1. MINIMUM DATA SETS (MDS)
DEBRA VERNA, RN, LNHA

2. TDOH PROVIDER SEMINAR - MDS
Nashville, Jackson, Cleveland
Nine Federal MDS Tags
F272- Resident Assessment using the RAI
F273-Admission Assessment
F274 SCSA (Significant Change in Status Assessment)
F275 Annual Assessment
F276-Quarterly Assessment
F278-Accuracy of Assessment
F279-Comprehensive Care Plans
F286-Maintain 15 months of MDS data
F287-Encoding & transmitting of MDS
April 2009

3. F286 (MDS Use) Effective March 1, 2009
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.

4. Deficiencies related to MDS have made
the top 10 list for last 3 years.

5. F272 - Resident Assessment using the RAI
2006
F272 - Resident Assessment using the RAI
cited % of TN facilities
F279-Comprehensive Care Plans
cited % of TN facilities
F278-Accuracy of Assessment
cited % of TN facilities

6. 2007 F279-Comprehensive Care Plans cited 40.50 % of TN facilities
F278-Accuracy of Assessment
cited % of TN facilities
F272 - Resident Assessment using the RAI
cited % of TN facilities

7. 2008 F278-Accuracy of Assessment cited 40.20 % of TN facilities
F272 - Resident Assessment using the RAI
cited % of TN facilities
F279-Comprehensive Care Plans
cited % of TN facilities

8. *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 % of TN facilities
F278-Accuracy of Assessment
cited % of TN facilities

9. __________________________________________________________________
_____________________________________________________________________________________
F % % % %
F % % % %
F % % % %
__________________________________________________________________

10. The information in the clinical record
must support not conflict with the MDS
and
the information must be substantiated.

11. The Administrator, Director of Nursing, Regional Administrator, Regional Nurse Consultant and the MDS Coordinator were informed of the
IMMEDIATE JEOPARDY

12. MDS Accuracy has an effect on:
Resident’s Care Plan
Payment
Quality Indicators/Quality Measures

13. Excerpts from actual IJ level deficiencies
Cited at
F272, F278, and F279

14. 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.

15. 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

16. F279 K Example #1
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 .

17. F279 J Example #2
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.

18. Behaviors
Relative to
MDS

19. MDS Section E: Mood & Behavior Patterns
Who gathers the data?
Assessors don’t diagnosis, only record what they have seen.

20. E1. Indicators of Depression, Anxiety, Sad Moods
Verbal expressions of distress
Sleep cycle issues
Sad, apathetic, anxious appearance
Loss of interest

21. E2. Mood Persistance
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

22. E3. Change in Mood Compare today’s mood with mood of last assessment
No change
Improved
Deteriorated

23. E4 Behavioral Symptoms 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.)

24. E4 (a). Behavioral Symptoms Frequency
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?

25. E4 (b) Behavioral Symptoms Alterability
Include:
Numbers
Frequency
Intensity &/or
Alterability
Review documentation, observation, talk to staff. Look at last quarterly.

26. MDS Section F: Psychosocial Well- being
Who fills this section out?
SW and nursing need to work together and agree on same assessment.

27. F1. Sense of Initiative/Involvement
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.

28. F2 Unsettled Relationships
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.

29. F3. Past Roles Observe and interview
Document resident’s recognition or acceptance of feeling regarding previous roles or status now that they are in a nursing home.

30. Behavior Management Programs
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?

31. Mood-Behavior Forms/Tools
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
Psychoactive Medication Use Reference Card
Non-Pharmacologic Intervention Record for Targeted Behavioral Symptoms
Antipsychotic Medication Quality Assurance Sheet
Unnecessary Medication/Quality Assurance Evaluation Sheet

32. *Use tools discerningly.
Caution:
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.

33. The Resident Assessment Instrument RAI
ASSISTS STAFF TO LOOK AT RESIDENTS HOLISTICALLY
STRENGTHENS TEAM COMMUNICATION
PROVIDES STRUCTURE in LTC FOR A PROBLEM IDENTIFICATION PROCESS

34. The Resident Assessment Instrument RAI
Surveyors use RAI/MDS assessments to assist in determination of accurate and comprehensive assessments of the condition of the resident.

35. The MDS does not relinquish the facility’s responsibility to document a more detailed assessment of resident.

36. MDS Coordinators must:
Observe resident
Talk with resident, caregivers, housekeepers, dietary staff, family
Observational and Communication skills are essential

37. Assists Staff to Look at Residents Holistically
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.

38. Strengthens Team Communication
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.

39. PROVIDES STRUCTURE in LTC FOR A PROBLEM IDENTIFICATION PROCESS
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.

40. 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.

41. PROVIDES STRUCTURE in LTC FOR A PROBLEM IDENTIFICATION PROCESS (cont.)
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.

42. Resident Assessment Protocols (RAP) Process
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.

43. Resident Assessment Protocols (RAP) Process
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.

44. Resident Assessment Protocols (RAP) Process
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:
Incorporate additional tools only if they are clearly beneficial in facilitating documentation and clinical decision-making.

45. Resident Assessment Protocols (RAP) Process
RAP “documentation” involves only what should already be taking place:
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

46. Care Planning Process
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.

47. Care Planning Process
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.

48. Care Planning Process
If used correctly, the entire care planning process will save time and effort while improving resident outcomes.
It should not involve duplication of effort.

49. Care Planning Process
The resident, family, or resident representative should be part of the team discussion and care planning process whenever they choose.

50. Care Planning Process
Communication is the key to effective care planning.
The care plan should present a true picture of the resident’s status.

51. Surveying Quality Improvement

52. Surveying Quality Improvement
Surveying the Quality Improvement process begins with reviewing the Quality Indicator reports during the offsite survey preparation.

53. Quality Indicator Reports
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

54. Quality Indicator Reports
Review the Facility Quality Indicator Profile for any “flags” , and for Quality Indicators with a percentile rank of 75% or greater.

55. Quality Indicator Reports
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.

56. Quality Indicator Reports
The Quality Indicators cover the following domains or broad areas of care:

57. Quality Indicator Reports
Accidents
Nutrition/Eating
Behavior/Emotional Patterns
Physical Functioning
Activities

58. Quality Indicator Reports
Quality of Life
Elimination/Incontinence
Skin Care
Infection Control
Psychotropic Drug Use
Cognitive Patterns

59. 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.

60. Quality Indicator Reports
They do represent common conditions and important aspects of care and life to residents.

61. 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 .

62. Quality Indicator Reports
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

63. SENTINEL EVENTS
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 .

64. SENTINEL EVENTS Prevalence of fecal impaction
Prevalence of dehydration
Prevalence of pressure sores (occurring in a Low Risk Population.)

65. Surveying The Facility Quality Improvement Process
The survey team determines if the facility:
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

66. Surveying The Facility Quality Improvement Process
The goal for this part of the survey:
To determine whether the facility has an effective method of identifying quality deficiencies and dealing with them.

67. Surveying The Facility Quality Improvement Process
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?

68. Surveying The Facility Quality Improvement Process
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.

69. Resources Treatment of Pressure Ulcers Clinical Guideline Number 15
AHCPR Publication No :
December
The National Pressure Ulcer Advisory Panel

70. RAI Appendix H Web Site Information
Resources (cont.)
RAI Appendix H Web Site Information
Contains websites addresses and links for:
MDS 2.0
MDS Correction Policy
SNF PPS
Swing Bed
State Operations Manual
CMS Quarterly Provider Update

71. State MDS/RAI Coordinator
Resources (cont.)
State MDS/RAI Coordinator
Debra Verna, RN, LNHA
Phone: