DQA
Quarterly Information Update
August 2005
[PDF
Version of this month's Quarterly Update (PDF, 68
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Wisconsin Assisted Living Provider Profiles on the Internet
In the Bureau of Quality Assurance's (BQA) continuing efforts to make
information more readily accessible to all of our stakeholders, as well as
consumers, we are pleased to announce that assisted living provider
profiles will be available on the Department of Health and Family
Services' internet website by the beginning of September 2005. Provider
profile information for the following facility types will be available:
Community Based Residential Facilities (CBRFs), Adult Family Homes (AFHs),
Residential Care Apartment Complexes (RCACs) and Adult Day Care Centers
(ADCs).
The assisted living facility profiles are designed to provide an
overview of the results of BQA inspections. When comparing facilities for
quality of care and safety, consumers should keep in mind that the
profiles do not contain information on facility size or the complexity of
health care needs of its residents/tenants. A profile should be considered
a "snapshot" of the facility, not the complete picture.
Information gathered from an inspection measures whether the facility
meets the minimum standard for a particular set of requirements at the
time of that inspection.
The assisted living provider profile contains a three-year history of
surveys, complaint investigations, and enforcement actions. In addition, a
Glossary of Terms provides consumer-friendly information about the data
and terminology found on the profile. Profiles can be accessed via: http://dhfs.wisconsin.gov/bqaconsumer/ResidOpts/seek.htm.
If there are questions or concerns about the accuracy of information
found on a facility profile, please contact the appropriate Bureau of
Quality Assurance Regional Office via the following website: http://dhfs.wisconsin.gov/bqaconsumer/AssistedLiving/ALSreglmap.htm.
Please Keep BQA Informed of Address Updates
From time to time, various BQA staff are contacted and told that people
are getting mail from the bureau that should not go to them. This is a
very common problem in state service. If this is happening to you, please
contact your assigned certification or licensing specialist. It is also
important that you contact this person with changes in facility
information. Please review the Contact information for your provider type
via http://dhfs.wisconsin.gov/rl_DSL/index.htm.
When you call about unwanted mail, it is helpful to let us know what
specific piece of mail you received. Hang on to the envelope too as it may
be that another agency generated the label.
For the most up-to-date listing for your facility or program, please
review the BQA provider directories at http://dhfs.wisconsin.gov/bqaconsumer/directories.htm.
BQA Numbered Memos May-July 2005
Access these memos via http://dhfs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm,
or from individual providers' publications pages via http://dhfs.wisconsin.gov/rl_DSL/.
The following BQA memos have been made obsolete:
- 04-013, "Provider Profiles Available on the Internet" (see
article)
- 01-050, "Regional Office Move" - Some address information
no longer correct, other information already available on the
Internet.
National Provider Identifier (NPI) - CMS
The Centers for Medicare and Medicaid Services (CMS) Administrator
announced a May 23, 2005 start for the National Provider Identifier (NPI).
The NPI is the standard unique health identifier for health care providers
that was adopted by the Secretary of Health and Human Services under the
Health Insurance Portability and Accountability Act of 1996. The
Administrator's announcement letter:
- Informs health care providers about the NPI;
- Describes three ways to obtain an NPI; and
- Gives them guidance as to what they should do once they have
obtained their NPI.
The letter, which also provides informational contacts and resources
can be viewed at www.cms.hhs.gov/hipaa/hipaa2/npi_provider.asp (exit
DHFS).
Medicare providers can find the article about NPI Implementation at www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0528.pdf (PDF
- Address changed;
exit DHFS).
CMS also issued Survey & Certification letter 05-30 on the subject at www.cms.hhs.gov/medicaid/survey-cert/sc0530.pdf (PDF;
exit DHFS).
CMS plans to issue quarterly reminders to health care providers to obtain
their NPI.
The NPI will replace the current health care provider identifiers for
standard health care transactions. Your health plan representative will
instruct you as to when you may begin using the NPI in standard
transactions. All HIPAA-covered entities, except small health plans, are
mandated to begin using the NPI on May 23, 2007. Small health plans have
until May 23, 2008. For additional information, and to complete an
application, visit https://nppes.cms.hhs.gov
(exit DHFS) on the web. Health care providers may also call 1-800-465-3203 to request
a paper application.
