April 1 2012 MDS Item Set Changes and Other Key MDS Information

Presented to

MDS National ConferenceSt Louis MOMarch 2012

Thomas Dudley MS RNCenters for Medicare amp Medicaid ServicesOffice of Clinical Standards and QualityQuality Improvement and Health Assessment GroupDivision of Chronic and Post Acute Care

1

Topics to be Covered

V108 of the MDS 30 RAI Manual

Changes to the Item Set

Discharge Assessments (Planned vs Unplanned)

Use of Dashes

Interviews

2

Topics to be Covered

V108 of the MDS 30 RAI Manual

Changes to the Item Set

Discharge Assessments (Planned vs Unplanned)

Use of Dashes

Interviews

2

MDS 30 RAI Manual V108

Published - January 20 2012 (wwwcmsgovNursingHomeQualityInits45_NHQIMDS30TrainingMaterialsasp)

Effective date ndash APRIL 1 2012

Format Changes

bull Only pages with actual changes have been updated and is indicated by the footer ldquoApril 2012rdquo

bull Unchanged pages are indicated with the footer ldquoOctober 2011rdquo

3

Known Issues in MDS 30 RAI Manual V108

February 23 2012 Errata document (available on the MDS 30 Training page)

4

Known Issues in MDS 30 RAI Manual V108

5

Issue - Page 14 of the change table for Chapter 3 Section Q the screenshot for Q500 was inserted where Q490 belongs This occurs only on the change table and not in the manual itself

Resolution - The screenshot of item Q0490 will replace that of Q0500 on page 14 of the change table for Chapter 3 Section Q

Known Issues in MDS 30 RAI Manual V108

6

Issue - Chapter 6 pages 6-38 and 6-40 the RUG calculation worksheet does not account for splitting tube feeding into while a resident and while not a resident

Resolution - For the K0500A RUG criterion K0500A is used for assessments with ARD before April 1 2012 but is replaced by K0510A1 or K0510A2 for ARDs on or after April 1 2012 K0500B is used for assessments with ARD before April 1 2012 but is replaced by K0510B1 or K0510B2 for ARDs on or after April 1 2012

Known Issues in MDS 30 RAI Manual V108

7

Issue ndash The term ldquomental retardationrdquo appears three times in Appendix C when it should have been changed to ldquointellectual disabilityrdquo CAAs 2 7 and 12 refer to item A1550 using the language ldquoMental retardation developmental disabilityrdquo instead of ldquoIntellectual disability developmental disabilityrdquo

Resolution ndash In appendix C CAAs 2 7 and 12 any use of ldquoMental retardationdevelopmental disabilityrdquo will be replaced by ldquoIntellectual disabilitydevelopmental disabilityrdquo

Known Issues in MDS 30 RAI Manual V108

8

Issue ndash Appendix E page E-7 the sample calculation contains typographical error that alters the result of a calculation

Line item 2 reads Multiply this sum by 1111 In the example 9 x 1286 = 11250

This is incorrect

The line should readMultiply this sum by 1111 In the example 9 x 1111 = 13332 In addition to avoid ambiguity the word ldquosumrdquo should be bolded

Resolution -

1 Compute the sum of the 9 items with non-missing values This sum is 12

2 Multiply this sum by 1111 In the example 12 x 1111 = 13332

3 Round the result to the nearest integer In the example 13332 rounds to 13

4 Place the rounded result in D0600

Known Issues in MDS 30 RAI Manual V108

9

Issue ndash Appendix E page E-7 the sample calculation contains typographical error that alters the result of a calculation

Line item 2 reads Multiply this sum by 1111 In the example 9 x 1286 = 11250

This is incorrect The line should read

Multiply this sum by 1111 In the example 9 x 1250 = 11250 In addition to avoid ambiguity the word ldquosumrdquo will be bolded

Resolution ndash 1 Compute the sum of the 8 items with non-missing values This sum is 92 Multiply this sum by 1250 In the example 9 x 1250 = 112503 Round the result to the nearest integer In the example 11250 rounds to 114 Place the rounded result in D0600

Known Issues in MDS 30 RAI Manual V108

10

Issue - In Chapter 4 page 4-8 the link to the State Operations Manual (SOM) contains a typographical error and therefore does not link properly to the webpage

Currently it reads httpwwwcmsgovManualsIOMlistasp

Resolution - The extra ldquordquo after ldquocmsrdquo needs to be removed

Known Issues in MDS 30 RAI Manual V108

11

Issue - The April 2012 MDS Item Set instructs providers to enter the number of days each of the medications listed were received in the last 7 days in Item N0410 as does the screen shot of item N0410 on page N-4 of the MDS 30 RAI Manual (v108)

