AANAC Education Advancement MDS Essentials: An Introduction to MDS 3.0 We want to provide you with the right education at the right time in your career path Consider the following to identify your needs: Experience with MDS/RAI process Goals for education Desire to obtain certification Goals for further career advancement Desire to teach others 1 2 MDS Essentials RAC CT Education Advancement Education Advancement Professional Development Expert within your Organization Successfully Completed RAC CT Completed QCP CT Completion of Medicare University RAC MT, QCP MT MDS Essentials: Introduction to RAI and MDS Process 3 4 MDS Essentials Learning Objectives 1. Interpret the regulatory mandate for the (MDS) 2. Differentiate the various functions of the MDS and their application in nursing homes 3. Describe the components of the Resident Assessment Instrument (RAI) process 4. Demonstrate awareness of key aspects of RAIspecific lingo 5. Explain the process for accurate and timely completion of the MDS 6. Describe how the RAI process is linked to resident care and positive outcomes 5 6 1
The (MDS) Page numbers in the follow section reference page number of Comprehensive MDS form Paper form or software version Must be submitted electronically to national MDS database known as QIES ASAP Core set of resident specific screening, clinical, and functional status items Screening tool rather than assessment Complex completion instructions and processes involved 7 8 Item Set Set of MDS items required depending on the reason for doing the assessment Nursing Home Comprehensive (NC) item set Contains the most items, used for clinical assessment Subsets of the NC items set Quarterly clinical assessment Discharge assessments Payment assessments Entry and Death records 9 Sections A Z: Topics Mandated by Law A. Identification Information B. Hearing, Speech, and Vision C. Cognitive Patterns D. Mood E. Behavior F. Preferences G. Functional Status GG. Functional Abilities and Goals H. Bladder and Bowel I. Active Diagnoses J. Health Conditions 10 K. Swallow/Nutrition L. Oral/Dental M. Skin N. Medications O. Special Treatments P. Physical Restraints Q. Participation/Goals V. CAAs/Signatures X. Correction Request Z. Assessment Admin Items Each section is further divided into specific items Example, Section E, Behavior (page 11) Item E0100, Potential Indicators of Psychosis Item E0200, Behavioral Symptoms Item E0300, Overall Presence of Behavioral Symptoms Item E0500, Impact on Resident Item E0600, Impact on Others Item E0800, Rejection of Care After each item label, list of answer options, such as: E0100. Potential Indicators of Psychosis E0100A. Hallucinations E0100B. Delusions E0100Z. None of the above OR 11 12 2
Further subdivided into more questions and the answer options: E0500: Did any of the identified symptoms: E0500A. Put the resident at significant risk for physical illness or injury? Yes/No E0500B. Significantly interfere with the resident s care? Yes/No E0500C. Significantly interfere with the resident s participation in activities or social interactions? Yes/No 13 Answer Options Coding conventions Check all that apply, such as E0100, or Select code and enter it into box, such as A0310 (p. 1), or Enter ID numbers, such as A0100 (p.1) or A0600 (p.2) Key Concept: Read coding instructions for each item 14 (RAI) (RAI) Regulatory Mandate Nursing Home Reform Act of 1987 known as OBRA 87 Standardized, periodic functional status assessments required for all nursing home residents To improve quality of assessment Spotlighting resident specific problems Targeting care planning Goal: Improving resident care and outcomes 15 16 Process of Investigation Parallels nursing process Components (MDS) Core set of screening, clinical, and functional status items Care Area Triggers (CATs) MDS items that alert staff to possible problems, needs, strengths Triggers need a complete assessment of the issue that meets standards of practice 17 Process of Investigation Care Area Assessments (CAAs) 20 care areas (MDS page 40) Complete assessments of issues identified by the MDS Identify causes, contributing factors, risk factors related to the problem Care Plan Working action plan that targets specific problems, needs, strengths and preferences including those identified by the MDS & CAAs 18 3
