Your PDPM Questions Answered – Part 3: Nursing Case Mix Groups

Ron Orth, RN, CHC, CMAC answers questions from part two of our six part PDPM webinar series, Nursing Case Mix Groups.

In Part 3: Nursing Case Mix Groups, of our PDPM series with Relias’ Senior Analyst for SNF Regulations and Clinical Reimbursements, Ron Orth, RN, CHC, CMAC, we received so many thoughtful questions. So, Ron has taken the time over the past week to respond to the most frequently asked questions.

Your Questions on PDPM’s Nursing Case Mix Groups

Q: It’s my understanding we need to Restorative started no later than day 2 so we can have the 6 days of Restorative in before day 8. Is that correct?

A: Yes, that would be correct.  In order to qualify for the restorative component (end split) there must be at least 6 days of restorative provided.


Q: What is section G being used for in PDPM?

A: Section G will not be used in the PDPM.  The PT/OT and  Nursing Function Scores (similar to the ADL score) will be calculated based on coding of specific items in Section GG.


Q: Are IV medications considered extensive services?

A: IV medications provided while a resident of the SNF qualify for Clinically Complex under the PDPM.  This is no different than the current RUG-IV criteria.


Q: If resident discharged from therapy, is this considered a significant change that we need to complete an Optional State Assessment (OSA)?

A: Under PDPM, there is no requirement to complete an OSA if all therapies are discontinued.  An OSA is an “Optional State Assessment” so would have to inquire with the State on what, if any requirements they would have related to this assessment.

Also, OBRA regulations related to completion of a SCSA still apply, so it may be possible that the person may qualify for a SCSA improvement.


Q: Do you know how the insurance payments will be based on? Will it follow the same PDPM?

A: Questions related to insurance plans other than traditional Medicare need to be addressed with the plan specifically.


For additional information, check out the FAQs from Part 2: Therapy Case Mix Groups. Don’t forget to join us on May 29 for Part 4 of the PDPM Webinar Series: Non-Therapy Ancillaries Case Mix Groups.

Why Are Children’s Mental Health Services Lacking in the U.S.?

Behavioral health services for children are lacking. Funding and accessibility are missing, and the problem may only grow worse. Find out more now.

Children’s mental and behavioral health are topics of concern among millions of parents and caregivers in the U.S. Unfortunately, tragedies and political discussions tend to obscure the sorrow and pain afflicting up to 20% of children ages 3-17, if not more, reports the National Alliance on Mental Illness (NAMI).

Meanwhile, the first study to review the prevalence of mental health illnesses and utilization of behavioral health resources among this group was only completed in 2011, explains the Centers for Disease Control and Prevention (CDC), and more recent results are not available. Statistically, attention-deficit hyperactivity disorder (ADHD) remains the most common mental illness affecting children, but this study’s finding could be askew because of parental influence and other confounding factors.

Making your services more available seems like the ideal solution, but you still need to understand the current state of children’s mental health services in the U.S. and why some avoid the topic entirely. However, you must also consider how access to these resources may change in coming months.

Current State of Children’s Behavioral Health in America

An ideal behavioral health system would virtually eliminate any concerns over self-injurious behaviors, severe emotional disturbance or suicide. Sadly, suicide is the third leading cause of death among adolescents, indicating the current use of services is clearly not meeting the demand. In a recent survey of state agencies responsible for treating children with mental health disorders, reports Medical Xpress, researchers identified the following causes of the problem:

There is a shortage of qualified workers

Licensed therapists and behavioral health specialists for children seem to be in short supply. However, it is not known if this caused by few people completing educational requirements or simply choosing to work in adult behavioral health.

Services are spread out or unavailable

Each state is supposed to offer mental health services to children of low-income families, reports the Centers for Medicaid and Medicare Services (CMS). However, those who do not meet income requirements may be faced with challenges in accessing covered services under private health insurance.

Lack of public awareness breeds stigma-based assumptions

Parents or caregivers may have objections to seeking behavioral health services for their children. Religion, politics and financial worries can affect parents’ decisions.

Few data and quality assurance systems result in lost opportunities

The best-funded behavioral services are ineffective if treatment is discontinued against medical advice. Unfortunately, missing quality assurance programs have left many children to fall through the cracks, causing worsening of symptoms and possible expansion of illnesses into substance abuse as well. Although 50% of mental health disorders begin by age 14, most children and teens do not receive comprehensive treatment or intervention for eight years.

Most funding is given to adult behavioral health services

Funding for children’s behavioral health continues to be missing in private health insurance. While it is covered under the Children’s Health Insurance Program (CHIP), the CMS only finalized this rule in March 2016.

Implementation of Affordable Care Act (ACA) is disorganized

Up to 81% of behavioral health directors surveyed believe expanding Medicaid eligibility and making children’s mental health services part of the ACA’s Essential Health Benefits for private insurance plans would “improve accessibility and availability of services.”

What Is Being Done?

As shown above, one of the key reasons why mental health services are deficient is due to a lack of accessibility. The inability to access children’s behavioral health services is a growing and obvious concern for millions of Americans. While more can and should always be done, the CDC has done work to address and bring awareness to these challenges. Some of their efforts include:

  • Supporting solutions like Behavioral Health Integration (BHI) as an approach to improve access to mental health services for children and families
  • Pilot testing programs in partnership with three universities to find more effective ways to educate behavior therapy providers by training professionals within the mental health field
  • Creating state maps that show providers who can assess, refer or treat children’s mental health concerns
  • Developing a policy report to help rural children with mental, behavioral or developmental disorders gain access to behavioral health services

What Can Your Organization Do?

Providers in your organization can begin to help prevent children from falling through the cracks by ensuring every employee understands the signs and symptoms of mental health disorders in children and teens. Implement new mental health training programs for identifying at-risk children and those already suffering, and understand a surge in people seeking services without financial responsibility is likely.

If parents or caregivers do not have the financial means to pay for services, you may need to explore other options, which may include submitting applications to Medicaid, CHIP and subsidies with the Health Insurance Marketplace. Essentially, children’s mental health services are facing a crisis, and you can do something about it by simply being present, making your organization’s services known in your community and always holding hope at the core of every treatment plan, application for services submitted and training.

