Instruction Manual For Conducting Patient Review Instrument (PRI) On-Site Reviews

01/02/04

Table of Contents

Part A - Overview

1. Purpose of PRI Audits
2. Roles, Rights and Responsibilities of the On-site Reviewer
3. Roles, Rights and Responsibilities of Facility Personnel
4. Initiating Audits
5. Entrance Conferences
6. Exit Conferences

Part B - Audit Process

1. Audit Framework: Stage I Reviews; Stages II & III Reviews; & "Exit Conference Visits" & "Expedited Audits"
2. Audit Principles
3. Resident Observation and Discussion With Staff
4. Suggested Audit Schedule
5. Instructions for Completing/Interpreting Audit Forms and Related Materials
6. Instructions for Checking Facility Census
7. Instructions for Completing Activity of Daily Living (ADL) Verification Forms
8. Instructions for Completing Resource Utilization Grouping (RUG/Hierarchy) and Dementia Checklists
9. Instructions for Completing Traumatic Brain Injury (TBI) Extended Care Reviews
10. Instructions for Re-Reviewing Previous Stage Controverted Items (CIs)
11. Other Audit Instructions
12. Assembly of Audit Materials

Part A - Overview

1. Purpose of PRI On-site Reviews

On-site reviews (audits) are conducted to assure that PRI resident data submitted to the State Department of Health (SDOH) by nursing facilities is in compliance with established reporting standards contained in the Department's regulations and PRI clarification sheet. Compliance is necessary for the SDOH to establish appropriate Medicaid reimbursement, since PRI data is an integral component of the rate setting system.

2. Roles, Rights and Responsibilities of the On-Site Reviewer

• The on-site auditor's principle responsibility during the site visit is to validate the information submitted by the facility through use of a specific audit process.
• In performing audits, the on-site auditor should give no thought to the potential reimbursement implications of his/her determinations. Further, the on-site auditor should not attempt to answer questions of facility personnel on the reimbursement system. Facility personnel should direct such questions to the SDOH.
• The On-Site Reviewer is responsible for:
  • representing the SDOH in an impartial, positive, professional and ethical manner.
  • maintaining confidentiality of pertinent aspects of a resident's condition and care.
  • documenting findings appropriately.
  • accurately communicating audit findings to facilities.
  • identifying conflicts of interest. The reviewer must not accept an assignment to audit a facility in which s/he has previously been employed or has a personal relationship with facility employees.
  • reporting any observed indicators of egregious care or patient abuse.
• The On-Site Reviewer has the right to:
  • access resident medical records.
  • question facility staff regarding residents' conditions and care.
  • observe residents.
  • adequate and comfortable space to perform the audit.
  • conduct audits in a non-confrontational environment.

3. Roles, Rights and Responsibilities of Facility Personnel

• The role of facility personnel is to provide support to the auditor to assure an effective and accurate review.
• Facility staff has the responsibility to:
  • designate a contact person with whom the auditor may discuss issues or ask questions as they arise during the audit. The contact person should be knowledgeable regarding all aspects of the facility's units, medical records and PRI assessment system.
  • ensure the timely availability of complete medical records.
  • set aside adequate and appropriate space in which the reviewer may conduct the audit.
  • present a professional and non-confrontational outlook on the audit process.
• Facility staff has the right to:
  • discussion with the auditor concerning the scope of the audit.
  • produce documentation during the conduct of the review should the reviewer not be able to substantiate the facility's assessment.
  • an explanation of audit findings by the reviewer at an exit conference.
  • ask questions regarding PRI qualifiers.

4. Initiating Audits

• SDOH generates an audit through transmission of review materials to the contractor. The contractor then makes telephone contact with facility personnel to arrange the date(s) and time(s) of the audit, including the time of the entrance conference. If the audit is a later Stage review, the facility will have already been notified that an audit would be generated when SDOH transmitted the results of the previous Stage review.
• Auditors and facility personnel are expected to demonstrate flexibility and responsiveness in expeditiously scheduling audits.
• If a facility refuses to schedule an audit, the contractor must notify the SDOH. If the situation cannot be resolved, the SDOH will deem the data unavailable, resulting in denial of all the hierarchies that would have been reviewed and coding of all ADLs that would have been reviewed at level one.
• The contractor is instructed to transmit the resident list for audit, provided by SDOH, to the facility by facsimile copy between 3:30 PM and 4:00 PM on the last workday before the review. This list notifies the facility of which resident records are to be reviewed, so that the facility can make medical records available at the beginning of the audit. If the contractor is unsuccessful in sending a facsimile copy by 4:00 PM due to transmission problems, a call must be placed to the facility to resolve the problem.

