Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay)

• CMSNet - Submission Access
• CMSNet - Submission Access Registration
• Computer Access Set Up (IT or Human Resources)
• Email Set Up and Email Proficiency
• Phone System Orientation

• Computer/Software Specific Training
• How to Access ADL Documentation
• Reviewing Census, Census Management and Insurance
• Reviewing Dashboard
• Reviewing Scorecard
• Reviewing Report Section
• Where to Locate Policy and Procedure Manual

• Introduction to IDT
• IDT Communication
• IDT Workflow Process
• IDT Section(s)
• MDS 3.0 Interdisciplinary (IDT) - CMS
• How to Obtain Incident Reports (esp. falls)

• 42 CFR § 483.20 - Resident Assessment
• Standards and Certification
• MDS Essentials: An Introduction
• OBRA ’87
• RAI Users Manual
• State RAI Coordinator
• Overview of the RAI Process
• Layout of the RAI Manual
• OBRA Guidelines

• Assessment Reference Date
  • Understanding the Importance of Reference Dates
  • Special ARD (UTI, Pain, Weight, etc.)
  • Selecting ARD
  • Sample ARD
• Naming, Timing, and Scheduling
  • Admission (Initial) Assessment
  • Annual Reassessment
  • Significant Change in Status Reassessment
  • Quarterly Assessment
  • Significant Correction of a Completed Prior Full Assessment
  • Significant Correction of a Completed Prior Quarterly Assessment
  • Practicing Scheduling MDS 3.0
• Tracking/Discharge MDS
  • Entry
  • Reentry
  • Discharge Assessments (Return Not Anticipated or Return Anticipated)
  • Planned
  • Unplanned
  • PPS Discharge Assessment
  • Respite
  • Death in Facility
• Line by Line Coding Sections
  • Section A: Identification Information
  • Section B: Hearing, Speech, and Vision
  • Section C: Cognitive Patterns
  • Section D: Mood
  • Section E: Behavior
  • Section F: Preferences for Routine and Activities
  • Section G: Functional Status
  • Section GG: Functional Abilities and Goals
  • Section H: Bladder and Bowel
  • Section I: Active Diagnoses
  • Section J: Health Conditions
  • Section K: Swallowing/Nutritional Status
  • Section L: Oral/Dental Status
  • Section M: Skin Conditions
  • Section N: Medications
  • Section O: Special Treatments, Procedures, and Programs
  • Section P: Restraints and Alarms
  • Section Q: Participation in Assessment and Goal Setting
  • Section S: State Optional Assessment
  • Section V: Care Area Assessment Summary
  • Section X: Correction Request
• Care Area Assessment
  • Delirium
  • Cognitive Loss/Dementia
  • Visual Function
  • Communication
  • ADL Functional/Rehabilitation Potential
  • Urinary Incontinence and Indwelling Catheter
  • Psychosocial Well-Being
  • Mood State
  • Behavioral Symptoms
  • Activities
  • Falls
  • Nutritional Status
  • Feeding Tube
  • Dehydration/Fluid Maintenance
  • Dental Care
  • Pressure Ulcer
  • Psychotropic Drug Use
  • Physical Restraints
  • Pain
  • Return to Community Referral
• Submitting MDS
• Validating MDS/Attestation
• Inactivation of Assessments
• Modification of Assessments

CAA Documentation and Care Planning Process

• Intro to Careplan in LTC
• The Interdisciplinary Team Members Role in Care Plan
• Baseline Care Plan
• Baseline Care Plan Component Review
• Comprehensive Care Plans
• Admission Care Plan with Admission MDS
• Significant Change Care Plan
• Annual MDS Care Plan
• Care Plan Completion Requirements for Comprehensive MDS
• Care Plan Invitation
• Care Plan Meeting
• Care Plan Review
• Updating Care Plan
• Fall Prevention

