MDS National Conference March 2012 April 1, 2012 MDS Item Set Changes and Other Key MDS Information Presented to: MDS National Conference St. Louis, MO March 2012 Thomas Dudley, MS, RN Centers for Medicare & Medicaid Services Office of Clinical Standards and Quality Quality Improvement and Health Assessment Group Division of Chronic and Post Acute Care

MDS National Conference March 2012 Topics to be Covered V1.08 of the MDS 3.0 RAI Manual Changes to the Item Set Discharge Assessments (Planned vs. Unplanned) Use of Dashes Interviews

MDS National Conference MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Published - January 20, 2012 (www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30Training Materials.asp) Effective date – APRIL 1, 2012 Format Changes: Only pages with actual changes have been updated and is indicated by the footer “April 2012.” Unchanged pages are indicated with the footer “October 2011.”

MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 February 23, 2012 Errata document (available on the MDS 3.0 Training page)

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 Issue - Page 14 of the change table for Chapter 3, Section Q, the screenshot for Q500 was inserted where Q490 belongs. This occurs only on the change table, and not in the manual itself. Resolution - The screenshot of item Q0490 will replace that of Q0500 on page 14 of the change table for Chapter 3, Section Q.

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 Issue - Chapter 6, pages 6-38 and 6-40, the RUG calculation worksheet does not account for splitting tube feeding into while a resident and while not a resident. Resolution - For the K0500A RUG criterion, K0500A is used for assessments with ARD before April 1, 2012 but is replaced by K0510A1 or K0510A2 for ARDs on or after April 1, 2012. K0500B is used for assessments with ARD before April 1, 2012 but is replaced by K0510B1 or K0510B2 for ARDs on or after April 1, 2012.

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 Issue – The term “mental retardation” appears three times in Appendix C, when it should have been changed to “intellectual disability.” CAAs 2, 7 and 12 refer to item A1550 using the language “Mental retardation / developmental disability” instead of “Intellectual disability / developmental disability”. Resolution – In appendix C, CAAs 2, 7, and 12, any use of “Mental retardation/developmental disability” will be replaced by “Intellectual disability/developmental disability”.

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 Issue – Appendix E, page E-7, the sample calculation contains typographical error that alters the result of a calculation.   Line item 2 reads: Multiply this sum by 1.111. In the example, 9 x 1.286 = 11.250   This is incorrect. The line should read: Multiply this sum by 1.111. In the example, 9 x 1.111 = 13.332.  In addition, to avoid ambiguity, the word “sum” should be bolded. Resolution -   1. Compute the sum of the 9 items with non-missing values. This sum is 12 2. Multiply this sum by 1.111. In the example, 12 x 1.111 = 13.332 3. Round the result to the nearest integer. In the example, 13.332 rounds to 13 4. Place the rounded result in D0600

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 Issue – Appendix E, page E-7, the sample calculation contains typographical error that alters the result of a calculation.   Line item 2 reads: Multiply this sum by 1.111. In the example, 9 x 1.286 = 11.250   This is incorrect. The line should read: Multiply this sum by 1.111. In the example, 9 x 1.250 = 11.250. In addition, to avoid ambiguity, the word “sum” will be bolded. Resolution – 1. Compute the sum of the 8 items with non-missing values. This sum is 9 2. Multiply this sum by 1.250. In the example, 9 x 1.250 = 11.250 3. Round the result to the nearest integer. In the example, 11.250 rounds to 11 4. Place the rounded result in D0600

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 Issue - In Chapter 4, page 4-8, the link to the State Operations Manual (SOM) contains a typographical error and therefore does not link properly to the webpage.   Currently, it reads: http://www.cms..gov/Manuals/IOM/list.asp.  Resolution - The extra “.” after “cms” needs to be removed.

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 Issue - The April 2012 MDS Item Set instructs providers to enter the number of days each of the medications listed were received in the last 7 days in Item N0410, as does the screen shot of item N0410 on page N-4 of the MDS 3.0 RAI Manual (v1.08).   However, pages N-5 and N-6, the instructions state for providers to “Check A” -- If antipsychotic med was received, to “Check B’ -- If antianxiety med was received, etc. Each of these coding tips need to be changed to address the specific item number that they reference.

