The Finalized MDS 3.0 RAI Manual: What you need to know about the new item set, new section, and more!

The Finalized MDS 3.0 RAI Manual: What you need to know about the new item set, new section, and more! Presented by: Amy Franklin RN, RAC-MT, DNS-MT, QCP-MT AANAC Curriculum Development Specialist 1 Faculty Disclosure I have no financial relationships to disclose I have no conflicts of interests to disclose I will not promote any commercial products or services 2 Copyright 2016 1

Requirements for Successful Completion 1.5 contact hours will be awarded for this continuing nursing education activity Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. *AAPACN d/b/a American Association of Nurse Assessment Coordination 3 Copyright 2016 Learning Objectives Delineate schedule and manage the new MDS item set Medicare Part A Discharge Assessment Integrate new definitions into daily practice to accurately code Section GG Identify the miscellaneous changes of the RAI manual that impact your daily coding practices 4 Copyright 2016 2

Review What Has Changed & Review Clarifying Coding Rules Chapter 2, Section C, GG, J, M, N,Q and Chapter 4 CAA - CAT Delirium 5 Copyright 2016 Chapter 2 New Item Set Part A PPS Discharge Assessment 6 Copyright 2016 3

IMPACT ACT 2014 Quality Reporting Program (QRP) developed to meet requirements of the IMPACT ACT 2014 Must have a means of comparing, measuring outcomes (Quality Measures [QMs]) and a systematic means of data collection of the Medicare Beneficiary across all Post-Acute Care (PAC) settings: Skilled Nursing Homes Inpatient Rehab Facility Long-term Care Hospital Home Health Care SNF Medicare Part A Beneficiary ONLY 7 Copyright 2016 Three QRP Data Collections of QMs Starts October 2016 Application of Percent of Long-Term Care Hospital Patients with an Admission & Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631) Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678) More QRP QMs coming in the future SNF QRP QMs Medicare Part A ONLY Application of Percent of Residents Experiencing One of More Falls with Major Injury (Long Stay) (NQF #0674) 8 Copyright 2016 4

QM: Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function Purpose of the QM: Reports the percent of Original Medicare Part A residents with an Admission and a Discharge Functional Assessment & a Goal that addresses Function Item Set Used: Medicare PPS 5-day Assessment PPS Part A Discharge Assessment MDS Section for the Required QM: Section GG Assessed at the time of admission and discharge First Collection Period October 2016 through December 2016 Payment Determination is May 2017 2% Penalty FY 2018 (Oct. 2017) Additional information regarding the IMPACT Act and associated quality measures may be found on CMS s website at: http://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/post-acute-care-quality- Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html. 9 Copyright 2016 Data collection for Section GG does not substitute for the data collected in Section G Different Rating scales Item definitions Type of data collected Look-back Providers are required to collect data for both Section GG and Section G 10 Copyright 2016 5

Three types of Discharge Assessments (MDS) OMRA - Discharge (NOD) Item Subset Discharge (ND) Item Set Part A PPS Discharge (NPE) Item Set PPS EOT OMRA Combined Discharge MDS Standalone OBRA Discharge MDS Standalone Part A PPS Discharge MDS Purposes - SNF QRP Return anticipated or Return-not anticipated Return anticipated or Return-not anticipated Medicare Part A stay ends Remains in the facility 11 Copyright 2016 DEFINITION Part A PPS Discharge Assessment A discharge assessment developed to inform current and future SNF QRP measures and the calculation of these measures The Part A PPS Discharge assessment is completed when a resident s Medicare Part A stay ends, but the resident remains in the facility Or may be combined with an OBRA Discharge if the Part A stay ends on the same day or the day before the resident s Discharge Date (A2000) (A-7) 12 Copyright 2016 6

New Item Set: SNF PPS Part A Discharge (End of Stay) Assessment 1 1 Must be a Planned Discharge 1 1 13 Copyright 2016 New Item Set: SNF PPS Part A Discharge (End of Stay) Assessment 9 9 Code 99 If Resident is Remaining in the SNF after Medicare Coverage Ends ^ 1 14 Copyright 2016 7

