2TDOH PROVIDER SEMINAR - MDS Nashville, Jackson, ClevelandNine Federal MDS TagsF272- Resident Assessment using the RAIF273-Admission AssessmentF274 SCSA (Significant Change in Status Assessment)F275 Annual AssessmentF276-Quarterly AssessmentF278-Accuracy of AssessmentF279-Comprehensive Care PlansF286-Maintain 15 months of MDS dataF287-Encoding & transmitting of MDSApril 2009
3F286 (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.
4Deficiencies related to MDS have made the top 10 list for last 3 years.
5F272 - Resident Assessment using the RAI 2006F272 - Resident Assessment using the RAIcited % of TN facilitiesF279-Comprehensive Care Planscited % of TN facilitiesF278-Accuracy of Assessmentcited % of TN facilities
62007 F279-Comprehensive Care Plans cited 40.50 % of TN facilities F278-Accuracy of Assessmentcited % of TN facilitiesF272 - Resident Assessment using the RAIcited % of TN facilities
72008 F278-Accuracy of Assessment cited 40.20 % of TN facilities F272 - Resident Assessment using the RAIcited % of TN facilitiesF279-Comprehensive Care Planscited % of TN facilities
8*2009F272- Resident Assessment using the RAI cited approx. ½ of nursing homes being surveyedas of this date 44.40%F279-Comprehensive Care Planscited % of TN facilitiesF278-Accuracy of Assessmentcited % of TN facilities
10The information in the clinical record must support not conflict with the MDSandthe information must be substantiated.
11The Administrator, Director of Nursing, Regional Administrator, Regional Nurse Consultant and the MDS Coordinator were informed of theIMMEDIATE JEOPARDY
12MDS Accuracy has an effect on: Resident’s Care PlanPaymentQuality Indicators/Quality Measures
13Excerpts from actual IJ level deficiencies Cited atF272, F278, and F279
14F272 JBased 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.
15F278 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
16F279 K Example #1Based 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 .
17F279 J Example #2Based 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.
19MDS Section E: Mood & Behavior Patterns Who gathers the data?Assessors don’t diagnosis, only record what they have seen.
20E1. Indicators of Depression, Anxiety, Sad Moods Verbal expressions of distressSleep cycle issuesSad, apathetic, anxious appearanceLoss of interest
21E2. Mood PersistanceBe sure to include night shift when talking to staffFor all behavior issues, check that the documentation is in place, like behavior flow sheets, care plan, nurses’ notesIt is essential the documentation is reflective of what is being communicated
22E3. Change in Mood Compare today’s mood with mood of last assessment No changeImprovedDeteriorated
23E4 Behavioral Symptoms Harmful to self, residents or staff Behaviors may occur at different times of dayNeed input from all shifts & disciplinesProgram 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.)
24E4 (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 behaviorWas behavior easily altered?Was resident easily distracted/redirected?Persistent behavior?
25E4 (b) Behavioral Symptoms Alterability Include:NumbersFrequencyIntensity &/orAlterabilityReview documentation, observation, talk to staff. Look at last quarterly.
26MDS Section F: Psychosocial Well- being Who fills this section out?SW and nursing need to work together and agree on same assessment.
27F1. Sense of Initiative/Involvement Observation, interviewObservations of cognitively impairedDiscrepancies may exist between how resident sees self and staff observations.Code what you observe not what resident thinks.
28F2 Unsettled Relationships How does the resident interact with others?Observe and interviewObserve the resident.Talk to staff and family.You are looking for an overall picture, a consensus view.
29F3. 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.
30Behavior 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?
31Mood-Behavior Forms/Tools Antipsychotic Medication Quarterly Evaluation/AIMSPsychoactive Medication Monthly Flow RecordBehavior Intervention Monthly Flow RecordAnti-Anxiety Side Effect SheetAnti-Depressant Side SheetAnti-Psychotic Side EffectPsychoactive Medication Use Reference CardNon-Pharmacologic Intervention Record for Targeted Behavioral SymptomsAntipsychotic Medication Quality Assurance SheetUnnecessary 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.
33The Resident Assessment Instrument RAI ASSISTS STAFF TO LOOK AT RESIDENTS HOLISTICALLYSTRENGTHENS TEAM COMMUNICATIONPROVIDES STRUCTURE in LTC FOR A PROBLEM IDENTIFICATION PROCESS
34The Resident Assessment Instrument RAI Surveyors use RAI/MDS assessments to assist in determination of accurate and comprehensive assessments of the condition of the resident.
35The MDS does not relinquish the facility’s responsibility to document a more detailed assessment of resident.
36MDS Coordinators must: Observe residentTalk with resident, caregivers, housekeepers, dietary staff, familyObservational and Communication skills are essential
37Assists 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.
38Strengthens 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.
39PROVIDES 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.
40PROVIDES STRUCTURE in LTC FOR A PROBLEM IDENTIFICATION PROCESS (cont.) Care Planning-Developing a course of actionthat 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.
41PROVIDES 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.
42Resident 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.
43Resident 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.
44Resident 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.
45Resident Assessment Protocols (RAP) Process RAP “documentation” involves only what should already be taking place:Clear assessmentsDecision-making by staff knowledgeable about the resident’s conditionCare plans developed based on a comprehensive assessment of the resident’s needs, strengths, and preferences
46Care Planning ProcessSpecific, 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.
47Care Planning ProcessThe 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.
48Care Planning ProcessIf used correctly, the entire care planning process will save time and effort while improving resident outcomes.It should not involve duplication of effort.
49Care Planning ProcessThe resident, family, or resident representative should be part of the team discussion and care planning process whenever they choose.
50Care Planning ProcessCommunication is the key to effective care planning.The care plan should present a true picture of the resident’s status.
52Surveying Quality Improvement Surveying the Quality Improvement process begins with reviewing the Quality Indicator reports during the offsite survey preparation.
53Quality 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
54Quality Indicator Reports Review the Facility Quality Indicator Profile for any “flags” , and for Quality Indicators with a percentile rank of 75% or greater.
55Quality 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.
56Quality Indicator Reports The Quality Indicators cover the following domains or broad areas of care:
58Quality Indicator Reports Quality of LifeElimination/IncontinenceSkin CareInfection ControlPsychotropic Drug UseCognitive Patterns
59Quality 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.
60Quality Indicator Reports They do represent common conditions and important aspects of care and life to residents.
61Quality 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 .
62Quality 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
63SENTINEL EVENTSAre 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 .
64SENTINEL EVENTS Prevalence of fecal impaction Prevalence of dehydrationPrevalence of pressure sores (occurring in a Low Risk Population.)
65Surveying The Facility Quality Improvement Process The survey team determines if the facility:Has identified quality deficienciesHas developed and implemented a plan to address those quality deficienciesHas evaluated, or has a plan to evaluate, the effectiveness of the planned implementation
66Surveying 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.
67Surveying 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?
68Surveying 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.
69Resources Treatment of Pressure Ulcers Clinical Guideline Number 15 AHCPR Publication No :December 1994The National Pressure Ulcer Advisory Panel
70RAI Appendix H Web Site Information Resources (cont.)RAI Appendix H Web Site InformationContains websites addresses and links for:MDS 2.0MDS Correction PolicySNF PPSSwing BedState Operations ManualCMS Quarterly Provider Update