1/28/2011. Good news: the better the care the better the financial outcome! operations.

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1 Good news: the better the care the better the financial outcome! By: Robin A. Bleier, RN, HCRM RB Health Partners, Inc. Objectives 1. List at least two highlights per each section of the MDS Explain three methods to incorporate the MDS 3.0 into day-to-day clinical operations. 3. Describe three methods to evaluate effectiveness of skilled clinical documentation. Objectives 4. Outline minimum of four significant changes between RUGs III &IV. 5. Discuss best methods to manage Medicare reimbursement. 6. State process to inspect what is expected related to MDS 3.0 & RUGs IV compliance. 1

2 Dietary Rehabilitation Resident Recreation OBRA 1987 Resident Pioneer Network 2

3 How Have We Grown in LTC? From OBRA 1987 forward to current, we have embraced the assessment process to support identification of clinical risk factors while also creating a reimbursement mechanism for our Residents using their Medicare part a benefit. Now the MDS 3.0 while similar to the 2.0 continues to have significant variances with a interview focus. RUGs IV re confirms the need for skilled clinical documentation, especially for those Residents not receiving rehab services. MDS 3.0 Section by Section Review Seeking key aspects in the MDS 3.0 from the 2.0. A0100: Facility Provider Numbers Item Rationale: Allows the identification of the nursing home submitting assessment. Explanation: A. NPI, B.CCN, and C. State provider Number (optional). Self explanatory- usually filled in by software system. 3

4 A0200: Type of Provider Rationale: Designation of type of provider Explanation: Answer is always 1 nursing home/snf 2 swing bed (hospital) A0310: Type of Assessment Rationale: Needed Assessment content Explanation: A. Enter coded for OBRA assessment. If not an OBRA assessment enter 99. B. Enter code for PPS assessment. Enter 01 if this is the first assessment ever done on the resident. Enter 06 if this a return/readmission assessment. (Do not do another 01 for this resident) C. OMRA Code no unless you are doing a SOT (Start of Therapy) EOT (End of Therapy) or SOT/EOT combination assessment. A0310: Type of Assessment D. Leave blank or answer 0 E. Since the most recent admission/readmission o Check yes if this is the first assessment done on this resident o Check yes if this is the first MDS 3.0 assessment done on this resident o Check no for all other assessments done on this resident. 4

5 A0310: Type of Assessment F. Entry/Discharge Reporting Enter code that applies to this resident. For a resident that comes and goes several times Admission- Entry Returns to hospital before day eight- Do a 99/01 and discharge return expected. Readmits to facility- do an Entry Tracking form Repeat this cycle as many times as necessary. The second time resident readmits code the PPS section of A0310B an 06- readmission/return. A0310: Type of Assessment Every admission/readmission and death must have a tracking form. Every discharge must have an assessment. The ARD is the date of discharge/death. A0310: Type of Assessment Audit: A0310B-If this is a return/readmission make sue code is 06, not 01 A0310E- check to see if this assessment is the first assessment in MDS 3.0 If this is a LTC assessment the answer would be yes. If this is the first assessment for the current date of admission code yes Any other assessments code no. A tracking form is not an assessment. A0310F- every discharge and return must have a discharge assessment and a Entry tracking form. 5

6 Hospice Benefit If a nursing home resident elects to use the hospice benefit, the nursing home is required to complete an MDS significant change in status assessment, new. The nursing home is also required to complete a SCSA when they come off the hospice benefit (revoke), new. A SCSA is to be completed EVERY time the hospice benefit has been elected, even if a recent MDS was done and only change is the election of hospice, new. A0410: Submission Requirement Rationale: Federal and or State authority to submit MDS assessment data to the MDS National Repository and Nursing homes must be certain that they are submitting the MDS assessments under the appropriate authority. Normally, number 3 is checked (coded 3) A0500-A1000: A1000: Resident Info Allows for Resident identification. Used for matching each of the resident s records. Provides demographic gender specific health trend information. Resident gender on the MDS should match what is in the Social Security System. Allows determination of age. Etc. 6

7 A1100: Language Explanation: Code this yes when the resident cannot understand or speak English and no one in the facility speaks their language Do: Be sure of the need for an interpreter. If you answer this yes, it is recommended to care plan arrangements for the interpreter, when they are available and so forth. Audit: - check for care plan if resident needs an interpreter or other communication assistance. A1200: Marital Status Allows understanding of the formal relationship the resident has and it noted as key in addition to emotional support this can be important for care and discharge planning. Notes important demographic information. A1300: Optional Resident Items A thru D Explanation: Please answer these questions, good information to have and use. C. Name the resident wishes to be called- very important to use this name when referring to resident. Do: Please fill these out, especially the name the resident wants to be calledaddress your documentation to this name, especially the care plans. 7