An instructional web tool, called the NPI Viewlet, is now available for
viewing at www.cms.hhs.gov/medlearn/npi/npiviewlet.asp (exit
DHFS),
and under "HIPAA Latest News" at www.cms.hhs.gov/hipaa/hipaa2 (exit
DHFS)
on the CMS website. This tool provides an overview of the NPI and a
walk-through of the application, as well as live links to the NPPES
website where the learner can apply for an NPI. This tool is designed for
all health care providers. In the near future, you will also be able to
access the viewlet at https://nppes.cms.hhs.gov (exit
DHFS).
Medicare Fraud Alerts
The Wisconsin Department of Health and Family Services has received
Fraud Alerts from the Centers for Medicare and Medicaid Services
concerning "Home Health Agency Capping" and "Staffing
agencies representing unlicensed personnel as Registered Nurses and/or
Licensed Practical Nurses." These Alerts are being relayed to the
provider community for informational purposes only.
Home Health Agency Capping
Capping is the practice of illegally exchanging monetary and/or
tangible goods, including offering and/or obtaining kickbacks for services
rendered. A number of Medicare home health providers have been identified
as billing for home health services for the same beneficiary population as
other home health agencies, durable medical equipment providers,
physician, and laboratories. However, investigation has found that the
beneficiaries either are not homebound, the services are not medically
necessary, and/or the home health services are not being provided to these
beneficiaries. This practice may also be spreading to hospice providers.
The home health scheme involves home health agencies (HHAs) obtaining
beneficiary Medicare Health Insurance (HIC) numbers and using them to bill
the Medicare Program for services they did not render. There are several
ways in which these numbers are being obtained, including the paying of
beneficiaries (referred to as "Capper benes") for their HIC
numbers. It is suspected that other business entities and individuals are
involved in the scheme, including nurse registries and billing service
companies that create falsified medical records. As a result, claims
submitted to the Affiliated Contractors (ACs) are made to appear
legitimate and have been processed accordingly.
The following describes this alleged fraud scheme in more detail:
- Beneficiaries are being moved among multiple HHAs (ping-ponging),
where there are identified connections between owners, administrators, and
nurse registries.
- HHA financial records reflect persons and organizations (including
nursing registries) in payroll accounts as receiving undocumented payments
from general cash accounts. At times, payments are noted to be recurring
monthly and are usually for identical amounts. There is no
documentation/agreement provided to support each transaction.
- Reimbursement maximization due to achieving "outlier
claims" status. One segment of the beneficiary population targeted is
diabetic patients. An inflated number of visits per patient is recorded,
thereby increasing Medicare reimbursement. However, it has been found that
billings include twice-daily insulin administration for beneficiaries who
are not on insulin.
- Nurse registries are complicit with HHAs in schemes, such as paying
beneficiaries for dropping their complaints to the PSC, and in the sharing
of "Capper" beneficiary Medicare numbers.
- Falsification of records may include forging physician signatures
and paying physicians for their signatures on home health Plans of Care,
the use of "canned" medical records, or home health services
that were allegedly provided that have no relation to previous home health
services or diagnoses on other bill types.
- Beneficiaries who reside in board and care/assisted living
facilities may be targeted for home health care services inappropriately.
Beneficiaries are found not to be homebound, and are receiving services
that are not medically reasonable and necessary. Many of the owners,
staff, and "house physicians" are active participants in the
scheme.
- HHAs are not staffed or operating in accordance with the Code of
Federal Regulations Conditions of Participation in Medicare.
Staffing agencies representing unlicensed personnel as Registered
Nurses and/or Licensed Practical Nurses
Some staffing agencies are representing unlicensed personnel as
Registered Nurses (RN) and/or Licensed Practical Nurses (LPNs). The
staffing agencies are employing recent immigrants with some nursing
experience in foreign countries, primarily the Philippines, and
representing them to hospice agencies as licensed RNs/LPNs. The hospice
agencies are aware that the contracted staff is not licensed, but continue
to use the staff as RNs/LPNs.
Many of the LPNs are providing many hours of continuous care services
to hospice beneficiaries. The bulk of the continuous care billed is
provided by the unlicensed LPNs. Contracted nurses can be used to
supplement the hospice nurses employed directly, but contracted nurses
should not be the sole providers of continuous nursing care. The hospice
agency must have procedures in place to verify that all staff providing
services meet state and federal licensing requirements.
In addition, some of the staffing agencies have Medicare provider
numbers and are billing as home health agencies.
