1. April MDS 3.0 Revisions Presented for the DOH by Catharine B. Petko, RN BSN Myers and Stauffer LC April 12, 2012

2. Resources RAI Manual 4/1/12: www.cms.hhs.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/NursingHomeQualityInits/ MDS30RAIManual.html www.cms.hhs.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/NursingHomeQualityInits/ MDS30RAIManual.html ISCs 4/1/12 and QM Manual: www.cms.hhs.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/NursingHomeQualityInits/ NHQIMDS30TechnicalInformation.html www.cms.hhs.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/NursingHomeQualityInits/ NHQIMDS30TechnicalInformation.html Use Item Subset Codes labeled v. 1.10.4 Effective 04/01/2012 Provider User’s Guide: https://www.qtso.com/mds30.html https://www.qtso.com/mds30.html RDRM: www.portal.state.pa.us/portal/server.pt/community/lon g-term_care_case_mix_information/ 19342 www.portal.state.pa.us/portal/server.pt/community/lon g-term_care_case_mix_information/ 19342

3. Final Quality Measures Moderate/Severe Pain (L & S) High-Risk Pressure Ulcer (L) New/Worsened Pressure Ulcer (S) Physical Restraints (L) Falls (L) Falls with Major Injury (L) Psychoactive Medications Without Condition (L) Antianxiety/Hypnotic Medication (L)

4. Final Quality Measures Behavior Symptoms Affecting Others (L) Depressive Symptoms (L) Urinary Tract Infection (L) Catheter Inserted and Left in Bladder (L) Low-Risk Residents Lose Bowel/Bladder Control (L) Excessive Weight Loss (L) Need for Increased ADL Help (L)

5. Inactivations 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 assure that assessments are accurate prior to submission. Such monitoring and documentation is a part of the provider’s responsibility to provide necessary care and services

6. Inactivations (2) If the event date or type of assessment is inaccurate: Inactivate the record in the QIES ASAP system Complete and submit a NEW MDS 3.0 record with correct event date or type of assessment (p. 5-12)

7. Inactivations (3) NEW If the Event Date or Type of Assessment was submitted incorrectly, 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 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

8. Inactivation Example Issue: A SNF is coding a 30-day assessment. A2300/ARD is coded 02/04/2012, but the correct date is 01/04/2012. The error is discovered on February 20 th. Solution: The improperly coded assessment must be inactivated and a new MDS 3.0 record created and submitted to the QIES ASAP. The ARD on this new assessment can be no earlier than February 20 th and all items and signatures must be reflective of this new ARD

9. Discharge after Discharge Do not Inactivate DRA and submit as DRNA Submit a second discharge for same date For 5/1 and 8/1, use new Discharge after Discharge Change form available at www.portal.state.pa.us/portal/server.pt/c ommunity/long- term_care_case_mix_information/ 19342 and the CMS MDS Welcome Page Bulletins section www.portal.state.pa.us/portal/server.pt/c ommunity/long- term_care_case_mix_information/ 19342 October 1: New Section S item

10. Unscheduled Assessments ARD must be set within 2 days of assessment window If the ARD of an unscheduled assessment falls in the window of a scheduled assessment, must be combined If scheduled follows unscheduled, it will be ignored and not used for payment purposes Unscheduled used for payment until next scheduled/unscheduled assessment

11. Unscheduled Assessments (2) If the ARD of a PPS assessment used for payment is set for on or prior to Day 7 of the COT observation period, then no COT OMRA would be required COT observation with ARD on Day 30 has decrease in therapy 30 day scheduled for Day 30; is not designated as COT per facility choice

12. Relevance of “used for payment” If resident discharged on Day 31: 30 day not used for payment COT OMRA required; if not done, becomes missed assessment and provider liable from Day 24 “If an assessment has an ARD set for on or prior to Day 7 of the COT observation period, but this assessment is not used for payment, then completing this assessment does not impact on the COT ARD calendar and the COT OMRA would still be required” – John Kane http://totalsolutions- inc.com/nationalconference/documents.phphttp://totalsolutions- inc.com/nationalconference/documents.php Clarification document v.1.1: www.cms.hhs.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/Downloads/SNF-Clarification-Memo- 20120330-v1-1.pdf www.cms.hhs.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/Downloads/SNF-Clarification-Memo- 20120330-v1-1.pdf

