Training Objectives Following completion of the presentation the - - PowerPoint PPT Presentation

What’s New with MDS,

Audits & Survey

Barbara A. Bates, MSN, RAC-CT, C-NE June 11, 2015

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Training Objectives

Following completion of the presentation the participants will:

• 1. Increase knowledge/awareness of MDS 3.0

updates.

• 2. Enhance knowledge of current OMIG audit

deficiencies and methods to prevent errors.

• 3. Improve knowledge of current NYS nursing

home survey deficiencies related to medical record documentation.

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MDS Focus Survey

• Nationwide 2015 – Immediate start date
• # of Assessments per audit – varies per

state.

• Minimum 2 surveyors trained how to

access accuracy MDS

• 2 day survey – with exit and review of

findings

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MDS Focus Survey

• Original Pilot (2014) – 25 nursing homes –

24 found deficient: MDS Coding Inaccurate staging/documentation of Pressure Ulcers Lack of Knowledge classification of Antipsychotic Drugs Poor Coding on Use of Restraints Kulus 2015

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MDS Focus Survey

On Entrance – Facility Provided Instructional Letter. Provide: Current Census Resident Census (Alphabetical) with Room # Copy of Floor Plan Within 1 hour of Entrance: 10 most recently completed MDS Assessments submitted for current resident Corrections submitted for these MDS Assessments if any Medical Records supporting MDS Coding

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MDS Focus Survey

Also provide: Policy & Procedures related to Resident Assessment Instrument, MDS and Quality Measures. Staffing schedule all staff involved in scheduling, coding & transmitting data with their role in assessment process delineated. Name & contact information for Quality Assurance & Assessment Coordinator. List all residents who have fallen in past 12 months – date of fall & any resulting injury.

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MDS Focus Survey

• Survey Provider Worksheet – provided by Surveyor:

List residents & room # with following conditions/devices used last 90 days: (More than one condition list separately) Pressure Ulcers Indwelling catheter - urethral, suprapubic, nephrostomy Restraints other than side rails including those used on a as needed basis UTI Record Review, Resident Observation, Staff/Resident interviews utilized to validate coding and staffing.

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MDS Focus Survey

• Could result in Deficiencies in F272 through 287

related to Resident Assessment .

• Person who completes a portion of assessment

must sign and certify completion.

• Civil penalties could be issued – falsification

assessment data.

• Could be sited for F Tags related Quality of Care,

Quality of Life or Nursing Services.

• Will also review self reported staffing.

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Top Annual Survey Citations F323 Free of Accidents #1

Identification

• f Residents

at risk for accidents/falls Resident Physical Restraint Adequate Care Plan Implementation of Procedures to Prevent Accidents

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Top Annual Survey Citations F309 Provide Care/Services for Highest Well Being #4

Resident

Accurate/ Complete Assessment

Care Plan Communi

• cation

with CNAs Care Plan Implemen

• tation/

Delivery

Review /Revise Care Plan and Interventions as needed

Evaluation

• f

Effectiveness

• f Care Plan

Resident Strengths, Needs, Wishes, Goals

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Survey Documentation Related Issues Advanced Directives

Findings:

• The system to identify Advance Directives is not

current and/or consistent with residents’ wishes

• Staff are unaware of the system to identify residents’

wishes

• Staff are not aware of the guidance regarding CPR
• Systems are convoluted and confusing

Complications:

• Resident has a change in status or condition
• Resident or legal representative change decision

about directives

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Survey Documentation Related Issues Advanced Directives

Best Practice:

• Obtain Advance Directive status on

admission and follow through on documentation to support residents’ wishes

• Have documentation of residents’ Advance

Directive wishes easily obtainable

• If in doubt, start CPR and contact 911

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MDS, OMIG and Supporting Documentation

• Review MDS for accuracy – prior to

submitting Automated Random Utilize QAPI to monitor MDS accuracy – develop an improvement plan for repeated errors.