Your PDPM Questions Answered – Part 2: Therapy Case Mix Groups

Ron Orth, RN, CHC, CMAC answers questions from part two of our six part PDPM webinar series, Therapy Case Mix Groups.

In Part 2: Therapy Case Mix Groups, of our PDPM series with Relias’ Senior Analyst for SNF Regulations and Clinical Reimbursements, Ron Orth, RN, CHC, CMAC, we received so many thoughtful questions. So, Ron has taken the time over the past week to respond to the most frequently asked questions.

Your Questions on PDPM’s Therapy Case Mix Groups

Q: If a patient is Med A and discharges on 10/1, what type MDS do we do? A0310F=10 and end of PPS? (To be covered in Part 5).

A: Yes, the change from RUG-IV to PDPM is not changing the requirements related to discharge assessments. If the resident is discharged on 10/1, then you would need to complete both an OBRA discharge assessment (A0310F) and a SNF Part A PPS Discharge (A310H). The may of course be combined.


Q: Another in-service I attended said that if more than one function score was a decimal, then to not round them individually, but wait to round the total at the bottom. Is this your understanding?

A: Yes, that is correct. Determine the score for each individual item in Section GG first (including calculation of the avg.).  Rounding of the Functional Score, if needed, would only occur when the TOTAL score is summed.  You do not round each individual score.  In the example given in the webinar, the Total score was 14.5, so this was rounded to 15.


Q: Are we able to use Z codes as a primary?

A: When assigning ICD-10-CM codes it is important to follow the Official Coding Guidelines for Coding and Reporting. The Guidelines state the following related to the use of “Z” codes

Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis.


Q: Wouldn’t that Z code (Z47.1) require and additional code to identify the joint that was replaced?

A: You are referring to the example provided about using Z47.1 as the diagnosis entered in I0020B to indicate the primary reason for the SNF admission. Since I002B only allows the reporting of 1 code, this is the only code you would use, if applicable.  However, assigning and reporting codes in the clinical record and on the Medicare claim you would need to use an additional code (e.g., Z96.641 right artificial hip joint), as instructed in the ICD-10-CM manual, to indicate the joint replaced.


Q: Where can I find the SLP comorbidity Mapping tool?  CMS PDPM page only has grouper, ICD-10, and NTA tools?

A: On the CMS PDPM website there is a link to the PDPM ICD-10 Mappings. This excel workbook contains several different worksheets (see tabs):

  1. Overview
  2. Clinical Categories by Diagnosis
  3. SLP Comorbidity
  4. NTA Comorbidity


Q: I am a Medicaid and private pay only facility, if they remove all RUG scores then how will Medicaid only be paid out?

A:  While Medicare is changing to the PDPM system, the MDS will still support and generate a RUG, as it does now, to be used for other payers that may continue with a RUGs based payment system (Medicare, Medicare Advantage, private insurance, etc.).


For additional information, check out the FAQs from Part 1: Laying the Foundation. Don’t forget to join us for Part 3 of the PDPM Webinar Series: Nursing Case Mix Groups.

Relias Nursing Insights Celebrating National Nurses Week

In honor of National Nurses Week, Relias nurses are taking time to share personal insights on the many ways the nursing industry is evolving and how celebrating nursing has shaped their lives.

Each year we celebrate National Nurses Week (May 6-12), chosen for Florence Nightingale’s birthday. National Nurses Week has been supported and promoted by the American Nurses Association (ANA), which has chosen the 2019 National Nurses Week theme, “4 million reasons to celebrate” in recognition and celebration of the nation’s four million nurses.

I’d like to take this opportunity to celebrate not only the many nurses here at Relias, but all our nation’s nurses and their countless contributions to patient care.

In honor of the 2019 National Nurses Week theme, Relias nurses are taking time to share personal insights on the many ways the nursing industry is evolving and celebrate how nursing has shaped their lives.

Thank you to all the nurses out there, and this week we celebrate you!

Sandhya Gardner, M.D.– Sandhya Gardner, MD
Chief Medical Officer, Relias


What inspired you to become a nurse?

There was an old “ER” episode where clinicians were being interviewed (I think medical students in that situation) and asked why they chose their career paths, and they repeatedly said, “to help people.” It was comical to hear candidate after candidate repeat the same answer. But, at the heart of the matter, most enter nursing to do just that … to help people …. to be there for people in a serious time of need and use healthcare expertise to make their journeys better and less stressful, if possible. There are many ways to help others, but being willing to enter the front lines and help people who are scared, stressed, and sometimes overwhelmed by a health crisis is truly a calling and not just a job. That motivation to help others when the fragility of life is clearly seen is the heart of a nurse. And, it was that inspiration to help others through uncertain times that was a part of my decision to become a nurse.

Maria Morales– Maria Morales, MSN, RN, CPAN
Director of Clinical Education, Relias


What advice would you give to our future nurses?

My advice to future nurses is simply this: “Always advocate for your patients first and foremost.”  It’s not always easy to do that: managing priorities and workload, maneuvering through conflicts with fellow nurses and physicians, laughing and crying through busy hectic days where you can’t even get a meal or go to the bathroom when you need to! If you advocate for your patient, you can be fulfilled in your role as a nursing professional and in your heart as you are making a positive difference for someone who is vulnerable and relies on you to keep them safe.

My own daughter is a new nurse of just nine months and this is the advice I’ve given her.  She’s called me unable to speak through her tears following a tough night shift. She’s questioned whether nursing was the right path for her, and she will tell you today, keeping her patients as the priority is what brings her the most satisfaction and why she loves being a nurse.

I’m also very proud of being a nurse professional.  Nursing has shaped me and given me opportunities to be where I am today; advocating for nursing and physician teamwork and communication that enables patient safety and high reliability.

Lora Sparkman– Lora Sparkman, RN, BSN, MHA
Clinical Effectiveness Consultant, Relias


How do you feel your nurse background helps you to be successful in your role today?

I think the combination of having obtained solid clinical experience and the completion of my master’s in nursing, has provided me with the knowledge and skills to write successfully today. In my role as a subject matter expert (SME) writer, I’m able to draw on my past clinical and educational experience.  In addition, I have lived and worked in 4 different countries, which has broadened my cultural understanding of healthcare, patients and nursing professionals. In each country, I was required to take the National Licensure Exam and additional certification exams. This personal experience has given me the tools and experience to successfully help prepare other nurses studying for various national certification exams.

Nadine Salmon– Nadine Salmon, MSN, RN-BC, IBCLC
SME Writer, Clinical Nursing, Relias


How do you think the nursing profession has changed in the past decade?

The healthcare landscape itself has changed significantly over the course of the past 10 years.  There has been a paradigm shift in reimbursements and therefore, we are seeing significant changes in how healthcare organizations are responding to these changes.  The primary driver of change in recent years is relative to Pay-for-Performance under the ACA.  Nurses are on the front lines and play a vital role in healthcare quality and in managing the complexities of today’s patient population.  Nurses are tasked with managing higher acuity patients while working long hours to ensure their patients receive excellent care.

In the past 10 years, we have also seen many advances in technology which have become a vital resource for nurses in the provision of care.  Another huge change is the opportunities that are available to the nursing professional.  Nursing has become more specialized and this provides many opportunities for professional growth and opportunities to develop expertise over time.  Certainly, this is not all encompassing however, it is important to note that nurses today have a tremendous opportunity at all levels and across the care continuum to make a measurable difference in safe & effective care.

Felicia Sadler– Felicia Sadler, MJ, BSN, RN, CPHQ
Lean Six Sigma Black Belt, Healthcare
Clinical Effectiveness Consultant, Relias


I think improved technology and medical advances mean nurses are seeing higher acuity patients in all areas of healthcare. These advances make continuing education essential. End of life conversations are also impacted by medical advances and sometimes lead to challenges for hospice-appropriate patients. Some patients are not referred to hospice in time to fully benefit from the service.

Susan Heinzerling– Susan Heinzerling, RN, CHPN
Content Writer – Post-Acute Care, Relias


Spotlight on Children’s Mental Health Awareness Day

National Children’s Mental Health Awareness Day is an annual event that shines a spotlight on the behavioral health of children, teens and young adults. This year, Children’s Mental Health Awareness Day, or “Awareness Day 2019,” is being kicked off on May 6, while the nationally observed day is May 9.

The 2019 theme is an important one: “Suicide Prevention: Strategies That Work,” which places a national focus on the impact suicide has on children, youth, young adults, families and communities.

In the U.S., suicide is the third-leading cause of death for youth between 10 and 24, with approximately 4,600 lives lost annually, and the suicide rate for children between ages 5 and 12 is increasing. In a short span of six years between 1999 and 2015, as many as 1,309 children in this age bracket took their own lives.

Awareness Day 2019 Events

National organizations, federal programs, and local communities team up for Awareness Day 2019, and on May 6, SAMHSA will host an event to kick off the activities that will take place throughout the nation on May 9.

The event will be held at the U.S. Department of Health and Human Services in Washington, DC. Tied to the 2019 theme of “Suicide Prevention: Strategies That Work,” SAMHSA will present evidence-based strategies to connect those in need to information, services and supports that can save lives.

Sharing personal accounts of experiences with suicide is an important step in providing insight and support to others going through the same thing. At SAMHSA’s May 6 event, suicide experts, national mental health leaders, and families and youth will do just that. They will share their experiences using evidence-based practices and the role they played in saving children’s lives and helping them recover.

The TED Talk-style discussions at the event will provide an opportunity to share information on resources and latest evidence-based best practices for suicide prevention with state agency personnel, primary and mental health care providers, child-serving professionals, and families, youth and young adults across the U.S.

Additionally, SAMHSA aims to:

  • Encourage children’s services providers to work in partnership with family and youth leaders to better meet the needs of children, youth, and young adults with severe emotional disturbance
  • Educate the public about the importance of looking for mental health services when they’re needed

The Importance of Seeking and Receiving the Right Support for Suicide Prevention

The theme “Suicide Prevention: Strategies That Work” underscores the importance of seeking mental health services when they’re needed. In turn, this requires mental health and children’s services providers to have the skills not only to identify the warning signs of suicidality, but also to confidently assess and screen for the risk of suicide to appropriately support those who do seek services.

But it’s the seeking of services that may pose a greater hurdle. In an article published by the American Psychological Association, although 90% of young children who commit suicide have a mental health disorder (usually major depression), the article indicates that many parents and teachers ignore the warning signs, including talking about or threatening suicide, because they believe kids don’t understand what suicide really is and therefore wouldn’t try it.

But, according to a 2018 article published by California Health Report, kids do understand the concept of suicide. They further state that children begin to understand death at around ages 5 to 7. It is the irreversibility of death that they don’t fully grasp until around age 11. It can be assumed, then, that the window of time between ages 7 and 11 can pose a higher risk when it comes to youth depression and suicidality, and parents, teachers, and mental health and children’s services providers should take greater caution in paying attention to the warning signs.


12 Warning Signs of Suicide

  • Feeling like a burden
  • Being isolated
  • Increased anxiety
  • Feeling trapped or in unbearable pain
  • Increased substance use
  • Looking for a way to access lethal means
  • Increased anger or rage
  • Extreme mood swings
  • Expressing hopelessness
  • Sleeping too much or too little
  • Talking to or posting about wanting to die
  • Making plans for suicide

Warning Signs in Children & Teens

  • Changes in eating or sleeping habits
  • Frequent or pervasive sadness
  • Withdrawal from friends, family and regular activities
  • Frequent complaints about physical symptoms often related to emotions, such as stomach aches, headaches, fatigue, etc.
  • Decline in the quality of schoolwork
  • Preoccupation with death and dying
  • Giving away cherished possessions
  • Stop talking about the future


While Awareness Day 2019 highlights and brings awareness to children’s mental health for one day of the year, the event should help providers remain aware of the mental health needs of children every day, and serve as a platform for sharing helpful resources and education so they can continue improving the lives of children. Thank you to those providers who serve children and families. We hope you share all that you’re doing to make your communities better on Awareness Day 2019 and beyond.

