption window.
• Code 1, yes: if the resident was discharged from SNF care (i.e., from a Medicare Part A-covered stay) but did resume SNF care in the same SNF within the interruption window.

Coding Tips

• Item A0310G1 indicates whether or not an interrupted stay occurred.
• The interrupted stay policy applies to residents who either leave the SNF, then return to the same SNF within the interruption window, or to residents who are discharged from Part A-covered services and remain in the SNF, but then resume a Part A-covered stay within the interruption window.

The following is a list of examples of an interrupted stay when the resident leaves the SNF and then returns to the same SNF to resume Part A-covered services within the interruption window. Examples include, but are not limited to, the following:

• Resident transfers to an acute care setting for evaluation or treatment due to a change in condition and returns to the same SNF within the interruption window.
• Resident transfers to a psychiatric facility for evaluation or treatment and returns to the same SNF within the interruption window.
• Resident transfers to an outpatient facility for a procedure or treatment and returns to the same SNF within the interruption window.
• Resident transfers to an assisted living facility or a private residence with home health services and returns to the same SNF within the interruption window.
• Resident leaves against medical advice and returns to the same SNF within the interruption window.

The following is a list of examples of an interrupted stay when the resident under a Part A-covered stay remains in the facility but the stay stops being covered under the Part A PPS benefit, and then resumes Part A-covered services in the SNF within the interruption window. Examples include, but are not limited to, the following:

• Resident elects the hospice benefit, thereby declining the SNF benefit, and then revokes the hospice benefit and resumes SNF-level care within the interruption window.
• Resident refuses to participate in rehabilitation and has no other daily skilled need; this ends the Part A coverage. Within the interruption window, the resident decides to engage in the planned rehabilitation regime and Part A coverage resumes.
• Resident changes payer sources from Medicare Part A to an alternate payer source (i.e., hospice, private pay or private insurance) and then wishes to resume their Medicare Part A stay, at the same SNF, within the interruption window.

If a resident is discharged from SNF care, remains in the SNF, and resumes a Part A-covered stay in the SNF within the interruption window, this is an interrupted stay. No discharge assessment (OBRA or Part A PPS) is required, nor is an Entry Tracking Record or 5-Day required on resumption.

If a resident leaves the SNF and returns to resume Part A-covered services in the same SNF within the interruption window, this is an interrupted stay. Although this situation does not end the resident’s Part A PPS stay, the resident left the SNF, and therefore an OBRA Discharge assessment is required. On return to the SNF, no 5-Day would be required. An OBRA Admission would be required if the resident was discharged return not anticipated. If the resident was discharged return anticipated, no new OBRA Admission would be required.

When an interrupted stay occurs, a 5-Day PPS assessment is not required upon reentry or resumption of SNF care in the same SNF, because an interrupted stay does not end the resident’s Part A PPS stay.

• If a resident is discharged from SNF care, remains in the SNF and does not resume Part A-covered services within the interruption window, an interrupted stay did not In this situation, a Part A PPS Discharge is required. If the resident qualifies and there is a resumption of Part A services within the 30-day window allowed by Medicare, a 5-Day would be required as this would be considered a new Part A stay. The OBRA schedule would continue from the resident’s original date of admission (item A1900).
• If a resident leaves the SNF and does not return to resume Part A-covered services in the same SNF within the interruption window, an interrupted stay did not In this situation, both the Part A PPS and OBRA Discharge assessments are required (and may be combined). If the resident returns to the same SNF, this would be considered a new Part A stay. An Entry Tracking record and 5-Day would be required on return. An OBRA Admission would be required if the resident was discharged return not anticipated. If the resident was discharged return anticipated, no new OBRA Admission would be required.
• The OBRA assessment schedule is unaffected by the interrupted stay policy. Please refer to Chapter 2 for guidance on OBRA assessment scheduling requirements.

The interrupted stay policy does not apply to Swing Bed providers.

Gina Tomcsik
Director of Compliance and Regulatory Strategy