MDS 3.0 ACCURACY SURVEY PROCESSPRESENTED BY

LEAH KLUSCH

EXECUTIVE DIRECTOR

THE ALLIANCE TRAINING CENTER

ALLIANCE, OHIO

NEW AND VERY PROBLEMATIC

First time the survey process has looked at MDS data base accuracy

In the past if the data base was not accurate it was only cited if it was related to the outcome of the resident care or another citation

Accuracy of the MDS data base has been the concern of the audits or charges of fraud and payment abuse.

This has allowed a lot of inaccurate data to be present and not identified

Data errors usually cost facilities reimbursement

Historically there are very few F-272 and F-tags cited.

TAG - 272

The facility must initially and periodically do a comprehensive, accurate, standardized, reproducible assessment of the resident’s functional status.

FOUR IMPORTANT WORDS THAT DRIVE THE DATA BASE

COMPREHENSIVE ACCURATE STANDARDIZED REPRODUCIBLE

THE PURPOSE OF THE ASSESSMENT

TO DOCUMENT THE RESIDENT'S FUNCTIONAL CAPACITY – AND THE TREATMENTS AND SERVICES THAT ARE BEING PROVIDED MUST BE CONGENIAL WITH THAT STATUS

WHERE IS THE ACCURACY STANDARD FOR THE DATA COLLECTION AND TRANSMISSION PROCESS?

First is the regulatory process – Federal tags 272 and following

Next is the issue of the data collection process and the selection of the proper assessment types and timing.

Chapter 1 of the RAI Manual – Privacy statement and interdisciplinary process

Coordination of the RAI Manual and federal regulations and policy statements – Medicare Benefit Policy Manual etc.

Directions, definitions and statements in the RAI Manual updated for the ARID of the assessment being completed – this is very important!

MANY OF THESE SOURCES ARE NOT USED BY THE R.N. ASSESSMENT COORDINATORS TO SCHEDULE AND COMPLETE ASSESSMENTS.

THE SURVEYORS AND AUDITORS HAVE ALL THESE REFERENCES.

BEFORE AN MDS NURSE COMPLETES OR CODES AN ASSESSMENT THEY MUST READ THE REGULATORY MATERIALS AND THE REQUIREMENTS FOR THE ASSESSMENT DATA.

THE INDUSTRY HAS A LOT OF HOMEWORK TO DO BEFORE THE SURVEY PROCESS BEGINS SO THEY ARE READY TO RESPOND TO REQUESTS AND INQUIRY ABOUT THE PROCESS

WHERE TO BEGIN ?????????

AN HONEST ASSESSMENT OF THE CURRENT DATA COLLECTION PROCESS IS ESSENTIAL

THIS INCLUDES CURRENT MANUALS AND REGULATORY MATERIALS

A WRITTEN REPRESENTATION OF THE FLOW OF THE DATA – WHO FILLS OUT THE SECTIONS OF THE DATA SET .

THE ASSESSMENT PROCESS IS THE RESPONSIBILITY OF THE ADMINISTRATOR OF THE FACILITY – “ THE FACILITY MUST……”

THE ADMINISTRATOR WILL BE ASKED QUESTIONS DURING THE SURVEY – THEY NEED TO BE READY AND AWARE OF THE PROCESS IN THE FACILITY.

WHAT ARE THE REQUIREMENTS IN THE PROCESS?

WHO IS THE R.N. ASSESSMENT COORDINATOR – THIS IS REQUIRED

HOW DID CMS BEGIN THIS PROCESS?

A PILOT STUDY WAS DONE TO TEST THE SURVEY PROCESS.

RECORDS WERE REVIEWED AT A SMALL NUMBER OF FACILITIES AND THEN THE MDS DATA WAS COMPARED TO THE MEDICAL RECORD FOR THE EXACT PERIOD OF TIME OF THE ASSESSMENT REFERENCE PERIOD.

THE FACILITIES THAT WERE PARTICIPATING IN THE PILOT WERE CITED FOR INACCURATE DATA – ALL BUT ONE FACILITY GOT CITATIONS.

THE RECORDS WERE EVALUATED FOR ACCURACY AND THE SCHEDULE OF THE ASSESSMENTS WAS ALSO COMPARED TO THE RAI MANUAL INSTRUCTIONS IN CHAPTER 2.

THE DEFINITIONS IN THE F-TAG WERE ALSO UTILIZED.

THE CA PROCESS AND CARE PLANNING WERE ALSO EVALUATED FOR TIMING AND DOCUMENTATION.

NEXT STEPS

THE SURVEY TASKS WERE EASY TO ESTABLISH BECAUSE THE DATA COLLECTION PROCESS IS VERY DEFINED AS WELL AS THE SCHEDULE FOR THE ASSESSMENTS.