Mental Health in Older Adults – Your Organization’s Role

The healthcare industry is shifting toward whole-person, integrated care, and the post-acute care industry is no exception to this shift. In order to provide whole-person care, it is crucial to consider not just the physical health of an individual, but also mental health and social well-being. May marks the beginning of Mental Health Awareness Month – now is the time to understand the prevalence of mental illness and risk factors for populations that you serve, and take action to ensure that you are well equipped to address these health challenges.

The Centers for Disease Control and Prevention report that 20% of people age 55 years or older experience some type of mental health concern – that’s 1 in 5 of the individuals at your assisted living or skilled nursing facility, or home healthcare agency.

20% of people age 55 years or older experience some type of mental health concern.

Mental illness factors into the public health issue of suicide in the United States, from which older adults are not exempt. In fact, older men over the age of 75 have the highest suicide rate of any age group. Although depression affects only about 5% of older adults, this number jumps to about 13.5% of those who receive home healthcare.

Older individuals may exhibit a number of factors that put them particularly at risk for some of the most common mental illnesses, such as depression and anxiety.

Factors That Contribute to Mental Illness for Older Adults

  • Chronic pain/chronic diseases: Chronic pain and illnesses that continuously flare up or return can lead to depression and anxiety as the individual may experience hopelessness and frustration with their situation. It can be increasingly difficult to enjoy day-to-day experiences with the presence of chronic illness.
  • Physical impairments/physical disabilities: Physical impairments that may occur as people age can reduce functionality and make it difficult to independently complete activities of daily living. This shift in independence can cause many to lose interest in activities they used to enjoy and feel helpless.
  • Major life changes and grief: Older adults who experience widowhood, grief with the loss of friends and family, and other major life changes are particularly at risk for depression.
  • Social isolation and loneliness: Older adults who may be confined to the home or a facility and lack easy access to social connection can become depressed and isolated in their life.

These are not the only factors that can contribute to mental health concerns in older adults – many people are predisposed to mental illness due to genetic factors, and environmental factors such as those above can trigger the onset of mental illness.

For these reasons, it is important that your organization and your staff are dedicated to caring for the whole-person, keeping in mind physical, mental, and social factors that contribute to the overall well-being of an individual.

Common Types of Mental Illness Experienced by Older Adults


Depression is NOT a normal part of aging, although you may have encountered people who believe that it is. Older adults are at high risk for depression because of their tendency to have at least 1 chronic health condition. Older adults’ symptoms of depression are often overlooked and undertreated, often attributed to sadness surrounding the aging process with an associated sense of loss.


Sometimes people with depression have dementia, too. This makes it more difficult to identify what is causing problems. The inability to concentrate, which can be part of both depression and dementia, can eventually lead to physical problems that result from such things as poor nutrition, illness, and medication misuse. This group of symptoms makes it challenging for the person with dementia to perform usual daily tasks.

Alzheimer’s Disease

The risk of Alzheimer’s disease increases with age and it represents 60-80% of all cases of dementia. As the disease progresses, you will see a significant loss of function related to the affected areas of the brain. For more information on Alzheimer’s disease and dementia, read about our collaboration with industry leader Teepa Snow.


Never assume an older adult is incapable of suicide. Regular assessment for suicide risk is imperative. Check with your organizational policy and protocol to determine the guidelines for you in your practice regarding assessing for suicide risk.

If an individual ever answers “yes” to your questions exploring whether they have had any thoughts about hurting or killing themselves in the past 2 weeks, stay with them until emergency services are in place and according to your organizational protocol. That admission should be taken seriously and requires immediate attention by a mental health professional.


Anxiety in older adults can lead to many health problems and interfere with daily life, even when symptoms do not warrant a diagnosable disorder. The most common anxiety disorders include generalized anxiety disorder and specific phobias, followed by less common panic disorder and social phobia. Additional common disorders that involve anxiety symptoms but that are not technically considered anxiety disorders are post-traumatic stress disorder and obsessive-compulsive disorder.

Substance Use Disorder

In 2014, over 1 million older adults had a substance use disorder (SUD) and that number is expected to rise to 5.7 million by 2020. Substance use in older adults is often not recognized by providers, so routine screening is critical.

Bipolar Disorder

Bipolar and related disorders (BRD), are a group of mood conditions involving manic symptoms and often, depressive symptoms. Generally, in BRD the individual experiences at least 1 manic episode or hypomanic episode, which is less severe symptoms of mania, with depressive symptoms. It is important to note that an individual can have a BRD without ever experiencing a depressive episode, as in a condition known as bipolar I disorder. Individuals commonly have dramatic mood swings, moving from depression to manic excitement within several days or weeks.

Eating Disorders

Eating disorders such as anorexia and bulimia are probably not something that you immediately think of as having a role in the lives of older adults, but researchers and healthcare professionals are discovering these disorders more often in both sexes, especially in older adult females. Many older adults lose their desire to eat and become clinically anorexic, which can be particularly detrimental to an older body with less resilience than in previous years.

Steps to Address Mental Health in Older Adults

  • Train your staff: Providing training on mental and behavioral health concerns will better equip your employees to recognize and address these concerns and ensure that you are dedicated to promoting the overall well-being of those you care for.
  • Be aware of signs and symptoms: The symptoms of common illnesses such as depression or anxiety can be easily overlooked and ignored – it is your responsibility to recognize and be able to use appropriate tools for behavioral health screening, and take next steps in their care when necessary.
  • Promote a culture of caring: Show your residents, clients, or patients that you care by speaking openly about mental health and reducing stigma. This can be particularly helpful for older adults who may be suffering but are otherwise unlikely to ask for help.

By providing training and promoting awareness of mental health in older adults, you can ensure that your entire staff is caring for the whole person, and your organization will continue to be well-equipped to address these challenges.

Your PDPM Questions Answered – Part 1: Laying the Foundation

Ron Orth, RN, CHC, CMAC answers questions from part one of our six part PDPM webinar series, Laying the Foundation.

In Part 1: Laying the Foundation, of our PDPM webinar series with Relias’ Senior Analyst for SNF Regulations and Clinical Reimbursements, Ron Orth, RN, CHC, CMAC, we received so many thoughtful questions. So, Ron has taken the time over the past week to respond to the most frequently asked questions.

