Technical Specs on Upcoming Changes to the MDS 10/1/2017 Presented - - PDF document
2/22/2017 Technical Specs on Upcoming Changes to the MDS 10/1/2017 Presented by: Jane C. Belt, MS, RN, RAC-MT, QCP February 22, 2017 Faculty Disclosure I have no financial relationships to disclose I have no conflicts of interests to
2/22/2017 1 Presented by: Jane C. Belt, MS, RN, RAC-MT, QCP February 22, 2017
services
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education activity
least 80% of the entire event. Partial credit may not be awarded
endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services
American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. *AAPACN d/b/a American Association of Nurse Assessment Coordination 3
Sections N and P effective October 1, 2017
impacted by the new MDS 3.0 items
the new items and the influence they may have on your MDS accuracy and survey
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MDS 3.0 Technical Information
December 22, 2016
Specifications was posted. This version scheduled to become effective October 1, 2017. This DRAFT version incorporates the changes identified for the DRAFT version (v1.15.0) of the MDS 3.0 item sets. New items have been added to Sections N and P, and there are a number of new Section S items as well. December 1, 2016
sets was posted and scheduled to become effective October 1, 2017
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Federal Government Code of Regulations (Chapter 42 of the Health Code), section 483 dealing with Skilled Nursing/Nursing Facility
– Requirements of Participation (10/4/2016) and were massive – to be implemented in 3 phases: 1 = 11/28/16; 2 = 11/28/17; 3 = 11/28/19 AND – State Operations Manual (SOM), in particular Appendix P and Appendix PP (Guidance and Compliance) (Advance Copy 11/9/2016) AND 2/10/17
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Improvements in Care, Safety, and Protections for LTC Residents
Policies are targeted
Strengthening rights of residents
dementia and in preventing elder abuse
provide person-centered care
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Discharge planning
discharge
services Infection prevention and control program
chosen to use the section - items defined by state States with Section S Items – October 1, 2017
Arkansas Maryland Ohio California Maine Pennsylvania Florida Mississippi South Dakota Illinois North Dakota Virginia Louisiana Nebraska Vermont Massachusetts New York West Virginia
Connecticut has terminated all Section S items
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– Item identification – Item text (label) – In which item subsets the item is activated – Item Values – Item Edits (errors) – Version Changes
certain to have a section S if you’re in a listed state
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MDS 3.0 Nursing Home Comprehensive (NC) Version 1.15.0 Effective 10/01/2017 DRAFT
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No changes for N0410 instructions
NOT how it is used
admission/entry or reentry if less than 7 days
received by the resident in the last 7 days
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Where does the new N0410H appear?
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NH PPS (NP/PPS) NH start of therapy/DC (NSD) SB Discharge (SD) Comprehensive (NC) NH Discharge (ND, NOD) Quarterly (NQ) NH PPS (NP/PPS) NH Start of Therapy/DC (NSD) Swing bed PPS (SP) SB OMRA- Discharge (SOD) SB OMRA SOT/Discharge (SSD)
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Effective 11/28/2016 – Appendix PP SOM revisions
– §483.25(k) Pain Management.
is provided to residents who require such services, consistent with professional standards
centered care plan, and the residents’ goals and preferences.
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– Misunderstanding of indicators for, benefits and risks of, opioids and other analgesics; or – Mistaken belief that older individuals have a higher tolerance for pain; or that pain is an inevitable part
attention – Communication issues due to illness or language and cultural barriers, need to be stoic about pain, and cognitive impairment
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actively dying, those with complex, chronic pain syndromes (> 3 months) that have not responded to non-opioid analgesics or other measures
treatment for chronic pain
receiving other medications with significant effects on the cardiovascular and central nervous systems.
– Careful dosing based on evaluating the drug effectiveness and occurrence of adverse consequences – Clinical record needs to reflect ongoing communication between the physician and the staff for optimal and judicious use of pain medications.
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is controlled relative to the resident’s goals
reduction of pain is vital as is status of causes, response to pain interventions, and possible presence of adverse effects of treatment
prevented or reduced. For example, opioids routinely cause constipation, which may be minimized by appropriate bowel regimen
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moderate to severe pain
treat chronic pain and are not well supported by evidence
inconsistent for function
low back pain, headache and fibromyalgia
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medications since admission/entry or reentry or the prior OBRA assessment
attempted?
