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EXAMPLES OF DOCUMENTATION TO SUPPORT SECTION P - 3

By Jamie Ross,2014-06-28 12:22
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EXAMPLES OF DOCUMENTATION TO SUPPORT SECTION P - 3 ...

    BEST PRACTICE”

     in Accuracy Review

     of

     Case-Mix Items

    Residential Care Services

    Aging and Disability Services Administration

     October 2004

    TABLE OF CONTENTS

    INTRODUCTION ......................................................................................................................2

    BACKGROUND INFORMATION .............................................................................................3

    GENERAL INFORMATON .......................................................................................................5

BEST PRACTICE INFORMATION ...........................................................................................6

    SECTION ―E‖ INFORMATION .................................................................................................8

    SECTION ―G‖ INFORMATION .............................................................................................. 11

    SECTION ―H3a‖ INFORMATION ........................................................................................... 14

    SECTIONS ―P1‖ AND ―P3‖ INFORMATION ......................................................................... 16

    DOCUMENTATION GENERAL STATEMENT ..................................................................... 19

    EXAMPLES OF DOCUMENTATION RELATED TO ...................................................... 20-39 NURSING REHAB/RESTORATIVE PROGRAMS

    1

     INTRODUCTION

This document was first introduced in October of 1998. It provided Key Concepts,

    strategies and examples for ―best practice‖ in the accuracy review and

    documentation of case-mix items for MDS sections E, G, H3a, P1 and P3. Since

    that time, it has been distributed to not only Washington State nursing facility staff

    and Residential Care Services staff in Washington, but to many interested persons

    across the United States.

There have been some changes and clarifications since 1998 and, in an effort to

    keep this a living, working document, it was updated in May, 2001.

Because we live in an ever changing world and are continually learning, current

    processes have been modified, new policies and procedures developed and

    clarifications received that dictate a third update to this best practice document.

Note: This document is intended as guidelines for RCS (Residential Care Services)

    staff in the State of Washington during the process of MDS accuracy reviews.

    The guidelines should improve the consistent responses of RCS staff. This is

    also being shared with providers. There are helpful hints for providers

    enclosed within the document; these are not to be construed as federal or

    state requirements.

     Revised October 2004

    2

     BACKGROUND INFORMATION

    ? The RAI was developed first and foremost, as a comprehensive assessment tool

    to be used by clinicians in designing individualized care plans and programs for

    the residents they serve. Adherence to item definitions and the proper time

    period for observation of the resident’s status, as determined by the assessment

    reference date (A3a), is critical to ensure the accuracy and reliability of the

    assessment, and to provide a solid foundation for rendering care and evaluating

    the resident’s response to services.

    ? To do this properly, clinicians must complete the MDS and utilize the RAPS

    according to the instructions provided by the Centers for Medicare and Medicaid

    Services (CMS) in the ―Revised Long Term Care Resident Assessment

    Instrument User’s Manual, Version 2.0‖ published December 2002 with

    additional updates in August, 2003, April 2004 and June, 2004. This manual,

    along with the MDS 2.0 forms, can be obtained at the following CMS website,

    www.cms.hhs.gov/medicaid/mds20

    ? Since the advent of PPS for SNF Medicare services, there may have been a

    tendency for some facilities to creatively push the boundaries of MDS item

    definitions to maximize coding of particular MDS items, slide the resident into a

    higher RUG category, and thereby increase payment to the facility. This practice,

    if engaged in, will ultimately lead to problems. MDS data will increasingly be

    used within regulatory quality monitoring activities at both the state and national

    level. The accuracy of each facility’s MDS data will also be more closely

    scrutinized as CMS has implemented new MDS validation activities such as the

    DAVE program; Fiscal Intermediary Medical Review activities, and Program

    Safeguard activities, raising the risk that facilities who routinely push the bounds

    of MDS item definitions will be subject to citations and/or for civil fines for

    submission of inaccurate MDS data.

Many providers have already come to the conclusion that the most efficient and

    practical way to complete the MDS is to do so using the

     ―clinical‖ rules put in place when the RAI system was originally implemented in

    1990, and that the changes in practice required to ―game‖ the system are not

    worth the resulting remuneration in the short term. Adherence to the ―clinical‖

    rules will provide an accurate picture of the resident, which should ensure that

    the facility receives a fair and equitable rate of reimbursement and is also

    evaluated fairly in activities that use MDS data to focus on regulatory quality

    3

    monitoring. Perhaps most importantly, accurate MDS coding is important for the benefit of the residents, as their care plans are derived from the MDS assessment.

