MDS 3.0 Tracking and Trending FY2016 Texas Health and Human Services Commission Office of Inspector General Division of Medical Services Nursing Facilities Utilization Review (NFUR) MDS 3.0 Tracking and Trending FY2016 Presented to Nursing Facility Utilization Review Quarterly Stakeholders Meeting December 12, 2016

Objectives I. Identify top 5 Sections of MDS 3.0 where errors were identified II. Outline assessment errors in 5 sections of MDS 3.0 III. Improve future clinical assessment

Section C: Cognitive Patterns I. Lack of specific documentation by Social Services or by an interdisciplinary team (IDT) indicating either a Brief Interview for Mental Status (BIMS) was conducted or attempted during the 7-day look-back period II. Missing signature (Z0400) of the person who completed Section C of the MDS 3.0 III. Signature on Z0400 indicates the facility employee completed Section C of the MDS 3.0 outside of the 7-day look-back period Note: Each person completing a section or portion of a section of the MDS is required to sign the Attestation Statement

Section D: Mood (PHQ‐9) I. Lack of specific documentation by Social Services or IDT indicating that either a resident mood interview (PHQ‐9) or a Staff Assessment of Resident Mood (PHQ-9-OV) was conducted during the 14-day look-back period II. Missing signature (Z0400) of the person who completed Section D of the MDS 3.0 III. Signature on Z0400 indicates the facility employee who completed Section D of the MDS 3.0 outside the 7-day look-back period

Section G: Functional Status I. Missing four late loss ADLs (bed mobility, transfer, toilet use, and eating) flow sheets or medical records with components of an ADL activity II. Late loss ADLs flow sheets without a performance-based scale III. Late loss ADLs flow sheets without a month and year when ADL activity was provided IV. Incorrect coding of late loss ADLs on the MDS 3.0 assessment form

Section O: Special Treatments, Procedures, and Programs I. Missing medical records to support Facility MDS 3.0 coding for items in Section O II. Therapy: CPT codes with therapy minutes rounded to the nearest 5th minute (Must record the actual minutes of therapy on MDS 3.0) Incorrect total number of minutes/days of therapy provided on an individual basis during the 7-day look-back period III. Criteria for restorative nursing programs not met IV. Respiratory Therapy: Lack of training material to support the respiratory nurses were proficient in the modalities listed by RAI Manual either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws

Section Z: Assessment Administration Missing signatures (Item Z0400 “Signatures of persons completing Assessment” and Item Z0500 “Signature of RN Assessment Coordinator certifying completion of MDS assessment”) Signature mismatch between Item Z0500 on MDS 3.0 and Long-Term Care Medicaid Information (LTCMI) Item Z0400 signed after Z0500 has been signed Item Z0500 signed before item Z0400 has been signed Signatures on item Z0400 indicate the facility employee completed Section C and Section D of the MDS 3.0 outside the 7-days look-back period Note: Intent of Section Z is to provide billing information and signatures of persons completing the MDS

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