5. Entrance Conferences

• This meeting is to be held at the beginning of the first day of each stage review and shall last approximately one-half hour. The meeting shall be attended, at a minimum, by the auditor and facility contact person (as designated by the administrator). The meeting is provided so the auditor can outline the purpose, scope and timetable of the particular stage audit to be conducted.
• The facility contact person should inform the auditor as to how s/he may be reached during the course of the audit.
• The reviewer should communicate the audit schedule to the facility contact person during the entrance conference.
• During the entrance conference, the auditor must secure the facility's written determination as to whether an exit conference is requested at the conclusion of that stage audit. The decision is binding. Facilities may have exit conferences at the conclusion of every stage audit if so requested at the applicable entrance conference. During the entrance conference, the auditor and facility personnel will set a planned time for the exit conference.
• At the entrance conference of a Stage I audit, facility staff must identify the census count for the last day of the PRI assessment period. The reviewer will enter this number on the On-Site Reviewer Cover Sheet. The PRI census date will be handwritten on this form. The census count is important in verifying that the number of PRIs submitted by the facility is accurate.
• At the entrance conference of a Stage II or Stage III audit, the auditor must secure the facility's written determination of which CIs from the immediately preceding stage audit the facility is requesting be re-reviewed. If the facility is requesting no CIs be re-reviewed, this also must be acknowledged in writing at the entrance conference. On rare occasions, the number of previous stage CIs to be re-reviewed may be so numerous that the auditor must contact the contractor's central office immediately after the entrance conference so that an additional day to conclude the audit and conduct an exit conference can be scheduled.
• At the conclusion of the entrance conference, the facility contact person will orient the reviewer to the work place from which the audit may be conducted and provide all necessary information regarding the facility's medical record documentation systems, facility layout and selected units, including introductions to other staff.

6. Exit Conferences

• The purpose of the exit conference is for the auditor to convey the provisional results of the review just conducted, as it relates to new CIs and any previous stage CIs re-reviewed at the written request of the facility. Further, the exit conference provides facility representatives the opportunity for discussion with the auditor regarding her/his findings. On occasion, this discussion may result in the auditor altering a decision, but this is not the actual purpose of the exit conference, which is largely a report-out by the auditor. The facility may not present additional medical record documentation for review during the exit conference, as opportunity for this will have been provided during the course of the audit.
• The exit conference will occur at the time established during the entrance conference, subject to revision based on mutual agreement of the auditor and facility personnel. The exit conference can last as long as 45 minutes, depending on necessity.
• Participants in the exit conference shall be limited to the facility administrator, the facility contact person, one other person not active as an assessor (who may be the director of nursing or other staff member), and an active facility assessor. Other persons may observe, but not participate, verbally, non-verbally or by written communication with participants. The auditor may ask any person to leave the exit conference if s/he determines the person's participation or presence is proving counter-productive.
• Exit conferences are not to be video taped, audio taped, or transcribed unless facility personnel secure approval of the SDOH prior to the first day of the particular Stage audit. Approval by SDOH requires the commitment of the facility to provide the auditor with a copy of the videotape, audiotape or transcribed record.
• The auditor will commence the exit conference with a short statement explaining its purpose, scope, limitations, time frame, and rules. The auditor will also inform attendees that they will receive a formal notification of audit outcomes from the SDOH.
• The auditor will next provide a review of his/her findings regarding the re-reviewed CIs from the immediately preceding stage review. The auditor will explain the reasons for his/her decisions. In instances where the auditor does not overturn a previous stage CI, facility staff will be afforded a single last opportunity to comment and make their case for overturn. The auditor has discretion to change his/her mind, or reserve the right to make a later decision.
• The auditor will then provide a review of his/her findings regarding the current stage audit, including the reasons for his/her CIs. Once again, the facility will be afforded an opportunity to make a case for the auditor to reverse these CIs and the auditor may or may not so decide, or reserve the right to make a later decision.
• In the course of presenting his/her findings, the auditor will have compiled resident specific examples of the documentation, or the lack thereof, which lead to each CI. The auditor will also note any instances in which PRI qualifiers appear to be consistently misapplied or misinterpreted by facility assessors.
• The tone of the exit conference is expected to be professional and neutral at all times. All parties must focus on the facts related to the qualifiers and attempt to be precise and concise in their discussions. Auditors have the authority to terminate discussion regarding a particular CI upon determining that all the related facts have been thoroughly addressed and the discussion has digressed or become repetitive and counterproductive.
• The auditor has authority to terminate the exit conference after 45 minutes or at any time s/he determines it to be contentious, unprofessional or unproductive. In such instances, there will no re-scheduling of the exit conference.