THE QUALITY OF THE DATA ON THE ASSESSMENT WAS DETERMINED BY THE BACK UP DOCUMENTATION IN THE RECORD.

SURVEYORS WILL USUALLY REVIEW AN MDS ASSOCIATED WITH A CASE THAT IS PART OF THE CASE REVIEW IN THE SURVEY IN GENERAL.

THE DEFINITION OF THE DATA IS IN TAG 272 – COMPREHENSIVE, ACCURATE , STANDARDIZED, REPRODUCIBLE DATA.

DATES WILL ALSO BE EVALUATED AS WELL AS THE REQUIREMENTS FOR CERTAIN DATA TO BE COLLECTED AT SPECIFIC TIMES.

When the surveyors do this task they will ask for the last 10 OKRA assessments that were completed and transmitted into the QI'S data base.

You will gather these assessments from your validation documents – they will know what the last assessments validated are – they will be checking your records.

They will ask for the policy and procedure documents for the assessment process ,and the Quality Measures. WHAT IS THIS??????????????

DO YOU HAVE A POLICY AND PROCEDURE FOR ASSESSMENT COMPLETION? MOST FACILITIES DO NOT.

ASSESSMENT POLICY AND PROCEDURE

This will reflect exactly how you schedule and complete the assessment documents.

Who is responsible for the data collection and data entry for each section or item on the MDS 3.0 and who signs the attestation of accuracy section Z for each item?

What is their training ? Do they have current resources for directions for coding and documentation?

Can they answer questions about their sections or items on the form and show the documentation that substantiates the coding?

The Administrator and the R.N. Assessment Coordinator are responsible for this. Many facilities in the Pilot program got cited for this requirement.

You can write your policy and procedure with the responsibility for coding by job title as long as that meets practice standards and the definitions in the current RAI Manual.

Be sure you are using the current updated RAI Manual – they check and if you say you have it on line and then your personnel need to know how to access the file and find the definitions etc. that they need.

Your policy must reflect the most current changes in the process – When do you weigh the resident for section K 300. It changed.

Who does interviews and when are they done?

What data does the MDS Nurse collect from the medical record and how is it substantiated with dates and checked for accuracy.

Tag 272 says – “standardized assessment” – You need to have a policy and procedure so that all assessments are done the same according to the structure in the RAI Manual.

Remember you are collecting Data not information or stuff.

Data collection needs to be part of orientation for all staff expected to be part of the data collection process. This is currently not being done in most facilities.

Surveyors will ask for a list of all personnel with responsibility for any data entered on to the assessments and their assigned sections or items. Do not forget Section A.

Surveyors will need staffing schedules for all staff involved in scheduling, coding and transmitting MDS data with their roles in the assessment process delineated. Prepare this now.

Surveyors will ask for the name and contact information for the quality assessment and assurance coordinator. Have information about the QA process in the facility and the frequency of the review of the QM reports.

They will also want a list of all the residents who have fallen in the last 12 months.

LET’S GO BACK TO THE REGULATORY LANGUAGE…

COMPREHENSIVE

ACCURATE

STANDARDIZED

REPRODUCIBLE ASSESSMENT

SCHEDULED ACCORDING TO THE DIRECTIONS IN CHAPTER 2 OF THE RAI MANUAL

COMPLETED ACCORDING TO THE RULES IN CHAPTER 2 AND CHAPTER 5 INCLUDING TRANSMISSION AND VALIDATION.

COMPREHENSIVE ASSESSMENT CONTROVERSY

NO CONTROVERSY – THE RULES FOR THE COMPLETION OF THE ASSESSMENT WITHIN THE FIRST 14 DAYS CHANGED WHEN THE NEW ASSESSMENT FORM WAS INTRODUCED IN OCTOBER 2011.

SECTION V DOCUMENTATION CHANGED AND THE DIRECTIONS FOR COMPETING THE ASSESSMENT FOR TRANSMISSION AND PROPERLY DATING V200C2 .

READ DIRECTIONS IN SECTION V FOR THIS DATE AND SIGNATURE CAREFULLY.

THIS IS VERY EASY FOR SURVEYORS TO CHECK WITH CARE PLAN MEETING DOCUMENTATION.

COMMON CODING PROBLEMS

NUMERICAL CODING IS VERY EASY FOR AUDIT CHECK

SCORES FOR BIMS, MOOD SEVERITY INTERVIEW, LEVELS OF PAIN, ADL SCORES, HEIGHT , WEIGHT, SPECIFIC TREATMENTS, DAYS OF THERAPY OR MEDICATIONS

DIAGNOSIS CODING MUST BE SPECIFIC AND CONFIRMED BY THE PHYSICIAN

LOOK AT SPECIFIC CODING INSTRUCTIONS – EXAMPLE - DEHYDRATION, PRESSURE ULCER CODING ETC.