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Section C – MDS Assessment

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10/14 RAI Manual

MDS Coding– Section C

• Staff Assessment for Mental Status

C0700 – Short term Memory OK Talk with and observe resident Collect data from all shifts/departments Code based on information collected during 7 day look back. Select code best describes level of function C0800 – Long term Memory OK Talk with residents/family, direct care staff - memory recall Collect data from all shifts direct care givers Search for medical record documentation providing cues – 7 day look back

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MDS Coding– Section C

• Staff Assessment for Mental Status

C0900 – Memory/Recall Ability Talk with resident family/direct care staff – recall Seek information all shifts/departments Medical record review 7 day look back C1000 – Cognitive Skills for Daily Decision Making Decisions regarding tasks for daily living Documentation Tips:

• Record of discussions – 7day look back – resident/staff/family
• Record of direct observations – 7 day look back
• Progress notes – Interdisciplinary team members – 7 day look

back

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Section D – MDS Assessment

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Section D – MDS Assessment

• PHQ9-OV - Staff Assessment Resident Mood

14 day look back. Staff members who know resident best – all shifts - interview. Encourage reporting of symptom frequency – even if not depression. Choose highest frequency reported by staff/family. New admission – less than 14 days – review transfer document – discuss with family. Documentation tips: Direct resident observations – 14 day look back IDT/direct care giver discussions – 14 day look back

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Section E – MDS Assessment

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Documentation Tips: Understand the difference between Hallucination/Delusions Frequency of hallucinations/delusions not required. Document actual occurrence – 7 day look back. Document direct observation or interview with staff. Progress notes in medical record describing behaviors in 7 day look back.

Section E – MDS Assessment

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Documentation Tips: Code based on how many days behavior(s) occurred during 7 day look back. Staff often normalize behaviors as usual, typical, “always is this way” – code as present. Document in flow sheets, behavior logs, - make sure frequency is captured. Progress notes capturing interview of staff all shifts. Record of direct observation of resident.

Section G – MDS Assessment

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Section G – MDS Assessment

Focus 4 Late Loss ADLs – Bed Mobility, Transfer, Eating and Toileting: Bed Mobility: How resident moves to/from lying position, turns side/side, positions body when in bed or alternate sleep furniture, Slide down in bed – how they get back up? Transfer: Moves between surfaces – to/from bed, chair, w/chair, standing position – not to/from bath/toilet. Eating: How residents eats/drinks regardless of skill – not during medication pass. Can be intake by other means – tube feeding, TPN, IV(for nutrition/hydration). Toilet Use: How uses restroom, commode, bedpan, urinal, transfer on/off toilet. Cleans self after elimination, changes pads/brief, adjusts cloths, manages ostomy or catheter. Not – emptying of bedpan, urinal, commode, catheter or

• stomy bag.

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Section G – MDS Assessment

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Section G – MDS Assessment

• G0110 Activities of Daily Living Assistance

Independent – No help/oversight – every time &

• ccurred 3+ times (Code 0) in 7 day look back.

Supervision – oversight, encouragement, cuing – no hands on - 3 or more times during 7 day look back (Code 1). Limited Assistance – resident highly involved, received physical help in guided maneuvering or not weight bearing assist 3+ during 7 day look back (Code 2). Extensive Assistance – Resident performed part over last 7 days and help of following type(s) provided 3+ times: Weight-bearing support provided 3 or more times OR Full staff performance 3+ during part but not all 7 days.

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Section G – MDS Assessment

Rule of Three: In order to properly apply Rule of 3, facility must 1st note which ADL activity occurred; How many times each ADL activity occurred; What type and level of support required for each ADL activity over entire 7 day period. Exceptions to the Rule: Independent – no help 100% Total dependence – no resident involvement 100% Activity occurred on once or twice – activity occurred less than 3 times in 7 day look back Activity did not occur – did not occur or family and or non-facility staff provided care 100% of the time during entire 7 day look back.

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Section G – MDS Assessment

• Documentation Tips:

ADL must reflect the number of times at each level for every ADL for each shift during 7 day look back and number of staff assisting the resident. Documentation types: Flow sheets – need to be accurate/complete - monitored Nurse notes based on interview with direct care staff giver recorded at the end of each shift. Electronic – Care Tracker, ADL – need to be monitored/accurate Conflict between CNAs and MDS scoring frequently issues – Frequent education, closely monitored and issues resolved.

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Section I – MDS Assessment

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Two required steps in this section: Diagnosis Identification – 60 day look back Diagnosis status – Active or Inactive – 7 day look back period (except UTI = 30 day look back).

• 1. Identify Diagnosis: Physician or Physician

Extender documented diagnosis in last 60 days.