13. Early COT If ARD set prior to Day 7: Bill the default rate for the total number of days the assessment is out of compliance Default effective from Day 1 of COT observation period defined by early ARD Bill RUG from early COT for the remainder of the observation period until the next scheduled/unscheduled assessment Early COT resets COT ARD calendar

14. Late COT Resident still on MC Part A but ARD not set for Day 7 Can’t be set any earlier than day omission identified, e.g., day 10 Total number of days the assessment is out of compliance, including the late ARD (days 8, 9 and ARD), must be billed as default beginning on Day 1 of the original observation period Use RUG from late COT for remaining days until scheduled/unscheduled assessment intervenes Late COT resets COT ARD calendar

15. Billing Requirements SNF must bill default or have provider liability only until the point when an intervening assessment would control the payment Day 7 of COT observation period is Day 37 ARD set for Day 52 (15 days out of compliance) EOT completed timely with ARD on Day 42 (last therapy day = Day 39) Bill default for Days 31 – 39; bill RUG from EOT from Day 40 to next scheduled/unscheduled assessment used for payment

16. Missed Assessment If the resident has been discharged from MC Part A and no ARD was set Assessment cannot be completed All days which would have been paid by the missed assessment, had it been completed timely, are provider liable Day 37 COT not completed Discharged Day 40 Omission discovered two weeks later Days 31 – 40 are provider liable

17. 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 scheduled or unscheduled assessment if the interview responses from the assessment were obtained no more than 14 days prior to the ARD of the unscheduled assessment on which those responses will be used. This change does not change other assessment policies with regard to the frequency of resident interviews.

18. Interviews (2) Qualifications for Unscheduled Assessment Interviews Only applies to standalone unscheduled PPS assessments. (A0310A = 99; A0310B = 07; A0310C = 1 – 4; use NS or NO ISC) 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 Only in cases where the resident interview was completed on the prior assessment, not staff interviews

19. Interviews (3) Operational issues Will be in the manual later To identify 14-day interval, measure from date interview was done on prior assessment to date when the next interview would be conducted for the unscheduled assessment If one interview meets 14-day limitation but others were older, may use the results of the one interview but must complete the others again Original interviewer must be person carrying interview data forward and signing for it Z0400 Sign date when interview was completed

20. Change Pages MR/Mental Retardation now ID/Intellectual Disability Admission/reentry now Admission/entry or reentry OBRA or PPS assessment now OBRA or Scheduled PPS assessment Last item on checklist now None of the above rather than, e.g., Not PPS assessment Emphasis/grammatical corrections

21. Useful Changes All references to PPS windows/grace days updated for 10/1/11 changes Page number references updated If item was changed significantly, assigned new number

22. A Identification Information A0050 Type of Record A0310G Type of Discharge Complete only if A0310F = 10 or 11 1 Planned 2 Unplanned Skip C0200-C0400 BIMS Skip Section D Mood Skip J0300-J0850 Pain Skip K0510C, D, Z Nutritional Approaches

23. Unplanned Discharge Acute-care transfer of the resident to a hospital or an emergency department in order to either stabilize a condition or determine whether an acute-care admission is required based on emergency department evaluation OR Resident unexpectedly leaves the facility against medical advice OR Resident unexpectedly decides to go home or to another setting (p. 2-36)

24. A Identification Information (2) A1500 PASRR rewritten: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? A1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions A. Serious mental illness B. Intellectual disability C. Other related conditions

25. A Identification Information (3) A1800 Entered From and A2100 Discharge Status have new response: 09 Long Term Care Hospital (LTCH) If the patient was admitted from/discharged to a hospital that is certified under Medicare as a short-term acute care hospital which has been excluded from the Inpatient Acute Care Hospital Prospective Payment System (IPPS) under § 1886(d)(1)(B)(iv) of the Social Security Act. For the purpose of Medicare payment, LTCHs are defined as having an average inpatient length of stay (as determined by the Secretary) of greater than 25 days.

26. E Behavior E0100 Psychosis now Potential Indicators of Psychosis E800 Rejection of Care Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family), and/or determined to be consistent with resident values, preferences and goals. 4/1/12 – just and

27. G Functional Status 8 Activity did not occur – Activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period Facility staff: Direct employees and facility- contracted employees (e.g., rehabilitation staff, nursing agency staff) Does not include individuals hired, compensated or not, by individuals outside of the facility’s management and administration such as hospice staff, nursing/CNA students, etc. (p. G-4) G0300E Surface to Surface Transfer Now includes chair as well as wheelchair

28. J0100B Pain Management Old: Received PRN pain medication? New: Received PRN pain medication OR was offered and declined?