15 Copyright 2016 New Item Set: SNF PPS Part A Discharge (End of Stay) MDS 1 1 0 0 1 2 0 1 6 1 0 1 1 2 0 1 6 16 Copyright 2016 8

New Item Set: SNF PPS Part A Discharge (End of Stay) MDS Combining May combine a planned OBRA Discharge to community with Part A PPS Discharge (NPE) if: Medicare stay ends one day before Discharge e.g.: Resident s last covered day is Friday and plans to discharge on Saturday = ARD would be Saturday Unscheduled PPS Assessments (COT, SOT, EOT, SEOT) are not to be combined with a NPE 17 Copyright 2016 Section GG: End of SNF PPS Stay Discharge Performance Section GG: Tech Spec. within your software will open Section GG when: A310H. = Yes and A2400.C = date of last covered Medicare Part A Day Look-back is 3 days prior to discharge or covered day o Includes day 3 discharge, 2 nd to last day, then 3 rd to the last day Day 3 being the date at A2400.C 18 Copyright 2016 9

Completion of the NPE Must be completed (Item Z0500B) within 14 days after the End Date of Most Recent Medicare Stay (A2400C + 14 calendar days) Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days) If the resident s Medicare Part A stay ends and the resident subsequently returns to a skilled level of care and Medicare Part A benefits resume, the Medicare schedule starts again with a 5-Day PPS assessment 19 Copyright 2016 Example of a combined OBRA and Part A PPS Discharge Mrs. G. began receiving services under Medicare Part A on October 14, 2016. Due to her stable condition and ability to manage her medications and dressing changes, the facility determined that she no longer qualified for Part A SNF coverage and began planning her discharge. An Advanced Beneficiary Notice (ABN) and an NOMNC with the last day of coverage as November 23, 2016 were issued. Mrs. G. was discharged home from the facility on November 24, 2016. (A-34) Code the following on her combined OBRA and Part A PPS Discharge assessment: A0310F = 10 A0310G = 1 A0310H = 1 A2000 = 11-24-2016 A2100 = 01 A2300 = 11-24-2016 A2400A = 1 A2400B = 10-14-2016 A2400C = 11-23-2016 20 Copyright 2016 10

Example of only an OBRA unplanned Discharge was required Mr. R. began receiving services under Medicare Part A on October 15, 2016. Due to complications from his recent surgery, he was unexpectedly discharged to the hospital for emergency surgery return anticipated on October 20, 2016, but is expected to return within 30 days to the hospital.(a-25) Code the following on his OBRA Discharge assessment: A0310F = 11 A0310G = 2 A0310H = 0 A2000 = 10-20-2016 A2100 = 03 A2300 = 10-20-2016 A2400A = 1 A2400B = 10-15-2016 A2400C = 10-20-2016 21 Copyright 2016 Example of a standalone Part A PPS Discharge (NPE) Mrs. K began receiving services under Medicare Part A on October 4, 2016. She was discharged from Medicare Part A services on December 17, 2016. She and her family had already decided that Mrs. K would remain in the facility for long-term care services, and she was moved into a private room (which was dually certified) on December 18, 2016. (A-35) Code the following on her Part A PPS Discharge assessment: A0310F = 99 A0310G = ^ A0310H = 1 A2000 = ^ A2100 = ^ A2300 = 12-17-2016 A2400A = 1 A2400B = 10-04-2016 A2400C = 12-17-2016 22 Copyright 2016 11

New Section GG New Coding Scale, Admission and Discharge Performance, and Discharge Goal Setting 23 Copyright 2016 Medicare Part A Stay Dates Dictate When to Code Section GG First Day of Medicare Part A: Item A2400.A is coded Yes to a Medicare Part A Stay Code A2400.B Start of Medicare Part A stay date Section GG: Look-back ends on day three of the Medicare stay Day 1 = Date at A2400.B Last Day of Medicare Part A: Item A2400.C Date is the last covered day of Medicare Part A Discharge or last covered day Section GG: Look-back within 3 days of the last covered day Day 3 = Date at A2400.C Look-back for usual performance is three days At the beginning of the original Medicare stay At the end of the original Medicare stay 24 Copyright 2016 12

