powerpoint presentation · schizophrenia, and huntington’s disease restraint use other than...

6/29/2015

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©Pathway Health 2013©Pathway Health 2013

Focused Survey for MDS Assessment

Idaho Health Care AssociationJuly 21, 1015

1:45 P.M. – 3:15 P.M.

Louann Lawson, BA, RN, RAC-CTAHIMA Approved ICD-10-CM/PCS Trainer

Nurse Consultant, Clinical Reimbursement Lead


• Review the results of the MDS pilot study.

• Examine the clinical indicators at risk for

inaccurate coding.

• Discuss processes to assure correct coding of the MDS assessment tool.

Objectives:

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• Purpose

– Assess Minimum Data Set, Version 3.0 (MDS 3.0) coding practices and the relationship to resident care in nursing homes

• Volunteer States

– IL, MD, MN, PA, and VA

• Method

– 5 surveys in each state conducted over 2 days by State RAI Coordinator and one of two state surveyors

• Findings

– “Relatively high levels of compliance related to RN coordination and assessment timing”

– “Room for improvement in 4 of 7 clinical conditions”

• 2015 Expansion

– All states

– Staffing component

2014 Pilot Study Abstract

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• 42 CFR 483.20 Resident Assessment

• Appendix PP of the State Operations Manual (SOM)

• Apply to all residents in Medicare and/or Medicaid certified nursing facilities

• F Tags 272 through 287

Federal Regulations

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• Compliance with RN conducting or coordinating the assessments

• Compliance with required timelines (OBRA)

• Agreement between MDS 3.0 assessments and the resident’s medical record

– Supplemented with observations and interviews

Goals of Pilot Study

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• CMS provided each of the 5 volunteer State Survey Agencies with a list of possible facilities

– Based upon QM trends

– Usually < 120 residents

– Survey to be completed in 2 days

Facility Selection Process

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• Off-site survey preparation

• Procedures for entrance to a pilot facility

• Conducting an entrance conference with

facility staff

• Touring the facility and obtaining direct observation of residents and staff

• Collection of documents from facility staff

• Daily team meetings

Survey Process Tasks (1 of 2)

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• General guidelines for validating the agreement of the MDS 3.0 assessment

• Determining compliance with specific (related) regulations

• Survey team decision making

• Conducting an exit conference.

Survey Process Tasks (2 of 2)

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• 90 Minute Webinar

– Understand types of assessments (OBRA)

– Understand why ARD is critical in determining the clinical information captured on the MDS 3.0

– Understand coding instructions for those items included in the study

– Understand the criteria for SCSA and how it relates to the assessment process

Surveyor Training

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• Results of the pilot are not generalizable to all nursing facilities

• Sample was not representative of U.S. nursing facilities (size, rural/urban, etc.)

• 25 facilities in pilot vs. 16,000 nursing facilities in U.S.

• About 1,000 MDS 3.0 assessments compared to about 1.6 million submitted to CMS each month

Findings: A Cautionary Note

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©Pathway Health 2013

• Non-Compliance with RN conducting or coordinating the assessments

– 6 of 1,027 assessments

– 0.6% non-compliance rate

– “No sign of widespread failure”

– “Little reason for CMS to focus on RN coordination as an area of concern”

Findings (1 of 3)

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• Non-Compliance with required timelines (OBRA)

– 23 of 1,027 assessments

– 2.2%

– Includes failures to initiate the assessment and/or complete the assessment in a timely manner

– Overall rate of compliance is high

– Non-compliance issues were high in 3 of 5 states with a total of 6 facilities (24%)

Findings (2 of 3)

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• Disagreement between MDS 3.0 assessments and the resident’s medical record

– Supplemented with observations and interviews

Findings (3 of 3)

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High Rate of Agreement Low Rate of Agreement

