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Long-Term Care Survey Alert
Your guide to survey and compliance success & quality innovation
December 2011, Vol. 13, No. 12 (Pages 81-88)
In this issue
Tool
The RAI User’s Manual’s Care
Area Assessment Resource
for Feeding Tubes Includes
Psychosocial Issues
p83
Clarification
CMS Pulls Back Revised
F322 (Tube Feeding) Survey
Guidance
p83
 Here’s why — and where to look
for the reissued guidance.
Documentation
Heed This HEAT Training Advice
for Documenting Diagnostic
Testing
p84
Quality of Life }
Help Residents Who Require Enteral Nutrition
Meet These Needs
If a resident feels self-conscious, you can do this, suggests activity expert.
Nurse attorney Barbara Miltenberger predicts surveyors will be taking a closer
look at socialization for the person with tube feedings. “Due to culture change,
there’s more emphasis on quality of life,” she points out.
Initially released survey guidance for tube feedings (F322), which CMS had at
press time temporarily withdrawn, says that “to assure that the resident being fed
by a feeding tube maintains the highest degree of quality of life possible, it is
important to minimize possible social isolation or negative psychosocial impact to
the degree possible (e.g., continuing to engage in appropriate activities, socializing
in the dining room).” (For more information on the guidance, see page 83.)
(Continued on page 82)
 OIG chief medical officer
provides 2 tips.
Quality of Care Reader Feedback
Find Out How This SNF Is
Handling Staff Flu
Vaccinations
p85
 Also find out what CMS rep has
to say on this issue.
Medical Expert Shares Views on Lab Testing
in Nursing Facilities
Know when to do a digitalis level as soon as possible.
Coding Quizzer
Code This RAI Manual Example
for Flu Vaccination
p86
MDS, Compliance & Clinical
News to Use
}
p86
Repeating certain lab tests is reasonable to do — “but probably not at the
frequency they are repeated in many cases,” says Naushira Pandya, MD, CMD,
associate professor and chair with the Department of Geriatrics at NSU College of
Osteopathic Medicine in Ft. Lauderdale, Fla.
Example: “You need to know the electrolytes for hypertensive patients on
multiple medications, such as ACE inhibitors and diuretics,” she says. “But even
the [American Heart Association] won’t tell you how often. In those cases, I
think every three months you should check kidney function and electrolytes,”
she advises.
(Continued on page 84)
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p81
Vol. 13, No. 12
(Continued from Cover)
Overcome this potential obstacle: “If a resident receiving
continuous tube feedings feels self-conscious of being
attached to a feeding pump while out of their room, you
can ask for a routine order for ‘feeding interruption time,’”
says Reta Underwood, an activity expert and president
of Consultants for Long Term Care Inc. in La Grange, Ky.
“This can be done with a PRN order for a specified time
frame, i.e., ‘PRN disconnect feed for no more than one
hour and 30 minutes to attend out of room activities.’”
At Northern Oaks Living and Rehabilitation Center, “we
encourage all residents to get out of their rooms and to
attend activities of their choice,” says Barbara Lohman,
MSW, social services director for the facility in Abilene,
Texas. “If a resident who is tube fed wants to attend an
activity, the activity director makes sure that they get to
that activity,” she tells Eli. “Some of our residents like to
pass the time ‘people watching’ in our lobby.”
“If a resident receiving continuous tube feedings
feels self-conscious of being attached to a feeding
pump while out of their room, you can ask for a
routine order for ‘feeding interruption time,’” advises
consultant Reta Underwood.
“The activity director and social services director make
room visits to those who do not like to get out of their
rooms much. Room activities might include one-on-one
conversational visits, reading a book to the resident,
pet therapy visits, or reading their mail to them,”
Lohman adds.
Underwood also notes that “just because someone
receives food from a tube doesn’t mean that they should
be isolated or excluded from food-related activities.
Olfactory sensation is important to sensory satisfaction
when a person loses the ability to swallow” and has to
rely on tube feedings, she says.
Safety tip: Miltenberger points out that if someone isn’t
supposed to have anything by mouth, taking the person
to the dining room to socialize could put them at risk “for
taking food off someone’s plate and aspirating. Your care
plan and documentation need to show that you’ve thought
about those issues,” advises Miltenberger, with Husch
Blackwell in Jefferson City, Mo.
