Nursing Facility Utilization Review Stakeholder Meeting IG Audit - - PowerPoint PPT Presentation
Nursing Facility Utilization Review Stakeholder Meeting IG Audit Division March 14, 2016 O FFICE OF I NSPECTOR G ENERAL Texas Health and Human Services Commission Page 1 N URSING F ACILITY MDS 3.0 R EVIEWS AND T RENDS The Utilization Review
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*Additional information is available on the IG Internet site (https://oig.hhsc.texas.gov/).
FY 2016 Work Plan Progress
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56 36 33 29 15 14 13 11 5 4
FY 2015 Error Trends (Listed from high to low.)
Unsigned Forms Lack of, incomplete, or conflicting documentation Missing forms, records, and/or LTCMI Signatures don't match LTCMI No documented training/training out of date Medical records not systematically organized or readily accessible BIM/RMI not within ARD/look-back period Restorative Nursing - lack of plans, goals not measureable, missing documentation Altered documentation No M.D. visit or visit outside of ARD, or no diagnosis
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32 18 16 11 5 5 4 4 3 3
FY 2016 Error Trends (Listed from high to low.)
Lack of, incomplete, or conflicting documentation Signatures don't match LTCMI Unsigned Forms BIM/RMI not within ARD/look-back period No documented training/training out of date Restorative Nursing - lack of plans, goals not measureable, missing documentation, claims 7 days after ARD Missing forms, records, and/or LTCMI ST/PT/OT Utilization/Incorrect dates of therapy Medical records not systematically organized or readily accessible Orders counted incorrectly
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285 545 530 102 111 116
35.8% 20.4% 21.9% 100 200 300 400 500 600
% Forms Reviewed with RUG Changes
Forms RUG Changes
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102 111 116 19 44 30
18.6% 39.6% 25.9% 20 40 60 80 100 120 140
% RUG Changes Requested for Reconsideration
RUG Changes Requests for Reconsideration
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19 44 30 12 42 24
63.2% 95.5% 80.0% 5 10 15 20 25 30 35 40 45 50
% of Onsite Review Decisions Upheld at Reconsideration
Reconsidered Forms Decisions Upheld
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2 1 1 2 3
# Cases With Onsite Decisions Upheld at Reconsideration and Requesting Appeal
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