8 A1500: PASRR II Explanation: If resident has a psychiatric diagnosis or MR/DD then before 40 days have elapsed a level II has to be done. Do: if you have a resident with a psych diagnosis, keep track of their days hereby 40 th day a level II needs to have been done. Audit: Does the resident have a psychiatric diagnosis - have they been in your facility 40 or more days? A1550: Conditions Related to MDS Status Reminder: Be sure you have physician written diagnosis A1600: Entry Date Rationale: To document the date of admission or reentry into the nursing home Reminder: This is the most current admission or readmission date. 8

9 A1700: Type of Entry Rationale: Captures if the date documented in A1600 is an admission or the reentry date. A1800: Entered From Rationale: Understanding the setting that the individual was in immediately prior to nursing home admission i informs care planning and may also inform discharge planning and discusses. Collect demographic information. A2000: Discharge Date Rationale: To close the case in the system. Explanation: Only do if this is a discharge Explanation: Only do if this is a discharge assessment. 9

10 A2100: Discharge Status Rationale: Demographic and outcome information. Explanation: Only do if this is a discharge assessment. A2200: Previous Assessment Reference Date for Significant Correlation Rationale: To identify the ARD of a previous comprehensive or quarterly assessment in which significant error is discovered. Explanation: Leave blank, unless a significant correction has been done A2300: Assessment Reference Date Rationale: Designates the end of the look back period so that all assessment items refer to the residents status during the same period of time. Explanation: This is your ARD for this assessment. 10

11 A2400: Medicare Stay Rationale: Identifies when Resident receiving services under SNF PPS, when services start & end, use the end date to determine if resident qualifies for the short stay assessment. Explanation: If this a Medicare resident code yes at A, put date of admission in B, and put dashes in C if not a discharge. If this is not a Medicare resident code no and go to Section B. Section B: Hearing, Speech, & Vision Intent: To document the resident s ability to hear, understand, and communicate with others and whether the resident experiences visual limitations related to disease common in aged persons. Note: Check for consistency with Section C. Section C: Cognitive Patterns Intent: The items in this section are intended to determine the resident s attention, orientation, and ability to register and recall new information. Do a BIM on everyone that can speak and hear. If you code 4 or more zero s, stop the interview and code C and proceed to staff interview. If C0500 is 7 or less this person is severely impaired and should be care planned as such. Staff interview (if done, should be coded 3 in C1000). RAI manual pages C4,5, and

12 Section C: Cognitive Patterns When you have a resident coded severely impaired, it is recommended that you evaluate if: a statement t t of incapacity, it a Health Care Proxy or Surrogate, and or A Guardian is in place as soon as possible and as appropriate. Section D: Mood Do: D0100- Do interview on everyone that can speak and hear. Recommend- doing care plan on all moods that resident indicate they are feeling. This is straight from the horses mouth. Audit: Check to see if there is a care plan for any responses made. This may not trigger a CAA, but should be care planned as it is the residents feelings. Section E: Behavior Intent: The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility resident, staff, or the care environment. Noting these behaviors as they may place a resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences, or illness. Note: Resident intent should NOT be taken into account when coding for items in this section. If rejection of care coded, check care plan for use of MDS 3.0 terminology and consider informed consent need. 12

13 Section F: Preferences for Customary Routine & Activities Rationale: Use this information as a guide to create an individualized plan of care based on preferences. Do: F0400- Daily preferences- when you code a 1- that this is very important- should be incorporated into a care plan, again this is straight from the resident. F0500- Activity preferences- When a 1 is coded, this is very important to the resident and should be specifically care planned on how you are going to provide these for the resident.(recommended.) Section F: Preferences for Customary Routine & Activities Audit: If F0400 and F0500 have any sections coded 1 as very important to the resident, look for a care plan to address these very Important issues. Section G: Functional Status The intent of the items in this section are present to assess the need for Resident assistance with activities of daily living (ADLs), altered gait and balance, and decreased range of motion. In addition, on admission, the Resident and Staff opinions regarding functional rehab potential are asked and noted. 13

14 Section G: Functional Status Key Definitions ALL of your Care Staff Team should know: 1. ADL 2. ADL Aspect 3. ADL Self-Performance 4. ADL Support Provided Do YOU? Define Functional Status Define: ADL ADLs are tasks related to personal care, these tasks are listed in section G Define Functional Status Define: ADL Aspect C t f ADL ti it F Components of an ADL activity. For example eating GO11OH includes eating and drinking, intake of nourishment or hydration by other means, including tube feeding, total parenteral nutrition, and IV fluids used for hydration. 14