Your Questions About PDPM

Q: Is there any reason we couldn’t do the following: our facility chooses to do a continuous GG assessment (every day from admission onward) and weekly BIMS — in order to be ready to jump on an IPA immediately when identified?

A: This would be up to facility policy.  There is nothing that says this could not be implemented and would provide you the information you need on a continual basis and provide information needed for an IPA assessment, if applicable.


Q: Any word if we need to do a 5-day MDS in September to get paid under RUG-IV then another one by 10/7/19 as an IPA to get paid correctly during the transition?

A:  Yes, since the RUG-IV system will end on September 30th and the PDPM system begin on 10/1, it will be necessary to establish a RUG-IV category to bill for days prior to 10/1 and a PDPM HIPPS code to bill 10/1 and after. CMS has developed a RUG-IV to PDPM transition plan. More detailed information regarding this question will be covered in Part 5.


Q: Any word if we are able to correct an MDS if an MDS is accidently sent with an invalid Diagnosis?

A:  At this time CMS has not proposed any change to the MDS Correction Policy and a modification should be able to be performed to correct any type of errors.


Q: What assessments will be required for Medicare Advantage plans that are paid by RUG?

A:  That will depend on the specific plan. Any questions related to PDPM and assessment requirements will need to be addressed direction to the MA plan. More detailed information regarding this question will be covered in Part 5.


Q: How would a resident qualify for PT, OT or SLP if they aren’t receiving it?

A:  The PDPM will determine the appropriate case mix group (CMG) for PT, OT and SLP based on clinical characteristics such as diagnosis, functional score, co-morbidities, surgical procedures, etc. as identified on the MDS. More detailed information regarding this question will be covered in Part 2 – be sure to attend!


Q: For clarification…It is my understanding that the IPA has to be done if the resident is discharged and out of the building for MORE than 3 days (4 or more).  Is that correct?

A:  No this is not correct, if a resident is gone for more than 3 days, then a new 5-day assessment is required to be completed. This is known as the “Interrupted Stay Policy”. More detailed information regarding this question will be covered in Part 5.


Q: When billing, does the Medicare co-pay still exist starting on day 21?

A:  Yes, the PDPM does not change regulations related to 100% coverage for days 1-20 and the daily co-payment beginning on day 21 of the Medicare benefit period.


Q:  Will you still be able to readmit to SNF LOC within 30 days if indicated and if so where will that fall on the variable rates scale? Would it start over or pick back up on day 19 or whatever day they used with the previous stay?

A:  Yes, the PDPM does not change regulation related to readmitting a person for Medicare skilled coverage during the 30-day readmission period.  The variable per diem would reset when a new 5-day assessment is completed.


Q: I was wondering, do 14 and 30-day MDS assessments go away completely, or do they just not factor into PDPM moving forward?

A:  They will go away completely.  They will no longer be an option on the MDS. More detailed information regarding this question will be covered in Part 5.


Q: To clarify, only the NTA gets the 3x adjustment for the first 3 days? I have seen information indicating it is for all components, and also information indicating it is for only the NTA component.

A:  The 3x adjustment for the first 3 days applies ONLY to the NTA component.


Q: Does the 5-day ARD have grace days?

A: The rules for completing the 5-day are not changing. The ARD would still be anywhere from days 1 – 8. More detailed information regarding this question will be covered in Part 5.


Q: Presumption of coverage under PDPM: does that mean that they have to meet 1 in each NSG, PT/OT, SLP, and NTA OR just meet 1 of those components?

A: To qualify for the Presumption of Coverage under PDPM, the resident must meet only 1 of the following 4 qualifiers:

  1. Assigned to a nursing group in the Extensive Services, Special Care High, Special Care Low, or Clinically Complex categories; or
  2. Assigned to one of the following PT/OT groups: TA, TB, TC, TD, TE, TF, TG ,TJ,TK, TN, and TO; or
  3. Assigned to one of the following SLP groups: SC, SE, SF, SH, SI, SJ, SK, and SL; or
  4. The NTA component uppermost (12+) comorbidity group.


Q: Will managed care assessment be done as a 5-day separate assessment that is not transmitted and we do Admission only on those?

A:  At this time CMS has not issued any change in policy related to submission of PPS assessments.  PPS assessments (5-day) completed under PDPM for non-Medicare beneficiaries should not be submitted unless otherwise directed in the future by CMS. It is advised to continue to separate the 5-day from the OBRA Admission assessment unless otherwise instructed.


Q: The 2% reduction in therapy- is it designed to keep stays short?

A:  CMS analysis indicates that therapy services decreases during a Medicare stay.  The 2% reduction is implemented to correspond with this reduction of services.


Q: We provide trach and vent care in Skilled Nursing Facilities. Most of our patients are Medicaid. How might this impact us?

A:  This would be a state specific question and depends on your specific state’s reimbursement system and what plans once PDPM is implemented.  Medicaid specific questions will need to be addressed directly to the respective state.

There may be no immediate impact as CMS will continue to support the RUG III/RUG-IV systems until further notice.  Also, an Optional State Assessment (OSA) will be implemented with the PDPM for states that require additional assessments.


Q: Will therapy still need to track and report co-treatment minutes on the MDS?

A:  Yes, the MDS will still have separate entries for individual, group, concurrent, and co-treatments.


Q: We often receive transfers from other LTC facilities wishing to admit to our facility. We would be doing a 5 day for our facility. The other facility already received the variable per diem rate adjustment. Does that preclude us from receiving the base rate adjustment? Or would we still be able to utilize the base rate adjustment?

A:  The variable rate adjustments are based on Medicare stays. Since the resident would be new to your facility, this is considered a new Medicare Part A stay, requiring a new 5-day assessment. The variable rate adjustments would be reset to day 1.


Q: Are MD certs required for 5-14-30-60-90 still or just for the 5 day?

A: SNF Physician certification and recertification regulatory requirements are independent of the current RUG payment system and the upcoming PDPM.  Physician certifications would still be required upon admission. Recertifications would still be required by day 14 and no later than every 30 days thereafter.


Q: What if a patient misses 3 days of therapy in a row? Will we have to do another MDS?

A:  No assessment would be required.  The PDPM is not based on the amount or frequency of therapy services. More detailed information regarding this question will be covered in Part 5 – be sure to attend!