Presence of an indwelling catheter

Diagnoses of neurogenic bladder and/or obstructive uropathy

Use of antipsychotic medications

Diagnoses of Tourette’s syndrome, Schizophrenia, and Huntington’s disease

Restraint use other than siderails

Presence of pressure ulcers, Pressure ulcer stage, Worsening of pressure ulcers

Late loss ADL status

FallsLevel of injury sustained during a fall as a major injury

MDS Accuracy Summary

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MDS Accuracy Data

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Numerator/ Denominator

Percent Disagreement

Assessment Area

8/47 17.0% Failure of facility staff to accurately reflect the status of the resident related torestraint use other than side rails

18/218 8.3% Failure of facility staff to accurately reflect the status of the resident related to thepresence of pressure ulcers

40/218 18.3% Failure of facility staff to accurately reflect the status of the resident related topressure ulcer stage

13/218 6.0% Failure of facility staff to accurately reflect the status of the resident related toworsening of pressure ulcer status since prior assessment or last admission/entry

MDS Accuracy Issues

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Numerator/ Denominator

Percent Disagreement

Assessment Area

1/132 0.8% Failure of facility staff to accurately reflect the status of the resident related to thepresence of an indwelling catheter

21/132 15.9% Failure of facility staff to accurately reflect the status of the resident related to thediagnoses of neurogenic bladder and/or obstructive uropathy

21/136 15.4% Failure of the facility staff to accurately reflect the status of the resident related tothe late loss ADL status. Late loss ADLs include bed mobility, toileting, transfer,and eating.

MDS Accuracy Issues

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Numerator/Denominator

PercentDisagreement

Assessment Area

24/94 25.5% Failure of the facility staff to accurately reflect the status of the resident related tothe level of injury sustained during a fall as a major injury

11/218 5.0% Failure of the facility staff to accurately reflect the status of the resident related tothe use of antipsychotic medications

7/218 3.2% Failure of the facility staff to accurately reflect the status of the resident related todiagnoses of Tourette’s syndrome, Schizophrenia, and Huntington’s disease

MDS Accuracy Issues

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State Breakdowns

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Restraint Use Total PA MD VA IL MN

# of assessments 47 4 25 3 4 11

# of disagreements 8 0 5 0 0 3

# of facilities with disagreements

4 ------ 3 ------ ------ 1

% disagreements 17.0% 0.0% 20.0% 0.0% 0.0% 27.3%

% of total Disagreements

100.0% 0.0% 62.5% 0.0% 0.0% 37.5%

MDS Validation Pilot Results by State

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Presence of Pressure Ulcers

Total PA MD VA IL MN

# of assessments 218 44 44 32 58 40



11 3 3 - 1 4

% disagreements 8.3% 6.8% 9.1% 0.0% 1.7% 25.0%


100% 16.7% 22.2% 0.0% 5.6% 55.6%


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Pressure Ulcer Stage


# of assessments 218 44 44 32 58 40



14 4 4 1 1 4

% disagreements 18.3% 11.4% 27.3% 3.1% 13.8% 35.0%


100.% 12.5% 30.0% 2.5% 20.0% 35.0%


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WorseningPressure Ulcers


# of assessments 218 44 44 32 58 40



8 4 2 ---- 2 -----

% disagreements 6.0% 11.4% 6.8% 0.0% 8.6% 0.0%


100.0% 38.5% 23.1% 0.0% 38.5% 0.0%


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Late Loss ADLs Total PA MD VA IL MN

# of assessments 136 26 31 25 29 25



12 1 2 1 4 4

% disagreements 15.4% 7.7% 19.4% 8.0% 24.1% 16.0%


100.0% 9.5% 28.6% 9.5% 33.3% 19.0%


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Falls Total PA MD VA IL MN

# of assessments 94 23 15 15 22 19

# of disagreements

10 1 6 2 0 1


6 1 2 2 -------- 1

% disagreements 10.6% 4.3% 40.0% 13.3% 0.0% 5.3%


100.0% 10.0% 60.0% 20.0% 0.0% 10.0%


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Falls w injury Total PA MD VA IL MN