15 Define Functional Status Define: ADL Self-Performance Measures what the resident actually did (not what they might be capable of doing) within each ADL category over the last 7 days according to a performance-based scale. Define Functional Status Define: ADL Support Provided Measures the MOST support provided by staff over the last 7 day period, even if that level of support ONLY occurred once. Functional Coding Keys The difference between Limited Assistance and Extensive Services. Can you define, staff assistance using? Limited v. Extensive 15

16 Functional Coding Keys Limited Assistance includes NO weight bearing staff assistance what-so- ever. It may include guided maneuvering. May also be associated with Contact Guard LIMITED Extensive Assistance Includes various levels of staff weight bearing assistance. May also be associated with Min, Mod, & Max EXTENSIVE Section H: Bladder & Bowel Intent: To gather data on the use of a bowel & or bladder appliances, the use & response to toileting programs, urinary & bowel conditions, patterns & training program. This is to identify those at risk for individualized care and services. Do: If resident is incontinent and you are doing a bladder training program is it appropriate to complete a bowel program at the same time? Section H: Bladder & Bowel Question? A resident on a every two-hour regime, is that considered a program? 16

17 Section H: Bladder & Bowel Answer: `tçuxr If the decision to provide a every two-hour regime is made based on a documented assessment than YES it can be considered a program as long as it has been educated on, documented, identified in the plan of care, and routinely evaluated for effectiveness. Section I: Active Diagnoses Intent: Identify diseases which have a relationship to the resident s CURRENT functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. This intent is crucial to appropriate clinical skilled documentation and especially key for those Residents using their Medicare benefit not yet included in a Rehab program although important to note every day during the skilled stay. Section I: Active Diagnoses Step 1 Step 2 Active v. Inactive The disease conditions in this section require a physician or extender documented diagnosis in the past 60 days. An ACTIVE diagnosis has a direct relationship to the Resident s functional status, cognitive status, mood or behavior, medical tx, nursing monitoring, or risk of death during the 7 day look back period. 60 day look back 7 day look back (exclude UTI) 17

18 Section J: Health Conditions Intent: To document a number of health conditions that impact the Resident s functional status and quality of life. Remember 5 day look back period. Do: If the resident can hear and speak- do the interview for pain. If resident says they have pain-care plan, using residents responses in interview. Consider using the descriptors & frequency coding in your facility based clinical pain evaluation tool. Section J: Health Conditions Falls are the leading cause of injury, morbidity, and mortality in older adults. Prior Falls, especially recent, are strong predictors for future falls and injury. History of Falls may cause fear thus reduce activities. Falls should be evaluated for reversible causes to reduce or eliminate the risk as clinically possible. What is a Fall? A fall is: unplanned change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall, no matter whether it occurred at home, while out of facility. Falls are NOT a result of an overwhelming force (e.g., a resident pushes another resident). 18

19 What is a Intercepted Fall? An Intercepted Fall occurs when the resident would have fallen if he or she had not caught themselves or had not been intercepted by another person. Question? Is this still considered a fall? [ ] Yes [ ] No Is an Intercepted Fall an Actual Fall? Question? Is this still considered a fall? [ x ]Y Yes [ ] No What do your policies and procedures define falls? Section J: Health Conditions Definitions: Injury related to a fall is a documented injury that occurred as a result of or was recognized within a short period of time (hours to a few days) after the fall and was attributed to the fall. Do: Investigate! If the injury was not attributed to the fall, ensure that you have documentation that supports that decision and when appropriate especially if a major injury, which is not attributed to the fall, include the physician s evaluation is if appropriate: documentation not under the facility control critical. 19

20 Section J: Health Conditions Definitions: Injury (except major)-includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains, or any fall- related injury that causes the resident to complain of pain. Major Injury-includes bone fractures, joint dislocations, closed head injuries and altered consciousness, subdural hematoma. Section K: Swallowing/Nutritional To assess the many conditions that COULD affect the resident s ability to maintain adequate nutrition and hydration. Do: Have the resident evaluated as indicated, Engage Rehab is indicated, Assess for s/s that suggest a disorder has not been successfully managed, and Care Plans should be developed to assist in safe/effective techniques, diets, positioning, etc. as well as monitoring. Section K: Swallowing/Nutritional Definitions: Weight Loss in 30 days-take weight closest to 30 days ago and multiply by.95, over 5% severe per F 325. Weight Loss in 180 days-take weight closest to 180 days and multiply by.90 is weight loss, over 180% severe per F