29. K Swallowing/Nutritional Status K0310 Weight Gain: Gain of 5% or more in the last month or gain of 10% or more in last 6 months 0 No or Unknown 1 Yes, on physician-prescribed weight-gain regimen Must be planned and pursuant to a physician’s order The expressed goal of the weight gain diet must be documented 2 Yes, not on physician-prescribed weight-gain regimen Compare the resident’s weight in the current observation period to his or her weight in the observation period 30 days/ 180 days ago

30. K Swallowing/Nutritional Status Old - K0500 Nutritional Approaches: Check all that apply New – K0510 Nutritional Approaches: Column 1: Check all nutritional approaches performed prior to admission/entry or reentry to the facility and within the 7 day look-back period. Leave Column 1 blank if the resident was admitted/entered or reentered the facility more than 7 days ago Column 2: Check all nutritional approaches performed after admission/entry or reentry to the facility and within the 7-day look-back period

31. M Skin Conditions M0700 Most Severe Tissue Type for Any Pressure Ulcer Code this item with Code 9, None of the above, in the following situations: Stage 1 pressure ulcer Stage 2 pressure ulcer with intact blister Unstageable pressure ulcer related to non-removable dressing/device Unstageable pressure ulcer related to suspected deep tissue injury Code 9 is being used in these instances because the wound bed cannot be visualized and therefore cannot be assessed

32. M Skin Conditions M0800 Old: Worsening in Pressure Ulcer Status Since Prior Assessments (OBRA, PPS or Discharge) Complete only if A0310E = 0 New: Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry Complete only if A0310E = 0 M1200E Old: Ulcer Care New: Pressure Ulcer Care

33. M Skin Conditions M1040G Skin tear(s): Skin tears are a result of shearing, friction or trauma to the skin that causes a separation of the skin layers. They can be partial or full thickness. Code all skin tears at this item, even if already coded in Item J1900B [Falls – Injury (except major)]

34. M Skin Conditions (2) M1040H Moisture Associated Skin Damage (MASD): Moisture associated skin damage is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration. MASD is also referred to as incontinence dermatitis.

35. N Medications N0410 Medications Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. Enter “0” if medication was not received by the resident during the last 7 days Eliminated Z None of the above were received

36. O0250 Influenza Vaccination O250A Did the resident receive the influenza vaccine in this facility for this year’s influenza season? 0 No Skip to O0250C to explain 1 Yes Skip to O0250B to provide date Dash (-) Unknown “Refer to current version of RAI manual for current flu season and reporting period” Varies annually Refer to the CDC Seasonal Influenza (Flu) website

37. O0250 Influenza Vaccination 7/8/11 MC Claims Processing Change Request 7453: “Recent CDC recommendations state that vaccination efforts should begin as soon as the seasonal influenza vaccine is available” The influenza season ends when Influenza is no longer active in your geographic area (p. O-7) Once the influenza vaccination has been administered to a resident for the current influenza season, this value is carried forward until the new influenza season begins (p. O-7)

38. O0400 Therapies Therapy Start Date (O0400A5, B5, C5): If there was more than one therapy regimen since the A1600 date, enter the start date of the most recent therapy regimen. Insert the EOT-R date from O0450B Co-treatment group must have four residents Because co-treatment is appropriate for specific clinical circumstances and would not be suitable for all residents, its use should be limited (p. O-20)

39. Q Participation in Assessment and Goal Setting Q0100B, C Participation in Assessment Old: 9 None of the Above - No family or significant other or No guardian New: Added “available” Resident has no family or legal guardian Coding Tips adds that this means that the resident has no family/significant other or legal guardian, not that they were not consulted

40. Q Participation in Assessment and Goal Setting Q0300A Resident Expectations 1 Expects to be discharged to the community “If the resident indicates an expectation to return home, to assisted living, or to another community setting” Coding Tips May include newly admitted MC SNF residents with a facility arranged DC plan May include Non-MC or MA residents with adequate supports already in plan; no referral to LCA needed May include residents who ask to talk with someone about returning to the community