As the focus shifts from therapy resource utilization to one of clinical characteristics and conditions, it will be important for SNF providers to receive accurate and up-to-date information related to this system. Our six part PDPM webinar series is designed with your concerns in mind. Don’t miss out on the next part of our PDPM Webinar Series. Register for the series today.

Adults with Autism: Supporting Quality of Life

For those individuals who need significant care and supports, the transition into adulthood often is full of unknowns. What kinds of supports does an adult with autism need?

When you think of a person with autism, is the image that comes to your mind one of a child or an adult? Just like all of us, most people with autism will spend much more of their lives as adults than as children. For those individuals who need significant care and supports, the transition into adulthood often is full of unknowns.

What kinds of supports does an adult with autism need? There are as many answers to that question as there are adults with autism. For those adults who need long-term supports and services, empowering them to have a high quality of life involves supporting them in doing activities of their choice, spending time with people of their choice, and doing work that they enjoy.

Chosen Activities

Chances are, you had to do things as a kid that you didn’t want to do – because someone else was in charge. The beauty of being an adult is that you can, within limits, do what you want. (Of course, we give up some of that autonomy when we make certain decisions and take on responsibilities, but that’s a different conversation.)

For the most part, we get to choose whether we want to go bowling, swimming or golfing during our free time. Many adults with autism who require support to access activities in their communities don’t get to make that choice.

All over the country, organizations that provide services to people with intellectual and developmental disabilities, including autism, face the daily challenge of providing individualized, person-centered services despite a shortage of funds and direct support professionals. Because hiring and retaining DSPs is difficult – and getting more difficult in the tight labor market – many service providers simply can’t find the staff they need to give everyone they serve the opportunity to do what they want to do, when they want to do it.

Perhaps nothing is more important to the quality of life for adults with autism and IDD than having well-trained, experienced DSPs – and enough of them to give each individual the opportunity to make their own choices regarding how they spend their time.

Chosen Community

IDD service providers have a mandate from the federal government and the US Supreme Court to strive for community integration of those they serve. Medicaid’s Home and Community Based Services (HCBS) program won’t provide funding for housing in settings it considers segregated. Most states had interpreted guidelines from the Centers for Medicare and Medicaid Services (CMS) to mean that HCBS dollars could not support housing where more than three or four residents have disabilities.

Just last month, CMS issued new guidance regarding HCBS and its definition of community-based. The guidance is still being interpreted, and different states may come to different conclusions about its meaning. However, it does appear that the guidance opens up the possibility of HCBS funding some housing options that had been considered segregated, such as intentional communities and specialized apartment complexes. Self-advocates have expressed concern about the new guidance, while some parent groups, especially those concerned with the well-being of individuals with significant disabilities due to their autism, have cheered the change.

How the new guidance plays out in states and communities remains to be seen.

Employment and ABA Services for Adults

Nearly half of 25-year olds with autism have never held a paying job. There are efforts all over the country to develop employment opportunities for adults with autism and other forms of IDD – from hydroponic farms to coffee shops to digital arts and animation. Some individuals enjoy working in sheltered workshops, while others long to find a job in their communities but cannot due to lack of support.

In addition to the shortage of DSPs and job coaches, adults with autism who still need to develop important skills before trying to enter the workforce face another obstacle. Many cannot access one form of therapy that excels in teaching such skills – applied behavior analysis.

Almost all states have mandates requiring insurance companies to provide ABA therapy to children with autism. Those who have Medicaid can get ABA coverage under the EPSDT provision of the Medicaid law until the age of 21. But there are many, many adults who have challenges with skill acquisition and could benefit from ABA, but state mandates and Medicaid don’t cover the service for them.

Task analysis and ABA can be used to teach a wide variety of daily living and job skills. Peter Gerhardt, Ed.D. outlines some interesting ideas in this presentation, including how supervisors can use ABA strategies to develop accommodations that increase the success of their employees with autism. Video prompting based on task analysis is also a great tool for teaching new skills to adults.

Every year, about 50,000 teenagers with autism become adults. There has been little research into the needs of adults or what supports best enable them to thrive. For many adults with autism who have significant support needs, their ability to access person-centered services and necessary therapies will be the determining factors in the quality of their entire adult lives.

16 Ways to Stop Burnout Among Children’s Service Providers

Burnout and turnover rates among children’s service providers, including social workers can be as high as 90 percent according to the CWIG.

Burnout and turnover rates among children’s service providers, including social workers, varies in severity across the United States. However, some areas may experience turnover rates of up to 90 percent, reports the Child Welfare and Information Gateway (CWIG). Children’s social workers and services providers must deal with endless challenges, which range from prioritization of timeliness over quality to a lack of a supportive, team environment. In addition, your organization’s reputation and ability to provide services to children, youth and families depends on having a qualified, experienced workforce. Fortunately, you can reduce the incidence of burnout and turnover in children services by making your organization more involved and encouraging employees to work against burnout as well.

5 Tips for Improving Your Organization’s Turnover Rates

Your organization can lead your employees toward less burnout by taking a few actions, as explained by Hunter College. Consider how each of these tips can create a more productive and enjoyable environment for your team members.

1) Make Quality Your Top Priority

Delivering positive outcomes is a fundamental career aspiration among children’s service providers, but it is not always feasible. Meanwhile, the stream of those in need has resulted in a shift of service goals. In other words, more organizations focus on speed of delivery, not quality. Consequently, the outcomes of individual cases suffer. Give your team members enough time to complete their duties fully. If a case requires additional time to review or investigate, grant it.

2) Encourage Healthy Behaviors Among Staff

Healthy behaviors encourage staff members to persevere and helps them cope with stressful situations. As an employer, you can create a health-conscious environment. For example, partner with local health clubs or heart-healthy restaurants to offer discounted rates or to host community awareness events that encourage a healthy, productive lifestyle. Other ways of increasing healthy behaviors include hosting a weekly, health-food potluck or providing training on the benefits of well-balanced nutrition. Each scenario gives employees an opportunity to interact with peers and gain insights from the experiences of other employees. Ultimately, social interaction in a healthy manner is essential to reducing burnout among social workers and employees that spend most working time in the field.