Assessment Requirement Comprehensive assessment MDS + CAAs Required at least every 366 days Quarterly assessment Subset of comprehensive assessment Required at least every 92 days Unscheduled comprehensive assessments Significant Change in Status Assessment Significant Correction of Prior Assessment Assessment Requirement OBRA required clinical assessments Required for all residents of nursing home facilities and units in facilities that are Medicare and/or Medicaid certified regardless of payer 19 20 (RAI) User s Manual CHAPTER 1 Overview Components of the MDS Layout of the RAI Manual Protecting the Privacy of the MDS Data 21 22 CHAPTER 1: Excerpt (1 7) Monitoring the Quality of Care. MDS assessment data are also used to monitor the quality of care in the nation s nursing homes. MDS based quality measures (QMs) were developed by researchers to assist: (1) State Survey and Certification staff in identifying potential care problems in a nursing home; (2) nursing home providers with quality improvement activities/efforts; (3) nursing home consumers in understanding the quality of care provided by a nursing home; and (4) CMS with long term quality monitoring and program planning. CMS continuously evaluates the usefulness of the QMs, which may be modified in the future to enhance their effectiveness. 23 CHAPTER 2 RAI Requirements Responsibility for Completing Assessments Assessment Types and Definitions Required OBRA Assessments Skilled Nursing Facility Medicare Prospective Payment System Assessments Combining Assessments Determining Item Set for an MDS Record 24 4
Chapter 2 Excerpt (2 6 2 7) Federal regulatory requirement [42 CFR 483.20(d)] requires nursing homes to maintain all assessments completed within previous 15 months in the active clinical record. Applies to all MDS assessment types regardless of the form of storage (i.e., electronic or hard copy). The 15 month period for maintaining assessment data may not restart with each readmission to the facility: When a resident is discharged return anticipated and the resident returns to the facility within 30 days, the facility must copy the previous RAI and transfer that copy to the new record. The15 month requirement for maintenance of the RAI data must be adhered to. When a resident is discharged return anticipated and does not return within 30 days or discharged return not anticipated, facilities may develop their own specific policies regarding how to handle return situations, whether or not to copy the previous RAI to the new record 25 Chapter 2 Excerpt (2 22) SIGNIFICANT CHANGE = decline or improvement in resident s status 1. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, is not self limiting (for declines only); 2. Impacts more than one area of the resident s health status; and 3. Requires interdisciplinary review and/or revision of care plan A significant change differs from a significant error because it reflects an actual significant change in the resident s health status and NOT incorrect coding of the MDS A significant change may require referral for a Preadmission Screening and Resident Review (PASRR) evaluation if mental illness, intellectual disability (ID), or related condition is present or is suspected to be present 26 CHAPTER 3 Item By Item Guide to MDS 3.0 Sections A Z Intent Rationale Coding instructions Examples Tips and special population CHAPTER 3: Excerpt (L 1) 27 28 CHAPTER 4 Care Area Assessments Background and rationale Other considerations regarding the use of CAAs When is the RAI not enough? The RAI and Care Planning The Twenty Care Areas 29 CHAPTER 4: Excerpt (4 4) CATs provide a flag for the IDT members, indicating that the triggered care area needs to be assessed more completely prior to making care planning decisions. Further assessment of a triggered care area may identify causes, risk factors, and complications associated with the care area condition. The plan of care then addresses these factors with the goal of promoting the resident s highest practicable level of functioning: (1) improvement where possible or (2) maintenance and prevention of avoidable declines. 30 5
CHAPTER 5 Submission and Correction of the MDS Assessment Transmitting MDS Data Validation Edits MDS Correction Policy Correcting MDS records that have not yet been accepted into the QIES ASAP system Correcting MDS records that have been accepted into the QIES ASAP System 31 CHAPTER 5: Excerpt (5 7) It is important to remember that the electronic record submitted to and accepted into the QIES ASAP system is the legal assessment. Corrections made to the electronic record after QIES ASAP acceptance or to the paper copy maintained in the medical record are not recognized as proper corrections. It is the responsibility of the provider to ensure that any corrections made to a record are submitted to the QIES ASAP system in accordance with the MDS Correction Policy. 32 CHAPTER 6: Excerpt (6-25) CHAPTER 6 Medicare Skilled Nursing Facility Prospective Payment System Resource Utilization Groups (RUGS IV) Relationship between assessment and claim RUGS IV 66 Group Model Calculation worksheet SNF PPS Policies Non compliance with the SNF PPS Schedule 33 34 Chapter 6 excerpt (6 39) APPENDIX A Glossary Common Acronyms 35 36 6
