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Significant change in status assessment required when therapy (and isolation) ends 2021, 1st Special Session HF33/SF37 Chapter 7, Article 13, Section 1 HHS omnibus bill Effective: August 1, 2021, and applies to all assessments with an assessment reference date of August 1, 2021, or later (Note bill language uses July 1, 2021, but the state agencies determined that a July 1, 2021 implementation was not possible)

Short description Effective for all MDS’ with therapy and isolation end dates on or after August 1, 2021, a significant change in status assessment (SCSA) is required when all speech, occupational, and physical therapies have ended. The assessment reference date (ARD) of this assessment must be set on day eight after all therapy services have ended. The last day therapy was provided is considered day 0 when determining the ARD of the SCSA.

A significant change in status assessment (SCSA) is also required when isolation for an infectious disease has ended. The ARD of this assessment must be set on day 15 after isolation has ended. The last day of isolation precautions is considered day 0 when determining the ARD of the SCSA.

Summary The proposal to require a significant change in status assessment (SCSA) when therapy (and isolation) ends was not new. For the previous 4-5 years, legislators had received complaints from constituents who believed the nursing facility was charging a higher case mix classification rate, even though the associated services ended earlier during the stay. Bill language was introduced in previous years. However, the recent HHH Blue Ribbon Commission reviewed and recommended the strategy as one way to reduce Medicaid expenditures. Governor Walz included the policy change in his recent budget, and the Minnesota Senate and House of Representatives adopted without modifying.

MDH hosted a 2021 CMR Program Statute Changes webinar on July 22, 2021 (https://bit.ly/3f2yuPY), where the following clarifications were provided to the following statement (from page 2): • All Medicaid participating facilities are required to complete a significant change in status assessment (SCSA) when all skilled therapy or strict isolation services end regardless of the resident’s payer source or RUG classification.

Is the SCSA necessary if no rehab or ES1 classification (page 6)? According to MDH, If the resident does not have a rehab or isolation classification, a SCSA would not be required at the end of skilled therapy or isolation.

• If the resident is receiving skilled therapy or strict isolation services and this is impacting the resident’s RUG-IV classification, the SCSA is required • A resident receiving isolation services may have an ES1 or a CA1 classification depending on their ADL score • Anytime the resident has a state rehab classification (RAA, RAB, RAC, RAD, and

RAE) the SCSA is required

Skilled vs. unskilled therapy services (page 10) • Skilled Therapy Services: • are medically necessary; • are ordered by a MD, PA, or NP; • require the skills, knowledge, and judgement of a qualified therapist; • are based on a qualified therapist’s assessment and treatment plan; • are documented in the medical record; and • are care planned and periodically evaluated • Therapy services that don’t meet these requirements are considered unskilled—An

SCSA is not required when unskilled therapy services end

During July 22, 2021, webinar, it was communicated that the significant change in status assessment (SCSA) is not required following the end of isolation or therapy if there is no impact on the RUG classification. For example, if there is no MDS on record coding therapy, then there would not be a requirement to do a SCSA for end of therapy.

Implications Besides making sure their processes comply with the new state requirements, nursing facilities must contend with two other implications: 1. For some nursing facilities, the new SCSA requirement will result in a reduction in annual revenue due to the reclassification of residents to a lower case mix classification 2. For all nursing facilities, the consequences of a late and missed SCSA are very significant: a. The penalty rate, AAA, will be assigned for all late or missed assessments b. The penalty rate will be assigned from the time the assessment was due, the ARD, until the 1st of the month following submission and acceptance of the late assessment into the QIES ASAP system

Bill language https://www.revisor.mn.gov/laws/2021/1/Session+Law/Chapter/7/

read: Section 1. Minnesota Statutes 2020, section 144.0724, subdivision 4, is amended to

Subd. 4. Resident assessment schedule. (a) A facility must conduct and electronically submit to the commissioner of health federal database MDS assessments that conform with the assessment schedule defined by Code of Federal Regulations, title 42, section 483.20, and published by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, in the Long Term Care Facility Resident Assessment Instrument User's Manual, version 3.0, and subsequent updates when or its successor issued by the Centers for Medicare and Medicaid Services. The commissioner of health may substitute successor manuals or question and answer documents published by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, to replace or supplement the current version of the manual or document.

(b) The assessments required under the Omnibus Budget Reconciliation Act of 1987 (OBRA) used to determine a case mix classification for reimbursement include the following: (1)a new admission comprehensive assessment, which must have an assessment reference date (ARD) within 14 calendar days after admission, excluding readmissions; (2)an annual comprehensive assessment, which must have an assessment reference date (ARD) ARD within 92 days of the a previous quarterly review assessment and the or a previous comprehensive assessment, which must occur at least once every 366 days; (3) a significant change in status comprehensive assessment, which must be completed have an ARD within 14 days of the identification of after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition, whether an improvement or a decline, and regardless of the amount of time since the last significant change in status comprehensive assessment or quarterly review assessment; (4) all a quarterly assessments review assessment must have an assessment reference date (ARD) ARD within 92 days of the ARD of the previous quarterly review assessment or a previous comprehensive assessment; (5)any significant correction to a prior comprehensive assessment, if the assessment being corrected is the current one being used for RUG classification; and (6)any significant correction to a prior quarterly review assessment, if the assessment being corrected is the current one being used for RUG classification.; (7)a required significant change in status assessment when: (i) all speech, occupational, and physical therapies have ended. The ARD of this assessment must be set on day eight after all therapy services have ended; and (ii)isolation for an infectious disease has ended. The ARD of this assessment must be set on day 15 after isolation has ended; and

(8) any modifications to the most recent assessments under clauses (1) to (7). (c) In addition to the assessments listed in paragraph (b), the assessments used to determine nursing facility level of care include the following: (1) preadmission screening completed under section 256.975, subdivisions 7a to 7c, by the Senior LinkAge Line or other organization under contract with the Minnesota Board on Aging; and (2) a nursing facility level of care determination as provided for under section 256B.0911, subdivision 4e, as part of a face-to-face long-term care consultation assessment completed under section 256B.0911, by a county, tribe, or managed care organization under contract with the Department of Human Services. EFFECTIVE DATE. This section is effective July 1, 2021 and applies to all assessments with an assessment reference date of July 1, 2021, or later.