However pages N-5 and N-6 the instructions state for providers to ldquoCheck Ardquo -- If antipsychotic med was received to ldquoCheck Brsquo -- If antianxiety med was received etc

Each of these coding tips need to be changed to address the specific item number that they reference

Known Issues in MDS 30 RAI Manual V108

12

Resolution ndash The new coding tips on pages N-5 and N-6 should read

N0410 A Antipsychotic Record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period (or since admissionentry or reentry if less than 7 days) N0410 B Antianxiety Record the number of days an antianxiety medication was received by the resident at any time during the 7-day look-back period (or since admissionentry or reentry if less than 7 days) N0410 C Antidepressant Record the number of days an antidepressant was received by the resident at any time during the 7-day look-back period (or since admissionentry or reentry if less than 7 days) N0410 D Hypnotic Record the number of days a hypnotic medication was received by the resident at any time during the 7-day look-back period (or since admissionentry or reentry if less than 7 days)(continued on slide 13)

Known Issues in MDS 30 RAI Manual V108

13

Resolution ndash The new coding tips on pages N-5 and N-6 should read (continued from slide 12)

N0410 E Anticoagulant (eg warfarin heparin or low-molecular weight heparin) Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admissionentry or reentry if less than 7 days) Do not code antiplatelet medications such as aspirinextended release dipyridamole or clopidogrel here N0410 F Antibiotic Record the number of days antibiotic medication was received by the resident at any time during the 7-day look-back period (or since admissionentry or reentry if less than 7 days) N0410 G Diuretic Record the number of days a diuretic medication was received by the resident at any time during the 7-day look-back period (or since admissionentry or reentry if less than 7 days)

Global Item Set Changes

Term ldquoMental Retardation (MR)rdquo is changed to ldquoIntellectual Disability (ID)rdquo

Several textlabel changes to be consistent throughout the assessment instrument ie AdmissionReentry vs AdmissionEntry or Reentry

AdjustedCorrected some of the skip patterns based on the specific item sets

14

Section A ndash IdentificationInformation Item Set Changes

Adds A0050 ndash Type of Record

Replaces X0100 ndash Type of Record

Adds A0310G ndash Planned or Unplanned discharge

A1800 amp A2100 ndash Entered From and Discharged To

Adds option 09 ndash Long Term Care Hospital(LTCH)

15

Section I ndash Active Diagnoses Item Set Changes

I1800 ndash Additional Active Diagnoses

(where ICD codes can be entered) ndash Removes the check box

16

Section K ndash Swallowing and Nutritional Status Item Set Changes

17

Adds K0310 ndash Weight Gain (secondary to the increase in obesity across the US population)

Deletes K0500 ndash Nutritional Approaches ndash and Replaces with K0510 ndash Nutritional Approaches

K0510 Includes

bull A 2-column approach to capture ldquoWhile a residentrdquo and ldquoWhile not a residentrdquo information (similar to item O0100 ndash Special Treatments Procedures and Programs)

bull Option C ndash Mechanically Altered Diet and D ndash Therapeutic Diet are factored into the determination of Pressure Ulcer Risk in conjunction with A0310G ndash Type of Assessment Type of Discharge

Section M ndash Skin ConditionsItem Set Changes

18

M0700 ndash Most Severe Tissue Type for Any Pressure Ulcer adds option ldquo9rdquo ndash None of the Above

M1040 ndash Other Ulcers Wounds and Skin Problems adds

bull Option ldquoHrdquo Moisture Associated Skin Damage (MASD) ie incontinence perspiration drainage

bull Option ldquoGrdquo ndash Skin Tears

Section N ndash MedicationsItem Set Changes

19

N0400 ndash Medications Received replaced with N0410 ndash Medications Received

N0410 ndash Medications Received now includes the ldquoNumber of days the resident received any of the listed classes of medications during the preceding 7 days since admissionentry or reentry if less than 7 daysrdquo

Section Q ndash Participation in Assessment and Goal SettingItem Set Changes

Deletes Q0400B ndash What determination was made by the resident and the care planning team regarding discharge to the community

Adds Q0490 ndash Residentrsquos Preference to Avoid Being Asked Question Q0500B ndash Return to Community

Adds Q0550 ndash Residentrsquos Preference to Avoid Being Asked Question Q0500B again

bull Captures whether the question should be asked on all assessments as well as the source of the information