Part B - Audit Process

1. Audit Framework: Stage I Reviews; Stages II & III Reviews; Exit Conference Visits; Expedited Audits

• For
• If a
• If a
• In instances where a facility has failed a Stage I or Stage II review but does not have any remaining residents yet to be reviewed (non-PAs), the facility will be offered a return visit solely to have the CIs from the immediately preceding audit re-reviewed by another auditor. These additional reviews are referred to as <"Exit Conference Reviews"
• SDOH has entered into agreements on a one-time basis with certain facilities to perform some of their reviews in a manner where all their residents will be audited in a single Stage. These reviews are so designated to the audit contractor. These reviews are referred to as <"Expedited Audits;"
• The SDOH informs the facility in writing of the results of each of the above reviews.

2. Audit Principles

• Reviews are meant to ascertain the accuracy of PRIs prepared and submitted by nurse assessors employed by facilities. To do so, reviewers are to complete the computer audit forms exclusively through a review of medical record documentation, with assistance from facility staff as needed. Facility records must document conformance with the PRI qualifiers for each of the conditions/treatments/levels reported by the facility on its submissions.
• Whenever it appears that the record is incomplete, unclear, conflicting, or does not substantiate the PRI response provided by the facility, the auditor must consult with the Facility Contact Person to determine whether additional supporting documentation may be available elsewhere. Each facility will have its own way of keeping records. It is important that the auditor become familiar with the facility's record keeping system and where records are to be found so that supporting documentation is not missed. This is especially important if the entire record for a resident is not to be found in one place.
• Documentation found after the completion of the on-site visit will not impact the results of that stage review.
• Under no circumstances should an auditor recommend that the facility adopt a specific format for medical record documentation. If a facility asks for such advice, the reviewer should merely advise that documentation demonstrate conformance with the PRI qualifiers.
• Reviewers should bring to each audit the following reference materials: the PRI; PRI Instructions; PRI Clarification Sheet; a calendar for the audit time period; a description of how the RUG is assigned; and relevant correspondence from SDOH. All these documents should be utilized when performing the audit.
• Auditors will work independently but may require intermittent assistance from facility staff. The facility contact person and designated facility staff must be available to assist the reviewer.

3. Resident Observation and Discussion with Staff

• PRI audits are first and foremost a review of medical records to determine if documentation supports facility PRI submissions. Information secured through observation and staff discussion should not result in audit determinations that are unsupported by the medical record. However, these tools can be important in:
  • assisting the auditor in understanding the facility's documentation, especially when it is unclear or conflicting; and,
  • identifying patterns of inaccurate medical record documentation that should be reported to SDOH.
• PRI reviewers should observe approximately 20% of residents selected for audit. When possible, the auditor should observe residents during a meal, as well as residents with reported medical conditions and treatments, including but not limited to decubitus ulcer, stasis ulcer and wound care. Such observation may take place in residents' rooms and/or congregate areas, such as dining rooms. While observing residents, the reviewer may engage in discussion with staff regarding the resident's care and level of independence.
• While the PRI review is not a quality of care audit, the reviewer may encounter situations that represent poor quality (e.g., empty water pitchers, signs of dehydration such as dry, caked lips). In such instances, the reviewer should separately document these concerns as part of the narrative report of the audit visit. If potential patient abuse or neglect is ever noted, the reviewer is instructed to make a report to the SDOH by calling 1-888-201-4563 and completing the New York State Department of Health - Office Of Health Systems Management Health Care Facility Report Form.