Underwood stresses the importance of getting the speech
language pathologist involved to make sure the resident’s
diet “is the least strict that it can be.”
Editorial Advisory Board
 Joseph C. Bianculli, JD
CONTACT INFORMATION
 Marie C. Infante, JD, RN
Long-Term Care Survey Alert (USPS 019-713) (ISSN 1535-363X) is published monthly by Eli Research, 2222 Sedwick
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Vol. 13, No. 12
“If a patient has severe swallowing issues including
choking on ice chips, etc., then … their primary nutrition
has to be the tube feedings,” says Joanna Liddell,
a speech language pathologist at Kolob Care and
Rehabilitation of St. George in St. George, Utah.
“We continue to evaluate the person’s swallowing and let
[the team] know when it’s better and when to switch to
bolus feedings” and try to get the person to eat more by
mouth, Liddell adds.
“If the person is getting a tube feeding because they
aren’t taking in enough calories, then you want them to
eat more by mouth in addition to the tube feedings to get
an adequate caloric intake,” says Liddell. “When they
are ready, we switch them to bolus feedings, which helps
their stomach to prepare for regular-sized meals again.
We may shut off the continuous feeding at night to allow
them to feel hungry for breakfast.”
Tasty tip: Flavored lip-gloss comes in “most soda, fruit,
chocolate and other candy flavor,” says Underwood, who
reports she’s even found a buttered popcorn flavored
lip-gloss. “In addition to the benefits of the taste, the lipgloss conditions the lips,” she adds.
Tool Resource: See the excerpt from the RAI User’s Manual
Care Area Assessment Resource for Feeding Tube(s) on
page 83. n
Clarification }
CMS Pulls Back Revised F322
(Tube Feeding) Survey Guidance
Here’s why — and where to look for the reissued
guidance.
On Oct. 21, CMS posted a notice on its website
stating: “We have retracted S&C Memo 11-37-NH
Revisions to Interpretive Guidance at Ftag 322, as
Part of Appendix PP so that we may incorporate
instructions that pertain to the Quality Indicator
Survey. We will notify you as soon as the revised
guidance is published.”
You can check for the F322 survey guidance at www.
cms.gov/SurveyCertificationGenInfo/PMSR/list.
asp#TopOfPage. n
}
The RAI User’s Manual’s Care Area Assessment Resource for
Feeding Tubes Includes Psychosocial Issues
CMS’s RAI Version 3.0 Manual Appendix C: CAA Resources 13. Feeding Tube(s) October 2011 Appendix C-56
Psychosocial
issues related to
tube feeding
Supporting Documentation
(Basis/reason for checking the item, including the location, date, and source
(if applicable) of that information)
□
Signs of depression (D0300, D0600, I5800); see Mood State CAA)
□
Ways to socially engage the resident with a feeding tube
□
Emotional and social support from social workers, other members of the healthcare team
Source: Printed verbatim from the RAI User’s Manual, Appendix CC. To review the entire CAA Resource, see
Appendix C-55 through C-57. n
Your Guide to State Survey Success And Quality Innovations
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p83
Vol. 13, No. 12
(Continued from Cover)
“And if someone is on a statin or antipsychotic that
might affect liver function,” she recommends testing liver
function every six months.
Pandya provides these additional testing suggestions:
» A1c: “If someone is diabetic, it’s reasonable to do
A1c every six months, but if the diabetes is not wellcontrolled — or the person’s therapy has changed
many times — it’s reasonable to do A1c every three
months,” says Pandya.
» Complete Blood Count. “You should do a CBC
annually,” Pandya suggests. “But if you know the
patient is anemic or has sudden fatigue or a gastric
ulcer or gastritis — or an unexplained drop in
“If you know the patient is anemic or has sudden
fatigue or a gastric ulcer or gastritis — or an
unexplained drop in hemoglobin — then you would
follow up on that with lab testing. It depends on the
clinical situation,” says Naushira Pandya, MD,
CMD.
Documentation Naushira Pandya, MD, CMD, says she knows of
some nursing facilities that do INRs every Monday,
Wednesday, and Friday. “Then the physicians on call
might not know what has been done, so they change
the dose, and the patient never has a time when he or
she reaches a steady state,” which takes about a week
to reach, she adds.
hemoglobin — then you would follow up on that
with lab testing. It depends on the clinical situation.
