6/29/2015. Focused Survey for MDS Assessment. Objectives: Review the results of the MDS pilot study.

Transcription

1 Focused Survey for MDS Assessment Idaho Health Care Association July 21, :45 P.M. 3:15 P.M. Louann Lawson, BA, RN, RAC-CT AHIMA Approved ICD-10-CM/PCS Trainer Nurse Consultant, Clinical Reimbursement Lead Objectives: Review the results of the MDS pilot study. Examine the clinical indicators at risk for inaccurate coding. Discuss processes to assure correct coding of the MDS assessment tool Pilot Study Abstract Purpose Assess Minimum Data Set, Version 3.0 (MDS 3.0) coding practices and the relationship to resident care in nursing homes Volunteer States IL, MD, MN, PA, and VA Method 5 surveys in each state conducted over 2 days by State RAI Coordinator and one of two state surveyors Findings Relatively high levels of compliance related to RN coordination and assessment timing Room for improvement in 4 of 7 clinical conditions 2015 Expansion All states Staffing component 3 1

2 Federal Regulations 42 CFR Resident Assessment Appendix PP of the State Operations Manual (SOM) Apply to all residents in Medicare and/or Medicaid certified nursing facilities F Tags 272 through Goals of Pilot Study Compliance with RN conducting or coordinating the assessments Compliance with required timelines (OBRA) Agreement between MDS 3.0 assessments and the resident s medical record Supplemented with observations and interviews 5 Facility Selection Process CMS provided each of the 5 volunteer State Survey Agencies with a list of possible facilities Based upon QM trends Usually < 120 residents Survey to be completed in 2 days 6 2

3 Survey Process Tasks (1 of 2) Off-site survey preparation Procedures for entrance to a pilot facility Conducting an entrance conference with facility staff Touring the facility and obtaining direct observation of residents and staff Collection of documents from facility staff Daily team meetings 7 Survey Process Tasks (2 of 2) General guidelines for validating the agreement of the MDS 3.0 assessment Determining compliance with specific (related) regulations Survey team decision making Conducting an exit conference. 8 Surveyor Training 90 Minute Webinar Understand types of assessments (OBRA) Understand why ARD is critical in determining the clinical information captured on the MDS 3.0 Understand coding instructions for those items included in the study Understand the criteria for SCSA and how it relates to the assessment process 9 3

4 Findings: A Cautionary Note Results of the pilot are not generalizable to all nursing facilities Sample was not representative of U.S. nursing facilities (size, rural/urban, etc.) 25 facilities in pilot vs. 16,000 nursing facilities in U.S. About 1,000 MDS 3.0 assessments compared to about 1.6 million submitted to CMS each month 10 Findings (1 of 3) Non-Compliance with RN conducting or coordinating the assessments 6 of 1,027 assessments 0.6% non-compliance rate No sign of widespread failure Little reason for CMS to focus on RN coordination as an area of concern 11 Findings (2 of 3) Non-Compliance with required timelines (OBRA) 23 of 1,027 assessments 2.2% Includes failures to initiate the assessment and/or complete the assessment in a timely manner Overall rate of compliance is high Non-compliance issues were high in 3 of 5 states with a total of 6 facilities (24%) 12 4

5 Findings (3 of 3) Disagreement between MDS 3.0 assessments and the resident s medical record Supplemented with observations and interviews 13 MDS Accuracy Summary High Rate of Agreement Presence of an indwelling catheter Diagnoses of neurogenic bladder and/or obstructive uropathy Use of antipsychotic medications Diagnoses of Tourette s syndrome, Schizophrenia, and Huntington s disease Low Rate of Agreement Restraint use other than siderails Presence of pressure ulcers, Pressure ulcer stage, Worsening of pressure ulcers Late loss ADL status Falls Level of injury sustained during a fall as a major injury 14 MDS Accuracy Data 15 5

6 MDS Accuracy Issues Numerator/ Denominator Percent Disagreement Assessment Area 8/ % Failure of facility staff to accurately reflect the status of the resident related to restraint use other than side rails 18/ % Failure of facility staff to accurately reflect the status of the resident related to the presence of pressure ulcers 40/ % Failure of facility staff to accurately reflect the status of the resident related to pressure ulcer stage 13/ % Failure of facility staff to accurately reflect the status of the resident related to worsening of pressure ulcer status since prior assessment or last admission/entry 16 MDS Accuracy Issues Numerator/ Denominator Percent Assessment Area Disagreement 1/ % Failure of facility staff to accurately reflect the status of the resident related to the presence of an indwelling catheter 21/ % Failure of facility staff to accurately reflect the status of the resident related to the diagnoses of neurogenic bladder and/or obstructive uropathy 21/ % Failure of the facility staff to accurately reflect the status of the resident related to the late loss ADL status. Late loss ADLs include bed mobility, toileting, transfer, and eating. 17 MDS Accuracy Issues Numerator/ Denominator Percent Disagreement Assessment Area 24/ % Failure of the facility staff to accurately reflect the status of the resident related to the level of injury sustained during a fall as a major injury 11/ % Failure of the facility staff to accurately reflect the status of the resident related to the use of antipsychotic medications 7/ % Failure of the facility staff to accurately reflect the status of the resident related to diagnoses of Tourette s syndrome, Schizophrenia, and Huntington s disease 18 6