21 Section K: Swallowing/Nutritional Definitions: Physician Rx Weight Loss Regime-a reduction plan ordered with care plan goal of weight reduction. May use calorie restricted, exercise, planned diuresis. Must show INTENTIONAL weight loss desired. BMI-Body Mass Index is a # calculated from a person s weight & height. BMI is used as a screening tool to identify possible weight problems. Section L: Oral/Dental Status Intent: to record any dental problems present in the last 7 day look-back period. Focus is related to poor oral health has a negative impact on: Quality of Life, Overall Health, and Nutritional Status. Do: identify pain as significant Risk and Care Plan should address as well as potential negative impact areas. Section M: Skin Conditions Do: M0100- Risk Determination normally expect to see code B and C. M0150-Risk of P.U.s increased with existing P.U., or scar over bony prominence or non-removable dressing or device. M 0210-Unhealed P.U.s M0300-Current Number of Unhealed P.U.s (M300 A-G) 21

22 Section M: Skin Conditions M0610-deminsions of unhealed stage 3 or 4 P.U.s or unstageable P.U. d/t slough or eschar M0700-most severe (reminder blisters are a stage II) M0800-worsening status (reminder for transition only assessments use last MDS 2.0 done to compare with). M0900-healed P.U.s (ended reverse stage process) M01030-number of Venous/Arterial Ulcers M01040 other Ulcers, Wounds, and Skin Problems M1200D-Skin and Ulcer Tx (reminder re: nutrition, code this when order written for wound healing or prevention of wound development) Section M: Skin Conditions Key Considerations: 1. Identification of Risk, 2. Confounding Problems, 3. Appropriate Tx (include outside support) 4. Consistent Evaluation, and 5. Consistent Documentation. Section M: Skin Conditions 1. Is every two-hour turning & repositioning considered a program? [ ] Yes [ ] No 2. If a Resident is admitted with a stage III wound and then is discharged to the Hospital later readmits with a stage III is a admitted with wound? [ ] Yes [ ] No 22

23 Section M: Answers 1. Is every two-hour turning & repositioning considered a program? [? ] Yes [? ] No [ x ] Maybe 2. If a Resident is admitted with a stage III wound and then is discharged to the Hospital later readmits with a stage III is a admitted with wound? [ ] Yes [ x ] No Section N: Medications The intent of this section is to record the number of days during the last 7 (or since admission or reentry is less than 7 days) that any type of injection, insulin, and or select oral medications were received by the Resident. Pay strict attention to coding directions as they have significantly changed as MDS 3.0 Section O: Special Treatments, Procedures, & Programs The intent of this section is to identify any special treatments, procedures, and programs that the resident received during the specified time period. This includes clinical treatments, vaccines, rehabilitation, etc. Please see handout provided at seminar 23

24 Section P: Restraints The intent of this section is to record the frequency over the 7 day look back period that the resident was restrained by any of the listed devices at any during the day or the night. It is essential that all staff understand what is and is not a restraint as it is NOT always about the device but rather the intent of the use of it. See F 222 as well as the MDS manual when evaluating this for your Residents. Section Q: Participation in Assessment & Goal Setting The intent is this section is to record the participation and expectations of the Resident, their family, and or other significant members of their support system in the assessment and to understand the resident s overall goal. It is understood that all Resident s goals may not be attainable and ultimately the decision for prescribed DC requires the physician, the interdisciplinary team, as well as the Resident and or their representatives. When completing CAA 20 it is important that any obstacles that could hinder a Resident s return to the community are identified and addressed. MDS as Day-to-Day Incorporate the MDS 3.0 & RAI into dayto-day clinical operations has become a necessity for success as it supports: o consistency in risk identification & assessment o methods to integrate care area assessments into daily clinical reviews o addressing risks and resident interview outcomes in the care planning process 24

25 Skilled Clinical Documentation The need for increased quality of the clinical skilled documentation for Residents using their Medicare part A benefit has increased with the RUGs IV program. The primary reasons for this include: o o o increase of skilled days, especially at the start of the skill benefit without rehabilitation services increase in reimbursement for clinical skill days of services always important for quality & continuity of care and services Medicare Management Questions? 1. How do YOU inspect what you expect? 2. Are you confident that the appropriate assessment reference date (ARD) was selected? 3. Does your staff demonstrate understanding of the requirements? 4. How do you track your Medicare program? 5. Who is responsible for documentation review you or a member of your team or the surveyors and State or Federal compliance auditors? please see handout at seminar Thank You! Thank you for having me back to Alabama! For questions, your speaker, Robin Bleier can be found on the web at for questions & answers or ed directly at robin@rbhealthpartners.com Please note the additional handouts provided by the speaker at the seminar are for your review and use only after approved by you, your organization, and through your systematic processes. They are not copyrighted as you are welcome to use as you and your company determine appropriate. 25