Transcript Document

April 1, 2012 MDS Item
Set Changes and Other
Key MDS Information
Presented to:
MDS National Conference
St. Louis, MO
March 5-6, 2012
Thomas Dudley, MS, RN
Centers for Medicare & Medicaid Services
Office of Clinical Standards and Quality
Quality Improvement and Health Assessment Group
Division of Chronic and Post Acute Care
1
 V1.08 of the MDS 3.0 RAI Manual
 Changes to the Item Set
 Discharge Assessments (Planned vs. Unplanned)
 Use of Dashes
 Interviews
2
 Published - January 20, 2012
(www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30Training
Materials.asp)
 Effective date – APRIL 1, 2012
 Format Changes:
•
Only pages with actual changes have been updated
and is indicated by the footer “April 2012.”
•
Unchanged pages are indicated with the footer
“October 2011.”
3
4
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.
5
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.
6
Issue – The term “mental retardation” appears three times
in Appendix C, when it should have been changed to
“intellectual disability.” CAAs 2, 7 and 12 refer to item
A1550 using the language “Mental retardation /
developmental disability” instead of “Intellectual disability /
developmental disability”.
Resolution – In appendix C, CAAs 2, 7, and 12, any use of
“Mental retardation/developmental disability” will be
replaced by “Intellectual disability/developmental disability”.
7
Issue – 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 1.111. In the example, 9 x 1.286 = 11.250
This is incorrect.
The line should read:
Multiply this sum by 1.111. In the example, 9 x 1.111 = 13.332.
In addition, to avoid ambiguity, the word “sum” 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 1.111. In the example, 12 x 1.111 = 13.332
3. Round the result to the nearest integer. In the example, 13.332 rounds to 13
4. Place the rounded result in D0600
8
Issue – 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 1.111. In the example, 9 x 1.286 = 11.250
This is incorrect.
The line should read:
Multiply this sum by 1.111. In the example, 9 x 1.250 = 11.250.
In addition, to avoid ambiguity, the word “sum” will be bolded.
Resolution –
1. Compute the sum of the 8 items with non-missing values. This sum is 9
2. Multiply this sum by 1.250. In the example, 9 x 1.250 = 11.250
3. Round the result to the nearest integer. In the example, 11.250 rounds to 11
4. Place the rounded result in D0600
9
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:
http://www.cms..gov/Manuals/IOM/list.asp.
Resolution - The extra “.” after “cms” needs to be removed.
10
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 3.0 RAI Manual
(v1.08).
However, pages N-5 and N-6, the instructions state for
providers to “Check A” -- If antipsychotic med was received,
to “Check B’ -- If antianxiety med was received, etc.
Each of these coding tips need to be changed to address the
specific item number that they reference.
11
Resolution – 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 admission/entry 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 admission/entry 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
admission/entry 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
admission/entry or reentry if less than 7 days).
(continued on slide 13)
12
Resolution – The new coding tips on pages N-5 and N-6 should
read (continued from slide 12):
N0410 E, Anticoagulant (e.g., 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 admission/entry or reentry if less than 7 days). Do not code
antiplatelet medications such as aspirin/extended 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 admission/entry 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 admission/entry or reentry if less than 7 days).
13
 Term “Mental Retardation (MR)” is changed to
“Intellectual Disability (ID).”
 Several text/label changes to be consistent
throughout the assessment instrument, i.e.,
Admission/Reentry vs. Admission/Entry or
Reentry.
 Adjusted/Corrected some of the skip patterns
based on the specific item sets.
14
 Adds A0050 – Type of Record
Replaces X0100 – Type of Record
 Adds A0310G – Planned or Unplanned discharge
A2100 – Entered From and Discharged To
Adds option 09 – Long Term Care Hospital(LTCH)
 A1800
&
15
I1800 – Additional Active Diagnoses
(where ICD codes can be entered) –
Removes the check box.
16

Adds K0310 – Weight Gain (secondary to the increase in obesity
across the US population)

Deletes K0500 – Nutritional Approaches – and Replaces with K0510
– Nutritional Approaches