If you have questions regarding these CMS Medicare Fraud Alerts, or
information about such practices in Wisconsin, contact TrustSolutions,
LLC, Donna L. Casey, RN, BSN, Fraud Information Specialist, phone (414)
226-6085, E-mail donna.casey@trustsolutionsllc.com. The street address for
TrustSolutions, LLC is 401 West Michigan St., Milwaukee, WI 53203.
Nursing Homes - Revisions to State Operations Manual, Appendix PP,
Urinary Incontinence, Tags F315 and F316
CMS has issued Transmittal 8, State Operations Manual, amending
Appendix PP regarding
F tags F315 and F316 for urinary incontinence. Please review the
transmittal at www.cms.hhs.gov/manuals/pm_trans/R8SOM.pdf [no longer
available]. Please note
that this transmittal rescinds Transmittal 7 on the same subject.
Hospices - Issues
Range of Visits
Questions have arisen regarding frequency of client visits, and whether
a range of visits is acceptable. Federal regulation 42 CFR 418.58(c) and
Wisconsin Administrative Code HFS 131.42(3)(b) require that the plan of
care states in detail the scope and frequency of services needed to meet
the patient's and family's needs.
A specific range of visits for each service is acceptable. Identifying
a specific range for visits may ensure that the most appropriate level of
service is provided to meet the needs of the patient. If fewer visits than
the upper limit of the range are provided, clinical record documentation
must support the patient-specific circumstances that guided the agency's
decision to provide fewer than the upper limit ordered.
The minimum number within the range should be at least one, unless
there is patient-specific criteria for no visits during a given time
frame.
The number of visits must be provided within the range based on the
patient's or family's needs, not staff availability. Staff availability is
not an acceptable reason for changing the frequency of physician ordered
services.
Dietary Counseling Services Within the Medicare Hospice Program
CMS is allowed to waive the requirement that hospices provide dietary
counseling directly. These waivers are available only to an agency that is
located in a non-urban area, and that can demonstrate it has been unable,
despite diligent efforts, to recruit appropriate personnel. CMS will use
the requirements for the nursing services waiver found at 42 CFR
418.83(a)(3) in determining that a hospice has made a diligent effort.
For more information on this waiver ability, please see BQA memo 00-029
and its attachment at http://dhfs.wisconsin.gov/rl_DSL/Hospice/Hospice00-029.htm.
Provision of Hospice Services to a Resident of a Community-Based
Residential Facility (CBRF)
There have also been questions related to hospice services in a CBRF.
Below are three sample scenarios:
Scenario #1: A hospice patient in a CBRF is receiving Oxycontin
20mg BID. At 3:00 a.m., the patient complains of increased pain. The CBRF
staff calls the hospice. The hospice calls the physician and he orders an
increase in the Oxycontin to 30mg BID. Since this is a medication the
patient is already on, can the CBRF staff accept the verbal order to
increase the medication from the hospice nurse over the phone? Also, can
the CBRF initiate that order without having a signed order on the chart at
that time, even though the hospice nurse and physician will fax those
orders later in the a.m.?
Response to Scenario #1: Transfer of the information to the CBRF
would be considered a verbal order. Wisconsin Administrative Code HFS
83.33(3)(a)1 states that the CBRF must have a written order and that
changes in a prescription order shall be communicated promptly.
Based on this regulation, several factors need to be taken into
consideration. For example: When was the last home visit conducted? Has
pain control been a concern? How frequently have the pain medications been
adjusted? What pain management interventions are evident on the jointly
developed plan of care? Using professional judgement and taking all
factors of any given situation into consideration, the hospice nurse must
make a decision.
In this case, it may be appropriate for the hospice nurse to provide
dosage instructions by phone to the CBRF staff and for the staff to
administer the medication. Clinical record documentation must support the
decision and actions taken. The change would then be communicated to the
CBRF later in the morning via fax or on-site hospice visit. If the CBRF
has a nurse, he/she should take the verbal order related to a dosage
increase.
Scenario #2: A hospice patient in a CBRF is on Oxycontin 20mg
BID. At 3:00 a.m., the patient complains of increased pain. The CBRF staff
calls hospice. The hospice calls the physician and receives an order for a
new medication (Roxanol 20 mg q 1hr prn). The hospice nurse calls the
pharmacy to deliver the Roxanol. Can the CBRF staff accept the verbal
order from the Hospice nurse on a new medication with the understanding
that the order will be faxed later in the a.m.? Can the CBRF staff
initiate giving the new Roxanol order with instruction from the hospice
nurse without a visit being made if they verbalize understanding on how to
give the new medication? If a hospice visit is made, can the CBRF staff
accept the order that the hospice nurse writes on their chart, although it
is not yet signed by the physician?