41. Q Participation in Assessment and Goal Setting Q0400 Discharge Planning Q0400A Old: Is there an active discharge plan in place for the resident to return to the community? Q0400A New: Is active discharge planning already occurring for the resident to return to the community? Many (rather than some) NH residents may be able to return to community A referral to the LCA may be appropriate for some individuals with Alzheimer’s disease Eliminated Q0400B

42. Q Participation in Assessment and Goal Setting Q0490 Resident’s Preference to Avoid Being Asked Question Q0500B Complete only if A0310A = 02, 06 or 99 Does the resident’s clinical record document a request that this question be asked only on comprehensive assessments? 0 No 1 Yes: Skip to Q0600, Referral 8 Information not available

43. Q Participation in Assessment and Goal Setting Q0500 Return to Community Eliminated Q0500A Has the resident been asked about returning to the community? Q0500B Ask the resident (or family or significant other or guardian, if resident is unable to respond): “Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community?” 0 No 1 Yes 9 Unknown or uncertain

44. Q Participation in Assessment and Goal Setting Q0550 Resident’s Preference to Avoid Being Asked Question Q0500B Again A. Does the resident (or family or significant other or guardian, if resident is unable to respond) want to be asked about returning to the community on all assessments? (Rather than only on comprehensive assessments) 0 No – then document in resident’s clinical record and ask only again on next comprehensive assessment 1 Yes 9 Information not available B. Indicate information source for Q0550A

45. Q Participation in Assessment and Goal Setting Q0600 Referral Has a referral been made to the Local Contact Agency? (Document reasons in resident’s clinical record) 0 No – referral not needed 1 No – referral is or may be needed (For more information see Section Q Care Area Assessment #20) 2 Yes – referral made

46. V CAA Summary V0200 CAAs and Care Planning Column B Old: Addressed in Care Plan New: Care Planning Decision Third column Old: Location and Date of CAA Information New: Location and Date of CAA Assessment Documentation

47. Discharge Assessments A0310G: If A0310F = 10 or 11, code whether it is a Planned (1) or Unplanned (2) discharge A1500-1550 PASSR questions: Only need to be completed if this is also a comprehensive assessment B0100 Comatose C0100 Should BIMS be conducted? If A0310G = 2, skip to C0700

48. Discharge Assessments (2) D0100 Should resident mood interview be conducted? If A0310G = 2, skip to E0100 Added E0200 Behavioral Symptoms, E0800 Rejection of Care, and E0900 Wandering G0110 ADL Assistance: Must only complete Self-Performance items Removed G0300 Balance, G0400 Functional Limitation and G0600 Mobility Devices

49. Discharge Assessments (3) I Active Diagnoses reduced to 13 items Added I5350 Tourette’s Syndrome and I6100 PTSD I8000 remains J0200 Should Pain Assessment interview be Conducted? Of resident is Comatose or if A0310G = 2, skip to J1100 Shortness of Breath J1550 Problem Conditions: Added responses D Internal Bleeding and Z None of the above Eliminated J1700 Fall History on Admission

50. Discharge Assessments (4) Added K0310 Weight Gain Includes reformatted K0510 Nutritional Approaches If A0310G = 2, skip C Mechanically Altered Diet, D Therapeutic Diet and Z None of the above; move to M0100

51. Discharge Assessments (5) M0100 Pressure Ulcer Risk has just one response – A Has a Stage I or greater or a scar over a bony prominence or a non-removable dressing/device M0300 Current Number of Unhealed Pressure Ulcers does not require reporting Present upon Admission except M0300G Unstageable – Deep tissue Eliminated M0150 Risk of Pressure Ulcers, M0210 Unhealed Pressure Ulcers, M0700 Most severe tissue type, M1050 Venous/Arterial Ulcers, M1040 Other Ulcers, Wounds and Skin Problems and M1200 Skin and Ulcer Treatments

52. Discharge Assessments Section N Medications N0410 All medications included Must report number of days

53. Discharge Assessments (5) Section O Special Treatments, Procedures and Programs O0100 Special Treatments: Only K Hospice Care required O0250 Influenza vaccine: Eliminated Date vaccine received O0400 Therapies: Added Days and dates for ST, OT, PT (not minutes) Eliminated O0600 Physician Examinations and O0700 Physician Orders Section Q Participation in Assessment Eliminated Q0100 Participation in Assessment and Q0300 Resident’s Overall Expectations Added Q0400 Discharge Plan and Q0600 Referral

54. Questions qa-mds@pa.gov Next teleconference: July 12, 2012