New: Safety & Quality of Performance Scale 1 Never Used for Discharge Goal 25 Copyright 2016 Assessment Period day 1 through day 3 Item Set: A0310B. 01 = 5 day PPS MDS A2400.B = Start Date Can be combined with OBRA MDS Utilizing the Safety and Quality of Performance Scale 06 = Independence 05 = Setup or Clean Up 04 = Supervision or Touching 03 = Partial/Moderate 02 = Substantial/maximal 01 = Dependent 26 Copyright 2016 13

Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C Complete only if: A0310G is = 1 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03 (acute hospital) Utilizing the Safety and Quality of Performance Scale 06 = Independence 05 = Setup or Clean Up 04 = Supervision or Touching 03 = Partial/Moderate 02 = Substantial/maximal 01 = Dependent 27 Copyright 2016 Complete when Medicare Part A coverage has ended and remains in the facility or planned discharges! GG0130 & GG0170 Admission & Discharge Performance Helper Assistance Only required because resident's performance is unsafe or of poor quality Score according to amount of assistance provided Activities may be completed with or without assistive devices Does not include: Family, Hospice, Private Duty, Student Nurses/Nurses Aide etc. 28 Copyright 2016 14

GG0130 & GG0170 Admission & Discharge Performance Performance Not the best/not the worst Usual Performance (Baseline Status) Over the course of three days No rule for the number of times at one level Admission performance- First three days of the covered stay Discharge performance Last three days of the covered stay Compare prior function from the acute event 29 Copyright 2016 6-Point Rating Scale Code 06 Independent: Resident completes the activity by him/herself with no assistance from a helper Code 05 Setup or Clean-Up Assistance : Helper SETS UP or CLEANS UP; resident completes activity. Helper assists only prior to or following the activity Code 04 Supervision or touching assistance : Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently 30 Copyright 2016 15

6-Point Rating Scale Code 03 Partial/Moderate Assistance: Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Code 02 Substantial/Maximal Assistance: Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort Code 01 Dependent: Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity 31 Copyright 2016 If Activity was not Attempted Code 07 Resident Refused If the resident refused to complete the activity Code 09 Not Applicable If the resident did not perform this activity prior to the current illness, exacerbation, or injury Code 88 Not attempted due to medical condition or safety concerns 32 Copyright 2016 16

Discharge GOAL Expected to Improve The IDT determines the resident is expected to make gains in function by discharge Not Expected to Improve The IDT determines the resident is not expected to progress to a higher level of functioning during the SNF Medicare Part A stay Expected to Decline The IDT determines decline in function is anticipated and unavoidable 33 Copyright 2016 Helper Effort Helper More Than Half 02. Substantial/ Maximal Assist Resident performed less than half May lift or hold or support trunk or limbs 34 Copyright 2016 Less Than Half 03. Partial/ Moderate Assist Resident performed more than half May lift or hold or support trunk or limbs Helper 17

Section GG: Functional Abilities, Goals and Discharge Performance GG130.A Eating The ability to use suitable utensils to bring food to the mouth and swallow food Once the meal is presented on a table/tray Includes modified food consistency If NPO/Enteral/Parenteral feeding with no Oral feedings then this is not evaluated -Code 09 or 88 35 Copyright 2016 GG130.B Oral Hygiene The ability to use suitable items to clean teeth Dentures: The ability to remove and replace dentures from and to the mouth, And manage equipment for soaking and rinsing them GG0130. Self-Care GG130.C Toileting Hygiene The ability to maintain perineal hygiene, Adjust clothes before and after using the toilet, commode, bedpan, or urinal If managing an ostomy, include wiping the opening but not managing equipment Section GG: Functional Abilities, Goals and Discharge Performance GG0170.B Sit To Lying The ability to move from sitting on side of bed to lying flat on the bed GG0170.C Lying To Sitting On Side Of Bed The ability to safely move from lying on the back to sitting on the side of the bed With feet flat on the floor GG0170.D Sit To Stand The ability to safely come to a standing position from sitting in a chair Or on the side of the bed And with no back support 36 Copyright 2016 GG0170. Mobility 18