APPENDIX A Glossary excerpt APPENDIX A Common Acronyms Excerpt 37 38 APPENDIX B State Agency and CMS Regional Office State RAI Contact information Located in the Downloads section on CMS s MDS 3.0 RAI Manual Web page: http://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/NursingHomeQualityInits/MDS30RAI Manual.html APPENDIX C Care Area Assessment Resources Provided as a courtesy CMS does not endorse or mandate use of this resource Facilities must use resource(s) that are current, evidenced based or expert endorsed research and clinical practice guidelines 39 40 Appendix C Example APPENDIX D Interviewing to increase resident voice in MDS Assessment Approaches and techniques to make interviews more effective 41 42 7
APPENDIX D: Excerpt (D 1) Find a quiet, private area where you are not likely to be interrupted or overheard. This is important for several reasons: Background noise should be minimized. Some items are personal, and the resident will be more comfortable answering in private. The interviewer is in a better position to respond to issues that arise. Decrease available distractions. APPENDIX E PHQ 9 Scoring Rules Instructions for administering the BIMS in writing 43 44 APPENDIX E: Excerpt APPENDIX F MDS item Matrix APPENDIX G References APPENDIX H MDS Forms 45 46 Skilled Nursing Facility Prospective Payment System (SNF PPS) SNF Prospective Payment System Regulatory Mandate Federal law mandated switch from cost based to case mix reimbursement in 1998 Cost based = pay facility whatever it spends on the resident s care Case mix prospective reimbursement = predict cost of care using resident specific information from MDS and pay facility based on that 47 48 8
SNF Prospective Payment System Calculating Payment Nursing Home PPS (NP) item set Specific items reflecting resident s acuity used to help quantify the cost of care and services, such as Functional status Functional abilities and goals Health conditions Diagnoses Certain treatments, procedures SNF Prospective Payment System Calculating Payment Completed assessment classifies resident into one of 66 categories known as Resource Utilization Groups (RUGs) Residents in a specific RUG share a common projected cost of care Specific diagnoses, treatments, etc. may be very different A daily payment rate is assigned to each group 49 50 SNF Prospective Payment System Assessment Requirement Law mandates set schedule for SNF PPS assessments to periodically recalculate RUG At approximately day 5, 14, 30, 60, and 90 as long as Part A is the payer Recalculation of RUG also required offschedule under specific circumstances This schedule is in addition and parallel to the OBRA required clinical assessments Quality Measures (QMs) 51 52 Quality Measures Intended to reflect quality of care in a facility CMS pulls data specific to particular conditions and problems from national database examples Rate of UTIs in a facility comes from I2300 Decline in ADLs computed from comparing G0110 data on successive assessments Quality Measures Long list of QMs, scores periodically updated Complex formulas and calculations involved Quality Measures info and User s Manual: https://www.cms.gov/medicare/quality Initiatives Patient Assessmentinstruments/NursingHomeQualityInits/NHQIQuality Measures.html 53 54 9
Quality Measures Publicly Reported QMs Takes facility specific resident care information directly to consumers To publicize the differences in quality to assist consumers in selection of a facility Nursing Home Compare website www.medicare.gov/nursinghomecompare/ search.html Quality Measures CASPER Reporting System Certification and Survey Provider Enhanced Reporting (CASPER) system Produces QM reports for facility to use in quality improvement efforts Surveyors also use similar list of QMs as part of the survey process 55 56 Survey Outcomes MDS and Survey Outcomes All Nursing Facilities participating in Medicare and/or Medicaid program are required to have a Life Safety and Standard Annual Survey Additional surveys MDS/Staffing Focus Survey Dementia Focus Survey Complaint Survey Must apply RAI guidelines and understand the Interpretative guidelines (SOM appendix PP) 57 58 Survey Outcomes MDS Related Tags F272 Comprehensive Assessment F273 Comprehensive Assessment 14 days after Admission F274 Comprehensive Assessment after Signification change F275 comprehensive Assessment at least every 12 months F276 Quarterly Assessment at least every 3 months F278 Assessment Accuracy/Coordinated by RN F279 Develop of Comprehensive Care Plans F280 Right to Participate in Planning care and treatment F286 Maintain 15 months of Resident Assessments F287 Encoding and Transmitting Resident Assessments 59 Survey Outcomes Interpretive Guidelines F278 Implementation: 11 26 14 483.20(g) Accuracy of Assessment The assessment must accurately reflect the resident s status. Intent 483.20(g) To assure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident s status, needs, strengths, and areas of decline. Interpretive Guidelines 483.20(g) The accuracy of the assessment means that the appropriate, qualified health professional correctly documents the resident s medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. The initial comprehensive assessment provides baseline data for ongoing assessment of resident progress. 60 10
