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

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

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.

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

F272 - Resident Assessment using the RAI 2006 F272 - Resident Assessment using the RAI cited 44.40 % of TN facilities F279-Comprehensive Care Plans cited 34.10 % of TN facilities F278-Accuracy of Assessment cited 22.20 % of TN facilities

2007 F279-Comprehensive Care Plans cited 40.50 % of TN facilities F278-Accuracy of Assessment cited 35.30 % of TN facilities F272 - Resident Assessment using the RAI cited 28.40 % of TN facilities

2008 F278-Accuracy of Assessment cited 40.20 % of TN facilities F272 - Resident Assessment using the RAI cited 37.90 % of TN facilities F279-Comprehensive Care Plans cited 29.50 % of TN facilities

*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 32.400 % of TN facilities F278-Accuracy of Assessment cited 20.60 % of TN facilities

__________________________________________________________________ _____________________________________________________________________________________ 2006 2007 2008 2009 F272 44.40% 28.40 % 37.90 % 44.40% F278 22.20 % 35.30 % 40.20 % 20.60 % F279 34.10 % 40.50 % 29.50 % 32.40 % __________________________________________________________________

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

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

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

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

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.

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

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 .

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.

Behaviors Relative to MDS

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

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

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

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

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.)

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?

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

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

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.

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.

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.

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?

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

*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.

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

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.

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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

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

Surveying Quality Improvement

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

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

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

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.

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

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

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

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.

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

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 .

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

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 .

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

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

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.

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?

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.

Resources Treatment of Pressure Ulcers Clinical Guideline Number 15 AHCPR Publication No. 95-0652: December 1994 http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.5124 The National Pressure Ulcer Advisory Panel www.npuap.org

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 http://www.azdhs.gov/als/ltc/postmans/raiappendixh.pdf

State MDS/RAI Coordinator Resources (cont.) State MDS/RAI Coordinator Debra Verna, RN, LNHA Phone: 865-588-4401 E-Mail: Debra.Verna@state.tn.us