Transcript Slide 1

MINIMUM DATA SETS (MDS)
DEBRA VERNA, RN, LNHA
Nine Federal MDS Tags
1. F272- Resident Assessment using the RAI
2. F273-Admission Assessment
3. F274 SCSA (Significant Change in Status Assessment)
4. F275 Annual Assessment
5. F276-Quarterly Assessment
6. F278-Accuracy of Assessment
7. F279-Comprehensive Care Plans
8. F286-Maintain 15 months of MDS data
9. F287-Encoding & transmitting of MDS
F286
(MDS Use)
Effective March 1, 2009
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Storage of paper copy of MDS for facilities
using all electronic records is no longer
required.
Maintaining the 15 months of MDS data is
still required.
MDS records must still be accessible to
clinical staff, the State and CMS.
Deficiencies related to MDS have made
the top 10 list for last 3 years.
2006
F272 - Resident Assessment using the RAI
cited 44.40 % of TN facilities
F279-Comprehensive Care Plans
cited 34.10 % of TN facilities
F278-Accuracy of Assessment
cited 22.20 % of TN facilities
2007
F279-Comprehensive Care Plans
cited 40.50 % of TN facilities
F278-Accuracy of Assessment
cited 35.30 % of TN facilities
F272 - Resident Assessment using the RAI
cited 28.40 % of TN facilities
2008
F278-Accuracy of Assessment
cited 40.20 % of TN facilities
F272 - Resident Assessment using the RAI
cited 37.90 % of TN facilities
F279-Comprehensive Care Plans
cited 29.50 % of TN facilities
*2009
F272- Resident Assessment using the RAI
cited approx. ½ of nursing homes being surveyed
as of this date 44.40%
F279-Comprehensive Care Plans
cited 32.400 % of TN facilities
F278-Accuracy of Assessment
cited 20.60 % of TN facilities
_____________________________________________________________________________________
F272
F278
F279
2006
2007
44.40%
22.20 %
34.10 %
28.40 %
35.30 %
40.50 %
2008
37.90 %
40.20 %
29.50 %
2009
44.40%
20.60 %
32.40 %
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The information in the clinical record
must support not conflict with the MDS
and
the information must be substantiated.
The Administrator, Director of Nursing,
Regional Administrator, Regional Nurse
Consultant and the MDS Coordinator were
informed of the
IMMEDIATE JEOPARDY
MDS Accuracy has an effect on:
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Resident’s Care Plan
Payment
Quality Indicators/Quality Measures
Excerpts from actual IJ level
deficiencies
Cited at
F272, F278, and F279
F272 J
Based on medical record review, facility policy
review, facility documentation review, and
interview, the facility failed to assess unsafe
behaviors for one resident (#5) who was
ventilator/trach dependent of five residents
reviewed on the facility's respiratory unit, placing
Resident #5 in immediate jeopardy.
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F278 J
Based on observation, record review, and
interview, it was determined the facility failed to
ensure Residents were accurately assessed. The
failure of the facility to accurately assess
pressure wounds and acute changes in condition
resulted in IMMEDIATE JEOPARDY for 2 of the
14 Residents on the sample
F279 K
Example #1
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Based on observation, interview and
record review it was determined that the
facility failed to develop a comprehensive
care plan for 10 (#5, #15, #19, #22,
#24, #29, #38, #41, #45 & #50) of 51
Residents sampled, placing Residents #22,
#24, #29, & #38 in Immediate Jeopardy .
F279 J
Example #2
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Based on medical record review and interviews,
it was determined the facility failed to develop a
comprehensive care plan for behaviors for 2
Residents (#17 and #5) of 21 sampled
Residents. The failure of the facility to care plan
wandering behavior and to implement
interventions resulted in IMMEDIATE JEOPARDY
for Resident #17. The Chief Financial Officer, the
Administrator, the Director of Nursing (DON),
and the Minimum Data Set Coordinator were
informed of the IMMEDIATE JEOPARDY.
Behaviors
Relative
to
MDS
MDS Section E:
Mood & Behavior Patterns
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Who gathers the data?
Assessors don’t diagnosis, only record
what they have seen.
E1. Indicators of Depression,
Anxiety, Sad Moods
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Verbal expressions of distress
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Sleep cycle issues
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Sad, apathetic, anxious appearance
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Loss of interest
E2. Mood Persistance
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Be sure to include night shift when talking
to staff
For all behavior issues, check that the
documentation is in place, like behavior
flow sheets, care plan, nurses’ notes
It is essential the documentation is
reflective of what is being communicated
E3. Change in Mood
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Compare today’s mood with mood of last
assessment
No change
Improved
Deteriorated
E4 Behavioral Symptoms
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Harmful to self, residents or staff
Behaviors may occur at different times of day
Need input from all shifts & disciplines
Program to minimize, alternate or eliminate
disruptive behaviors.
Care plan needs to be in place.
Observe the behavior, not the intent (doesn’t
mean to hurt someone, just afraid.)
E4 (a). Behavioral Symptoms
Frequency
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Need documentation. If not in place, put
in place.