REMEMBER ALL DATA ON THE MDS NEEDS TO BE REPRODUCIBLE IN THE MEDICAL RECORD DURING THE TIME FRAMES DICTATED BY THE DIRECTIONS IN THE RAI MANUAL.

BE VERY CAREFUL WITH REHAB CODING

MINUTES OF THERAPY HAVE A VERY SPECIFIC DEFINITION IN SECTION O OF THE RAI MANUAL

THERAPY MINUTES MUST BE JUSTIFIED WITH NOTES AND THEN CAREFULLY CODED IN THE RECORD TO THE MINUTE – NO ROUNDING OF MINUTES

THERAPY MINUTES IN SECTION O 400 A,B,C SHOULD BE SIGNED FOR BY THE THERAPY MANAGER OR THE INDIVIDUAL THERAPISTS IN SECTION Z FOR ACCURACY.

ALL THERAPY MINUTES ON THE MDS MUST BE FOR SKILLED THERAPY SERVICES ONLY AND BE IDENTIFIED BY THE TYPES OF MINUTES DEFINED IN SECTION O.

CO TREATMENT AND INDIVIDUAL MINUTES ARE DOUBLE CODED SINCE THE LAST RAI MANUAL REVISION.

The surveyors will also use the Focused Survey Facility Worksheet to review any residents who had any of the following during the last 90 days:

Pressure ulcers

Indwelling catheters if all types

Restraints other than side rails

Urinary Tract Infections

Antipsychotic Medications

Resident reviews will be augmented by resident observations, resident interviews, entries into the medical record and other treatment and medication records.

Surveyors will use F-tags 272 thru 287 to site any issues they find.

Facilities must be aware that the Code of Federal Regulations also states that civil money penalties could be issued for falsification of assessment data including dates and clinical and treatment information.

The pilot program also had citations for deficient practices related to quality of care, quality of life or nursing practices.

Big issue – do you document Section V 200b2 correctly

Completion of the formal care plan – after the care plan meeting

Then and only then can column B of Section V be filled in and the V200c can be signed and dated on the date of the care plan meeting or later.

THEN AND ONLY THEN CAN THE 14 DAY ASSESSMENT BE TRANSMITTED AND VALIDATED UNLESS YOU DID THE CAAs ON THE FIVE DAY ASSESSMENT.

PLEASE READ SECTION V IN CHAPTER 3 OF THE RAI MANUAL CAREFULLY – THIS IS AN ACCURACY AND A COMPLIANCE ISSUE.

SO WHAT DO WE DO NOW?

START NOW WITH DOCUMENTATION OF YOUR ASSESSMENT PROCESS WITH A POLICY AND PROCEDURE THAT IS ACCURATE AND OPERATIONALLY CORRECT.

CHECK THAT ALL MEMBERS OF THE TEAM COMPLETING ITEMS ON THE MDS HAVE THE CORRECT, UPDATED DIRECTIONS FROM THE MANUAL

REVIEW THE SUBSTANTIATING DATA IN THE MEDICAL RECORD – THE CRITERIA IS REPRODUCIBLE – EXACT DOCUMENTATION.

ALL INTERVIEWS NEED TO BE DOCUMENTED IN THE RECORD – ALL 6 INTERVIEWS !!!!!!!!

ATTESTATION SIGNATURES AND DATES NEED TO BE COMPLIANT WITH THE DIRECTIONS.

NO ONE SHOULD TAKE CREDIT FOR ACCURACY OF DATA IN SECTION Z THAT THEY DID NOT CREATE OR SECURE FROM THE RECORD.

SINCE THERAPY MINUTES AND DAYS PRODUCE SIGNIFICANT PAYMENT RISK THEY SHOULD BE ATTESTED TO BY THE THERAPY MANAGER OR A THERAPIST.

DO YOU HAVE A LIST OF ALL THE STAFF INVOLVED WITH THE SCHEDULING AND COMPLETION OF THE MDS PROCESS – THAT INCLUDES TRANSMISSION AND VALIDATION AS WELL AS CORRECTIONS.

WHERE ARE THE MANUALS AND ARE THEY UPDATED TO FEBRUARY 2015.

SHOULD WE AUDIT ? GOOD IDEA!!!!!!!!!!!

CHECK ON TRAINING

DO NOT ASSUME STAFF HAVE READ MATERIALS FROM THE MANUAL – CHECK ON THEIR UNDERSTANDING AND COMPLIANCE.

NO ONE SHOULD EVER SIGN FOR ACCURACY OF DATA THAT THEY ARE NOT COMPLETING OR CREATING.

THIS NEW SURVEY TASK IS VERY PROBLEMATIC AND RISKY – BE CAREFUL.

QUESTIONS ?????????????