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08  Resolution – The new coding tips on pages N-5 and N-6 should read: N0410 A, Antipsychotic: Record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).   N0410 B, Antianxiety: Record the number of days an antianxiety medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0410 C, Antidepressant: Record the number of days an antidepressant was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0410 D, Hypnotic: Record the number of days a hypnotic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). (continued on slide 13)

Known Issues in MDS 3.0 RAI Manual V1.08 MDS National Conference March 2012 Known Issues in MDS 3.0 RAI Manual V1.08 Resolution – The new coding tips on pages N-5 and N-6 should read (continued from slide 12):  N0410 E, Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here.   N0410 F, Antibiotic: Record the number of days antibiotic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0410 G, Diuretic: Record the number of days a diuretic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

Global Item Set Changes MDS National Conference March 2012 Term “Mental Retardation (MR)” is changed to “Intellectual Disability (ID).” Several text/label changes to be consistent throughout the assessment instrument, i.e., Admission/Reentry vs. Admission/Entry or Reentry. Adjusted/Corrected some of the skip patterns based on the specific item sets.

Section A – Identification Information Item Set Changes MDS National Conference March 2012 Section A – Identification Information Item Set Changes Adds A0050 – Type of Record Replaces X0100 – Type of Record Adds A0310G – Planned or Unplanned discharge A1800 & A2100 – Entered From and Discharged To Adds option 09 – Long Term Care Hospital(LTCH)

Section I – Active Diagnoses Item Set Changes MDS National Conference March 2012 Section I – Active Diagnoses Item Set Changes I1800 – Additional Active Diagnoses (where ICD codes can be entered) – Removes the check box.

Section K – Swallowing and Nutritional Status Item Set Changes MDS National Conference March 2012 Section K – Swallowing and Nutritional Status Item Set Changes Adds K0310 – Weight Gain (secondary to the increase in obesity across the US population) Deletes K0500 – Nutritional Approaches – and Replaces with K0510 – Nutritional Approaches K0510 Includes: A 2-column approach to capture “While a resident” and “While not a resident” information. (similar to item O0100 – Special Treatments, Procedures, and Programs) Option C – Mechanically Altered Diet and D – Therapeutic Diet are factored into the determination of Pressure Ulcer Risk in conjunction with A0310G – Type of Assessment / Type of Discharge

Section M – Skin Conditions Item Set Changes MDS National Conference March 2012 Section M – Skin Conditions Item Set Changes M0700 – Most Severe Tissue Type for Any Pressure Ulcer, adds option “9” – None of the Above M1040 – Other Ulcers, Wounds, and Skin Problems, adds: Option “H” Moisture Associated Skin Damage (MASD) i.e. incontinence, perspiration, drainage Option “G” – Skin Tears

Section N – Medications Item Set Changes MDS National Conference March 2012 Section N – Medications Item Set Changes N0400 – Medications Received replaced with N0410 – Medications Received N0410 – Medications Received now includes the “Number of days the resident received any of the listed classes of medications during the preceding 7 days since admission/entry or reentry if less than 7 days”

MDS National Conference March 2012 Section Q – Participation in Assessment and Goal Setting Item Set Changes Deletes Q0400B – What determination was made by the resident and the care planning team regarding discharge to the community? Adds Q0490 – Resident’s Preference to Avoid Being Asked Question Q0500B – Return to Community. Adds Q0550 – Resident’s Preference to Avoid Being Asked Question Q0500B again Captures whether the question should be asked on all assessments as well as the source of the information.

Section X – Correction Request Item Set Changes MDS National Conference March 2012 Section X – Correction Request Item Set Changes Deletes X0100 – Type of Record Replaces by A0050 – Type of Record

MDS National Conference Discharge Assessments March 2012 Discharge Assessments

Definition of an Un-Planned Discharge MDS National Conference March 2012 Definition of an Un-Planned Discharge Acute-care transfer of the resident to a hospital or an emergency department in order to either stabilize a condition or determine if an acute-care admission is required based on emergency department evaluation. OR Resident unexpectedly leaving the facility against medical advice. Resident unexpectedly deciding to go home or to another setting.  

