MDS 3.0 What s New & A Review. Focused Survey NOMNC 10/31/2014. Carol Hill, MSN, RN, RAC CT, C NE, RAC MT

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1 MDS 3.0 What s New & A Review Carol Hill, MSN, RN, RAC CT, C NE, RAC MT Focused Survey Focused Minimum Data Set (MDS) Survey April 18, 2014 S& C:14 22 NH Pilot Began 2014 Intent to document MDS 3.0 coding practices and associated care planning NOMNC Notice of Medicare Non Coverage CMS NOMNC As of August 1, 2014 form should reflect KEPRO as the QIO that beneficiaries would contact for an appeal. 1

2 Discharge Assessments August 25, 2014 S& C: NH Reinforced requirement that discharge assessments are required when a resident transfers from a Medicare and/or Medicaidcertified bed to a non certified bed. 5 STAR CMS Announces Two Medicare Quality Improvement Initiatives CMS Press Release October 6, 2014 Beginning 2015 Nationwide Focused Survey Inspections Verification of Staffing and Quality Measures Payroll Based Staffing Reporting Quarterly Reporting A System Auditable Back to Payroll 5 STAR CMS Announces Two Medicare Quality Improvement Initiatives January 2015 Add a Quality Measure Extent of Antipsychotic Use Additional Quality Measures to be added later Also going to work on revising the methodology for calculating facility quality measures 2

3 MDS Updates No Updates for April 2014 Most recent MDS update effective October 1, 2014 Already has been a revision to this update UPDATES OCTOBER A discharge assessment is required when: A resident is discharged from the facility to a private residence (as opposed to going on an LOA); Resident is admitted to a hospital or other care setting (regardless of whether the nursing home discharges or formally closes the record) Resident has a hospital observation stay greater than 24 hours, regardless of whether the hospital admits the resident, Resident is transferred from a Medicare and/or Medicaidcertified bed to a noncertified bed. 3

4 2 21 & 2=22 If hospice election can be captured on the admission assessment a significant change assessment is not required after hospice election The reference date for a significant change assessment must be less than or equal to 14 days after the interdisciplinary team determines the resident has met the criteria for a significant change assessment Admission Admitted for the first time to this facility or Readmitted after a discharge return not anticipated or Readmitted after a discharge return anticipated when return was not within 30 days of discharge 2 33 Reentry Readmitted to the facility after discharged return anticipated and return within 30 days of discharge 4

5 2 33 & 2 37 The ARD for a discharge assessment equals the discharge date and can be coded any time during the Discharge assessment completion period (discharge date plus 14 calendar days) 2 36 & 2 37 A dash is used when unable to determine a response including interview items. For an unplanned discharge the facility should complete the assessment to the best of its ability 2 41 Readmission/return assessment type was deleted 2 48 For an EOT a treatment day is 15 minutes of therapy a day as defined in Chapter 3 Section O 2 52 The COT ARD may not precede the ARD of the first scheduled or unscheduled PPS assessment of the Medicare stay used to establish the patient s initial RUG IV therapy classification in a Medicare Part A SNF stay 5

6 2 52 A COT may be completed when a resident is not currently classified into a RUG IV therapy group, but only if both of the following conditions are met: Resident has been classified into a RUG IV therapy group on a prior assessment during the residents current Medicare Part A stay and No discontinuation of therapy services (planned or unplanned) occurred between Day 1 of the COT observation period for the COT OMRA that classified the resident into his/her current non therapy RUG=IV therapy group 2 56 Combining a COT and Scheduled Assessment The ARD must be set within the window for the scheduled assessment and on day 7 of the COT observation period in order to combine a COT and Scheduled Assessment 2 73 If a resident is eligible for Medicare Part A, requires and receives a skilled service and has days available under Medicare Part A the first required Medicare assessment is always the Medicare required 5 day assessment 6

7 2 74 & 2 75 Services provided during a leave of absence that takes place during part of the assessment reference period can be included on the MDS when permitted by MDS coding guidelines Throughout the manual the word nursing home was changed to Facility A 7 A0410 The title of this question was changed to Unit Certification or Licensure Designation Payer source is not the determinant by which this item is coded. Code based on authority CMS and/or state has to collect MDS data for this resident. 1 Not Medicare nor Medicaid certified & MDS not required by State 2 Not Medicare nor Medicaid certified but MDS required by State Does not apply to Swing Bed 3 Medicare and/or Medicaid certified 7