If someone wasn’t anemic last year but this year
they are, we will do relevant iron studies or B-12 or
look for GI blood loss. You can’t dictate that type of
testing in a protocol fashion.”
Watch for this: “Doing repeat lab testing can make a
patient anemic,” Pandya warns. She reports being asked
to do consultations on patients to find out why they are
anemic. And “I find out that when the person came into
are
Medic rsement
u
b
im
Re
anion
Comp
}
Heed This HEAT Training Advice for
Documenting Diagnostic Testing
Expert Guidance
for Optimal
Reimbursement
OIG chief medical officer provides 2 tips.
Heads up: Providing “clear information showing
your rationale for performing a diagnostic test helps
demonstrate that the test was necessary and will help
you meet the medical necessity requirement,” advised
Julie Taitsman, MD, JD, OIG’s chief medical officer,
during a session in the government’s HEAT training,
which is now available online.
Also: “Clear documentation of the test results helps
substantiate that the test was completed and will also
help substantiate the need for subsequent care that
might get later billed to the programs,” Taitsman
added. n
p84
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www.eliresearch.com
Vol. 13, No. 12
the hospital, they weren’t anemic. They got sick and they
had a lot of blood drawn for tests.”
» Cholesterol. Pandya notes that “some physicians test
a patient’s cholesterol every two to three months.”
But she doesn’t think that’s required “unless you
are changing the statin dose. I think you can check
cholesterol [initially] every six months and, if it’s
stable, every year.”
» Drug levels. “You also want to check drug levels
of patients on seizure medications,” says Pandya.
She thinks it’s reasonable to do that testing every
couple of months. “It’s reasonable to check digitalis
levels every six months,” she adds, but you should
do a “dig level as soon as possible, if a patient has
bradycardia, arrhythmias, or unexplained confusion.”
INR Testing ‘Very, Very Important,’ Stresses Expert
INRs for patients on Coumadin (warfarin) are “very, very
important,” says Pandya. “Most Coumadin clinics and
Reader Feedback cardiology offices do them every month,” she points out,
noting that she believes “we do way too many in longterm care.” For example, Pandya says she knows of some
nursing facilities that do INRs every Monday, Wednesday,
and Friday. “Then the physicians on call might not know
what has been done, so they change the dose, and the
patient never has a time when he or she reaches a steady
state,” which takes about a week to reach, she adds.
“If a patient on Coumadin has stable, therapeutic INR
levels, I do a level every two weeks. Some people are
hard to control; so in those cases, I do them every week.”
What if a patient starts a medication that interacts with
Coumadin? “You need to do INRs more frequently,”
says Pandya. “For example, a quinolone antibiotic can
increase INR within two days, and you can have someone
overcoagulated.”
Editor’s note: For Pandya’s recommendations for doing
creatinine testing in nursing facilities, see an upcoming
Long-Term Care Survey Alert. n
}
Find Out How This SNF Is Handling Staff Flu Vaccinations
Also find out what CMS rep has to say on this issue.
In response to the article on influenza vaccination in the
last Long-Term Care Survey Alert, Barb Hulwick, RN,
reported that the SNF where she works is requiring all
staff to get the flu vaccine by Dec. 30.
notes that “a number of staff have expressed concerns
about receiving the flu vaccine, such as the preservatives
in the vaccine, etc. We have been able to find studies and
FAQs to address all of their concerns,” Hulwick adds.
“So far, 80 percent of staff have received it,” says
Hulwick, clinical care coordinator for Kalkaska Eden
Center, which is affiliated with Munson Medical Center
in Traverse City, Mich. (The flu vaccination policy
applies to employees, medical staff who have privileges
at the SNF, and volunteers, according to an organization
spokesperson.)
CMS weighs in on flu vaccinations: The agency’s
Tom Dudley relayed during the Oct. 20 SNF/LTC Open
Door Forum that he “really can’t emphasize enough that
vaccinating just your residents is not enough. The staff
really need to be encouraged to get vaccinated, too, to
protect the residents you’re taking care of, as well as to
avoid staff illnesses and inadequate staff.”
“If someone has a medical or religious reason, etc., for
refusing the vaccine, they have to see the infectious
disease doctor at the hospital,” Hulwick explains. She
Dudley also noted that the CDC has a website that “may
be helpful so you can see the number of flu cases in your
area” (www.cdc.gov/flu/weekly/usmap.htm). n
Your Guide to State Survey Success And Quality Innovations
©The Long-Term Care Survey Alert. For Subscription Information, Call 1-800-874-9180
p85
Vol. 13, No. 12
Coding Quizzer }
Code This RAI Manual Example for Flu Vaccination
How would you code the following at O0250 (Influenza
Vaccine)? For the coding questions and options, see the
picture of that MDS section below.