Section GG: Functional Abilities, Goals and Discharge Performance GG0170.E Chair/Bed-to-Chair Transfer The ability to safely transfer to and from a bed to a chair (or wheelchair) GG0170.F Toilet Transfer The ability to safely get on and off a toilet or commode GG0170. Mobility 37 Copyright 2016 Section GG: Functional Abilities, Goals and Discharge Performance GG0170. J Walk 50 Feet With Two Turns Once standing, the ability to walk at least 50 feet and make two turns GG0170.K Walk 150 Feet Once standing, the ability to walk at least 150 feet in a corridor or similar space GG170.R Wheel 50 Feet With Two Turns Once seated in wheelchair/ scooter (manual or motorized), can wheel at least 50 feet and make two turns GG170.S Wheel 150 Feet Once seated in wheelchair/ scooter (manual or motorized), can wheel at least 150 feet in a corridor or similar space The Intent is to assess usual performance and if the resident is able to perform the task safely. GG0170. Mobility 19

RAI Technical Specifications Updates related to Section GG 39 Copyright 2016 RAI Technical Specifications - 3863 Consistency Warning Self-Care and Mobility Discharge Goals: If A0310B=[01] Then at least one of the Discharge Goal items (GG0130A2, GG0130B2, GG0130C2, GG0170B2, GG0170C2, GG0170D2, GG0170E2, GG0170F2, GG0170J2, GG0170K2, GG0170R2, GG0170S2) should be equal to [01,02,03,04,05,06] - 3871 Skip pattern Fatal a) If A0310B=[01], then the following items must not be equal to [^]: GG0130A1, GG0130A2, GG0130B1, GG0130B2, GG0130C1, GG0130C2 b) If A0310B=[02,03,04,05,07,99], then the following items must be equal to [^]: GG0130A1, GG0130A2, GG0130B1, GG0130B2, GG0130C1, GG0130C2 40 Copyright 2016 20

RAI Technical Specifications -3872 Skip pattern Fatal a) If A0310G=[1,^] and A0310H=[1] and A2400C - A2400B is greater than 2 and A2100=[01,02,04,05,06,07,08,09,99,^], then GG0130A3, GG0130B3, and GG0130C3 must not be equal to [^] b) If A0310G=[2] or A0310H=[0] or A2400C - A2400B is less than or equal to 2 or A2100=[03], then GG0130A3, GG0130B3, and GG0130C3 must be equal to [^] 41 Copyright 2016 RAI Technical Specifications -3874 Skip pattern Fatal a) If A0310G=[1,^] and A0310H=[1] and A2400C - A2400B is greater than 2 and A2100=[01,02,04,05,06,07,08,09,99,^], then the following items must not be equal to [^]:GG0170B3, GG0170C3, GG0170D3, GG0170E3, GG0170F3, GG0170H3, GG0170Q3 b) If A0310G=[2] or A0310H=[0] or A2400C - A2400B is less than or equal to 2 or A2100=[03], Then the following items must be equal to [^]: GG0170B3, GG0170C3, GG0170D3, GG0170E3, GG0170F3, GG0170H3, GG0170J3, GG0170K3, GG0170Q3, GG0170R3, GG0170RR3, GG0170S3, GG0170SS3 42 Copyright 2016 21

Section X NPE added 43 Copyright 2016 Coding Instructions for X0600H, Is this a Part A PPS Discharge Assessment? If item A0310H was incorrect on an assessment that was previously submitted and accepted by the QIES ASAP system, then the original assessment must be modified or inactivated per the instructions in Chapter 5 (Section 5.7) Enter the code exactly as submitted for item A0310H, Is this a Part A PPS Discharge Assessment? on the prior erroneous record to be modified/inactivated. (X-6 X-7) Code 0, no: if this is not a Part A PPS Discharge assessment Code 1, yes: if this is a Part A PPS Discharge assessment Note that the code in X0600H must match the current value of A0310H on a modification request 44 Copyright 2016 22