20

Section X ndash Correction RequestItem Set Changes

21

Deletes X0100 ndash Type of Record

Replaces by A0050 ndash Type of Record

Discharge Assessments

22

Definition of an Un-Planned Discharge Acute-care transfer of the resident to a hospital or an

emergency department in order to either stabilize a condition or determine if an acute-care admission is required based on emergency department evaluation

OR

Resident unexpectedly leaving the facility against medical advice

OR

Resident unexpectedly deciding to go home or to another setting

23

Current Discharge Assessment Maximum 111 Questions

24

Identification Information (A) - 22 SwallowingNutritional Status (K) - 3

Hearing Speech and Vision (B) ndash 8 OralDental Status (L) - 0

Cognitive Patterns (C) ndash 12 Skin Conditions (M) ndash 11

Mood (D) - 7 Medications (N) ndash 1

Behavior (E) ndash 1 Special Treatments Procedures and Programs (O) - 6

Preferences for Customary Routine and Activities (F) - 0 Restraints (P) ndash 1

Functional Status (G) ndash 5 Participation in Assessment and Goal Setting (Q) ndash 1

Bladder and Bowel (H) - 3 CAA Summary (V) ndash 0

Active Diagnoses (I) ndash 0 Correction Request (X) ndash 12

Health Conditions (J) - 15 Assessment Administration (Z) - 1

April 1 2012 Un-Planned Discharge Assessment ndash Maximum 77 Questions

25

Identification Information (A) ndash 24 (added A0310G ndash plannedunplanned) SwallowingNutritional Status (K) - 4

Hearing Speech and Vision (B) ndash 1 OralDental Status (L) - 0

Cognitive Patterns (C) ndash 4 Skin Conditions (M) ndash 5

Mood (D) - 0 Medications (N) ndash 1

Behavior (E) ndash 4 Special Treatments Procedures and Programs (O) - 4

Preferences for Customary Routine and Activities (F) - 0 Restraints (P) ndash 1

Functional Status (G) ndash 2 Participation in Assessment and Goal Setting (Q) ndash2

Bladder and Bowel (H) - 3 CAA Summary (V) ndash 0

Active Diagnoses (I) ndash 1 Correction Request (X) ndash11

Health Conditions (J) - 7 Assessment Administration (Z) - 3

April 1 2012 Planned Discharge Assessment ndash Maximum 89 Questions

26

Identification Information (A) - 24 SwallowingNutritional Status (K) - 4

Hearing Speech and Vision (B) ndash 1 OralDental Status (L) - 0

Cognitive Patterns (C) ndash 5 Skin Conditions (M) ndash 5

Mood (D) - 7 Medications (N) ndash 1

Behavior (E) ndash 4 Special Treatments Procedures and Programs (O) - 4

Preferences for Customary Routine and Activities (F) - 0 Restraints (P) ndash 1

Functional Status (G) ndash 2 Participation in Assessment and Goal Setting (Q) ndash 2

Bladder and Bowel (H) - 3 CAA Summary (V) ndash 0

Active Diagnoses (I) ndash 1 Correction Request (X) ndash 11

Health Conditions (J) - 11 Assessment Administration (Z) - 3

Future Item Set ChangesUpdates

CMS will use errata documents to correct any ldquoinaccuraciesrdquo identified in V108 until they are corrected in V109 in Fall 2012

Next update to the item sets and manual expected in September 2012 to reflect any PPS changes or other policy changes

CMS is attempting to go to annual updates beginning in 2013

27

Possible Data Assessment Issues

Overuse Inappropriate use of dashes on assessments

Skipped Interviews

28

29

Potential Overuse of Dashes

( )

Initial Analysis of MDS 30 Data

30

Assessment data of First Year of MDS 30 Data

bull Shows a large percentage of dashes

bull Used for up to 40 of items

bull Has implications for use of data particularly QMs

Use of Data for Quality Measures1

Several QMs use data from MDS sections assessing mental status depression and pain

Includes data from the discharge assessment under certain circumstances

31

Use of Data for Quality Measures2

Uses data from resident interview if complete

Uses data from staff assessment if interview is not complete

Use of dash may result in resident being excluded from QM measure calculations

32

Excessive Use of Dashes Affects the accuracy of QMs

Affects the accuracy of reporting

bull Nursing Home Compare

bull 5-Star Nursing Home Quality Rating System

33

Effects on Facility QM Sample Reduces the size of the facilityrsquos quality

measure resident sample

bull Skews QM data

bull Results in an inaccurate representation of the facilityrsquos actual resident population