Section I – MDS Assessment

• 2. Determining Active Diagnosis – Active

Diagnoses have direct relationship to resident’s current functional, cognitive, mood, or behavior status, medical treatments, nursing monitoring or risk of death during 7 day look back. Not: Resolved conditions – not affecting current status; Do not drive resident care plan during 7 day look back

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Section I – MDS Assessment

• Documentation Tips:

Physician Documentation – Progress notes, recent history/physical, transfer documents, discharge summaries, diagnosis/problem lists, other sources as available. Problem list – only diagnosis confirmed by physician should be entered. Diagnoses communicated verbally must be documented by physician to ensure follow up. Diagnostic information, including past history

• btained from family – must be documented

in medical record by physician to ensure validity and follow up.

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Section I – MDS Assessment

• Documentation Tips:

Nursing Documentation – May Include: Progress notes describing monitoring/treatment of specific condition(s). Therapeutic efficacy of medication (not monitoring for adverse effects as part of usual nursing practice. Treatment records Vital signs/graphic records Lab test reports

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Section J – MDS Assessment

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Fever: Temperature 2.4 degrees F higher than baseline. Baseline not established – temperature of 100.4 degrees F on admission would be considered a fever. Record Fever in Medical Record. Resident baseline temperature should be established prior to ARD. Establish only 1 time, keep in record.

Section K – MDS Assessment

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Height: Base height done since most recent admission/entry; Height must be recorded yearly. Record to nearest whole inch – use mathematical rounding Weight: Base weight within last 30 days; Weight needs to be taken within 30 days of ARD of each assessment; If weight more than 30 days prior ARD or previous weight not available weigh resident again. Weight taken more than once during month use most recent Height/Weight should appear in the medical record. BMI auto calculated by software.

Section 0 – MDS Assessment

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Section 0 – MDS Assessment

• Documentation Tips:

Documentation to support IV medications pre-admission found in information from hospital stay or other settings. Base Coding for column one (while not a resident) supported by pre-admission history.

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Section O – MDS Assessment

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Section O – MDS Assessment

• Therapies:

Medically necessary, occurred after admission Ordered by physician or extender – based on qualified therapist assessment and treatment plan; Documented in medical record AND Care Planned and periodically evaluated to ensure resident receives needed therapies and current plan is effective. Services must be reasonable; Must Be: Directly/specifically related to active written treatment plan designed by physician after any needed consultation with qualified therapist.

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Section O – MDS Assessment

• Therapy – SLP, OT and PT

Can’t count resident/family requested therapy even if done by qualified therapist. Documentation Tips: Include rational for course of therapy treatment; Document prior level of function and Expectation regarding improvement, etc.

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Section O – MDS Assessment

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Documentation Needed: Evaluation by RN – who then plans program. Measurable objectives/interventions in care plan/clinical record Staff providing care documents amount of minutes of care provided each time care given. (Flow sheets). May include information on how resident performed in relation to goals.

Section O – MDS Assessment

• Restorative Nursing Documentation:

Tracking sheet or method to capture days/minutes each RNP modality Progress notes/periodic evaluation Need 2 or more RNP modalities at least 6 days per week for 15 minutes each day to impact RUG (except toileting program).

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Section O – MDS Assessment

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Physician Orders: # Days during 14 day look back in which physician changed orders. Written orders by Medical Drs., Doctors of Osteopathy, Podiatrists, Dentist, PA, NP or Clinical Nurse Specialists. Written, telephone, fax or consultation orders – new or altered treatment. Not standard admission orders, return, renewal or clarifying orders without changes. Documentation: May be found in – but not limited to - Physician Progress notes/ Nursing Progress Notes Physician orders Consult orders/notes

Additional Documentation

Conflicting Documentation in Medical Record: Document a progress note, clarify and resolve the issue. Care Plans: Describes a holistic picture of the resident – resident centered. Documents Resident needs/problems/ complications and potential risks. Builds on resident strengths, goals and wishes. Goals are measurable, time specific, purposeful and realistic. What interventions have been and are being used. Outcomes, evaluation and revision. If care plan is evaluated AFTER ARD, it does not provide documentation for supporting MDS coding.

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Auditing Documentation

• Review Documentation – Backwards through look

back periods

• Ask ? – Can the MDS be coded based on what is

documented in the record?

• If NOT – WHY NOT – Use a root cause analysis to

determine reason.

• Develop an action plan to improve documentation.
• Determine Educational needs of staff.
• Implement improvement plan, monitor
• utcomes/revise as needed.
• Audit documentation – check for compliance –

corrective actions as needed.

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Helpful Resources

Centers for Medicare and Medicaid Services (CMS) NYS Department of Health American Association of Nurse Assessment Coordinators (AANAC) Resident Assessment Manual – October 2015 Office of Medicaid Inspector General (OMIG)

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Thank you

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