Section C CAM language & definitions have changed 45 Copyright 2016 C1310: Signs and Symptoms of Delirium Coding Instructions for C1310A, Acute Mental Status Change Code 0, no: if there is no evidence of acute mental status change from the resident s baseline Code 1, yes: if resident has an alteration in mental status observed in the past 7 days or in the BIMS that represents a change from baseline 46 Copyright 2016 23

C1310. Definition DELIRIUM A mental disturbance characterized by new or acutely worsening confusion, disordered expression of thoughts, change in level of consciousness or hallucinations INATTENTION Reduced ability to maintain attention to external stimuli and to appropriately shift attention to new external stimuli. Resident seems unaware or out of touch with environment (e.g., dazed, fixated or darting attention) FLUCTUATION The behavior tends to come and go and/or increase or decrease in severity. The behavior may fluctuate over the course of the interview or during the 7- day look- back period. Fluctuating behavior may be noted by the interviewer, reported by staff or family or documented in the medical record DISORGANIZED THINKING Evidenced by rambling, irrelevant, or incoherent speech 47 Copyright 2016 Coding Instructions for C1310C, Disorganized Thinking Code 0, behavior not present: If all sources agree that the resident s thinking was organized and coherent, even if answers were inaccurate or wrong Code 1, behavior continuously present, did not fluctuate: If, during the interview and according to other sources, the resident s responses were consistently disorganized or incoherent, conversation was rambling or irrelevant, ideas were unclear or flowed illogically, or the resident unpredictably switched from subject to subject 48 Copyright 2016 Code 2, behavior present, fluctuates: If, during the interview or according to other data sources, the resident s responses fluctuated between disorganized/incoherent and organized/clear. Also code as fluctuating if information sources disagree 24

C1310.D Definitions of ALTERED LEVEL OF CONSCIOUSNESS VIGILANT Startles easily to any sound or touch LETHARGIC Repeatedly dozes off when you are asking questions, but responds to voice or touch STUPOR Very difficult to arouse and keep aroused for the interview COMATOSE Cannot be aroused despite shaking and shouting 49 Copyright 2016 Coding Instructions for C1310D, Altered Level of Consciousness Code 0, behavior not present: If all sources agree that the resident was alert and maintained wakefulness during conversation, interview(s), and activities. Code 1, behavior continuously present, did not fluctuate: If, during the interview and according to other sources, the resident was consistently lethargic (difficult to keep awake), stuporous (very difficult to arouse and keep aroused), vigilant (startles easily to any sound or touch), or comatose. 50 Copyright 2016 Code 2, behavior present, fluctuates: If, during the interview or according to other sources, the resident varied in levels of consciousness. For example, was at times alert and responsive, while at other times resident was lethargic, stuporous, or vigilant. Also code as fluctuating if information sources disagree. 25

CAM Assessment Scoring Methodology BOTH Item A = 1 or Item B, C or D = 2 The indication of delirium by the CAM requires the presence of: Item B = 1 or 2 Item C = 1 or 2 EITHER Item D = 1 or 2 51 Copyright 2016 Section J New coding rules with falls 52 Copyright 2016 26

J1900 Planning for Care A fall should stimulate evaluation of the resident s need for rehabilitation or ambulation aids and of the need for monitoring or modification of the physical environment It is important to ensure the accuracy of the level of injury resulting from a fall Since injuries can present themselves later than the time of the fall, the assessor may need to look beyond the ARD to obtain the accurate information for the complete picture of the fall that occurs in the look back of the MDS (J-31) 53 Copyright 2016 J1900 Steps for Assessment Ask the resident, staff, and family about falls during the look-back period. Resident and family reports of falls should be captured here, whether or not these incidents are documented in the medical record (J-32) Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results), and ensure that this information is used to code the assessment (J-32) 54 Copyright 2016 27

