New Survey Focus MDS Accuracy and Staffing -Compliance Risk Alert- Rodney Farley, CHC Terry Raser, RN, RAC-CT, C-NE LW Consulting, Inc. LW Consulting, Inc. 5925 Stevenson Ave, Suite G 5925 Stevenson Ave, Suite G Harrisburg, PA 17112 Harrisburg, PA 17112 717.213.3123 610.314.5095 rfarley@lw-consult.com traser@lw-consult.com 1
Objectives Learn the intent and purpose of the new focused survey process Learn about the deficiency target areas Learn about the forms required by the survey team Ways to have deficiency free Survey 2
Intent of Focused Survey Asses compliance with 42 CFR 483.20 (Resident Assessment) F-tag 272-287 Identify if the information used to calculate the Five Star Rating is accurate RN is coordinating the RAI process MDS adherence to Type and Scheduling Identification of significant change in status Accuracy of MDS assessments Key Targeted Areas 3
Focused Survey Pilot 2014 Surveys Five states were selected: IL, MD, MN, VA, PA Five facilities in each state 25 Facility Surveys Deficiencies identified Resulted in citations Staffing 4
Number of Focused Surveys Two phase process States assigned to a phase Number of Surveys per state PA- 16 DE- None MD- 6 NJ- 9 The last surveys for 2015 is September 30, 2015 5
Focused Survey Pilot 2014 Deficiencies Identified: Falls with major injury (25%) Pressure ulcer status (18%) Late Loss ADLs (15%) Restraint Use (18%) 6
Focused Survey Pilot 2014 Staffing F-tag 356 671 Form Actual staffing levels Sufficient Staff Turnover and Tenure 7
What To Expect 2 Day Survey 2 Surveyors MDS Focus but other areas of concern identifiedreport to the state Like Standard survey- Resident and staff interviews, resident observation, record review, MDS review and supporting documentation 10 recently accepted MDSs MDS corrections and original MDS 8
Provide Immediately- 1 hour Complete Worksheet #1 Current Census Name, Room Number and Unit Issues in the last 90 days Restraints Falls with major injury Pressure Ulcers- even if healed Urinary Catheters UTI Antipsychotic Meds Extensive Assist of 2 9
Provide Immediately Continued Worksheet #1 Skilled or LTC Note residents not currently in the facility Hospital LOA, etc. Number of residents Medicare Medicaid Other- Insurance 10
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Provide Immediately Computer Access- Immediately or citation of hindering the survey process Copy of Facility Floor Plan Copy of the last 90 days transfer records Identification of the wound care nurse/team Identification of the staffing coordinator 12
Due In One Hour 10 recently accepted OBRA MDSs Any modifications of the MDSs Correlating Medical Records/Supporting Documentation Copy of policies and procedures RAI process MDS Copy of policies and procedures related to Staffing and scheduling Contact information for QAPI coordinator Completed 671(Within 24 hours) 13
Deficiencies Identified 14
Transfer Records Copy of the last 90 days transfer records List of all admissions, readmissions, and discharges Dates Where they went Where they came from 15
Appropriateness of Timing Follow regulations for MDS timing in the RAI manual Chapter 2 section 2.5 Admission assessment completed timely CAAs completed timely Care plan completed timely Quarterly ARD set timely Annual ARD set timely Timely completion Timely Submission Significant Change in Status ARD set timely- Hospice 16
CAAs CAAs completed with every comprehensive assessment The MDS is assessment number 1 Identifies actual or potential problems CAAs are assessment number 2 Cause, risk factors, contributing factors, location and date CAAs drive the care plan Review Section V of the RAI manual for timeline Review Chapter 4 of the RAI manual- CAA & CP 17
Care Planning Person Centered Care Plans Care provided according to care plan Frontline staff know care plan interventions Process in place OIG report 2013 37% of facilities did not provide services according to the care plan 18
MDS Section Z0400 RAI Manual- Chapter 3 Section Z Z0400- Signature of Person completing assessment Name, Titles, Sections or Portions of sections completed and date Make sure electronic signatures include: First name Last name Credentials 19
MDS Section Z0500 Z0500- Signature of RN Coordinator Verifies assessment is complete Prior to signing Z0500 Verify all MDS items have been completed Verify all MDS items have been signed for by person completing in Z0400 Electronic Signatures Facility must have a policy to ensure proper security measures 20
Restraints- Focus on: Frequency of use in last 7 days Not used Used less than daily Used daily What is considered a restraint RAI Manual- Section P What is the need and medical symptom Effect the restraint has on normal function Restricts freedom of movement 21
Falls With Major Injury Focus on: RAI Manual- Section J1700, J1800, J1900 Falls prior to admission Falls since admission/re-entry or prior assessment (90 days ago) Number of falls No Injury Injury (Except Major) Major Injury Family reported falls, community falls 22
Scenario Resident falls Hematoma on the forehead and minimal pain in the low back. Resident is being evaluated. Continues with back pain. The MDS is scheduled to be completed. The fall is coded on the MDS as fall with injury but not a major injury 2 days later the MDS is completed but the resident still has back pain and is sent to ER for assessment. X-ray shows fractured vertebrae. No one modified the MDS to show fall with major injury and you get cited for inaccurate MDS coding. 23
Definition of Injury Related Fall Any documented injury that occurred as a result of, or was recognized within a short period of time (e.g., hours to a few days) after the fall and attributed to the fall. 24
Pressure Ulcers Focus on: RAI Manual- Section M Staging- #1 problem area Documentation- conflicting Know the wound type- cause Look back period- In the past 7 days from the ARD 25
Urinary Catheter Focus on: F-tag 315 Urinary Incontinence Urethral, Suprapubic and Nephrostomy Catheters Must have a documented clinical condition Diagnosis Evaluate Need 26
UTI Focus on: F-tag 315 Urinary Incontinence RAI Manual- Section I- Criteria 30 day look-back period Physician documented diagnosis Documented signs and symptoms Significant lab findings Current medication or treatment in last 30 days 27
Antipsychotic Medications Focus On: RAI Manual Section N Number of days received medication in last 7 days or since admission/re-entry Antipsychotic Drug classification 28
Extensive Assist of 2 or More Activities of Daily Living (ADLs) 30% of Reimbursement Importance of accuracy 29
What to do to prepare Educate staff Accurate Assessments Know RAI regulations Know F-tags 272-278 Review QM s for high flag areas Setup QAPI team Work CAAs Update care plans Focused Survey Facility Worksheet Monitor and/or audit 30
Compliance Areas Focused Survey Facility Worksheet Process for identify situations that are not reported on MDS Enforcement Implications 31
Questions? Terry Raser, RN, RAC-CT, C-NE LW Consulting, Inc. 5925 Stevenson Ave., Suite G Harrisburg, PA 17112 TRaser@LW-Consult.com 610.314.5095 Rodney Farley, CHC LW Consulting, Inc. 5925 Stevenson Ave., Suite G Harrisburg, PA 17112 Rfarley@LW-Consult.com 717.213.3123 32