First Class Solutions - Skilled Nursing and Long-Term Care Services

First Class Solutions, Inc.^SM launched its Skilled Nursing and Long-Term Care Services in 2009. Our SNF-LTC division focuses on health information management/medical records oversight, improving documentation, process improvements, coding accuracy, and HIPAA services.

We serve all types of long-term care entities that desire guidance and/or oversight of their resident and client health information. Our clients include:

• Skilled Nursing Facilities and Nursing Homes

• Assisted Living Facilities

• Memory Care Facilities

• Hospital-Based Skilled Nursing Facilities/Swing-beds

• Continuum of Care Communities

Our full-suite of SNF-LTC services include:

Documentation and Billing Audits:

A facility’s backbone for reimbursement and continuity of care is dependent upon the medical record documentation. We provide comprehensive medical record audits including but not limited to:

• CASPER Validation Audits: Does the CASPER report reflect the true quality of services provided by your facility? One incorrect entry on the MDS can have devastating effects on your CASPER report and 5-Star reported quality metrics. Our focused CASPER audits validate the quality metrics and can identify documentation voices that may contribute to lower quality scores. We also can provide assistance with internal tracking of these metrics and integration into the Quality Assurance process.

• Billing Audits: Does your documentation support what you billed? Our comprehensive billing audits review your documentation from the medical record to the UB04 to ensure billing compliance. We drill into documentation including nursing and therapy support of medical necessity, therapy minutes, Medicare A certifications and ADL capture to validate RUG scores and identify any potential billing issues.

Our medical record audits include, but are not limited to:

• CASPER Validation

• Medicare "Skilled" Requirements

• Psychotropic Medications

• Discharge/Transfer

• Pain Management

• Admission and Discharge Medication Reconciliation

• Documentation to Support QAPI Initiatives

• MDS Accuracy

• Care Plan Accuracy

• Incident Documentation (e.g. falls, skin tear, potential abuse/neglect)

• Billing Accuracy

• Diagnostic Order and Result Reconciliation

• Immunizations

Survey Preparation and Plan of Correction Assistance:

Whether you are expecting a survey or need assistance correcting cited deficiencies, our professionals can help ensure your HIM department and medical records get back on track. Fluent in Illinois, Kansas, Mississippi, Missouri and Texas state and federal regulations, we can assess the HIM department and record documentation for compliance with regulations and initiate any necessary plans of correction.

Medical Record/Health Information Management (HIM) Operational Assessment and Consulting Services:

Assessment and consulting services for HIM/Medical Records departments include, but are not limited to:

• Policies and procedures, including:

✪ Completion of medical records,

✪ Documentation standards,

✪ Thinning records,

✪ Late entries and clinician amendments,

✪ Release of Information including patient access, amendments, and fees,

✪ Legal Health Record definition and inventory,

✪ Concurrent and closed record reviews,

✪ Retention requirements (medical, administrative, and financial records), and

✪ Abbreviations

• Implementation of Electronic Health Records including template design, HIM workflow analysis, and document imaging coordination

• Maintenance of medical records, including:

✪ Retention,

✪ Record organization and accessibility,

✪ Concurrent and retrospective reviews for documentation deficiencies,

✪ Follow-through on record completion,

✪ Establishing the legal health record inventory and definition

✪ Proper record destruction procedures, and

✪ e-Discovery readiness.

• Communication protocols between HIM and clinical staff

• Training and education opportunities/access/content development for:

✪ HIM staff

❇ New clerk orientation and

✪ Facility staff:

✳ Privacy and Disclosure Practices

✳ Coding (ICD-10CM)

• Review of HIM staff qualifications and contribute to performance evaluations

• HIM and other related staff position description composition

• Form design

Health Insurance Portability and Accountability Act (HIPAA) Compliance:

Our certified and experienced professionals will conduct an assessment of your organization’s HIPAA readiness based on the latest Health Information Technology for Economic and Clinical Health (HITECH) and Office for Civil Rights (OCR) regulation

Have you created and updated your HIPAA policies and procedures after your full (or partial) EHR implementation? Are you in compliance with the HITECH changes from 2013? Is your facility ready for an OCR audit?

The scope of our assessments can be facility-wide or focus on a single aspect such as:

• Policy development and updating

• Release of information and disclosure practices and forms

• Capturing HITECH in the current policies and procedures

• Identifying weaknesses and omissions in the organization’s current practices

Our team of consultants includes professionals certified in privacy and security. We utilize the latest OCR audit protocol and guidance to assess your facility for compliance. We can develop policies and procedures, provide education, and serve as an ongoing resource for your privacy related issues.

ICD-10 Coding Validation and MDS Support Services

While ICD-10 was implemented in 2015, changes to the classification system continue to occur at least annually. Are you certain your MDS and HIM staff are capturing the correct and complete codes for your residents? Our certified and credentialed coding professionals can audit a sample of your claims and provide coding guidance and education for your team. Learn how to use the 70,000+ codes to comprehensively describe the complexity of the residents you serve and accurate populate your public profiles

Have a vacancy in your MDS coordinator team? Call us! We may have MDS certified staff available to virtually fill that void until you are able to fill it permanently.