J1900 Coding Tip If the level of injury directly related to a fall that occurred during the look-back period is identified after the ARD and is at a different injury level than what was originally coded on an assessment that was submitted to QIES ASAP, the assessment must be modified to update the level of injury that occurred with that fall (J-33) 55 Copyright 2016 J1900: Example of the injury that did not present itself right after the fall Mr. R. fell on his right hip in the facility on the ARD of his Quarterly MDS and complained of mild right hip pain. The initial x-ray of the hip did not show any injury. The nurse completed Mr. R s Quarterly assessment and coded the assessment to reflect this information. The assessment was submitted to QIES ASAP. Three days later, Mr. R. complained of increasing pain and had difficulty ambulating, so a follow-up x-ray was done. The follow-up x-ray showed a hairline fracture of the right hip. This injury is noted by the physician to be attributed to the recent fall that occurred during the look-back period of the Quarterly assessment. (J-34) 56 Copyright 2016 Original Coding: J1900B, Injury (except major) was coded 1, one. Rationale: Mr. R. had a fall-related injury that caused him to complain of pain. Modification of Quarterly assessment: J1900B, Injury (except major) is coded 0, none and J1900C, Major Injury, is coded 1, one. 28

Section M Clarification on Present on Admission 57 Copyright 2016 M0300 Numbering and content revised for Step 3: Determine Present on Admission Should not be coded as present on admission If the pressure ulcer was present on admission/entry or reentry and subsequently increased in numerical stage during the resident s stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered as present on admission Should not be coded as present on admission If the pressure ulcer was unstageable on admission/entry or reentry, but becomes numerically stageable later, it should be considered as present on admission at the stage at which it first becomes numerically stageable. If it subsequently increases in numerical stage, that higher stage should not be considered present on admission Should not be coded as present on admission 58 Copyright 2016 If a resident who has a pressure ulcer that was originally acquired in the facility is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer should not be coded as present on admission because it was present and acquired at the facility prior to the hospitalization 29

M0300 Numbering and content revised for Step 3: Determine Present on Admission Code present on admission If a resident who has a pressure ulcer that was present on admission (not acquired in the facility) is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer is still coded as present on admission because it was originally acquired outside the facility and has not changed in stage Code present on admission If a resident who has a pressure ulcer is hospitalized and the ulcer increases in numerical stage during the hospitalization, it should be coded as present on admission at that higher stage upon reentry 59 Copyright 2016 Example of M0300 Numbering and content revised for Step 3: Determine Present on Admission Ms. K is admitted to the facility without a pressure ulcer. During the stay, she develops a stage 2 pressure ulcer. This is a facility acquired pressure ulcer and was not present on admission. Ms. K is hospitalized and returns to the facility with the same stage 2 pressure ulcer. This pressure ulcer was originally acquired in the nursing home and should not be considered as present on admission when she returns from the hospital. (M-7) Admitted to the nursing home WITHOUT a pressure ulcer Develops a pressure ulcer in the nursing home (facility acquired) Discharged to hospital for acute change in condition Readmitted to nursing home with same pressure ulcer that was facility acquired 60 Copyright 2016 NOT Present on Admission 30

Example of M0300 Numbering and content revised for Step 3: Determine Present on Admission Mr. J is a new admission to the facility and is admitted with a stage 2 pressure ulcer. This pressure ulcer is considered as present on admission as it was not acquired in the facility. Mr. J is hospitalized and returns with the same stage 2 pressure ulcer, unchanged from the prior admission/entry. This pressure ulcer is still considered present on admission because it was originally acquired outside the facility and has not changed. (M-8) 61 Copyright 2016 Admitted to the nursing home WITH a pressure ulcer (Not facility acquired Discharged to hospital for acute change in condition Readmitted to nursing home with the same pressure ulcer that was not facility acquired Present on Admission Section N Updated Resources and Tool links 62 Copyright 2016 31