34

Impact on Resident Data Important clinical information

regarding resident condition may be missing

Skews QM data

35

Make Every Effort toComplete Each Assessment

Complete all resident interviews (comatose residents are individuals that definitely cannot complete the interviews otherwise)

Complete staff assessments if an interview is not feasible

36

Complete Each Assessment

Every assessment must be completed

as fully as possible with all available

information at the time of assessment

37

Interview Matters1

CMS has received reports from State Survey Agencies identifying facilities that are not completing interviews when residents are capable

This has been verified during site visits

Nursing Homes need to be aware that this is not acceptable and that they will be cited in instances where such practice is verified

38

The interview items such as the PHQ-9 are standardized instruments that have been tested and have been proven to be reliable

When completing the interviews follow the instructions for the individual interview instrument

bull eg if the look-back period states 7 days then that is how you phrase the statements to the resident

Keep in mind that the interviews are intended to assess the residentrsquos status from the residentrsquos perspective

39

Interview Matters2

40

Interview Matters3

Good NewshellipUnscheduled Assessment Interviews - Effective April 1 2012

when coding a standalone unscheduled PPS assessment (COT

EOT SOT) the interview items may be coded using the responses

provided by the resident on a previous assessment if the interview

responses from the scheduled assessment were obtained no more

than 14 days prior to the date of the unscheduled assessment on

which those responses will be used

This change does not change other assessment policies with regards

to the frequency of resident interviews

(Continued on Slide 41)

41

Interview Matters4

(Continued from Slide 40)

Qualifications for Unscheduled Assessment Interviews

bull Applies only to standalone unscheduled PPS assessmentsbull Does not apply in cases where the unscheduled PPS

assessment is combined with a non-PPS assessment or scheduled PPS assessment

bull At the discretion of the provider if a change is observed during the observation period for the unscheduled PPS assessment then responses may not be carried forward

bull Can be applied only in cases where the resident interview was completed on prior assessment not when a staff assessment was completed

Once completed edited and accepted into the QIES ASAP

system providers may not change a previously completed

MDS assessment as the residentrsquos status changes during the

course of the residentrsquos stay ndash the MDS must be accurate

as of the date of the ARD established by the time of the

assessment Providers should have a process in place to

ensure assessments are accurate prior to submission Such

monitoring and documentation is a part of the providerrsquos

responsibility to provide necessary care and services (continued on slide 43)

Inactivations

42

(continued from slide 42)

When the provider determines that an event date (ARD of any

clinical assessment entry date and discharge date) or item

A0310 (type of assessment) is inaccurate the provider must

inactivate the record in the QIES ASAP system then complete

and submit a new MDS 30 record with the correct event date or

type of assessment ensuring that the clinical information is

accurate (Long-Term Care Facility Resident Assessment

Instrument Userrsquos Manual MDS 30 Page 5-12)

(continued on slide 44)

Inactivations

43

(continued from slide 43)

If the ARD or Type of Assessment is entered incorrectly and the provider

does not correct it within the encoding period the provider must complete

and submit a new MDS 30 record In this instance a new ARD date

must be established based on MDS requirements which is the date

the error is determined or later but not earlier The new MDS 30

record being submitted to replace the inactivated record must

include new signatures and dates for all items based on the look-

back period established by the new ARD and according to

established MDS assessment completion requirements

(continued on slide 45)

Inactivations

44

(continued from slide 44)

Example

Issue A SNF is coding a 30-day assessment Item A2300 (Assessment

Reference Date) is coded as 02-04-2011 but it was supposed to be coded

as 01-04-2012 This error is discovered on February 20th

Solution The improperly coded assessment must be inactivated and a

new MDS 30 record must be created and submitted to the QIES ASAP

The ARD on this assessment can be no earlier than February 20th When

completing the assessment all items are to be completed according to

established MDS completion guidelines for the specific assessment being

completed Remember that this includes all dates and signatures for the

new MDS that is being completed These signatures and dates must be

reflective of the ARD that is established for this replacement assessment

Inactivations

45

The Resident MUST ALWAYS come first

The assessment instrument will continue to change periodically in order to remain current with clinical practices

CMS does and will continue to listen to your comments and concerns

The MDS is just one tool to use when assessing residents

Parting Thoughts

46

MDS Training Resources

For a closer look at MDS 30 training resources please visit

wwwcmsgovNursingHomeQualityInits45_NHQIMDS30TrainingMaterialsasp

47

Thank you

48