4. Suggested Audit Schedule

• It is estimated that a reviewer will need to be on-site at the facility approximately 7.5 hours for every 40 residents to be reviewed. Reviewers have flexibility as to how they structure their work within the audit day, in consultation with facility personnel. However, for day one of each review, the reviewer should:
  • determine whether s/he is in the correct facility by checking the posted operating certificate in the lobby to determine if the number on it matches the operating certificate number cited on the audit cover sheet. Discrepancies in operating certificate numbers may result from changes in ownership, changes in facility name and other reasons. Discrepancies must be resolved. If the facility cannot explain the reason for the difference, the reviewer should contact the contractor's central office, which will call SDOH.
  • immediately follow with an entrance conference, which includes a check of census data if it is a Stage I review (see sections on Entrance Conferences and Checking Facility Census);
  • immediately follow by having the facility contact person provide all necessary information regarding the facility's medical record documentation systems, facility layout and selected units, including introductions to other facility staff;
  • for a Stage I review, immediately follow by completing the TBI checklists generated by SDOH for selected residents, if any. By doing these reviews first, you will be able to determine if the facility will need to provide medical records for additional TBI residents (see section on Instructions for Completing TBI Extended Care);
• After the above, the reviewer may complete the remaining individual computer audit forms, CI re-reviews and other relevant documents in any manner that is both efficient and amenable to all parties. For example, ADL, RUG, Dementia and CI checklists for various residents may be completed in any order. Further, reviews may be performed on nursing and other units in the facility or a centralized location. In evaluating how to structure the remainder of his/her workday, the auditor will consider the checklists to be completed and CIs to be re-reviewed.
• The auditor should inform the facility contact person whenever s/he is leaving the facility for lunch or other purposes. The facility contact person should do the same for the auditor.
• If the facility decided in writing during the entrance conference that an exit conference would occur, it must be conducted at the close of the audit. Note: If there are more previous stage CIs that must be re-reviewed than the reviewer can fit into the audit schedule, s/he should contact the contractor's central office after the entrance conference on the morning of the first day on-site so that a return visit can be scheduled to conclude the reviews and conduct an exit conference (see section on Exit Conferences).

5. Instructions for Completing/Interpreting Audit Forms and Related Materials

• When SDOH generates an audit, it forwards to the contractor the following materials:
  • On-Site Review Cover Sheet
  • Resident List for Audit
  • Audit Checklist Summary
  • Computerized Audit Forms For Specific Residents: ADL Verification Forms and RUG Category, TBI Extended Care and Dementia Checklists
  • Controverted Item Summary (Stage II, Stage III and Exit Conference Visits only)
  • Controverted Resident List for Previous Audit (Stage II, Stage III and Exit Conference Visits only)
• Additionally, it is the responsibility of the contractor to assure that auditors have the following materials in their possession with each audit, because the SDOH does not transmit them each time it generates an audit:
  • blank computerized audit forms for use in performing any re-reviews of previous Stage CIs and additional TBI extended care reviews;
  • blank copies of the On-Site Reviewer Report: Cover Sheet; Review Schedule; Record of Disagreements; Exit Conference - Summary of Disagreements
  • blank copies of the Controverted Items to be Reviewed form
  • Exit Conference Request Form
  • the PRI
  • PRI Instructions
  • PRI Clarification Sheet;
  • RUG "Spider Graph";
  • relevant correspondence from SDOH;
  • Health Care Facility Report Form; and,
  • a calendar for the audit time period.
• All notations on forms are required to be made in ink. If changes are made, the reviewer should cross out the original response, write the new response next to it and initial the change.
• On
• On the second page <(the On-Site Reviewer Report Review Schedule)
• On the third page <(the On-Site Reviewer Report Record of Disagreements)
• On the fourth page, <(the On-Site Reviewer Report Exit Conference Summary of Disagreements)