3) Request and Apply Staff Feedback

Your team members have ideas for improving the work environment and how cases are managed. Create a way for your team to provide feedback on their positions and duties. But, you need to also make sure that you follow up with action. If a suggestion cannot be implemented, explain why, and speak with the person suggesting it personally as to why it will not work.

4) Create a Team Environment, and Spread Success Stories

Your organization needs to foster a team environment and encourage the spread of success stories. In health and human services, the negative stories often outweigh and outpace the spread of good stories. Encourage team members to spread success stories throughout the organization. Meanwhile, you can help create a team environment by encouraging collaboration and a sense of unilateral purpose. In other words, get involved with your team members in handling caseloads and providing support during difficult times.

5) Identify Secondary Traumatic Stress Disorder Early

Secondary traumatic stress disorder (STSD) results from repeated exposure to negative, traumatic events while working. For children, youth and family social workers, in-home visits can result in extreme stress. For example, parents or children may become violent when faced with an in-home visit or removal from the home. Children may bite, kick or scratch, causing physical, and possibly mental, injury to workers. Unfortunately, the in-the-field nature of social workers means they may not be able to express their feelings, including upset, following these encounters. So, you need to actively work to educate staff on the risk of mental anguish, depression and STSD. Send out awareness bulletins or create support groups for STSD in your organization.

11 Tips for Social Workers to Reduce Burnout

Social workers and employees can also take the initiative in reducing burnout. Per, a branch of Rodale Publishing, social workers and other HHS staff can increase job satisfaction and reduce stress through these 11 tips:

1) Negotiate your responsibilities

Your staff members should have the authority to negotiate responsibilities, which may include schedule management. In your role as an upper-level management leader, do not overwhelm staff members, and be ready to accept that some workers cannot handle additional workloads.

2) Be selective on which cases you accept

Some cases are more difficult than others, but even social workers develop specific areas of expertise. For example, some social workers may work well with children who are victims of violence, and others may be best-suited for managing the well-being of children with intellectual or developmental disability. Thus, social workers should identify their preferred areas and focus on accepting cases within such areas of focus.

3) Disconnect and unplug from the world at night

This is hard. Social workers have a personal stake in being available for anything, but it is important to remember that other people can answer the call as well. Service providers that are not on call should unplug from the world at night. In other words, do not check emails or otherwise “work” unless – and only – if it is an emergency.

4) Maintain self-care

People cannot care for others if they do not first care for themselves. Your employees need to care for themselves, including maintaining mental and physical health check-ups and being properly groomed. Although you cannot request your staff member’s health information, you can encourage self-care by hosting on-site health clinics and wellness events.

5) Have fun as needed

The life of children’s service providers should be more than courtrooms and in-home visits; it should include recreational activities. So, your organization can partner with local movie rental vendors to promote “movie night” among your staff. In fact, you could use Redbox’s promo code site to purchase discounted, bulk rental promo codes, so you can “gift” your team with a free movie rental on a recurring basis.

6) Change up your routine

Providing services can get monotonous, so encourage your team members to switch it up appropriately. For example, change working schedules to reflect the needs of individual staff members.

7) Challenge yourself

Challenges are great ways to test readiness for advancement. Give your staff members challenges and use their progress as a guide for advancement.

8) Get involved in social events

Your employees need social interaction, so host social events for them. The key is making the events take place at third-party locations.

9) Take time for rest and relaxation (R&R)

Overtime rules may change with the new administration, but in the interim, make sure your team members have adequate time for R&R, too.

10) Make friends in the office

It is easy to get lonely at work, but friends can make the days pass much more quickly and smoothly. Encourage appropriate friendships among staff members.

11) Don’t take setbacks in cases personally

There will be times when disciplinary action is needed, or case outcomes may incur serious setbacks. Social workers must avoid taking these events personally. Ultimately, if you cannot change something, you need not worry about it.

Final Thoughts

Children, youth and family service providers are not resigned to facing unchecked turnover rates and increasing burnout hopelessly. You can improve employee satisfaction and reduce turnover by implementing these tips and practices in your organization. In fact, print out the “11 Tips for Social Workers” section and distribute copies to your team. An ounce of prevention and action today can help stop the worsening of turnover rates in the future.

The Fatal Four: What You Need to Know About Seizures

Seizure disorders should not be ignored in those with IDD. It makes the Fatal Four conversation even more important. Learn how it impacts those with IDD.

How do you help a person with an intellectual disability achieve a higher quality of life?

Providing support, companionship, and dedicated, compassionate care can go a long way, but the Fatal Four can destroy any foundation you work to build. Dehydration, constipation, aspiration and seizures make up the Fatal Four. These conditions have the potential to severely impact a person’s quality of life and, in some cases, can be deadly.

Why are Seizures One of the IDD Fatal Four?

A seizure is an event in which a person’s brain experiences a surge or “storm” of electrical activity, which interrupts the brain’s typical functioning. About 1 in 10 people will experience a seizure at some point in their life, and many of those seizures do not recur. However, some people experience multiple seizures and are diagnosed with a seizure disorder.

Seizure disorder, also called epilepsy, is a developmental disability. Like autism and cerebral palsy, many individuals with epilepsy have typical IQs and live highly independent lives. However, there are many individuals with IDD who have epilepsy in addition to another disability. As many as 35 percent of individuals with cerebral palsy and 75 percent of individuals who have experienced brain injuries may also have a seizure disorder.

Seizures can be dangerous in the moment they occur, because the individual experiencing them often loses control of their body, loses consciousness, or both. This can result in a variety of injuries, accidents, and dangerous situations: imagine what would happen if a person suddenly lost consciousness while swimming, driving, or crossing a busy street.

The accumulated effects of seizures over a lifespan can also be deadly. Individuals whose seizure disorder is not well-controlled may experience severe complications, including death.

Risk Factors for Seizures

Individuals who have a known seizure disorder may have seizures at any time for no apparent reason. However, some circumstances might provoke a seizure even in a person who does not have epilepsy. These include:

  • Stroke
  • Brain injury
  • Dementia
  • Brain infections
  • Liver or kidney failure
  • Severe high blood pressure
  • High fever (typically in children)
  • Drug use or toxic substances

For individuals who do have epilepsy, anything that causes stress to their brain or body systems could increase the risk of a seizure. Further, some individuals have specific “triggers” for seizures. Classic examples include flashing lights or certain sounds.