Current Discharge Assessment Maximum 111 Questions MDS National Conference March 2012 Current Discharge Assessment Maximum 111 Questions Identification Information (A) - 22 Swallowing/Nutritional Status (K) - 3 Hearing, Speech, and Vision (B) – 8 Oral/Dental Status (L) - 0 Cognitive Patterns (C) – 12 Skin Conditions (M) – 11 Mood (D) - 7 Medications (N) – 1 Behavior (E) – 1 Special Treatments, Procedures, and Programs (O) - 6 Preferences for Customary Routine and Activities (F) - 0 Restraints (P) – 1 Functional Status (G) – 5 Participation in Assessment and Goal Setting (Q) – 1 Bladder and Bowel (H) - 3 CAA Summary (V) – 0 Active Diagnoses (I) – 0 Correction Request (X) – 12 Health Conditions (J) - 15 Assessment Administration (Z) - 1

April 1, 2012 Un-Planned Discharge Assessment – Maximum 77 Questions MDS National Conference March 2012 April 1, 2012 Un-Planned Discharge Assessment – Maximum 77 Questions Identification Information (A) – 24 (added A0310G – planned/unplanned) Swallowing/Nutritional Status (K) - 4 Hearing, Speech, and Vision (B) – 1 Oral/Dental Status (L) - 0 Cognitive Patterns (C) – 4 Skin Conditions (M) – 5 Mood (D) - 0 Medications (N) – 1 Behavior (E) – 4 Special Treatments, Procedures, and Programs (O) - 4 Preferences for Customary Routine and Activities (F) - 0 Restraints (P) – 1 Functional Status (G) – 2 Participation in Assessment and Goal Setting (Q) –2 Bladder and Bowel (H) - 3 CAA Summary (V) – 0 Active Diagnoses (I) – 1 Correction Request (X) –11 Health Conditions (J) - 7 Assessment Administration (Z) - 3

April 1, 2012 Planned Discharge Assessment – Maximum 89 Questions MDS National Conference March 2012 April 1, 2012 Planned Discharge Assessment – Maximum 89 Questions Identification Information (A) - 24 Swallowing/Nutritional Status (K) - 4 Hearing, Speech, and Vision (B) – 1 Oral/Dental Status (L) - 0 Cognitive Patterns (C) – 5 Skin Conditions (M) – 5 Mood (D) - 7 Medications (N) – 1 Behavior (E) – 4 Special Treatments, Procedures, and Programs (O) - 4 Preferences for Customary Routine and Activities (F) - 0 Restraints (P) – 1 Functional Status (G) – 2 Participation in Assessment and Goal Setting (Q) – 2 Bladder and Bowel (H) - 3 CAA Summary (V) – 0 Active Diagnoses (I) – 1 Correction Request (X) – 11 Health Conditions (J) - 11 Assessment Administration (Z) - 3

Future Item Set Changes/Updates MDS National Conference March 2012 Future Item Set Changes/Updates CMS will use errata documents to correct any “inaccuracies” identified in V1.08 until they are corrected in V1.09 in Fall 2012. Next update to the item sets and manual expected in September 2012 to reflect any PPS changes or other policy changes. CMS is attempting to go to annual updates beginning in 2013.

Possible Data / Assessment Issues MDS National Conference March 2012 Possible Data / Assessment Issues Overuse / Inappropriate use of dashes on assessments Skipped Interviews

MDS National Conference March 2012 Potential Overuse of Dashes (  )

Initial Analysis of MDS 3.0 Data MDS National Conference March 2012 Initial Analysis of MDS 3.0 Data Assessment data of First Year of MDS 3.0 Data: Shows a large percentage of dashes. Used for up to 40% of items. Has implications for use of data, particularly QMs.

Use of Data for Quality Measures1 MDS National Conference March 2012 Use of Data for Quality Measures1 Several QMs use data from MDS sections assessing mental status, depression, and pain. Includes data from the discharge assessment under certain circumstances.

Use of Data for Quality Measures2 MDS National Conference March 2012 Use of Data for Quality Measures2 Uses data from resident interview if complete. Uses data from staff assessment if interview is not complete. Use of dash may result in resident being excluded from QM measure calculations.

Excessive Use of Dashes MDS National Conference March 2012 Excessive Use of Dashes Affects the accuracy of QMs. Affects the accuracy of reporting: Nursing Home Compare 5-Star Nursing Home Quality Rating System

Effects on Facility QM Sample MDS National Conference March 2012 Effects on Facility QM Sample Reduces the size of the facility’s quality measure resident sample. Skews QM data. Results in an inaccurate representation of the facility’s actual resident population.

Impact on Resident Data MDS National Conference March 2012 Impact on Resident Data Important clinical information regarding resident condition may be missing. Skews QM data.

Make Every Effort to Complete Each Assessment MDS National Conference March 2012 Make Every Effort to Complete Each Assessment Complete all resident interviews. (comatose residents are individuals that definitely cannot complete the interviews otherwise...). Complete staff assessments if an interview is not feasible.