61 : THE authoritative resource for all official instructions & information Chapters 1: Overview 2: Timing and scheduling of assessments 3: Item by item coding instructions 4: Care Area Assessments and care planning 5: MDS correction policy and transmission 6: RUG IV calculations 8 appendices 62 Download from CMS website http://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/NursingHomeQualityInits/MDS30RAIMan ual.html AANAC s Web Page www.aanac.org/information resources/mds30/ 63 64 Chapter 3 Process based on the standard format for the instructions for each item Background included for each item Intent/reason for including item on MDS Rationale/purpose for assessing the topic How the topic of the item affects quality of life How assessment of the topic can contribute to appropriate care planning Chapter 3 Item specific coding instructions Steps for assessment: Sources for information and methods for determining the correct code Specific coding instructions with explanation of individual response options Coding tips/clarifications, issues of note, conditions to be considered Case examples 65 66 11
B0700. Makes Self Understood Item Rationale Health related Quality of Life Problems making self understood can be very frustrating for the resident and can contribute to social isolation and mood and behavior disorders. Unaddressed communication problems can be inappropriately mistaken for confusion or cognitive impairment 67 B0700. Makes Self Understood Planning for Care Ability to make self understood can be optimized by not rushing the resident, breaking longer questions into parts and waiting for reply, and maintaining eye contact (if appropriate) If a resident has difficulty making self understood: Identify the underlying cause or causes Identify the best methods to facilitate communication for that resident 68 B0700. Makes Self Understood Steps for Assessment 1. Assess using the resident s preferred language 2. Interact with resident. Be sure he/she can hear you or have access to his or her preferred method for communication. If the resident seems unable to communicate, offer alternatives such as writing, pointing or using cue cards. 3. Observe his/her interactions with others in different settings and circumstances. 4. Consult with the primary nurse assistant (over all shifts), if available, the resident s family, and speech language pathologist. 69 B0700. Makes Self Understood Coding Instructions Code 0, understood: if the resident expresses requests and ideas clearly Code 1, usually understood: if the resident has difficulty communicating some words or finishing thoughts but is able if prompted or given time. He or she may have delayed responses or may require some prompting to make self understood Code 2, sometimes understood: if the resident has limited ability but is able to express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet) Code 3, rarely or never understood: if, at best, the resident s understanding is limited to staff interpretation of highly individual, resident specific sounds or body language (e.g., indicated presence of pain or need to toilet) 70 Timeframe for Data Collection Based on Assessment Reference Date (ARD), item A2300 (p. 5) Last date for collecting data for the particular MDS Most items look back 7 days: ARD plus the 6 days preceding it This is the observation period or look back period (these terms are synonymous) Using the wrong dates or not using every day in the look back is likely to result in accuracy problems 71 Who Takes Part in MDS Process? A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals (42CFR483.20[h]) It must be an RN who signs item Z0500A certifying completion of all of the MDS items (483.20([I]) This is not verifying accuracy of the items 72 12
Who Takes Part in MDS Process? the physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs (interpretive guidelines, 42CFR483.20[h]) How is Accuracy Validated? Chart documentation that supports the MDS coding Any surveyor or auditor reading the chart should come up with the same coding decision that the person coding the MDS did 73 74 MDS Essentials Please continue with MDS Essentials: Sections A, B, C, H and I 75 76 Questions Please submit questions to: The New to MDS Community 77 13