Example: “Mr. K. wanted to receive the influenza
vaccine if it arrived prior to his scheduled discharge on
October 5th. Mr. K. was discharged prior to the facility
MDS, Compliance & Clinical News to Use receiving their annual shipment of influenza vaccine, and
therefore, Mr. K. did not receive the influenza vaccine
in the facility. Mr. K. was encouraged to receive the
influenza vaccine at his next scheduled physician visit,”
the RAI manual states.
Please see the answer on the last page of this issue. n
}
During CMS’ Nov. 3 national provider call on the
MDS 3.0, the agency’s John Kane clarified an Oct. 1
RAI manual revision on Part A therapy co-treatment.
“As a formal definition, co-treatment refers to a case
of two clinicians, which is two therapists, two therapy
assistants, or some combination thereof, from different
disciplines, treating one Part A resident at the same time
with different treatments,” said Kane. “For example, if a
speech language pathologist and an occupational therapist
do a meal with a patient, the OT is working on feeding
skills and fine motor coordination of the utensils while
the SLP is working on swallowing skills,” he added.
both disciplines may code the full treatment session.
Therefore, in the example just presented, both the OT
and the SLP could code the full session as individual
therapy.”
“This would an example of a proper co-treatment
session,” Kane said. “In such cases of co-treatment,
Kane and CMS’ Penny Gershman also explained
recent PPS clarifications. (For details, see the lead
p86
A slide from the call also quotes from the RAI manual,
which states: “The decision to co-treat should be made on
a case by case basis and the need for co-treatment should
be well documented in the plan of care for each patient.”
“This is because,” said Kane, “co-treatment, as defined
here, would only be appropriate for specific clinical
circumstances and not necessarily for every patient.”
Please let us know what you would like to see addressed in our report.
Call Karen Lusky, Editor-in-Chief, at 1-615-708-8568
www.eliresearch.com
Vol. 13, No. 12
article in MDS Alert, Vol. 8, No. 11.) You can access the
slides for the call online at www.cms.gov/SNFPPS/03_
RUGIVedu12.asp.
Check out the September 2011 “Guideline on
Preventing Venous Thromboembolic Disease
in Patients Undergoing Elective Hip and Knee
Arthroplasty” from the American Academy of
Orthopaedic Surgeons (AAOS). “For these guidelines,
we identified three critical outcomes that are the most
important consequences of the complication of venous
thromboembolic disease (VTED) in patients receiving
hip and knee replacements,” says Joshua Jacobs, MD,
second VP of the AAOS and chairman of the guideline
workgroup. The outcomes, which he notes are rare,
“include symptomatic pulmonary embolism, mortality,
and major bleeds,” with the latter being related to
anticoagulation, Jacobs told Eli in an interview. “The
critical outcomes do not include deep vein thrombosis,
which may occur after a hip or knee replacement.” But
the DVT “may cause only minor, if any problems —
particularly if it’s below the knee.”
According to a press release from AAOS, the guideline
recommends patients “receive anticoagulant therapy
(unless they have a medical reason for not being able
to use these drugs, such as a bleeding disorder or
active liver disease) and/or mechanical compression
devices after a hip or knee replacement surgery. There
is, however, insufficient evidence to recommend any
particular preventive strategy or the duration of these
treatments. Patients should discuss the duration and type
of preventive treatment with their physician.”
“To have good evidence to make such specific
recommendations, further research is required with very
large studies using the critical outcomes mentioned above
as the endpoints,” adds Jacobs.
The guideline also recommends that “after hip or knee
replacement, patients should get up and walk as soon as
safely possible,” states the release. “Although there is
insufficient evidence that ‘early mobilization’ reduces DVT
rates, early mobilization is low cost, of minimal risk and
consistent with current practice,” the release continues.
A summary of the guideline posted on the AAOS website
also states: “In the absence of reliable evidence, it is
the opinion of this work group that patients undergoing
elective hip or knee arthroplasty, and who have also had a
previous venous thromboembolism, receive pharmacologic
prophylaxis and mechanical compressive devices.”