• Overview of ICD-10 for MDS 3.0
• ICD-10 for MDS 3.0 Mapping
• ICD-10 Mapping for PDPM Components
• ICD-10 Clinical Category Mapping
• ICD-10 Rehab Mapping
• ICD-10 Categories
• ICD-10 Resources | CMS
• MCD Search (cms.gov)
• PDPM
  • CMS Patient Driven Payment Model Website
  • Naming and Scheduling: PPS PDPM
  • 5-day PPS Assessment
  • Interim Payment Assessment (IPA)
  • PPS Discharge Assessment
  • Default Rate
  • Default Prevention Guidelines
  • Scheduling to Maximize Reimbursement
  • Anti-Kickback Statute
  • IPA Management
  • Fact Sheet: PDPM
  • PDPM Case Mix Components
  • PDPM Components (OT, Nursing, SLP, PT, Non-Case Mix, NTA)
  • ICD 10: Coding/Sequencing
  • PDPM Clinical Categories
  • FAQs: Patient-Driven Payment Model
  • Naming and Scheduling: PPS RUG

• Review of Medicaid CMI Management
• Maximizing the ARD: Adjusting for Capturing Care Services

• Medication Safety – High Alert and Hazardous Medication
• Drug Classification & Categories
• Gradual Dose Reduction

• Reviewing Clinical Report
• Skilled Care Documentation
• End of Month and Triple Check
• Clinical Checklist/Audit
• Reviewing ADL Documentation
• How to Review All Referral (Admission/Readmission) as IDT - Referral Review

• Medicare Basics
• What is Skilled Care? / Criteria for Skilled Care Coverage
• Skilled Nursing Facility 3-Day Rule Billing
• Medicare SNF Coverage Guidelines Under PPS
• Factors Impacting Medicare A
• Presumption of Care
• Clinical Eligibility Requirements - Medicare
• Technical Eligibility Requirements - Medicare
• Medicare 30-day Window
• Medicare 60 Day Wellness Period
• Medicare A / Hospice Dual Coverage
• Medicare Certs
• MCD Search (cms.gov)
• TRICARE For Life
• TRICARE Reimbursement Manual
• Medicare Secondary Payer (MSP)
• Deferred Covered Treatment
• Understanding Medicare Part B: Frequency and Duration
• Medicare Meeting
• Managed Care Basics
• Managed Medicare/Medicare Advantage
• HMO Managed
• Bed-Hold Policies
• Denial and ABN Forms and Process
• Denial Letters (Medicare A, Medicare Advantage, Medicare B)
• Appeals Process
• Detailed Explanation of Non-Coverage
• Medicare Benefit Policy Manual
• Medicare Program Integrity Manual
• Medical Review Additional Development Request (ADR) Process

• Preparation of Survey Process (Annual Survey / Licensing Inspection / Complaint Investigation)
• State Operations Manual
• Understanding the Survey Process
• Federal Regulatory Groups for Long Term Care Facilities
• Mock Survey Resource
• Nursing Home Search Page
• Forms to Keep Updated
• Completing Plan of Correction (POC)
  • The Statement of Deficiencies and Plan of Correction (CMS-2567)
  • Statement of Deficiencies and Plan Correction
• LC Survey Pathways & Entrance Conference Form
• LTCSP Initial Pool Care Areas
• Quality Reporting Programs
  • Quality Measures & Five Star Rating System for SNF
  • CMS SNF QRP
  • 5 Star Reporting
  • CASPER
  • QM
  • Missed Assessment
  • QRP
  • QM Manual
  • How to QAPI for Improvement of QM
  • Nursing Home Compare
  • RAC Audit

• Daily Clinical Meeting
• Huddles
• Morning Meeting
• Worksheet
• 48/72 Care Conference
• Medicare Meeting
• Risk Meeting
• Care Plan Meeting (See under Care Planning)
• Discharge Meeting
• QAPI Meeting

• Interpreting Weekly Summary Financial
• Understanding How the MDS is Utilized in SNF Clinical Reimbursements

• McGeer Criteria for Infection Surveillance Checklist
• 42 CFR § 483.80 - Infection Control
• Antibiotic Stewardship for Nursing Homes
  • Core Elements Checklist
  • Nursing Home Resources

• Activities Director: What They Do?
• Social Services: What They Do?
• Dietician: What They Do?
• DON: What They Do?
• Nursing Team: What They Do?
• Department Heads: What They Do?