Training Objectives Following completion of the presentation the - PowerPoint PPT Presentation

What’s New with MDS, 5/29/2015 Audits & Survey New York Health Information Management Association Barbara A. Bates, MSN, RAC-CT, C-NE June 11, 2015

Training Objectives Following completion of the presentation the 5/29/2015 participants will: 1. Increase knowledge/awareness of MDS 3.0 New York Health Information Management Association updates. 2. Enhance knowledge of current OMIG audit deficiencies and methods to prevent errors. 3. Improve knowledge of current NYS nursing home survey deficiencies related to medical record documentation .

MDS Focus Survey • Nationwide 2015 – Immediate start date • # of Assessments per audit – varies per 5/29/2015 state. New York Health Information Management Association • Minimum 2 surveyors trained how to access accuracy MDS • 2 day survey – with exit and review of findings

MDS Focus Survey • Original Pilot (2014) – 25 nursing homes – 24 found deficient: 5/29/2015 MDS Coding New York Health Information Management Association Inaccurate staging/documentation of Pressure Ulcers Lack of Knowledge classification of Antipsychotic Drugs Poor Coding on Use of Restraints Kulus 2015

MDS Focus Survey On Entrance – Facility Provided Instructional Letter. Provide: Current Census 5/29/2015 Resident Census (Alphabetical) with Room # New York Health Information Management Association Copy of Floor Plan Within 1 hour of Entrance: 10 most recently completed MDS Assessments submitted for current resident Corrections submitted for these MDS Assessments if any Medical Records supporting MDS Coding

MDS Focus Survey Also provide: Policy & Procedures related to Resident Assessment Instrument, MDS and Quality Measures. 5/29/2015 Staffing schedule all staff involved in scheduling, coding & transmitting data with their role in assessment New York Health Information Management Association process delineated. Name & contact information for Quality Assurance & Assessment Coordinator. months – date of List all residents who have fallen in past 12 fall & any resulting injury.

MDS Focus Survey • Survey Provider Worksheet – provided by Surveyor : List residents & room # with following 5/29/2015 conditions/devices used last 90 days: (More than one condition list separately) New York Health Information Management Association Pressure Ulcers Indwelling catheter - urethral, suprapubic, nephrostomy Restraints other than side rails including those used on a as needed basis UTI Record Review, Resident Observation, Staff/Resident interviews utilized to validate coding and staffing.

MDS Focus Survey • Could result in Deficiencies in F272 through 287 related to Resident Assessment . 5/29/2015 • Person who completes a portion of assessment must sign and certify completion. New York Health Information Management Association • Civil penalties could be issued – falsification assessment data. • Could be sited for F Tags related Quality of Care, Quality of Life or Nursing Services. • Will also review self reported staffing.

Top Annual Survey Citations F323 Free of Accidents #1 5/29/2015 Identification of Residents at risk for accidents/falls Physical New York Health Information Management Association Restraint Resident Implementation of Adequate Care Procedures to Prevent Plan Accidents

Top Annual Survey Citations F309 Provide Care/Services for Highest Well Being #4 5/29/2015 Accurate/ Complete Assessment Care Plan Resident New York Health Information Management Association Communi Strengths, -cation Needs, Wishes, with Goals CNAs Resident Care Plan Evaluation Implemen of -tation / Effectiveness of Care Plan Delivery Review /Revise Care Plan and Interventions as needed

Survey Documentation Related Issues Advanced Directives Findings: • The system to identify Advance Directives is not current and/or consistent with residents’ wishes 5/29/2015 • Staff are unaware of the system to identify residents’ wishes New York Health Information Management Association • Staff are not aware of the guidance regarding CPR • Systems are convoluted and confusing Complications: • Resident has a change in status or condition • Resident or legal representative change decision about directives

Survey Documentation Related Issues Advanced Directives Best Practice: • Obtain Advance Directive status on 5/29/2015 admission and follow through on New York Health Information Management Association documentation to support residents’ wishes • Have documentation of residents’ Advance Directive wishes easily obtainable • If in doubt, start CPR and contact 911

MDS, OMIG and Supporting Documentation • Review MDS for accuracy – prior to submitting 5/29/2015 New York Health Information Management Association Automated Random Utilize QAPI to monitor MDS accuracy – develop an improvement plan for repeated errors.

Section C – MDS Assessment 5/29/2015 New York Health Information Management Association 10/14 RAI Manual

MDS Coding – Section C • Staff Assessment for Mental Status C0700 – Short term Memory OK Talk with and observe resident 5/29/2015 Collect data from all shifts/departments Code based on information collected during New York Health Information Management Association 7 day look back. Select code best describes level of function C0800 – Long term Memory OK Talk with residents/family, direct care staff - memory recall Collect data from all shifts direct care givers Search for medical record documentation providing cues – 7 day look back

MDS Coding – Section C • Staff Assessment for Mental Status C0900 – Memory/Recall Ability Talk with resident family/direct care staff – recall 5/29/2015 Seek information all shifts/departments Medical record review 7 day look back New York Health Information Management Association C1000 – Cognitive Skills for Daily Decision Making Decisions regarding tasks for daily living Documentation Tips: • Record of discussions – 7day look back – resident/staff/family • Record of direct observations – 7 day look back • Progress notes – Interdisciplinary team members – 7 day look back

Section D – MDS Assessment 5/29/2015 New York Health Information Management Association

Section D – MDS Assessment • PHQ9-OV - Staff Assessment Resident Mood 14 day look back. Staff members who know resident best – all shifts - 5/29/2015 interview. Encourage reporting of symptom frequency – even if New York Health Information Management Association not depression. Choose highest frequency reported by staff/family. New admission – less than 14 days – review transfer document – discuss with family. Documentation tips: Direct resident observations – 14 day look back IDT/direct care giver discussions – 14 day look back

Section E – MDS Assessment 5/29/2015 New York Health Information Management Association Documentation Tips: Understand the difference between Hallucination/Delusions Frequency of hallucinations/delusions not required. Document actual occurrence – 7 day look back. Document direct observation or interview with staff. Progress notes in medical record describing behaviors in 7 day look back.

Section E – MDS Assessment 5/29/2015 New York Health Information Management Association Documentation Tips: Code based on how many days behavior(s) occurred during 7 day look back. Staff often normalize behaviors as usual, typical, “always is this way” – code as present. Document in flow sheets, behavior logs, - make sure frequency is captured. Progress notes capturing interview of staff all shifts. Record of direct observation of resident.

Section G – MDS Assessment 5/29/2015 New York Health Information Management Association

Section G – MDS Assessment Focus 4 Late Loss ADLs – Bed Mobility, Transfer, Eating and Toileting: Bed Mobility : How resident moves to/from lying position, turns side/side, positions body when in bed or alternate 5/29/2015 sleep furniture, Slide down in bed – how they get back up? New York Health Information Management Association Transfer: Moves between surfaces – to/from bed, chair, w/chair, standing position – not to/from bath/toilet. Eating: How residents eats/drinks regardless of skill – not during medication pass. Can be intake by other means – tube feeding, TPN, IV(for nutrition/hydration). Toilet Use: How uses restroom, commode, bedpan, urinal, transfer on/off toilet. Cleans self after elimination, changes pads/brief, adjusts cloths, manages ostomy or catheter. Not – emptying of bedpan, urinal, commode, catheter or ostomy bag .

Section G – MDS Assessment 5/29/2015 New York Health Information Management Association