7 State Breakdowns 19 Restraint Use Total PA MD VA IL MN # of assessments # of % 17.0% 0.0% 20.0% 0.0% 0.0% 27.3% 100.0% 0.0% 62.5% 0.0% 0.0% 37.5% 20 Presence of Pressure Ulcers Total PA MD VA IL MN # of assessments # of % 8.3% 6.8% 9.1% 0.0% 1.7% 25.0% 100% 16.7% 22.2% 0.0% 5.6% 55.6% 21 7

8 Pressure Ulcer Stage Total PA MD VA IL MN # of assessments # of % 18.3% 11.4% 27.3% 3.1% 13.8% 35.0% 100.% 12.5% 30.0% 2.5% 20.0% 35.0% 22 Worsening Pressure Ulcers Total PA MD VA IL MN # of assessments # of % 6.0% 11.4% 6.8% 0.0% 8.6% 0.0% 100.0% 38.5% 23.1% 0.0% 38.5% 0.0% 23 Late Loss ADLs Total PA MD VA IL MN # of assessments # of % 15.4% 7.7% 19.4% 8.0% 24.1% 16.0% 100.0% 9.5% 28.6% 9.5% 33.3% 19.0% 24 8

9 Falls Total PA MD VA IL MN # of assessments # of % 10.6% 4.3% 40.0% 13.3% 0.0% 5.3% 100.0% 10.0% 60.0% 20.0% 0.0% 10.0% 25 Falls w injury Total PA MD VA IL MN # of assessments # of % 25.5% 8.7% 60.0% 26.7% 13.6% 31.6% 100.0% 8.3% 37.5% 16.7% 12.5% 25.0% 26 DX Neuro Bladder Total PA MD VA IL MN # of assessments # of % 15.9% 5.6% 17.2% 37.5% 9.1% 14.3% 100.% 9.5% 23.8% 42.9% 9.5% 14.3% 27 9

10 UTI Total PA MD VA IL MN # of assessments # of % 17.6% 14.0% 11.9% 8.0% 13.0% 50.0% 100.0% 18.8% 15.6% 6.3% 18.8% 40.6% 28 Data Analysis Conclusion Low Rate of Agreement Restraint use other than side rails Presence of pressure ulcers, Pressure ulcer stage, Worsening of pressure ulcers Late loss ADL status Falls Level of injury sustained during a fall as a major injury 29 Why Are There Low Agreement Rates? Differences in MDS education and training A lack of internal MDS audit practices Differences in state-level MDS or case mix audit practices

11 Restraints Disagreement rate of 17% Surveyor observation and investigation identified additional restraint usage Additional guidance and education to ensure correct identification RAI Manual, Chapter 3, Section P S&C Pressure Ulcers Presence 8.3% Staging 18.3% Worsening 6.0% Lack of an accurate clinical assessment of the pressure ulcers Head to toe assessment Once a week Licensed nurse Training/Certification 32 Activities of Daily Living Disagreement rate of 15.4% One in every seven cases of late loss ADLs was coded differently than would be expected These directly affect facilities QM ratings and 5 Star Ratings and reimbursement Accuracy of coding at the C.N.A. level Orientation At least quarterly Concurrently with observation period 33 11

12 Falls Largest disagreement overall 25% of the reviewed assessments (24 out of 94) indicated disagreement for level of injury documented after a fall Additional guidance and education to ensure correct identification Nurses notes, progress notes, ER reports, X- rays, incident reports RAI Manual, Chapter 3, Section J Definition of fall Definition of major injury : Nationwide Focused Surveys MDS Focused Survey combined with a review of nursing home staffing Intend to strengthen the Nursing Home Five-Star Quality Rating System Survey worksheets revised Rollout in two phases by CMS regions and states Notified of group in February Training began in April (Webinars) Deficiencies identified during the surveys will result in relevant citations and enforcement actions. 35 Payroll-Based Staffing Reporting CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information. This new system will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing. Implementation will be improved by funding provided in the recently enacted, bipartisan Improving Medicare Post-Acute Care Transformation Act (IMPACT) of

13 Additional Quality Measures CMS will increase both the number and type of quality measures used in the Five- Star Quality Rating System. Antipsychotic medication use was added in February Future additional measures will include claims-based data on re-hospitalization and community discharge rates. 37 Timely and Complete Inspection Data CMS will also strengthen requirements to ensure that States maintain a userfriendly website and complete inspections of nursing homes in a timely and accurate manner for inclusion in the rating system. 38 Nursing Home Preparation MDS RAI Manual Appendix PP of the SOM There are no new regulations involved in these surveys. Train your staff 39 13

14 Thank you for your participation! Louann Lawson, BA, RN, RAC-CT AHIMA Approved ICD-10-CM/PCS Trainer Nurse Consultant, Clinical Reimbursement Lead Pathway Health (651)