Complications from Seizures

The most common immediate dangers of seizures are not from the seizures themselves. Seizures can result in falls, drowning, or other injuries, and a person who vomits during a seizure can choke on or aspirate their vomit. However, there may be other serious complications due to a seizure or ongoing seizure disorder:

  • Emotional distress. Individuals coping with epilepsy are at a greater risk of depression and other psychological disorders due to the fear and uncertainty that seizures often cause.
  • Cognitive decline. Individuals who experience many seizures over a long period of time may experience gradual memory loss and other cognitive decline.
  • Status epilepticus. This occurs when a seizure or series of seizures continues indefinitely without the person recovering in between. Very long seizures can be dangerous and require medication to resolve.
  • Sudden unexpected death in epilepsy. SUDEP occurs in one-tenth of a percent of people with epilepsy, and it is not fully understood. SUDEP typically occurs during or immediately after a seizure.

In general, seizures that last longer than 5 minutes are considered a medical emergency. A series of seizures is also considered an emergency. These situations can result in permanent injury or death.

Note that aspiration, another of the Fatal Four conditions, is a possible complication from seizures.

Signs of Seizures

There are many different types of seizures. Seizures don’t always involve full-body convulsions; in fact, seizures that impact only part of the brain or body are more common. Here are some examples of possible signs of a seizure:

  • Tremors or “shaking”
  • Loss of control over parts of the body
  • Unusual eye movements
  • Drooling
  • Vomiting
  • Sensory abnormalities
  • Appearing “absent” or staring
  • A scream or cry
  • Incontinence
  • Loss of consciousness
  • Disorientation or confusion
  • Exhaustion
  • Headache

Seizures are very individualized, and there are many more signs than can be listed here. People who experience repeat seizures typically develop a pattern of seizure that is typical for them. However, seizures can still occur unpredictably even for people with an established pattern.

Responding to Seizures

Since there are so many types and causes for seizures, there is no one-size-fits-all response to a seizure. In general, you should consider these actions:

  • Monitor for environmental risks. Be alert to the potential for falls, for colliding with furniture or other items, for walking into traffic, or any other hazards in the environment. Do what you can to prevent injury.
  • Prevent choking or aspiration. Some individuals may vomit while seizing, which puts them at risk of aspiration or choking. If possible, help the person turn onto their side or in a recovery position. Don’t put anything into the mouth of a person who is seizing.
  • Do not restrain them. Restraining or holding a person down can cause injury, and in their disoriented state they may struggle.
  • Prepare to report. Pay attention to the details of the seizure, including what was happening before, if you noticed any initial warning signs, how the person behaved while seizing, the time it started, and how long it lasts. You will document this later, and if the person needs medical support you will share it with the emergency responders.
  • Support the aftermath. People who are coming out of seizures may not act like themselves. They may be disoriented, frightened, tired, or weak. Avoid offering food or beverage, or asking the person to do anything physically taxing, in the immediate aftermath of a seizure. Stay with them until you are sure they are fully awake.
  • Get help if you need it. Contact emergency medical services (call 911) if indicated on the person’s plan, or if you have any concerns about the course of their seizure. Anyone who is not breathing, who is pregnant, who sustains a significant injury due to a fall or other hazard, or who has never had a seizure before should receive immediate medical assistance.

Many individuals who experience repeated seizures will have a personalized seizure plan or protocol written by their doctor. They may require specific intervention, such as using a medication to stop their seizure or calling 911 if certain conditions are met. Be sure to follow this plan carefully and notify the person’s medical team of any changes or concerns.

10 Ways DSPs Can Prevent Seizures or Related Injuries

Seizures aren’t always preventable, but direct support professionals (DSPs) can play an important role in helping the people they support to reduce their risk of seizures or related injuries.

1) Provide medication support

Anticonvulsant medications can substantially lower a person’s risk of having a seizure. Help the individuals you serve take their medications on time and as prescribed by their doctor.

2) Avoid known seizure triggers

This can vary tremendously from person to person. Some individuals have seizures triggered by specific songs, by flashing lights, or by monthly hormonal fluctuations. Some individuals have no known triggers. Drugs and alcohol are common triggers.

3) Know their warning signs

Some individuals have specific warning signs prior to a seizure. They may feel dizzy, lose sensation in part of their body, or have other unique indicators that a seizure is imminent. Recognizing these signs can create an opportunity to lie down, move away from hazards, or call for help if needed.

4) Recommend showers

It takes very little water to drown, so a seizure while in the bath can be fatal. Encourage individuals at risk for seizures to take showers instead, and consider the use of a shower chair to reduce the risk of slipping and falling if a seizure occurs.

5) Beware the heat

Intense heat can increase dehydration, another of the Fatal Four conditions. Dehydration is a risk factor for seizures.

6) Support sleep hygiene

Not getting enough sleep can increase a person’s risk of seizures.

7) Treat fevers

Illnesses, particularly high fevers, can sometimes trigger seizures, particularly in individuals with a known seizure disorder.

8) Help manage stress

High levels of stress can trigger seizures in some individuals. Stress can also trigger other risk factors, such as dehydration due to forgetting to drink fluids or not getting enough sleep.

9) Recognize situational hazards

Although individuals with seizure disorders can often participate in a wide array of typical activities, be aware of which activities pose special risk for the individual you support. Stairs, for example, can be dangerous for someone who typically falls when they seize and who has no prior warning of an oncoming seizure.

10) Document all seizures

Even if a seizure seems minor, it is important to keep a record of it. The individual’s medical team can learn valuable information about treatment needs by knowing facts such as the time, duration, and features of a seizure. Documenting all seizures or suspected seizures can help to identify patterns of possible triggers or warning signs.

DSPs and other caregivers need to know how seizures and the rest of the Fatal Four – dehydration, constipation, and aspiration – interact and potentially cause other serious health problems. The only way to keep the Fatal Four from claiming more lives is education and prevention.


Additional Posts About The Fatal Four

Dehydration Signs and Risk Factors

How Constipation Impacts Health

Aspiration’s Dangers and Key Interventions