MDS and STAFFING FOCUS SURVEYS LeadingAge Michigan May 17, 2015 1:30-2:30pm 2015 FR&R Healthcare Consulting, Inc. 1
Marilyn Mines, RN, BC, RAC-CT Senior Manager of Clinical Services 111 S. Pfingsten Road, Suite 300 Deerfield, IL 60015 mmines@frrcpas.com Main: (847) 236-1111 or (888) 377-8120 Direct: (847) 282-6416 2015 FR&R Healthcare Consulting, Inc. 2
Debra Stanton, RN, RAC-CT Senior Nurse Consultant 111 S. Pfingsten Road, Suite 300 Deerfield, IL 60015 dstanton@frrcpas.com Main: (847) 236-1111 or (888) 377-8120 Direct: (847) 282-6464 2013 FR&R Healthcare Consulting, Inc. 3 2015 FR&R Healthcare Consulting, Inc. 3
Disclaimer This presentation and handouts are for general information and do not include a full analysis of any specific circumstances or situations. Information contained herein is accurate at the time of publication. We recommend that you consult with your FROST advisor before implementing any action. 2015 FR&R Healthcare Consulting, Inc. 4
BACKGROUND 2015 FR&R Healthcare Consulting, Inc. 5
Pilot Study Maryland, Pennsylvania, Virginia, Illinois, and Minnesota participated in the pilot program in June and July, 2014 Facilities with less than 120 beds were included The purpose was twofold: To determine how facilities are adhering to timing requirements and an RN coordinating To determine whether the MDS coding relates to other information in the clinical record 2015 FR&R Healthcare Consulting, Inc. 6
Pilot Study Results: Concentrated in a small number of States Little issue with timing and coordination Room for improvement in continuity of MDS coding and clinical record information 2015 FR&R Healthcare Consulting, Inc. 7
Pilot Study 4 areas of improvement were identified: Severity of injury secondary to a fall Pressure ulcer status Restraint use Late loss activities of daily living status 2015 FR&R Healthcare Consulting, Inc. 8
Pilot Study Result Statistics 25% indicated a disagreement between MDS coding and clinical documentation in the chart 18% indication inconsistency between the MDS and chart for pressure ulcers staging 17% revealed inconsistencies related to restraint use 15% identified conflicts in relation to late loss ADLs 2015 FR&R Healthcare Consulting, Inc. 9
Also. The establishment of the MDS process was to have a method of identifying resident needs to develop an individualized care plan and delivery person-centered care Data from previous studies, many conducted by the Office of the Inspector General (OIG) identified issues with delivery of care based on established care plans and lack of care plans for discharge planning 2015 FR&R Healthcare Consulting, Inc. 10
The Expansion An additional purpose of the upcoming surveys relates to the staffing component of the Five-Star rating system CMS wants to ensure that there is adequate staffing to meet the needs of all their residents Electronic quarterly reporting will be established Looking for retention, turnover, and levels/types of staffing 2015 FR&R Healthcare Consulting, Inc. 11
The Expansion: Staffing CMS-671 identifies the type of staff working in the facility including the number of hours they worked This form is only collected during annual surveys. It is felt that staffing may change over the course of the year 2015 FR&R Healthcare Consulting, Inc. 12
2015 SURVEYS 2015 FR&R Healthcare Consulting, Inc. 13
Surveyor Preparations April 2015 begins training: 4-hr webinar Each state to allocate 3 surveyors: 1 must be an RN Rollout will be in 2 phases: regions and states will be assigned to 1 of the groups Though these will be nationwide, the numbers per state will vary 2015 FR&R Healthcare Consulting, Inc. 14
Surveyor Reports Complete and submit post survey information to CMS or its contractor Specific universal tools are being developed If patterns of inaccuracies are identified, a referral will be made to the CMS Regional Office and Central Office for follow-up If concerns are identified during the survey, the State Agency will be notified Citations may be made for quality of care and quality of life, as well as others when appropriate 2015 FR&R Healthcare Consulting, Inc. 15
Purpose Remains the Same Assess MDS coding and its relationship to care Enhance the ability of surveyors to identify errors and deficiencies related to MDS coding and resident care Report staffing levels and identify changes in levels throughout the year 2015 FR&R Healthcare Consulting, Inc. 16
Survey Process Record Review Resident observations Staff and/or resident interview Series of questions related to staffing and MDS practices 2015 FR&R Healthcare Consulting, Inc. 17
Survey Process Provider training Read the RAI manual and Appendix PP 2015 FR&R Healthcare Consulting, Inc. 18
Facility Preparation Direct care staff must know their residents: all about them MDS and Medical records match MDSs are completed on time MDSs are coordinated by an RN 2015 FR&R Healthcare Consulting, Inc. 19
Facility Preparations Know what to expect Within 1 hour of entrance provide them with the 10 most recent MDS assessments and any corrections for these assessments that were completed and submitted for current residents plus the medical records to support their completion 2015 FR&R Healthcare Consulting, Inc. 20
Facility Preparations Know what to expect Provide with Copied of policies and procedures for RAI and Quality Measures Staffing schedules Contact information for the QAA coordinator 2015 FR&R Healthcare Consulting, Inc. 21
Facility Preparations Know what to expect Provide with A list of residents with falls within the last 12 months including the date and injury if any 2015 FR&R Healthcare Consulting, Inc. 22