6. Instructions for Checking Facility Census

• On a Stage I review, the facility census for the date handwritten on the form must be checked and recorded. The census reflects the number of residents as of 4:00 PM, which may be different from the census at midnight. In the case of a discrepancy between the reviewer's determination and the number of PRIs the facility submitted, the reviewer must inform the facility contact person that s/he must resolve the issue. If the census discrepancy cannot be fully explained before the auditor leaves the facility, the reviewer should encourage the facility to continue its analysis because the SDOH will be contacting the facility directly about the problem until the census is resolved. If the census discrepancy is resolved while on-site, the reviewer should make an effort to secure and transmit to SDOH with the audit package the following:
  • a cover letter on facility letterhead explaining the reason(s) for the discrepancy;
  • the facility's submission of additional PRIs for any residents excluded in error from the original submission. The PRI must be based on a date within the original assessment period and include name, social security number and all other required data;
  • identification of residents whose PRIs were submitted in error in the original submission, including names and social security numbers. Audits that may have been generated for any of these residents are not to be reviewed. Instead, they are to be so marked and attached to the On-Site Reviewer Report. They should not be left with the other checklists.
• Regardless of whether the census discrepancy is resolved prior to conclusion of the audit, the reviewer must note the discrepancy on the on-site reviewer report cover sheet and enter the correct census number on the on-site review cover sheet.
• If the facility asserts the reviewer is checking the incorrect date, s/he must call the contractor's central office, which will contact the SDOH to verify the date. If for some reason no response is available from SDOH before the audit is completed, the reviewer should obtain information for both dates so that the census can be entered on the audit cover sheet once the correct date is determined.

7. Instructions for Completing ADL Verification Forms

• Reviewers are verifying the findings of nurses in the facility as they relate to the PRI for the 28-day period ending the day of assessment (ascertained through the beginning and ending dates specific to each resident printed on each of the audit forms).
• Reviewers must enter their reviewer ID numbers on each resident specific ADL verification sheet transmitted by SDOH. The ADL verification form lists and defines all three of the ADLs used in calculating an ADL score (eating, transfer and toileting), each of which must be verified for a selected resident. For each ADL, the reviewer should choose the description on the form that most accurately describes the amount of assistance the resident actually received in performing the task in question (toileting, transfer, eating) and record the number preceding that description on the field "audit level". In general, this determination should reflect the assistance required at least 60% of the time the activity was performed. There are four such care descriptions from which to choose for eating and three for transfer and toileting. The numbers associated with these care descriptions represent the point value for the ADL score, not the "Level" on the PRI form.
• During a Stage I review, the auditor is said to be performing a "blind review", because s/he is not informed by SDOH as to how the facility answered the ADL questions.
• During Stage II and III reviews, the auditor is aware of how the facility answered the questions and must document the points of disagreement in the manner specified on the bottom of the audit worksheet.
• All ADL verification forms will indicate the resident's name as well as medical record, unit, and room numbers. It is important for the reviewer to assure that the medical record s/he is reviewing is for the correct resident.
• Occasionally, a facility is unable to locate the record for a given resident, or is able to locate only part of a record. If no ADL records are found, record a level '1' for all three ADLs and note on the audit form that no medical records were produced related to the item.

8. Instructions for Completing RUG Category (Hierarchy) and Dementia Checklists

• Reviewers are verifying the findings of nurses in the facility as they relate to the PRI for the 28-day period ending the day of assessment (ascertained through the beginning and ending dates specific to each resident printed on each of the audit forms).
• Reviewers must enter their reviewer ID numbers on each resident specific RUG category checklist transmitted by SDOH. In the verification of RUG categories, the auditor checks to ensure that each of several qualifiers was met. If a specified qualifier has been met, the reviewer enters a '1' to answer 'yes'. If the qualifier has not been met, the reviewer enters '2' to answer 'no'. The same methodology applies to the Dementia checklist.
• The transmission of a RUG category checklist or dementia checklist indicates the facility claimed the associated item when submitting its PRIs.
• Some resident records may be subject to no RUG category reviews, others resident records may be subject to multiple reviews for various PRI questions.
• All RUG category and dementia checklists will indicate the resident's name as well as medical record, unit, and room numbers. It is important for the reviewer to assure that the medical record s/he is reviewing is for the correct resident.
• Occasionally, a facility is unable to locate the record for a given resident, or is able to locate only part of a record. If no records are found relative to a RUG category or dementia checklist, mark '2' for all the questions and note on the audit form that no medical records were produced related to the item.