Resources & Tools updated in section N GlobalRPh Drug Reference, http://globalrph.com/drug-a.htm Medline Plus, https://www.nlm.nih.gov/medlineplus/druginformation.html The DrugLib.com Index of Drugs by Category, http://www.druglib.com/drugindex/category/ USP Pharmacological Classification of Drugs, http://www.usp.org/usp-healthcare- professionals/usp-medicare-model-guidelines/medicare-model-guidelines-v50- v40#guidelines6. Directions: Scroll to the bottom of this webpage and click on the pdf download for USP Medicare Model Guidelines (With Example Part D Drugs) 63 Copyright 2016 Section Q Coding item changes 64 Copyright 2016 32

Section Q0490 & Q0550 Code 8, Information not available: if the resident cannot respond and the family or significant other is not available to respond on the resident s behalf and a guardian or legally authorized representative is not available or has not been appointed by the court Code 9, None of the above 65 Copyright 2016 Chapter 4 Delirium Trigger Change 66 Copyright 2016 33

Delirium CAT Logic Table Triggering Conditions (any of the following): A0310A = 03, 04 or 05) as indicated by: C1310A = 1 AND C1310B = 1 or 2 AND EITHER C1310C = 1 or 2 or C1310D = 1 or 2 67 Copyright 2016 Cognitive Loss/Dementia CAT Logic Table This CAA is triggered if the resident is exhibiting an acute change in mental status and/or the presence of inattention, disorganized thinking or altered mental status 4. BIMS summary score has missing value of 99 or and at least some difficulty making decisions regarding tasks of daily life as indicated by: C0500 = 99, -, or ^ AND C1000 >= 1 AND C1000 <= 3 5. BIMS, staff assessment or clinical record suggests presence of inattention, disorganized thinking, or altered level of consciousness as indicated by: C1310B = 1 or C1310B = 2 68 Copyright 2016 or C1310C = 1 or C1310C = 2 or C1310D = 1 or C1310D = 2 34

69 Copyright 2016 Task for the Staff Education Administrator Integration Software Rehabilitation Discharge Planning Interdisciplinary Team (IDT) Direct Care Staff Business Office Manager Medical Records Point Of Care MDS Rehab Orders Screens not for GG Pre-Admit-Rehab/Medical By Day 3 Social Work 70 Copyright 2016 35

Team Meeting to Review the Following Ask your team: Is there paper versions for Section C, and the Delirium CAA need to be changed due to C1310? How does the coding clarification rule on fall with injury change the process within the facility? Who will be the expert coder of GG and who will be the back-up? Who will help when rehab is not treating the resident? When should we start practicing? Usual Performance team discussion? o Not Worst or Best o Compare prior to the event o Which documents do you need? Would a Questionnaire be helpful? When will the software have your new item set available to practice? Seek your Rehab team for discharge goal setting advice A2400.B equals 10-1-16 Section GG begins 71 Copyright 2016 Remember this is for Medicare Part A ONLY Resources RAI Technical Specifications https://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/nursinghomequalityinits/nhqimds30technicalinformation.ht ml QRP Manual updated April 2016 https://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/NursingHomeQualityInits/Downloads/Skilled-Nursing- Facility-Quality-Reporting-Program-Quality-Measure-Specifications-for-FY- 2016-Notice-of-Proposed-Rule-Making-report.pdf MDS 3.0 RAI Manual v1.14 August 2016 https://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/NursinghomeQualityInits/MDS30RAIManual.html Section GG Data Collection Tools Link www.aanac.org/section-gg-resources 72 Copyright 2016 36

Questions? 73 Copyright 2016 September 14 th, 2016 at 2 pm EDT Join us next Wednesday, September 14 th at 2 pm EDT in the LTC Network discussion group, where experts Amy Franklin and Judi Kulus Will host a 60-minute post-webinar Q&A chat session to continue answering your questions about the updates It s easy to join the conversation, simply navigate to the community on the 14 th at 2:00 pm EDT to view the online chat and post a new message with your question The experts will present on some of the most frequently asked questions from the September 8 th webinar and follow up on your own questions by responding in realtime So be sure to refresh your screen every few minutes This opportunity is not eligible for CE and is only available to AANAC members. 74 Copyright 2016 37