8 A 14 A1100 for answers 0 & 9 added Skip to A1200, Marital Status A 19 A1500 A new link was added regarding information for PASRR A 21 A1600 Heading changed to Most Recent Admission, Entry or Reentry into this facility A 21 Removed the notation that Swing beds would always code entry trackings as an admission A 25 A1900 New Item Admission Date (Date this episode of care in this facility began) This date may be the same as A1600 for the entire stay if the resident never discharged. J 2 J0100 Non medication pain intervention does not include herbal or alternative medicine products 8

9 K 16 & K 17 An example was provided when all 7 days of the look back were not in the facility O 3 O0100F Ventilator or respirator: Residents requiring closed system ventilation includes those residents receiving ventilation via an endotracheal tube (e.g. nasally or orally intubated) as well as those with a tracheostomy. O 6 Included information about flu vaccine reactions O 5 through O 9 Inserted the word vaccination between any notations in the manual that said influenza season now reads influenza vaccination season O 8 Once administered carry the influenza vaccination status forward until a new influenza season begins O 8 Immunize with the influenza vaccine as soon as vaccine becomes available and continue until influenza is no longer circulating in your geographic area. 9

10 O 18 O0400 Co treatment minutes: Skip the item if no co treatment was provided X2 X7 Added clarifications of where items in section X should be obtained from (example X0150 Type of Provider would be completed using A0200 on the existing record to be modified/inactivated) 5 10 A correction can be submitted for any accepted record within 3 years of the target date of the record for facilities that are still open. A correction can be submitted within 2 years of the target date of the record for facilities that have been terminated Records with the incorrect Unit Certification or Licensure Designation or Wrong state_cd or facility ID can only be corrected via manual deletion. The State Agency must be contacted to assist the facility with a manual deletion. 10

11 6 12 With an EOT R it is possible that the ARD for an EOT may be set for the first grace day of the allowable grace days for a scheduled PPS assessment, while the ARD for the scheduled assessment was set for a day within the normal ARD window. In this limited subset of cases, the resumption of therapy should occur during the previous RUG IV therapy level (which should be the same as the therapy level determined on the scheduled PPS assessment if the resumption is appropriate) but using the Activities of Daily Living (ADL)score from the most recent PPS Assessment For a Medicare Short Stay indicator if there is a fraction in the average daily minutes the total therapy minutes is not rounded and only the whole number is used Refer to Appendix E for cases in which the PHQ 9 or (PHQ 9 OV ) is complete but all questions are not answered. Updated in September 2014 MDS 3.0 Providers Users Guide Casper Reporting Users Guide for MDS Providers 11

12 MDS REVIEW Documentation All items coded on the MDS should be supported in the medical record with the exception of the interviews. Section A Identification Information Legal name as it appears on Medicare card, Medicaid card or other government issued document Gender must match gender listed in the social security data base Occupation main occupation before retiring or entering the nursing home 12

13 Section B Hearing, Speech, and Vision MDS is a functional assessment How can resident see and hear with appliances if used? Just because resident wears glasses staff often document impaired vision rather than how resident can see with the glasses. Section C Cognitive Patterns Brief Interview for Mental Status (BIMS) Use script for conducting the interview Complete any time during the look back period Specific criteria listed in Appendix E if BIMS is administered in writing Section D Mood Patient Health Questionnaire (PHQ 9) Use script to conduct interview Cue cards are required to complete interview Conduct preferably the day before or the day of the reference date 13

14 Section E Behaviors Is the resident having behaviors that are not documented in the medical record Inconsistencies in documenting behaviors Section F Preferences for Customary Routine and Activities Use script to conduct interview Cue cards are required to complete interview Conduct interview any time during the look back period Section F Preferences for Customary Routine and Activities The only interview that can be completed by family/significant other if resident cannot complete the interview Information from the interview should be incorporated into the plan of care 14

15 Section G Functional Status Inconsistencies in documenting activities of daily living Lack of supporting documentation for activities of daily living If using MDS terms to document staff must have an understanding of what those terms mean (example: limited, extensive, total) When staff documents they should consider the full definition of the activity (example dressing also includes applying prosthesis and ted hose) Section G Functional Status Does MDS staff know how therapy terms apply to MDS coding? Mobility devices pushing a wheelchair is coded as a walker Section H Bladder and Bowel To code a toileting program the program must meet the MDS criteria for a program Staff should have a clear understanding of the difference between continence and incontinence Constipation two or fewer bowel movements during the look back or if for most bowel movements their stool is hard and difficult to pass regardless of the frequency 15