? The State of Washington does NOT have required formats or forms related to

    supporting documentation for the NF's MDS.

? CMS revised the LTC RAI User’s Manual Version 2.0 in December 2002.

    Updates were issued in August 2003, April and June 2004.

    ? CMS will continue to provide updates to the RAI Manual which will be

    posted on the CMS website.

    ? Providers and Residential Care Services (RCS) staff will be notified of these

    revisions via ―Dear Provider‖ letters and Management Bulletins and will be

    expected to implement changes as directed by these updates. ? Dear Provider letters written by RCS may also be sources of clarification of

    MDS issues, especially as they apply to Washington State.

? The concepts in this document apply to all RCS staff QANs (Quality Assurance

    Nurse), surveyors, complaint nurses, etc. in reviewing the MDS for accuracy.

    What is acceptable during the QAN accuracy review needs to be consistent with

    RCS practice.

? Key concepts:

    ? Is the MDS response reasonable?

    ? Is there clinical validity to the response?

    ? Is there internal consistency within the MDS assessment? ? Is there internal consistency within the medical record? ? Is there internal consistency between the MDS and the medical record?

    4

     GENERAL INFORMATON

    ? Stopwatches are not necessary or appropriate, and have never been considered

    (for RCS staff or for providers). However, the documentation of the amount of

    time that restorative/rehabilitative nursing programs are provided is required.

    This change occurred as a result of the revision to the RAI User’s Manual in

    December 2002. The format that the facility chooses for recording the time is up

    to the facility and there is great flexibility in how that can be accomplished.

    ? Reviewing for the clinical relevance and validity of the program(s) for that

    resident continues to be a major focus. QANS should observe the program being

    delivered if there are any questions about the relevance or validity of the program.

    ? If there is no evidence (through observations, interviews, internal consistency of

    the MDS and the record) to discredit or challenge the coded values, then accept

    them if they are reasonable and clinically valid. This process needs to make

    clinical sense.

    ? During accuracy review visits, the QAN focuses on validating the MDS items

    that were transmitted to the CMS database managed by the state, that placed the

    resident into a particular RUG group. If care problems are observed, note them

    and put them aside for a follow up QA monitoring visit.

    ? Visits for both the case mix accuracy review and QA monitoring may identify

    potential care problems. A focused review will provide further clarification of

    why a care outcome occurred and whether or not it was avoidable. Refer any

    concerns to the Field Manager for follow-up in the QAN protocol process.

    5

     BEST PRACTICE

? The CMS Revised LTC RAI User’s Manual Version 2.0 December 2002 with

    updates in August 2003, April and June 2004 is the source document for coding

    the MDS. All previous Q&A documents published by CMS (formerly HCFA)

    and Washington State Q&A documents (1998 and 2001) have been rescinded.

? Use information from your observations and interviews with the resident, staff

    and family (if available), as well as information from the clinical record when

    validating MDS accuracy. This is not a paper review.

? Have all staff use MDS/RAP language (chart to the RAI)

    ? Reduce duplication

    ? Collect data for the assessment period only

    ? Evaluate your documentation to ensure that MDS items used in the RUG-

    III classification system are supported in some other area of the record.

    If they are not, modify or supplement as needed

    ? Make the RAI the core of your assessment, care planning and

    documentation system

    ? Use processes you already have in place to tie things together

? Ask yourself: Does the resident get the services he needs, and does he need the

    services he gets?

? Once a good database has been established, providers can ―refer to‖ with

    appropriate modifications in future assessments.

? Focus on the quality of the assessment (or reassessment), especially the analysis

    piece, rather than spending time rewriting something that is already documented

    in the record. Ask yourself if the interventions have accomplished what you

    intended them to, and if not, why not? Record the result of this discussion in the

    clinical record (record your clinical thinking).

? If a facility chooses to utilize worksheets to collect assessment data, they may

    choose to limit the data collection to only the assessment period. This is

    perfectly acceptable, we do not expect to see them collecting data for 7 days per

    week times 52 weeks per year! Requiring data collection to this degree is not an

    efficient practice.