K0510 Includes:
• A 2-column approach to capture “While a resident” and “While not
a resident” information. (similar to item O0100 – Special
Treatments, Procedures, and Programs)
• Option C – Mechanically Altered Diet and D – Therapeutic Diet are
factored into the determination of Pressure Ulcer Risk in
conjunction with A0310G – Type of Assessment / Type of
Discharge
17
 M0700 – Most Severe Tissue Type for Any Pressure Ulcer,
adds option “9” – None of the Above
 M1040 – Other Ulcers, Wounds, and Skin Problems, adds:
• Option “H” Moisture Associated Skin Damage (MASD)
i.e. incontinence, perspiration, drainage
• Option “G” – Skin Tears
18
 N0400 – Medications Received replaced with
N0410 – Medications Received
 N0410 – Medications Received now includes
the “Number of days the resident received any
of the listed classes of medications during the
preceding 7 days since admission/entry or
reentry if less than 7 days”
19
 Deletes Q0400B – What determination was made by the
resident and the care planning team regarding discharge
to the community?
 Adds Q0490 – Resident’s Preference to Avoid Being
Asked Question Q0500B – Return to Community.
 Adds Q0550 – Resident’s Preference to Avoid Being
Asked Question Q0500B again
•
Captures whether the question should be asked on all
assessments as well as the source of the information.
20
 Deletes X0100 – Type of Record
 Replaces by A0050 – Type of Record
21
Discharge
Assessments
22
 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
Identification Information (A) - 22
Swallowing/Nutritional Status (K) - 3
Hearing, Speech, and Vision (B) – 8
Oral/Dental Status (L) - 0
Cognitive Patterns (C) – 12
Skin Conditions (M) – 11
Mood (D) - 7
Medications (N) – 1
Behavior (E) – 1
Special Treatments, Procedures, and
Programs (O) - 6
Preferences for Customary Routine and
Activities (F) - 0
Restraints (P) – 1
Functional Status (G) – 5
Participation in Assessment and Goal
Setting (Q) – 1
Bladder and Bowel (H) - 3
CAA Summary (V) – 0
Active Diagnoses (I) – 0
Correction Request (X) – 12
Health Conditions (J) - 15
Assessment Administration (Z) - 1
24
Identification Information (A) – 24 (added
A0310G – planned/unplanned)
Swallowing/Nutritional Status (K) - 4
Hearing, Speech, and Vision (B) – 1
Oral/Dental Status (L) - 0
Cognitive Patterns (C) – 4
Skin Conditions (M) – 5
Mood (D) - 0
Medications (N) – 1
Behavior (E) – 4
Special Treatments, Procedures, and
Programs (O) - 4
Preferences for Customary Routine and
Activities (F) - 0
Restraints (P) – 1
Functional Status (G) – 2
Participation in Assessment and Goal
Setting (Q) –2
Bladder and Bowel (H) - 3
CAA Summary (V) – 0
Active Diagnoses (I) – 1
Correction Request (X) –11
Health Conditions (J) - 7
Assessment Administration (Z) - 3
25
Identification Information (A) - 24
Swallowing/Nutritional Status (K) - 4
Hearing, Speech, and Vision (B) – 1
Oral/Dental Status (L) - 0
Cognitive Patterns (C) – 5
Skin Conditions (M) – 5
Mood (D) - 7
Medications (N) – 1
Behavior (E) – 4
Special Treatments, Procedures, and
Programs (O) - 4
Preferences for Customary Routine and
Activities (F) - 0
Restraints (P) – 1
Functional Status (G) – 2
Participation in Assessment and Goal
Setting (Q) – 2
Bladder and Bowel (H) - 3
CAA Summary (V) – 0
Active Diagnoses (I) – 1
Correction Request (X) – 11
Health Conditions (J) - 11
Assessment Administration (Z) - 3
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 CMS will use errata documents to correct any
“inaccuracies” identified in V1.08 until they are
corrected in V1.09 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
 Overuse / Inappropriate use of
dashes on assessments
 Skipped Interviews
28
Potential Overuse of Dashes
()
29
Assessment data of First Year of MDS 3.0 Data:
•
Shows a large percentage of dashes.
•
Used for up to 40% of items.
•
Has implications for use of data, particularly QMs.
30
 Several QMs use data from MDS sections assessing
mental status, depression, and pain.
 Includes data from the discharge assessment under
certain circumstances.
31
 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
 Affects the accuracy of QMs.
 Affects the accuracy of reporting:
• Nursing Home Compare
• 5-Star Nursing Home Quality Rating System
33
 Reduces the size of the facility’s quality
measure resident sample.
• Skews QM data.
• Results in an inaccurate representation
of the facility’s actual resident population.
34
 Important clinical information
regarding resident condition may be
missing.
 Skews QM data.
35
 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
Every assessment must be completed
as fully as possible with all available
information at the time of assessment.
37
 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.
•
e.g., 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 resident’s status from the resident’s perspective.
39
Good News….
Unscheduled 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)
40
(Continued from Slide 40)
Qualifications for Unscheduled Assessment Interviews :
• Applies only to standalone unscheduled PPS assessments.
• Does not apply in cases where the unscheduled PPS
assessment is combined with a non-PPS assessment or
scheduled PPS assessment.
• 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.
• Can be applied only in cases where the resident interview
was completed on prior assessment, not when a staff
assessment was completed.
41
Once completed, edited, and accepted into the QIES ASAP system,
providers may not change a previously completed MDS assessment
as the resident’s status changes during the course of the resident’s
stay – 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
provider’s responsibility to provide necessary care and services.
(continued on slide 43)
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 3.0
record with the correct event date or type of assessment, ensuring
that the clinical information is accurate. (Long-Term Care Facility
Resident Assessment Instrument User’s Manual, MDS 3.0, Page 5-12.)
(continued on slide 44)
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 3.0 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 3.0 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)
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
3.0 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.
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.
46
For a closer look at MDS 3.0 training
resources, please visit:
www.cms.gov/NursingHomeQualityInits
/45_NHQIMDS30TrainingMaterials.asp
47
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