16 Section I Active Diagnosis Identify all diagnosis documented by physician in the last 60 days of those diagnosis which ones were active in the last seven days. Only code on the MDS those active in the last seven days. Remember to use V codes as indicated by resident status Section I Urinary tract infection 30 day look back Must have all four criteria in the look back in order to code on the MDS Diagnosis Signs and symptoms Significant lab findings Treatment Section J Health Conditions Non medication interventions should be listed in the plan of care, documented they were received and the effectiveness of the intervention in order to code on MDS Pain Interview Use script for conducting interview Cue cards are required for the interview Conduct the interview preferably the day before or the day of the reference date 16

17 Section J Health Conditions Documentation should indicate what the shortness of breath was associated with (example at rest, with exertion, when lying flat) If resident is receiving hospice services the J1400 prognosis question should be coded yes Fever: 2.4 degrees above baseline or prior to establishing a baseline temperature Does your facility establish baseline temperatures? Section K Swallowing/Nutritional Status Height should be obtained yearly Weight loss and weight gain is only looking at two points in time one month & six months Section L Oral/Dental Status Dental exam should be conducted during the look back period Code L0200B when the resident has upper and lower dentures as resident does not have any natural teeth. Has staff followed up on abnormal findings from the dental exam? 17

18 Section M Skin Conditions Accurately staging pressure ulcers is key Tracking pressure ulcers in order to determine if the pressure ulcer was present on admit If the onset date of a stage II pressure ulcer is not known code as dashes Does your staff measure pressure ulcers according to RAI manual instructions? If the most severe tissue type is an open stage 2 pressure ulcer the correct code is epithelial tissue in M0700 Section M Skin Conditions Do you have supporting documentation for mattress & cushion use? Does your turning/repositioning program meet the definition of a program for the MDS? Does your nutrition or hydration interventions meet the definition to code on the MDS in section M? Section N Medications Code medications based on classification, not why given Remember to include medications given via any route (example topical antibiotics) 18

19 Section O Special Treatments, Procedures, and Programs Isolation Strict criteria to code isolation MDS coding does not include isolation for wounds, urinary tract infection or encapsulated pneumonia Influenza vaccine Flu season begins when vaccine is available in your area, ends when no longer an outbreak in your area Restorative nursing programs Must meet definition of a restorative program to code on the MDS Section O Therapy If the resident has ever received therapy since the date in A1600 the start and end dates of the most recent therapy should be coded regardless of whether the resident is currently receiving therapy Section P Restraints If the method, device, material or equipment meets the definition of a restraint it must be coded on the MDS 19

20 Section Q Participation in Assessment and Goal Setting Is a discharge plan documented in the medical record? Is there documentation in the medical record regarding residents preference to be asked about return to the community? Does staff know who the local contact agency is? Is there documentation in the medical record to support contact made to the local contact agency? Section Z When signing the MDS at Z0400 you are signing for the date the information was collected or coordination of collection Which would be interviews on or before the ARD and all other items with a look back period no earlier than the day after the ARD MDS Transmission Two people at the facility should have passwords to transmit MDS Passwords are individual passwords and should not be shared Are validation reports reviewed to see if accepted records contain errors that should be corrected? 20

21 Short Stay If the Medicare stay is 8 days or less does the resident qualify for a short stay? If Z0100 RUG on the short stay comes out as a AAA Check to make sure A2400C is coded correctly Check to make sure the therapy end dates are coded correctly Does the resident meet all 8 criteria for the short stay? Does the nursing RUG pay more than the theapy RUG? Examples obtained from 2567 on Nursing Home Compare (last accessed 10/30/14) Date range 8/8/13 through 8/21/14 A * indicates areas that were written more than one time. The greater the number of * the greater the number of times the area was noted. F272 Resident Assessment Must conduct initially and periodically a comprehensive assessment of each resident s functional capacity Accurate, standardized, reproducible Did not assess nutritional needs Staff assessment for cognition not completed Eating ability not assessed Weekly skin assessment not completed No periodic assessment for lesser restrictive device 21

22 F273 Resident Assessment Conduct comprehensive assessment within 14 calendar days after admission Admission assessment completed late F274 Resident Assessment Comprehensive assessment 14 days after significant change Significant change not completed for hospice*** Quarterly completed rather than significant change F275 Resident Assessment Annual assessment not less than once every 12 months F276 Resident Assessment Quarterly review assessment not less frequently than once every 3 months F278 Resident Assessment Accuracy of Assessment Assessment must accurately reflect resident s status An RN must conduct or coordinate assessment with the appropriate participation of health professionals RN sign and certify assessment is completed Persons completing a portion of the assessment sign and certify accuracy of that portion of the assessment Penalty for falsification 22