Response to Scenario #2: If the order for the medication is
called into the pharmacy, and the pharmacy delivers the medication to the
CBRF, the label on the bottle would constitute the written order. Clinical
record documentation must support the medication change noted on the
treatment label and hospice instructions related to the medication. Based
on the reported change in patient condition of increased pain, an on-site
visit and assessment by the hospice nurse may be warranted.
Scenario #3: A hospice patient in a CBRF is on Oxycontin 20mg
BID. At 3:00 a.m., the patient complains of a new symptom, nausea. The
CBRF staff calls hospice, hospice calls the physician, and the physician
orders Compazine 10mg q 6hrs prn for the nausea. Can the CBRF initiate
this new order after being instructed by the hospice nurse by phone, when
the order will not be faxed until 7:00 a.m., and without a hospice nursing
visit being done?
Response to Scenario #3: In this scenario, a new order is
initiated, so the pharmacy would need to be involved and the label on the
bottle would constitute the written order. Clinical record documentation
must support the medication change noted on the treatment label and
hospice instructions about the medication. However, based on the fact that
the patient is complaining of a new symptom, an on-site visit and
assessment by the hospice nurse would be warranted.
If the CBRF has a nurse on duty at night who could assess or assist
with the assessment of the reported changed in patient condition/need, the
hospice could use that information as a basis for plan of care decisions.
If the CBRF does not have a nurse on staff to assess or assist with the
assessment of the reported change in patient condition/need, a home visit
would be warranted.
Latest CMS Survey & Certification Letters
Below is a list of Survey and Certification (S&C) Letters
distributed by CMS during the last quarter. Letters pertaining only to
state agency operations are omitted. All S&C Letters can be viewed as
PDF files at the Internet site
www.cms.hhs.gov/medicaid/survey-cert/letters.asp [Site changed - see
individual letters].
If you have questions about individual letters, contact Susan Hespen of
BQA at (608) 266-0582, or e-mail hespesj@dhfs.state.wi.us.
Administrative Rules Update
HFS 83 - "Community Based Residential Facilities"
The HFS 83 re-write workgroup continues to work with an advisory
committee, consisting of various providers and association
representatives, to develop the proposed rules for Chapter
HFS 83. The workgroup is in the process of completing the Rule Summary and
will submit the summary along with the draft rule to the DHFS Office of
Legal Council for review by the end of July 2005. The Department plans to
submit a draft rule-making order to the Legislative Council Rules
Clearinghouse in September 2005. You may view the Statement of Scope of
proposed rules on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov
(exit DHFS)
for more information.
HFS 124 - "Hospitals"
The Wisconsin Administrative Register published the Statement of Scope
of proposed rules to amend Chapter HFS 124 on April 1, 2005. The
Department is planning to update ch. HFS 124 to eliminate overly
prescriptive regulations, clarify the Department's enforcement authority,
and bring ch. HFS 124 into line with Medicare by requiring compliance with
federal minimum standards of operation, maintenance and patient care. For
more information, you may view the Statement of Scope on the Wisconsin
Administrative Rules web-site at http://adminrules.wisconsin.gov (exit
DHFS).
HFS 132 - "Nursing Homes"
The Department is proposing to update ch. HFS 132 to reflect current
standards of practice, enhance the Department's authority relating to the
initial licensing of nursing homes, and remove provisions that duplicate
applicable federal requirements. The proposed rules are the subject of a
Statement of Scope published in the Wisconsin Administrative Register on
April 15, 2005. For more information, you may view the Statement of Scope
on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov (exit
DHFS).
HFS 133 - "Home Health Agencies"
The Department is in the process of drafting rules to amend ch. HFS
133. On October 15, 2004, the Wisconsin Administrative Register published
the "Statement of Scope" of proposed rules that are the subject
of the ch. HFS 133 rule order. For more information, you may view the
Statement of Scope on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov (exit
DHFS).
HFS 148 - "Cancer Drug Repository Program"
The Cancer Drug Repository Administrative Rule was published June 1,
2005 and became effective July 1, 2005. Providers can find copies of these
rules on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov (exit
DHFS).
For additional information, you may view the BQA Cancer Drug Repository
website at http://dhfs.wisconsin.gov/bqaconsumer/cancerdrugreposy.htm.
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Last Revised: October 24, 2008 |