Is there a restraint in use? Resident in
geri-chair to keep from exhibiting behavior
Was behavior easily altered?
Was resident easily distracted/redirected?
Persistent behavior?
E4 (b) Behavioral Symptoms
Alterability
Include:
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Numbers
Frequency
Intensity &/or
Alterability
Review documentation, observation, talk to staff.
Look at last quarterly.
MDS Section F:
Psychosocial Well- being
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Who fills this section out?
SW and nursing need to work together
and agree on same assessment.
F1. Sense of Initiative/Involvement
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Observation, interview
Observations of cognitively impaired
Discrepancies may exist between how
resident sees self and staff observations.
Code what you observe not what resident
thinks.
F2 Unsettled Relationships
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How does the resident interact with
others?
Observe and interview
Observe the resident.
Talk to staff and family.
You are looking for an overall picture, a
consensus view.
F3. Past Roles
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Observe and interview
Document resident’s recognition or
acceptance of feeling regarding previous
roles or status now that they are in a
nursing home.
Behavior Management Programs
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Does your facility have a Behavioral
Management Program?
Does your staff know what the program consists
of and which residents are on the program?
Is the Behavioral Management Program
incorporated in the resident Care Plan?
Who monitors and evaluates the program?
Does your program work?
How do you determine that it is working?
Mood-Behavior
Forms/Tools
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Antipsychotic Medication
Quarterly
Evaluation/AIMS
Psychoactive Medication
Monthly Flow Record
Behavior Intervention
Monthly Flow Record
Anti-Anxiety Side Effect
Sheet
Anti-Depressant Side
Sheet
Anti-Psychotic Side
Effect
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Psychoactive Medication
Use Reference Card
Non-Pharmacologic
Intervention Record for
Targeted Behavioral
Symptoms
Antipsychotic Medication
Quality Assurance Sheet
Unnecessary
Medication/Quality
Assurance Evaluation
Sheet
Caution:
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Some facilities use tools to assist in data collection and
reflection of care provided.
Blank, incomplete or inaccurate information reflected on
tools could also reflect/indicate non-compliance.
Incorporate additional tools only if they are clearly
beneficial in facilitating documentation and clinical
decision-making.
*Use tools discerningly.
The Resident Assessment
Instrument
RAI
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ASSISTS STAFF TO LOOK AT RESIDENTS
HOLISTICALLY
STRENGTHENS TEAM COMMUNICATION
PROVIDES STRUCTURE in LTC FOR A
PROBLEM IDENTIFICATION PROCESS
The Resident Assessment Instrument
RAI
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Surveyors use RAI/MDS assessments to
assist in determination of accurate and
comprehensive assessments of the
condition of the resident.
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The MDS does not relinquish the facility’s
responsibility to document a more detailed
assessment of resident.
MDS Coordinators must:
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Observe resident
Talk with resident, caregivers,
housekeepers, dietary staff, family
Observational and Communication skills
are essential
Assists Staff to Look at Residents
Holistically
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Residents are individuals for whom quality
of life and quality of care are equally
significant and necessary.
It is important for staff to gather definitive
information on a resident’s strengths and
needs.
Staff must be able to track changes in the
resident’s status.
Strengthens Team Communication
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The process of problem identification is
integrated with sound clinical interventions by an
interdisciplinary team.
The RAI process assists staff to evaluate goal
achievement.
With strengthened communication, all necessary
resources and disciplines will be used to ensure
that residents achieve the highest level of
functioning possible, and maintain their sense of
individuality.
PROVIDES STRUCTURE in LTC FOR A PROBLEM
IDENTIFICATION PROCESS
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Assessment- Evaluate all observations,
information and knowledge about a resident;
finding out who the resident is.
Decision-making- Determining the severity,
functional impact, and scope of the resident’s
problems; finding out the “what’s” and “why’s”
of the resident’s problems.
PROVIDES STRUCTURE in LTC FOR A PROBLEM
IDENTIFICATION PROCESS
(cont.)
 Care Planning-Developing a course of action
that will move a resident toward a specific goal,
utilizing the resident’s strengths and the
interdisciplinary team expertise; building the
“how” of resident care.
 Implementation-Putting the care plan
interventions into motion by staff knowledgeable
about the resident’s goals and approaches;
carrying out the “how” and “when” of resident
care.
PROVIDES STRUCTURE in LTC FOR A PROBLEM
IDENTIFICATION PROCESS (cont.)
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Evaluation-Critically reviewing care plan
goals, interventions, and implementation
in terms of achieved resident outcomes,
and assessing the need to modify the care
plan to adjust to changes in the resident’s
status.
Resident Assessment Protocols
(RAP) Process
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The RAP Guidelines are an aide, a tool, a
starting point.
Information in the RAP is used to supplement
clinical judgment and stimulate creative
thinking when trying to understand or resolve
difficult or confusing symptoms and their
causes.
Resident Assessment Protocols
(RAP) Process
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Participation in this process by all
members of the interdisciplinary team will
assist in assuring that a meaningful
assessment of the resident is completed.
This will then lead to an appropriate,
individualized plan of care.