23 F278 Resident Assessment Accuracy of Assessment Hospice not coded* Fall not coded Antipsychotic not coded Dentures not coded Determination of pressure ulcer risk incorrectly coded F279 Resident Assessment Comprehensive Care Plan Measureable objectives and timeframes to meet needs identified in the comprehensive assessment Interdisciplinary team develop care plan Care plan addresses needs, strengths, preferences, manage risk F279 Resident Assessment Comprehensive Care Plan No antipsychotic care plan* No hospice care plan** No behavior care plan No dehydration care plan No care plan to address medical condition/drug usage 23

24 F279 Resident Assessment Comprehensive Care Plan No foley care plan Not care planned for refusal of breathing treatment No care plan for BIPAP No pain care plan No depression care plan No care plan for bed/chair alarm No nutrition care plan F280 Resident Assessment Comprehensive Care Plan Resident right to participate in care plan, treatment or changes in care and treatment Care plan developed within 7 days after completion of comprehensive assessment Prepared by interdisciplinary team, periodically reviewed and revised F280 Resident Assessment Comprehensive Care Plan Care plan not updated after a fall**** Care plan not updated after pressure ulcer developed Resident or sponsor were not invited to care plan meeting* Care plan not updated for fluid restriction Care plan not revised for cognitively impaired resident Care plan not updated for oxygen change Care plan did not show cc per shift for fluid restriction 24

25 F281 Resident Assessment Services Provided Services provided must meet professional standards of quality B/P and Pulse not done prior to administering antihypertensive med Toenails not trimmed Aspiration precautions not followed Did not initial the medication administration record Did not give medication within the 2 hour timeframe**** Flex pen not primed prior to use Fail to cleanse site before injection F281 Resident Assessment Services Provided Services provided must meet professional standards of quality Not follow order to change PICC line dressing Nursing assistant operated feeding tube pump Medication given early Prunes not given as ordered Pocket not made when administering eye medication Order for PEG flushes not followed Medications not dissolved before administering via PEG No order for oxygen F281 Resident Assessment Services Provided Services provided must meet professional standards of quality Order for oxygen not followed No order for medical treatment No treatment to surgical wound Wound treatment stopped without order Treatment provided without an order Orders not transcribed as ordered Labs not drawn as ordered 25

26 F282 Resident Assessment Care provided by qualified persons in accordance with written plan of care Heel protectors not used Not turned every hour Not checked and changed every two hours******* Shower not done three times a week Toenails not trimmed Seatbelt not released as care planned * Not encouraged to eat Not offered fluids F282 Resident Assessment Care provided by qualified persons in accordance with written plan of care Not observed while eating Not offered alternative if refused or eat less than 50% Not using two persons with hoyer lift Not following tube feeding care plan Left in room unattended Bed not in lowest position** Non skid socks not used Healthshake not given Did not prevent heel pressure ulcer development F282 Resident Assessment Care provided by qualified persons in accordance with written plan of care Fall mat not in place* Lift not used Two people not present during care Did not monitor for side effects of medication Three people not used with transfer Two people not used for transfers* Geri sleeves not used* Incontinent resident not changed as care planned** Heels not floated** 26

27 F282 Resident Assessment Care provided by qualified persons in accordance with written plan of care Fall care plan not followed* Dycem not used in seat Sensor pad not used in wheelchair Ted hose not used Wheelchair breaks not locked Not put to bed after meals Extremities not elevated Soap and water not used after bowel movement F282 Resident Assessment Care provided by qualified persons in accordance with written plan of care Not given food preferences Leg protectors not used Pad not used between legs Not turned and repositioned every two hours** Not kept clean and dry AIMs not completed Weekly weights not monitored Glasses not on daily Treatment was not completed 283 Resident Assessment Discharge Summary Includes recapitulation of resident s stay Final summary of resident s status Discharge summary does not mention skin at discharge No discharge summary completed at discharge 27

28 284 Resident Assessment Discharge Summary Post discharge plan of care is developed with participation of resident and his/her family which will assist the resident to adjust to his/her new living environment. 285 Resident Assessment Coordination Must coordinate assessments with the preadmission screening and resident review program under Medicaid. PASRR Level II not completed* F286 Maintain all resident assessments completed within the previous 15 months in the residents active clinical record Staff did not have access to the MDS 28

29 F287 Automated Data Processing Requirement Assessment encoded within 7 days after completion Electronically transmit within 14 day after completing a resident s assessment Hill Educational Services Inc. Carol Hill MSN, RN, RAC MT, C NE th Street East Warrior, AL Phone: Fax: chill@hilledservices.com 29