    6

? If a facility utilizes worksheets to collect assessment data, such as an ADL flow

    sheet, and that data conflicts with the actual MDS coding, it is expected that

    there be some written explanation of ―why‖ the discrepancies exist in the clinical

    record.

? If data gathering tools do not provide helpful information, either modify them or

    don’t use them. They are not required by either CMS or Washington State.

? Key concepts:

    ? Know the MDS definitions-use the RAI manual

    ? Use the RAI as the core to your assessment processes

    ? Analyze and use your data

    ? Review the clinical record for internal consistency

    ? Build viable nursing restorative programs

    7

     SECTION “E” INFORMATION

In order to increase the consistency of QAN responses during the Case Mix

    Accuracy Review Process, the following are guidelines for the PROCESS OF

    REVIEWING THE ACCURACY of Section E. (Mood and Behavior Patterns).

    These guidelines for the PROCESS of review are not meant to replace or alter in

    any ways the RAI User’s Manual instructions for completing these sections. The

    guidelines below should be used in conjunction with the RAI Manual to ensure that

    a QAN’s judgment or conclusion on the accuracy of individual RUG items on a

    specific MDS would be consistent with another QAN’s judgment/conclusion about its accuracy.

Specific worksheets completed by the facility staff for these sections during the A3a

    time period and the ―window‖ of time specified on the MDS are NOT a requirement.

    If the facility utilizes such worksheets, there is no requirement that the worksheets

    be kept and available for QAN review in the MDS Accuracy Review Process. The

    key concepts for the QAN are the ―reasonableness‖ of the facility’s coded response,

    the ―clinical validity‖ of the response, and the ―internal consistency‖ of the MDS

    assessment itself, the medical record itself, and the MDS assessment in relation to

    the medical record. As always, facilities are expected to comply with current

    medical record practices. The key expectations for facility documentation systems

    are that they focus on collection of supporting data in relationship to improving,

    maintaining, or minimizing decline in resident function. Clinical standards of

    practice often dictate the types and frequency of documentation.

    ? Expect to find some collaborative data somewhere in the record that supports

    the coding (progress notes, RAP assessment, plan of care, social service

    assessments, etc.) If inaccuracies are apparent, or supporting data is not

    evident, VALIDATE this by talking with staff who know the resident. We

    may accept staff's rationale if it is reasonable, has clinical validity and/or it is

    consistent with other data from the MDS and the medical record.

    ? The RAI User’s Manual states that it is important to document chronic

    symptoms as well as new onset. The medical record should support resident

    status as reported on the MDS.

    8

     PROCESS FOR REVIEW OF SECTION E:

     MOOD AND BEHAVIOR PATTERNS

    ? Scan the MDS, firmly fixing in mind the A3a time period. Note also the time

    periods reflected by the 30 day ―window‖ for Section E1; the 7 day

    ―window‖ for E2 and E4; and the 90 day (or since last assessment) reference

    for E3 and E5. Scan the care plan.

    ? Utilize the Cognitive Performance Scale {B2a (short term memory), B4

    (cognitive skills for daily decision making) and C4 (making self understood)}

    to assist in establishing the cognitive functioning of the resident.

? Briefly observe the resident and their ―space‖ before completing an in depth

    record review. A brief social contact with the resident may set the stage for a

    more in depth interview later. This initial contact may assist in sorting

    through the enormous amount of data in a record while focusing on key

    relevant facts.

    ? Review the 30 day ―window‖ in the progress notes, and the social services

    and activity progress notes (if kept separately), the social history as needed,

    the related mental health assessments and visits, and attendance and response

    in activity programs.

    ? Review drug regimen for related drugs and behavioral/drug monitoring flow

    sheets for the specific time frame(s).

    ? Look for care/treatment/food refusals on NAC flow sheets, in Restorative

    program flow sheets, meal monitoring, and specialized therapy.

    ? If the resident is non-verbal, look especially for the E1 components that

    would still be applicable, such as E1j, k,l,m,n,o,and p.

    ? When appropriate, ask the resident questions that might key into Section E.

    e.g. ―Has this been a difficult adjustment for you?‖ ―What has helped?‖

    ―What could still be better‖. Etc.

    ? If Section E. is not done collaboratively (by a combination of disciplines), but

    completed by only one discipline, then check with staff who did NOT

    9

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