Resident Assessment Protocols
(RAP) Process
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Each facility should establish a documentation
process that “works” for them.
Some facilities have developed tools to assist in
data collection and reflection of care provided.
These tools can be used as a part of MDS
validation review.
Caution:
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Incorporate additional tools only if they are clearly
beneficial in facilitating documentation and clinical
decision-making.
Resident Assessment Protocols
(RAP) Process
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RAP “documentation” involves only what
should already be taking place:
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Clear assessments
Decision-making by staff knowledgeable
about the resident’s condition
Care plans developed based on a
comprehensive assessment of the resident’s
needs, strengths, and preferences
Care Planning Process
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Specific, individualized approaches must
then be developed.
These are actually instructions for resident
care and will provide continuity of care by
all staff.
These instructions should be short and
concise so they can be easily understood
by all staff.
Care Planning Process
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The effectiveness of the care plan must be
continually evaluated, and modified as
necessary.
The care plan is designed to be an
effective tool for providing appropriate,
individualized care.
Care Planning Process
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If used correctly, the entire care planning
process will save time and effort while
improving resident outcomes.
It should not involve duplication of effort.
Care Planning Process
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The resident, family, or resident
representative should be part of the team
discussion and care planning process
whenever they choose.
Care Planning Process
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Communication is the key to effective
care planning.
The care plan should present a true
picture of the resident’s status.
Surveying Quality
Improvement
Surveying Quality Improvement
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Surveying the Quality Improvement
process begins with reviewing the Quality
Indicator reports during the offsite survey
preparation.
Quality Indicator Reports
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The QI reports are used to identify areas
of potential problems or concerns that
may require further investigation .
The reports are not determinations of
facility compliance
Quality Indicator Reports
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Review the Facility Quality Indicator Profile
for any “flags” , and for Quality Indicators
with a percentile rank of 75% or greater.
Quality Indicator Reports
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Review the Resident Level Summary and
pre-select residents for the Phase I sample
who have conditions representing the care
concerns selected on the Facility Quality
Indicator Profile.
Quality Indicator Reports
The Quality Indicators cover the following
domains or broad areas of care:
Quality Indicator Reports
Accidents
Nutrition/Eating
Behavior/Emotional Patterns
Physical Functioning
Activities
Quality Indicator Reports
Quality of Life
Elimination/Incontinence
Skin Care
Infection Control
Psychotropic Drug Use
Cognitive Patterns
Quality Indicator Reports
These areas of care or “domains” do not
represent every care category or situation
that could occur in the long-term care
setting.
Quality Indicator Reports
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They do represent common conditions and
important aspects of care and life to
residents.
Quality Indicator Reports
The Quality Indicators and Quality Indicator
Reports are not considered as a single
source of information but are used in
conjunction with all pertinent information
about a facility, such as Infection control,
and Safety, among others .
Quality Indicator Reports
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Use of the Quality Indicators and their
reports in the survey process offer an
additional source of information from
which surveyors may make planning
decisions about the survey of a provider
and from which provider staff can plan
their internal quality improvement
initiatives
SENTINEL EVENTS
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Are Quality Indicators that should occur
very infrequently in a facility.
The nature of these indicators is serious
enough to warrant an investigation EVEN
IF IT OCCURS ONLY ONCE .
SENTINEL EVENTS
Prevalence of fecal impaction
 Prevalence of dehydration
 Prevalence of pressure sores
(occurring in a Low Risk Population.)
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Surveying The Facility Quality
Improvement Process
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The survey team determines if the facility:
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Has identified quality deficiencies
Has developed and implemented a plan to
address those quality deficiencies
Has evaluated, or has a plan to evaluate, the
effectiveness of the planned implementation
Surveying The Facility Quality
Improvement Process
The goal for this part of the survey:
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To determine whether the facility has an
effective method of identifying quality
deficiencies and dealing with them.
Surveying The Facility Quality
Improvement Process
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Does the facility have a QA/QI Committee
which addresses quality concerns and do
staff know how to access that process?
Is the QA/QI Committee responsive to QA
concerns submitted to it?
Surveying The Facility Quality
Improvement Process
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Are facility staff members aware of the quality
assurance improvement plan?
Has the plan been implemented as a routine
part of resident care?
Communication, implementation, monitoring and
evaluation are keys to the quality improvement
process.
Resources
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Treatment of Pressure Ulcers
Clinical Guideline Number 15
AHCPR Publication No. 95-0652:
December 1994
http://www.ncbi.nlm.nih.gov/books/bv.fcgi
?rid=hstat2.chapter.5124
The National Pressure Ulcer Advisory Panel
www.npuap.org
Resources
(cont.)
RAI Appendix H
Web Site Information
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Contains websites addresses and links for:
MDS 2.0
MDS Correction Policy
SNF PPS
Swing Bed
State Operations Manual
CMS Quarterly Provider Update
http://www.azdhs.gov/als/ltc/postmans/raiappendixh.pdf
Resources
(cont.)
State MDS/RAI Coordinator
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Debra Verna, RN, LNHA
Phone: 865-588-4401
E-Mail: [email protected]