9. Instructions for Completing TBI Extended Care Reviews

• If the facility has reported any residents as qualifying for TBI extended care, there will be a verification process as part of Stage I.
• The Audit Checklist Summary lists individually

10. Instructions for Re-Reviewing Previous Stage Controverted Items (CIs)

• When a facility is undergoing a Stage II or III review, the facility may request a re-review of CIs from the immediately previous Stage. In the case of a Stage III review, only items controverted on the Stage II review may be re-reviewed and all CIs resulting from the Stage I review are final. The audit packet provides a listing identifying those CIs from the immediately preceding stage that are open for review should the facility so request.
• While the auditor knows the previous auditor's CIs, s/he does not know which qualifier(s) were unmet. Therefore, the re-review is accomplished though a complete review of all the qualifiers for the applicable resident classification. All of the questions must be tested in the same way they would be for a resident being reviewed for the first time.
• Previous Stage CIs may relate to RUG categories, ADLs, dementia or TBI extended care. Keep in mind that, if there were TBI denials on the Stage I, other reported TBIs would have been reviewed. Any such denials will not be listed on the Controverted Resident List prepared for the auditor; these will be identified on the Controverted Item Summary sent to the facility with a room number of 'TBINO'. Such residents may have been selected for the Stage II, making it possible to do an initial review of ADLs and a re-review of the TBI.
• Reviewers are to use the blank audit forms they brought to the facility to complete these re-reviews and must enter the facility name, opcert, and patient name and identification number on each sheet in a legible manner in order to reduce errors in keying. For these CI re-reviews, list the audit purpose as a '1'.

11. Other Auditing Instructions

• The facility may claim that some information the reviewer seeks to audit is not what was submitted by the facility on the PRI. Among other reasons, this may happen in situations where the facility: completed a PRI based on a date after the census date; erroneously claimed the wrong type of therapy (e.g. PT/OT), or claimed a treatment not provided. To make its case, the facility may sometimes provide a hand written copy, or a computer printout, showing different information. Regardless, the auditor must answer the questions on the computer audit forms generated by SDOH for the cited ATP because they are based on the information actually submitted by the facility.
• Careful documentation is in the auditor's best interest. Documentation should always be adequate to allow the reviewer to recall the precise circumstances of the determination, even after the lapse of a significant period of time. Reviewers should include all the following information in their notes and reports to document the basis for their determinations:
  • Date(s): List all relevant dates in the record that support your findings. For example, resident absences from therapy in the 28 day ATP.
  • Time(s): Give exact time (or times) of discussion with staff, (e.g. 10:15 AM).
  • Place(s): Cite the place where discussion took place. (e.g., E wing nurse's station).
  • Record Type(s): Cite where medical record documentation was found or absent, including but not limited to: nurses' progress notes; weekly or monthly summaries; medication records; physician's notes; therapists' notes; dietician's notes; social worker's notes; decubitus sheet, etc.
  • Name(s): Give names of recorders whether nurse, physician, therapist, etc. If the signature is not legible, try to determine the correct spelling from the charge nurse. List names of any staff members with whom you discussed the patient's condition (e.g., Nancy White, RN; Donna Brown, RPT).
• If the reviewer discovers that the facility has entered the resident's social security number incorrectly, a note of this should be made on the audit sheet, but the pre-printed information on the sheet should not be changed.
• It is important that the facility have ample time to locate records and the reviewer should not appear to be rushing facility personnel in this regard. On the other hand, the facility did have the resident list before the audit began, so the auditor is not expected to stay beyond the normative and planned time for leaving.

12. Assembly of Audit Materials

• The following forms must be completed in accordance with the instructions in this manual, assembled and mailed to the Department of Health for processing:
  • On-Site Reviewer Report;
  • Exit Conference Request form;
  • Controverted Items to be Reviewed form (for other than Stage I reviews);
  • the On-Site Review Cover Sheet; and all ADL verification Forms, RUG Category Checklists, TBI Extended Care Checklists, and Dementia Checklists
• In preparing the audit to send to the Department, the auditor should staple together in the upper left hand corner all of the sheets pertaining to one resident. The ADL checklists should be on top of any other checklists and the cover sheet should be on top of the audit checklists.
• The reviewer must sign the first page of the on-site reviewer report and note the facility name and reviewer's name on all the following pages of the report.
• Mail all the required forms to:
  Mr. Robert Loftus
  Bureau of Financial Management and Information Support
  New York State Department of Health
  Room 984, Corning Tower Building
  Empire State Plaza
  Albany, New York 12237-0719