Jacobs further notes that “the guideline recommends against
routine ultrasonography for all patients” after a hip or knee
replacement. “Ultrasound after surgery is an appropriate
test if there’s a clinical suspicion of a DVT,” he adds.
“We updated the 2007 AAOS Guidelines in order to be
included in the Agency for Healthcare Quality (AHRQ)
National Guideline Clearinghouse, which requires an
update of guidelines every five years,” Jacobs reports.
“Since the first AAOS guideline on this topic, the
Institute of Medicine (IOM) issued a report in 2011
entitled ‘Clinical Practice Guidelines We Can Trust,’”
which provides “standards for developing clinical practice
guidelines.” Jacobs says that “the AAOS process meets or
exceeds these IOM standards.”
Read the “Guideline on Preventing Venous
Thromboembolic Disease in Patients Undergoing Elective
Hip and Knee Arthroplasty” at www.aaos.org/research/
guideline/VTE/VTE_guideline.asp.
The hospice section of the 2012 OIG work plan says
the agency “will review hospices’ marketing materials
and practices and their financial relationships with
nursing facilities.” The work plan goes on to point out
that “MedPAC, an independent congressional agency that
advises Congress on issues affecting Medicare, has noted
that hospices and nursing facilities may be involved in
inappropriate enrollment and compensation. MedPAC has
also highlighted instances in which hospices aggressively
marketed their services to nursing facility residents,” the
work plan states. “We will focus our review on hospices
that have a high percentage of their beneficiaries in
nursing facilities,” the work plan states.
“What we know the OIG is looking at by virtue of their
very articulate posting on the Internet, in congressional
testimony — and in the recently released OIG 2012 work
plan — is improper relationships between hospices and
nursing homes,” says attorney Paula Sanders, with Post
& Schell in Harrisburg, Pa. “That part is focused on
hospice marketing and what hospices are telling nursing
homes. But on occasion, we see nursing homes in areas
with high hospice penetration asking for additional
services in order to allow hospice into their facility —
that’s a risk area,” she adds.
Your Guide to State Survey Success And Quality Innovations
©The Long-Term Care Survey Alert. For Subscription Information, Call 1-800-874-9180
(Continued on next page)
p87
Vol. 13, No. 12
MDS, Compliance & Clinical News to Use (cont...) “The fact that might be a standard in the market doesn’t
make it legal,” Sanders warns. “Nursing homes should
make sure their staff, including their social workers, who
usually deal with hospice, are aware of the anti-kickback
requirements.”
Sanders also notes that one frequent compliance issue
related to hospice in nursing facilities is “inconsistent
CODING QUIZZER ANSWER
Answer to Coding Quizzer (see question on page 86).
“Coding: O0250A would be coded 0, no; O0250B
is skipped, and O0250C would be coded 9, none of
the above,” states the RAI manual.
“Rationale: Mr. K. was unable to receive the
influenza vaccine in the facility due to the fact that
the facility did not receive its shipment of vaccine
until after his discharge. None of the codes in
O0250C, Influenza vaccine not received, state
reason, are applicable.”
Source: Printed verbatim from the RAI User’s
Manual. n

billing where the nursing home pharmacy is billing the
resident separately [or a payer] for medications covered
by the hospice.”
“Sometimes it’s a judgment call and a clinical decision
where you have to sit down as a team and evaluate the
patient and figure out which drugs are related to the terminal
illness that hospice is responsible for,” says attorney Connie
Raffa with Arent Fox in New York City.
Another issue, which represents a “huge survey and
care risk” involves “poor communication and poor
documentation between the hospice and nursing home
[so that] the care plans don’t align — or the nurses at the
respective organizations don’t understand the delineation
of their responsibilities,” adds Sanders, with Post &
Schell in Harrisburg, Pa.
Editor’s note: For more information on the OIG’s views
on hospice and nursing homes, see the transcript from
an OIG podcast on the agency’s recent report, “Medicare
Hospices That Focus on Nursing Facility Residents,” at
http://oig.hhs.gov/newsroom/podcasts/2011/nudelman.
asp. Also read that report at oig.hhs.gov/oei/reports/
oei-02-10-00070.pdf. n
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E-mail: [email protected]
Please let us know what you would like to see addressed in our report.
Call Karen Lusky, Editor-in-Chief, at 1-615-708-8568