continued
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continued
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contraindicated
clinically contraindicated
continued
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Continued CMS Quality Initiative of Reducing Antipsychotics Requirements of Participation revisions Appendix PP continued updating
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2011Q4 = 23.9%
2016Q3 = 16.1%
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Problems with adverse events related to medications warrants close monitoring
– Occurs in 1 of 5 SNF residents – 37% related to medications – 66% of medication-related AEs were preventable – Often occurs due to substandard treatment or insufficient monitoring – Use of multiple medications complicates the determination of the primary cause of events
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includes a resident’s MEDICAL RECORD monthly
(includes, but not limited to any drug that meets the “unnecessary drug” criteria)
– Report (written) must include at least resident’s name, relevant drug, and irregularity – Must be sent to attending, director of nursing, and medical director, who must act on said report
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that identified irregularity was reviewed and what, if any, action taken. If no changes, must document rationale
– Time frames for steps in process – Steps pharmacist must take when he/she identifies an irregularity that requires urgent action to protect the resident
antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.
annually, unless clinically contraindicated
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Considerations Specific to Antipsychotics
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Considerations Specific to Antipsychotics
antipsychotic medication to treat behavioral symptoms, the GDR may be considered clinically contraindicated if:
– Resident’s target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and – Physician documented rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or increase distressed behavior
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disorder (e.g., schizophrenia, bipolar mania, or depression with psychotic features), GDR may be considered contraindicated, if: – Continued use follows standards of practice
– Resident’s target symptoms returned or worsened after most recent GDR attempt and – Physician documented rationale for why any additional attempted dose reduction would likely impair resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder
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Considerations Specific to Antipsychotics
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drug that affects brain activities associated with mental processes and behavior
– Antipsychotics – Anti-anxieties – Antidepressants – Hypnotics
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§483.45(e) Psychotropic Drugs. [§483.45(e)(1)-(5) will be implemented beginning November 28, 2017 (Phase 2)]
resident, the facility must ensure that--
1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; 2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;
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3) Residents do not receive psychotropic drugs based on a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and 4) PRN orders for psychotropic drugs are limited to 14 days. Except if attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days; he/she should document rationale in the resident’s medical record and indicate the duration for the PRN order 5) PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication
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Restraints and Alarms
– Definition of Physical restraint unchanged – Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
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An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected.
Coding:
Enter codes in Boxes
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F222 Restraints (continued)
interventions not only to minimize the medical symptom, but also to address any underlying problems.
might incorporate into care planning: – Equipping the resident with a device that monitors his/her attempts to rise
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F222 Restraints
Right to be free from any restraint imposed for discipline
Definitions: “Convenience” is defined as any action taken by the facility to control a resident’s behavior
behavior with a lesser amount
in the resident’s best interest
F252 Environment
de-emphasizes institutional character of the setting….
“homelike” in this regulations is that the NH should provide an environment as close to that of a private home
elimination of: – Widespread and long- term use of chair and bed alarms
F309 Quality of Care
If medical causes of behaviors ruled out as root cause, facility should conduct systematic analysis and consideration of possible causes, including but not limited to:
example noise levels that could cause misinterpretation of noises, such as… alarms
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F323 Accidents
SUPERVISION is an intervention and means of mitigating accident risk. Adequate supervision may very from resident to resident and from time to time for the same resident. Tools or items, such as personal alarms can help monitor a resident’s activities, but do not eliminate the need for adequate supervision
Think about:
highest level of function
100 decibels – similar to lawnmower starting
as restraints – encourages resident NOT to move, sit still; loss of mobility, increased weakness, skin issues.
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requiring significant change in clinical practices
education, communication, compliance with protocols, feedback, management support, resident safety as a priority, and non-punitive response to mistakes
night – individualized care at night. Sleep hygiene programs do work!!
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in a 3-year grant program studying falls, found that noise was a major environmental factor contributing to falls – reduce noise = a reduction in falls
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Staff conversations (night shift) TVs Hearing linked to balance – increases fall risk if trying to orient self Telephones Radios Personal alarms – same decibels as lawnmower, motorcycle start
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Remember to keep checking the website for more helpful information and events
AANAC Conference in St. Louis – May 3-5, 2017
Thank you for your participation!!
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– https://www.federalregister.gov/documents/2016/10/04/ 2016-23503/medicare-and-medicaid-programs-reform-of- requirements-for-long-term-care-facilities
– https://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment- Instruments/NursinghomeQualityInits/MDS30RAIManual. html
– https://www.cms.gov/medicare/quality-initiatives- patient-assessment- instruments/nursinghomequalityinits/nhqimds30technical information.html
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Department of Health and Human Services, Centers for Disease Control and Preventions (CDC), March 2016.
https://www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf
https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey- and-Cert-Letter-17-07.pdf
CMS Quality Measure, based on MDS 3.0 data
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Quality Partners of Rhode Island, state Quality Improvement Organizations, under contract with CMS, 2007
Falls and Alarms.
www.pioneernetwork.net/Providers/StarterToolkit/Step2/ Mobility
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