# of assessments 94 23 15 15 22 19



12 1 3 3 3 2

% disagreements 25.5% 8.7% 60.0% 26.7% 13.6% 31.6%


100.0% 8.3% 37.5% 16.7% 12.5% 25.0%


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DX Neuro Bladder


# of assessments 132 36 29 24 22 21



13 1 4 4 1 3

% disagreements 15.9% 5.6% 17.2% 37.5% 9.1% 14.3%


100.% 9.5% 23.8% 42.9% 9.5% 14.3%


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UTI Total PA MD VA IL MN

# of assessments 182 43 42 25 46 26



12 2 3 2 1 4

% disagreements 17.6% 14.0% 11.9% 8.0% 13.0% 50.0%


100.0% 18.8% 15.6% 6.3% 18.8% 40.6%


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• Low Rate of Agreement

– Restraint use other than side rails

– Presence of pressure ulcers, Pressure ulcer stage, Worsening of pressure ulcers

– Late loss ADL status

– Falls

– Level of injury sustained during a fall as a major injury

Data Analysis Conclusion

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• Differences in MDS education and training

• A lack of internal MDS audit practices

• Differences in state-level MDS or case mix audit

practices.

Why Are There Low Agreement Rates?

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• Disagreement rate of 17%

• Surveyor observation and investigation identified additional restraint usage

• Additional guidance and education to ensure correct identification

– RAI Manual, Chapter 3, Section P

– S&C 07-22

Restraints

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• Disagreements

– Presence 8.3%

– Staging 18.3%

– Worsening 6.0%

• Lack of an accurate clinical assessment of the pressure ulcers

– Head to toe assessment

– Once a week

– Licensed nurse

• Training/Certification

Pressure Ulcers

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• Disagreement rate of 15.4%

– One in every seven cases of late loss ADLs was coded differently than would be expected

• These disagreements directly affect facilities’ QM ratings and 5 Star Ratings and reimbursement

• Accuracy of coding at the C.N.A. level

– Orientation

– At least quarterly

– Concurrently with observation period

Activities of Daily Living

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• Largest disagreement overall

• 25% of the reviewed assessments (24 out of 94) indicated disagreement for level of injury documented after a fall

• Additional guidance and education to ensure correct identification

– Nurses notes, progress notes, ER reports, X-rays, incident reports

– RAI Manual, Chapter 3, Section J

• Definition of fall

• Definition of major injury

Falls

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• MDS Focused Survey combined with a review of nursing home staffing

• Intend to strengthen the Nursing Home Five-Star Quality Rating System

• Survey worksheets revised

• Rollout in two phases by CMS regions and states

– Notified of group in February

– Training began in April (Webinars)

• Deficiencies identified during the surveys will result in relevant citations and enforcement actions.

2015: Nationwide Focused Surveys

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• CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information.

• This new system will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing.

• Implementation will be improved by funding provided in the recently enacted, bipartisan Improving Medicare Post-Acute Care Transformation Act (IMPACT) of 2014

Payroll-Based Staffing Reporting

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• CMS will increase both the number and type of quality measures used in the Five-Star Quality Rating System.

• Antipsychotic medication use was added

in February 2015.

• Future additional measures will include claims-based data on re-hospitalization and community discharge rates.

Additional Quality Measures

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• CMS will also strengthen requirements to ensure that States maintain a user-friendly website and complete inspections of nursing homes in a timely and accurate manner for inclusion in the rating system.

Timely and Complete Inspection Data

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• MDS RAI Manual

• Appendix PP of the SOM

• There are no new regulations involved in

these surveys.

• Train your staff

Nursing Home Preparation

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Louann Lawson, BA, RN, RAC-CTAHIMA Approved ICD-10-CM/PCS Trainer

Nurse Consultant, Clinical Reimbursement LeadPathway Health (651) 407-8699

www.pathwayhealth.com

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Thank you for your participation!

http://www.pathwayhealth.com/

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