Complete Each Assessment! MDS National Conference March 2012 Complete Each Assessment! Every assessment must be completed as fully as possible with all available information at the time of assessment.

MDS National Conference March 2012 Interview Matters1 CMS has received reports from State Survey Agencies identifying facilities that are not completing interviews when residents are capable. This has been verified during site visits. Nursing Homes need to be aware that this is not acceptable and that they will be cited in instances where such practice is verified.

MDS National Conference March 2012 Interview Matters2 The interview items such as the PHQ-9 are standardized instruments that have been tested and have been proven to be reliable. When completing the interviews, follow the instructions for the individual interview instrument. e.g., if the look-back period states 7 days then that is how you phrase the statements to the resident. Keep in mind that the interviews are intended to assess the resident’s status from the resident’s perspective.

MDS National Conference March 2012 Interview Matters3 Good News…. Unscheduled Assessment Interviews - Effective April 1, 2012, when coding a standalone unscheduled PPS assessment (COT, EOT, SOT), the interview items may be coded using the responses provided by the resident on a previous assessment, if the interview responses from the scheduled assessment were obtained no more than 14 days prior to the date of the unscheduled assessment on which those responses will be used. This change does not change other assessment policies with regards to the frequency of resident interviews. (Continued on Slide 41)

MDS National Conference March 2012 Interview Matters4 (Continued from Slide 40) Qualifications for Unscheduled Assessment Interviews : Applies only to standalone unscheduled PPS assessments. Does not apply in cases where the unscheduled PPS assessment is combined with a non-PPS assessment or scheduled PPS assessment. At the discretion of the provider, if a change is observed during the observation period for the unscheduled PPS assessment, then responses may not be carried forward. Can be applied only in cases where the resident interview was completed on prior assessment, not when a staff assessment was completed.

MDS National Conference March 2012 Inactivations Once completed, edited, and accepted into the QIES ASAP system, providers may not change a previously completed MDS assessment as the resident’s status changes during the course of the resident’s stay – the MDS must be accurate as of the date of the ARD established by the time of the assessment.  Providers should have a process in place to ensure assessments are accurate prior to submission.  Such monitoring and documentation is a part of the provider’s responsibility to provide necessary care and services.  (continued on slide 43)

MDS National Conference March 2012 Inactivations (continued from slide 42)   When the provider determines that an event date (ARD of any clinical assessment, entry date, and discharge date) or item A0310 (type of assessment) is inaccurate the provider must inactivate the record in the QIES ASAP system, then complete and submit a new MDS 3.0 record with the correct event date or type of assessment, ensuring that the clinical information is accurate. (Long-Term Care Facility Resident Assessment Instrument User’s Manual, MDS 3.0, Page 5-12.) (continued on slide 44)

MDS National Conference March 2012 Inactivations (continued from slide 43)   If the ARD or  Type of Assessment is entered incorrectly, and the provider does not correct it within the encoding period, the provider must complete and submit a new MDS 3.0 record.  In this instance a new ARD date must be established based on MDS requirements, which is the date the error is determined or later, but not earlier. The new MDS 3.0 record being submitted to replace the inactivated record must include new signatures and dates for all items based on the look-back period established by the new ARD and according to established MDS assessment completion requirements.   (continued on slide 45)

MDS National Conference March 2012 Inactivations (continued from slide 44) Example Issue: A SNF is coding a 30-day assessment. Item A2300 (Assessment Reference Date) is coded as 02-04-2011, but it was supposed to be coded as 01-04-2012. This error is discovered on February 20th. Solution: The improperly coded assessment must be inactivated and a new MDS 3.0 record must be created and submitted to the QIES ASAP. The ARD on this assessment can be no earlier than February 20th. When completing the assessment, all items are to be completed according to established MDS completion guidelines for the specific assessment being completed. Remember that this includes all dates and signatures for the new MDS that is being completed. These signatures and dates must be reflective of the ARD that is established for this replacement assessment.

MDS National Conference March 2012 Parting Thoughts The Resident MUST ALWAYS come first. The assessment instrument will continue to change periodically in order to remain current with clinical practices. CMS does and will continue to listen to your comments and concerns. The MDS is just one tool to use when assessing residents.

MDS Training Resources MDS National Conference March 2012 MDS Training Resources For a closer look at MDS 3.0 training resources, please visit: www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp

MDS National Conference March 2012 Thank you!