Facility Preparations Know what to expect Provide with Completed Survey Facility Worksheet that the surveyor will provide, which includes names and room numbers of residents with the following during the last 90 day Pressure ulcer Indwelling Catheters Restraints UTIs 2015 FR&R Healthcare Consulting, Inc. 23
Facility Preparations Pressure Ulcers Review RAI manual Chapter 3, section M Know what is coded as a pressure ulcer and as present on the prior assessment 2015 FR&R Healthcare Consulting, Inc. 24
Facility Preparations Pressure ulcer assessment/documentation Uniform validated assessment tool Stage (1-4 or unstageable) Size Location Wound bed Drainage Peri-wound tissue 2015 FR&R Healthcare Consulting, Inc. 25
Facility Preparations Review the entire section M Ensure that documentation related to All definitions are met Coding tips are followed Ulcers present at the time of admission 2015 FR&R Healthcare Consulting, Inc. 26
Facility Preparations Antipsychotic medication use Classification correct (not how it is used) Include all meds given in last 7 days by any route 2015 FR&R Healthcare Consulting, Inc. 27
Facility Preparations Physical restraints Know the definition Know the requirements in State Operation Manual Appendix PP 2015 FR&R Healthcare Consulting, Inc. 28
Facility Preparations Physical restraints Understand the term remove easily Intentionally by resident In same manner that staff applies and removes it Consider the resident s ability to accomplish the reason for removing it 2015 FR&R Healthcare Consulting, Inc. 29
Facility Preparations Physical restraints vs. Enabler Consider the effect the item has on the resident, not the purpose An enabler may also meet the definition of a restraint Code other is the device does not fit into one of the categories Consider the resident s ability to accomplish the reason for removing it 2015 FR&R Healthcare Consulting, Inc. 30
Facility Preparations ADL coding: Clear understanding of definitions Documentation accurate and timely: no holes in CNA documentation Contradictions between direct care and licensed staff Rule of three not properly used 2015 FR&R Healthcare Consulting, Inc. 31
DEMENTIA FOCUS SURVEYS 2015 FR&R Healthcare Consulting, Inc. 32
Pilot Surveys 2014 Began in 2012 when CMS initiated a partnership to improve dementia care Primary goal at that time was the reduction of medication, mainly antipsychotic drugs In addition, 2 new quality measures in relation to drug use were added 5 states conducted 5 2015 FR&R Healthcare Consulting, Inc. 33
Results 1 The dementia care focused survey was a positive and valuable learning experience 2 Many surveyors identified learning needs related to enforcement (e.g., scope and severity), basic dementia care practices and prescribing practices. A number of surveyors wanted more preparation /training related to the focused survey and process 2015 FR&R Healthcare Consulting, Inc. 34
Results 3. survey in its present form is timeintensive but yields valuable information that enabled the surveyors to better identify and cite deficient practice when compared to the standard annual or complaint surveys. 4 there is a need for a more detailed/focused survey..to be able to identify and cite deficient dementia care and psychoactive medication prescribing practices 2015 FR&R Healthcare Consulting, Inc. 35
Results 5 Some opportunities exist to shorten the current focused survey worksheets and process without losing the ability to cite dementia care and related practices effectively 6 The majority of surveyors believe that a more detailed evaluation of dementia care practices.should be integrated into the annual survey process... 2015 FR&R Healthcare Consulting, Inc. 36
Results 80% cited either F309 or F329 55% cited both tags Other tags cited were F520 and F279 2015 FR&R Healthcare Consulting, Inc. 37
Results Total of 68 deficiencies cited 4 were at the G level Deficient practices were identified shortly after a standard a survey team cited no deficiencies related to dementia care 2015 FR&R Healthcare Consulting, Inc. 38
Conclusions Additional assessment of the survey and enforcement process around dementia care would be useful Participation will be voluntary Surveyors will utilize a standard tool Stand-alone focus surveyors will have 3-4 staff members on site for 1.5-2 days The focus survey may be extended and/or converted to a complaint survey 2015 FR&R Healthcare Consulting, Inc. 39
GOING FORWARD 2015 FR&R Healthcare Consulting, Inc. 40
Knowledge is Power All areas on the MDS are available for review Validate MDS completion processes Conduct quality assurance activities 2015 FR&R Healthcare Consulting, Inc. 41
Knowledge is Power Conduct mock audits Use Quality Measure reports to identify potential issues Question direct care staff regarding resident needs and services rendered 2015 FR&R Healthcare Consulting, Inc. 42
Trust but Verify Who is responsible for obtaining them? How does this person know when to get it? How it is obtained? What type of oversight is there? 2015 FR&R Healthcare Consulting, Inc. 43
RESOURCES 2015 FR&R Healthcare Consulting, Inc. 44
October 14, 2014 http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Surveyand-Cert-Letter-15-06.pdf February 13, 2015 http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Surveyand-Cert-Letter-15-26.pdf http://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Surveyand-Cert-Letter-15-25.pdf 2015 FR&R Healthcare Consulting, Inc. 45
Thank You 2015 FR&R Healthcare Consulting, Inc. 46